Small Animal Sx - Exploratory Celitomy Biopsy Techniques

drraythe's version from 2015-11-24 19:37


Question Answer
why would you want to do an exploratory celiotomy in a abdominal trauma pt?dont just pack inside and suture, dont know how much damage has been made or how much contamination is done
Indications for an exploratory celiotomoy?dx, prog, indicates therapy, most efficient path (dx tool) to a definitive dx
Indications--> how does fluid accumulation appear on radiographs?"ground glass appearance"
indications--> example of non-responsive pain youd want to explore further?colic
indications--> examples of what Abnormal discharge might mean/why youd want to check it out?bladder, uterus, fistula
what should creatinine levels be like in the abd cavity fluid?normal value of creatinine in abdomen in 0, creatinine is not free floating, only find if rupture of bladder/urethra
what is a lap sponge? how do you use it?big, thick pieces of gauze with a little goose string that should stay outside of pt to remind that something has been placed in cavity
what is optimization?reach best stabilization you can before sx (but theyre not totally stable)
what is a DPL, and why might it convince you to do an exploratory?diagnostic perineal lavage- insert warm LRS, roll patient around and get sample for preliminary dx- if you see possible tumor cells etc you might wanna go in (more accurate to determine types of fluid in abdomen than FNA)
which is usually more desirable as a scrub- chlorhex or betadine(Povidone-iodine)?betadine is inactivated by organic material and alcohol, and chlorhex lasts longer and has a little bit of antifungal activity so usually prefer chlorhex
what is a Trendelemburg setting, and why/when do you use it? how is the patient layed on this?This is when the table is tilted so the head is lower than the feet-- which is great for Ca abdomen stuff since the organs slide cr. The REVERSE trendelemburg is when the head is higher than the feet, and this is good for Cr abdomen things since organs slide Ca. *Dorsal recumbency most common
If you use a Trendelemburg setting, what should you tell the anesthetist?tell anesthetist that there will be a upload? so viscera will be displaced cranially so diaphragm will be overloaded
when might you want to add a paracostal approach to your ventral midline approach when opening the abdomen?in case you need better exposure in the cranial abdomen, need for gallbladder and liver sx
what is the approach (where/how do you cut) for an exploratory celiotomy? what should you avoid?Ventral midline approach from xyphoid to pubis. He said NO keyhole incisions for this. (paracostal incision? <-- i think he means consider this in combination possibly)
what are the instruments you will need for your exploratory celiotomoy?Balfour or Gosset retractors, Gelpi retractors, Lap sponges, Suction, Doyen intestinal forceps, Electroscalpel, Delicate thumb forceps
how can Balfour retractors be used?good for keeping abd open and keep hands free
what should you know about contamination?CONTAMINATION IS NOT INFECTION! contamination of 65000 bact per hour. 10^6 bac per gram of skin to be classified as infection. no abx given for contamination, just infection. (pre- abx- given 1 hr to 30 min pre surg and then repeated 90 min later in sx)
After entering the peritoneal cavity what should you obtain while youre in there?obtain samples of free fluid
what is the technique you should use to explore the abdomen?Begin cranially with diaphragm and work through all 4 "quadrants" (L,R, Cr, Ca). Always use same technique, and Be consistent, efficient. Use your anatomical retractors (some people use gastroepiploic line as differentiation between cranial and caudal)
what are the anatomical retractors?cecum (R) and descending colon (L)
picture of structures to observe on technique
After thorough exploration, if Surgical diagnosis is not possible, what do you wanna do?obtain MULT biopsy samples
what order do you want to take your biopsies in?First, tissues with the least potential for contamination. Last, tissues with greater contamination potential
excisional biopsy vs incisional biospyexcisional is when you take the whole lesion out. Incisional is when you take out only a part of the lesion, along with a little bit of the healthy tissue surrounding it
what are margins like in an excisional biopsy?safety margin 1-1 1/2 cm all way around and deep. (mark edges L , R, Cr, Ca and make sure go at least one full tissue layer deep)
why might an incisional biopsy be useful?would be able to tell is there a boundary or has the dz gone beyond it?
commonly biopsied organs?Liver, Intestines, Lymph nodes, Kidneys, prostate
6 ways to biopsy the liverFinger crushing, Ligature fracture technique (Guillotine), Instrument fragmentation, Wedge resection, Biopsy punch, Tru-cut
once you have a sample of the tissue biopsied what should you always do?keep it moist (wet sponge or sthing)
what is nice about the ligature fracture technique (Guillotine) for biopsying the liver? what isn't so nicce?cuts parenchyma but not billliary ducts and vessels Efficiently performed, however, Requires surgical assistant and is Limited to sampling margin of hepatic lobe
how is Hemostasis achieved after a liver biopsy?with Surgicel®, Vetspon® or omentum
how do you close a Wedge resection?need mattress stitches to suture back to approximate edges
If you are going to biopsy the intestines, how much should you take? and in what fashion? (how long, how many, how should you be careful?)Do not exceed 20% of intestinal circumference, Obtain multiple samples along length of intestine that are full thickness and ~1cm long, Preserve luminal diameter, and Protect properly closed site
If you are going to biopsy the intestines, how do you close? what can you do to make the closure a little more leak-proof?Single layer closure with a simple apposition pattern. You can use Omental or serosal patching
If you take a biopsy of the intestines, how can you close to preserve or increase the lumen?
