Small Animal Sx- approaches to abdominal cavity

wilsbach's version from 2015-11-04 18:45

Abdominal cavity

Question Answer
What is the diff between celiotomy and laparotomy?Celiotomy is the more correct term when generally referring to opening the abdomen (surgical incision into the abdominal cavity via the ventral midline), whereas laparotomy refers to a FLANK approach to the abd. cavity
what are the 4 main approaches to the abdomen (combinations of these can occur)ventral midline, paramedian, flank, paracostal
*What is the ventral midline approach like? why do we like it?most commonly used, *cut through linea alba (he said try to dissect SQ from linea alba before cutting). used most in sm ani, easiest and quickest to approach/close, minimal bleeding, exposure of all abd organs
what is the paramedian approach like?when you cut to the side of the ventral midline- usually the "oops" cut
what is the flank approach like? pros/cons?between tuber coxi and last rub--- middle of this distance. Usually vertical incision. (lateral incision between last rib and tuber coxae). It gives you LIMITED access to the entire abdomen, however, is Excellent exposure of one kidney, one adrenal gland, one ovary
what is the paracostal approach like? whens it used/cons?1-2 fingers caudal to last rib and parallel to it- curved incision- rarely used by itself. Very limited exposure.
why is a paramedian approach not ideal?because you are cutting through the rectus abdominus there is more bleeding, longer closure time,inc exposure of organs on ONE side of the body (may or may not be bad)
what are the two kinds of paramedian approaches?(1) transrectal (cutting through the abd mm) (2) pararectal (not going through rectus abdominus muscle. go lateral or medial to it-- mm belly will not be touched-- reduce bleeding. Easier to close also.)
hemorrhage vs bleeding vs oozinghemorrhage= LIFE THREATENING CONDITION. Bleeding= not as bad. Oozing= slow capillary bleeds
what's the thing you might cut if you do a ventral midline approach?falciform lig (ligament that attaches the liver to the anterior (ventral) body wall.) - can have some bleeding bc of falciform ligament- fat and adipose tissues and bvs from embryo
what is the GRID approach? what is it good for? separate mm fibers in direction of their insertion. split mm fibers instead of cutting through them. easier closure. Kinda like working through a funnel tho (since pulling apart 3 mm layers). good for extraperiteoneal kidney, or flank castration/ovarioectomy but not OVH (each layer must be sutured back independently or it will restrict mm movement). You will need a longer incision on the skin for more room to retract mm
if you hear borborygamy behind the costal spaces, does that guarantee a diaphragmatic hernia?No... cupula of diaphram can reach high up-- so up to costal spaces there can be abdominal content (3-5 spaces into costal space)
(combined approaches) why do we like the ventral midline + paracostal? why do we not?Increased exposure, especially of gall bladder and liver lobes (right), but more bleeding and longer closure
*(combined approaches) why do we like the ventral midline + median sternotomy? why do we not?Increased exposure of cranial abdomen (liver and diaphragm). However, opens pleural cavity so *assisted ventilation is REQUIRED!!! also the sternum must then be closed again, as well as thoracic drainage must be done. (need a thoacostomy tube to recreate the neg pressure. if not lungs wont expand.)
in the Ventral Midline Approach, what is a landmark which should be included in the sx field?umbilicus
exploratory celiotomy opens from where to where?xyphoid process to pubis
if you do Ventral Midline Approach, what is the skin incision like? what do you do after that?The skin incision should be extended 1cm cranial and caudal to the anticipated body wall incision (prevent incisional hernia). Then sq layer incised in the same line as the skin. Then The linea alba is identified, tented and incised
in the Ventral Midline Approach where is the lina alba usually found?at or cr to the umbilicus
what vessels are around the linea that you need to be careful of?cr superficial epigastric vessels run parallel to the linea cr to the umbilicus
(what two grips for cutting midline?) when you're cutting, what must you be mindful of/do?pencil grip for short precise incisions, violin grip for long incisions. If you're gonna cut, CUT. dont do little ecking cuts all the way down, you're causing more wounds+ more inflammatory processes. tell the anesthesiologist when you are about to start cutting!
If the surgeon asks for "scissors" which scissors are they asking for?metzenbaum. All others will be asked by name.
what's special about the ventral midline approach in male dogs?the penis/prepuce is in the way, so you need to drape the preputial orifice out of the sx field. (towel clamp the prepuce NOT PENIS) You will still need to have the skin incision detour laterally to the prepuce. *Preputialis mm. must be severed in half, ends are tagged for later reattachment (if not they pee off to the side). The incision returns to midline after branches of caudal superficial epigastric vessels are ligated
