Anatomic reviewImportant anatomic points

and helpful hintsVasculatureGastric cardia – palpation

of stomach tubeFundus – greater

curvature area of necrosisAntrum – location of

gastropexy incisionPylorus I.D. by decrease

in luminal diameter more than palpation

Gastric wall – “slipping membranes”

Anatomic reviewProximal duodenum

Duodenal papillaMajor – bile duct

and pancreatic duct

Minor – accessory pancreatic duct

Anatomic reviewProximal duodenum

Duodenal papillaMajor – bile duct

and pancreatic ductMinor – accessory

pancreatic duct

Anatomic reviewProximal duodenum

Duodenal papillaMajor – bile duct

and pancreatic ductMinor – accessory

pancreatic duct

Anatomic reviewDuodenocolic ligament

Holds distal descending duodenum to dorsal body wall

Challenge to running bowel

Easily transected if needed

Difficult to suture adjacent duodenum if not transected

Anatomic Review

Full abdominal exploration - “Open them up”

Be systematicBe gentle especially

with linear foreign body

Systematic Exploration

My approachLiverStomachDuodenum and right

pancreatic limbRight kidney and adrenal Jejunum, Ileum and ColonLeft kidney and adrenalBladder+/- Gall bladder

expression+/- Opening omental

bursa and left pancreatic limb

Systematic Exploration

Surgical optionsGastrotomyGastropexyGastrectomyGastric resection

anastomosis

Gastric surgical techniques

Gastric surgical techniquesGastrotomy

Location – ventral surface equidistance from greater and lesser curvature

Gastric surgical techniquesGastrotomy

Minimize contaminationPack off abdomenStay suturesSuction helpfulTowel ready to

receive what comes out

Orogastric tube prior to entering lumen if fluid filled

Gastric surgical techniquesGastrotomy

Minimize contaminationPack off abdomenStay suturesSuction helpfulTowel ready to

receive what comes out

Orogastric tube prior to enter lumen if fluid filled

Gastric surgical techniquesGastrotomy

Stab incisionExtend with scissors

parallel to curvatures

Separation of layersMucosa-submucosa Muscularis-serosa

Gastric surgical techniquesGastrotomy

Single or double layer closureI typically close in

two layers using 3-0 PDS Mucosa-submucosa –

simple continuous Serosa-muscularis –

interrupted lembertNo leak testThe stomach wants

to heal

Gastric surgical techniquesGastropexy

LocationTechnique

I only perform incisional

2-4 cm from pylorusVentral midpoint of

antrumAvoid lumen

penetrationSeparation of layers+/- stay sutures

Gastric surgical techniquesGastropexy

LocationTechnique

Be aware of diaphragm = pneumothorax

Glistening fascia Transverse incision not

too dorsal Suture deepest to most

superficial2-0 PDS two continuous

strands joined at most ventral aspect of pexy

Avoid lumen penetration

Gastric surgical techniquesGastrectomy

IndicationsNecrosis - GDVNeoplasiaUlcer with

perforationRupture

Gastric surgical techniquesGastrectomy

Gastric viabilityColor

Gray = badPurple = likely OKRed = good

ThicknessTemperatureBleeding on cut

serosal surface

Gastric surgical techniquesGastrectomy

TechniqueStapled – TA or GIACut and sew, cut and

sew, etc.Lots of stay suturesTechnically challenging

Contamination Tissue thickness in

intestinal forcepsInvagination

Serosa to serosa healing

EasyNo contamination

Gastric surgical techniquesGastric R-A

IndicationsNeoplasiaPerforating ulcer

Hand sewnSingle layerComplicated

technicallyLots of potential

complications

Duodenal and jejunal techniquesEnterotomy and

resection-anastomosis

Appositional bestMaintains luminal

diameterLess fibrosis

Duodenal and jejunal techniquesSimple interrupted vs

simple continuousStaples vs suturesCompendium 2000

Simple continuous better apposition

FasterStaples – TA 35 (0.51

diameter close to 4.8mm x 3.4mm)Place 3 stay sutures

and staples in between

Duodenal and jejunal techniquesWhat do I do?

Ligaclips for vascular ligation

Maintain as much mesoduodenum or mesojejunum as possible

Suture terminal vessels

Duodenal and jejunal techniquesWhat do I do?

SI with 3-0 or 4-0 PDS

Take healthy bites 3-mm spacingDon’t worry about

mucosal eversion unless severe

Always leak test

Duodenal and jejunal techniquesEnterotomy

Pack off to minimize contamination

Surface to receive what is being removed

Have everything readyNeedle driversSutureThumb forcepsDoyens or assistant

No manipulation of vasculature

Duodenal and jejunal techniquesEnterotomy

Longitudinal incision to transverse closureIncreases luminal

diameterOnly used if small

incision (i.e. biopsy)Generally not

applicable at site of foreign body excision.

Good for closure of site to cut string

BE GENTLE especially with small thread foreign bodies

Typically hung in pylorus = gastrotomy

Typically require multiple enterotomiesReleasing and removingMinimize

Critically evaluate viability Mesenteric borderDuodenum adjacent to

ligamentConsider re-enforcements

Linear foreign bodies

Ileocolic techniques

IndicationsIntussusceptio

nNeoplasiaForeign body

Ileocolic techniquesSpecial considerations

Contamination issuesGram neg. and anerobes

Vasculature dissection more tedious

Separation of layersLuminal disparity

Oblique transectionVariable tissue spacingSpatulationEnd-to-side

Ileocolic techniquesSpecial considerations

Contamination issuesGram neg. and anerobes

Vasculature dissection more tedious

Separation of layersLuminal disparity

Oblique transectionVariable tissue spacingSpatulationEnd-to-side

Ileocolic techniquesSpecial considerations

Contamination issuesGram neg. and anerobes

Vasculature dissection more tedious

Separation of layersLuminal disparity

Oblique transectionVariable tissue spacingSpatulationEnd-to-side

TyphlectomyIndications

NeoplasiaCecal inversion

TechniqueIleocecal and

accessory cecocolic folds transected

TA stapler very handy

Simple interrupted

TyphlectomyIndications

NeoplasiaCecal inversion

TechniqueIleocecal and

accessory cecocolic folds transected

TA stapler very handy

Simple interrupted

TyphlectomyIndications

NeoplasiaCecal inversion

TechniqueIleocecal and

accessory cecocolic folds transected

TA stapler very handy

Simple interrupted

TyphlectomyIndications

NeoplasiaCecal inversion

TechniqueIleocecal and

accessory cecocolic folds transected

TA stapler very handy

Simple interrupted

Intra-op decisionsClosure re-

enforcementOmentum

Generally will attach without tacking.

Tacking may speed up the process

Serosal patchingTime consumingI perform if I am

worried

Intra-op decisions

Closure re-enforcementOmentum

Benefits Increased blood flow Rapid fibrin seal

Generally will attach without tacking.

Tacking may speed up the process

Serosal patchingTime consumingI perform if worried

Intra-op decisionsNutritional support

Jejunostomy tube

Explore again to make sure

Full thickness BIOPSYStomachDuodenum and

jejunum4-mm skin punch

biopsy(+/-) IleumDon’t biopsy colon

unless essential

What to do if negative explore

Intra-op decisionsLavage

Warm saline in water bath or microwave

200-300 ml/kgI use:

Small dogs and cats – 1-2 liters

Medium dogs – 2-3 liters

Large dogs – 4-6 liters

Keep flushing until clear

Remove blood clots