do you want inverting, everting, or simple apposition for intestinal biopsy closure?SIMPLE APPOSITION, not enough lumen room for an inverting (simple interrupted shown in pic)
after you have closed your biopsy of the intestine, what should you check and now?water test to check for leaks to see if suture is patent (inject saline into lumen near site of closure). only do small amount of water bc low pressure system so if add a lot will obviously have a leak
3 common lymph nodes that are biopsied in the abdomen?Mesenteric, External iliac, Colic
3 most common ways to do a bx on a LN? is one preferred over another?FNA, Wedge, Excisional. Excisional techniques preferred to FNA
what are some reasons an excisional biopsy is preferred for a LN?Provides morphologic information, Preserve regional blood supply (Ligate blood supply), Minimal handling
what is Finger crushing liver biopsy technique like?grab piece of lobe and squeeze parenchyma and break parenchyma but not vessels
best method of liver bx is? how do you do it?ligature fracture (guillotine) wrap a piece of suture, make a loop and tie not all the way down and squeeze
what must you be very careful of when doing the ligature fracture technique?(guillotine) be sure theres no biliary leak - leak of bile can lead to chemical perionitits which can be generalized and then go to septic peritonitis
what is omental/serosal patching? when do you use this?for intestinal bx, place omentum on top of suture line and it'll adhere
once you have gotten your intestinal biopsy, how do you handle it?dont squeeze sample with thump forceps or else you'll destroy the tissue put it in a wet sponge and give to someone
is a dermal punch of the intestines partial or full thickness?full
what is a water test?inject 5 cc of saline into intestinal lumen and keep it clamped to see if theres a leak and squeeze it gently must do every time you open or resect intestines
what should you be careful of when bx the kidney?high pressure system, be careful not to damage any time you enter the cortex (tru-cut or cylinder cut)
how should you do a needle aspiration on the kidney?Caudal to cranial parallel to the cortex
how do you achieve hemostasis for a kidney bx?Digital pressure to achieve hemostasis, Omentum or oxidized cellulose to maintain hemostasis
what are the risks of a wedge resection with the kidney?hge
how do you close a kidney bx, cautions?can close with Mattress or continuous, it is a high pressure system so be careful when suturing or else guillotine
what should you absoultely know about the anatomy of the prostate?the urethra goes through it!! don't cut this!
what can you manipulate to help reach the prostate?Exteriorize urinary bladder
which part of the prostate should you avoid, aside from the urethra inside?Avoid dorsal aspect- sometimes when enlarged may be invading the trigonal area (the blood supply and functional area of the bladder)
what are the two ways you can try to bx the stomach, and pros/cons of each?endoscopy less invasive but can't get full thickness. exploratory celiotomy allows full thickness biopsy, but is more invasive
two ways to bx spleen?partial splenectomy or wedge resection
how do you bx the pancrease, and WHERE?partial pancreatectomy, distal aspect (use the most caudal aspect of R or L arm of the pancreas-- R is easier to access)
do you want partial or full thickness bx of bladder? how do you close?full thickness, One or two layer closure (one is simple apposition, two layers would be a connel or cushing combination)
what might pearls on the omentum indicate?there has been trauma - might find lacerated or severed but already healed spleen
which part of the omentum would you want to bx?distal aspect
what should you ALWAYS do after major abdominal sx?LAVAGE the abdomen, immediately prior to abdominal closure. Indicated whenever peritoneal contamination has occurred
what might you want to add to your abdominal lavage solution?Add heparin to lavage solution (100 micrograms/kg)???---> increases survival and significantly reduces abscess formation in experimental peritonitis
big benefits of abdominal lavage before closure?Removal of contaminants (tissue fragments, fibrin clots, fat, bacteria), Patient warming (use warm fluid),
what fluid do you use for an abd lavage? when do you know to stop lavaging?use Isotonic fluid, repeat lavage until retrieved fluid is clear
when would you not completely close the abd after exploratory?Perform unless open peritoneal drainage provided
what SHOULD you incorporate in your abdominal closure, what should you not?Incorporate only external abdominal fascia-- *Avoid rectus abd. muscle in suture (and don't incorporate internal sheath, doesnt help at all) Paramedian incision closed the same way.
why do you want want to do too much saline in your lavage?too much saline flush bad, bodies defenses cant keep up (floating in saline and cant get to the contaminants)
what should you be careful to esp do with a pancreatic bx? ligate pancreatic duct thoroughly- otherwise leak- saponification of fat and chemical peritonitis focally into generally then bacterial peritonitis and then septic peritonitis
***What position will you use for Exploratory Celiotomy biopsy technique?Trendelemburg + dorsal recumbancy
***Which position will displace organs inside to push against the diaphragm?Trendelemburg (NOT REVERSE)
***What is the most important respiratory muscle in animals?Intercostal muscles
***Which retractor has a spoon?Balfour
***True or False - when doing an exploratory celiotomy biopsy you want to obtain the tissue with greater contamination potential lastTrue *First tissues with least potential for contamination* **Also, Neoplasia... you don’t want to spread it... do it last**
***What is the safety margin for biopsy?2cm all the way around and depth wise!
***When performing a biopsy of the intestine what % of the intestinal circumference should you not exceed?Do NOT Exceed 20% of the intestinal circumference!
***What suture pattern will you use when suturing the kidney after a biopsy?Mattress or Continuous