whats some stuff you see when you FIRST open the abd?omentum, spleen crossing over, maybe greater curvature of stomach
first things you see when abd opened--> which way do you want to move the omentum? what should you keep in mind when moving the spleen?displace omentum cranially or laterally. spleen attached via gastro-splenic ligament- move gently
how would you go about cutting to get through the linea alba? lift up S with forceps and separate sq from linea alba. then can do blade cutting to expose linea alba. tent linea alba before cutting and pierce linea alba. grooved director can be used to cut cranial and caudal to increase incision length protects internal organs. can use finger in a v shape if have no grooved director like pic in middle. use balfore abd retractor
how does a cat's linea alba compare to a dogs?wider and thinner linea in cats
(landmark on the L or R of abdomen?)cecum on the right. left is descending colon
what are the two natural retractors of the abdomen?duodeinum (R hand side). on L had side, descending colon- more moveable, better retraction on L then. both allow you to check vertebral gutters-- bc need to check ovarian pedicle before closure
**What is the HOLDING LAYER of the vental body wall in the ventral midline approach?*external rectus fascia. only layer need to include in closure of linea is this one!! (dont bother with the internal sheath-- doesnt add strength and might inc adhesion risks. ALSO dont suture rectus mm layer, just causes inflammation)
how do you treat the closure of a ventral midline approach, if it's on the midline? If mm is exposed? how are sutures placed?midline= fill thickness bite. MM= external rectus sheath (fascia) only part included in bite. Sutures are placed 3-5 mm apart and incorporate 3-5 mm of tissue.
Ventral midline approach- if doing a simple interrupted closure (linea alba), what kinda suture and size? (sp diff?)Monofilament absorbable or non-absorbable suture (PDS), Size 3/0 to 0 in dogs, 3/0 or 4/0 in cats (cats= smaller)
Ventral midline approach- if doing a simple continuous closure (linea alba), what kinda suture and size? (sp diff?)Monofilament synthetic absorbable or non-absorbable suture (Do not use chromic gut or stainless steel suture in continuous pattern in linea alba!) , size 3/0 to 0 in dogs, 3/0 or 4/0 in cats
what are two different ways you can do a Simple continuous closure with the vental midline approach?(1) Start at one end and close at the other end of the incision (2) Start at each end and close toward the center of the incision. Tie 2 sutures together at center of incision
how is the SQ tissue closed in a ventral midline approach? (skin?)Subcutaneous tissue is closed in simple continuous or simple interrupted pattern, using 2/0 to 4/0 synthetic absorbable suture (In the male dog the preputialis muscle must be accurately apposed!) (Skin is closed with 3/0 or 4/0 nylon)
reasons for stitches to rupture#1 cause- too tight! (ischemia--> tissue death--> no strength--> pop sutures)
why do you want to/ how can you help reduce dead space when doing your SQ closure on the ventral midline incision?to reduce dead air space that will fill with serum or fluid (hematoma) to reduce infectin. so when taking bite of sq- grab bite of rectus fascia
what suture material should you not use when closing the linea alba in a continuous pattern?*no chromic gut or stainless steel
If you are closing the ventral midline incision on a MALE dog, what do you absolutely need to remember to do?*suture back preputialous mm (or theyll pee sideways)
when would you want to use an interlocking(ford) suture on a ventral midline incision?lg animals that need a better hold
(someone elses notes said) what kinda suture patters would you want to avoid when closing midline?things that cause tension like mattresses that will cause everting
***Which approach is used for increased exposure of the gall bladder and right liver lobes?VM + Paracostal
***which approach is used for Exposure of Cranial abdomen (Liver/ diaphragm)?VM + Median Sternotomy
***True or False - VM + Median Sternotomy requires assisted ventilation True - you have created a pneumothorax along with assisted ventilation a Thoracic drain must be placed to regain negative pressure
***With the VM approach how far should the skin incision be extended cranial and caudal to the anticipated body wall incision?1 CM
***In Dogs, the linea alba is most easily recognized.... where? **At or **Cranial to the Umbilicus
***In Male Dogs, during VM approach, what muscle is severed in half and must be reattached before the end of your procedure?Preputialis mm
***What is the holding layer of the Ventral Body Wall?External Rectus Fascia
***When closing the VM incision how should you place your sutures...?5-10mm apart, incorporate 5-10mm of tissue (<--old notes said this. new notes say 3-5mm apart and 3-5mm deep)
***What suture pattern will you use when suturing back the preputialis mm.?Cruciate pattern is the best for muscle