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Surgery Memberships Study > 6. Abdomen > Flashcards

6. Abdomen Flashcards

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1
Q

Define coeliotomy

A

Surgical incision into the abdominal cavity

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2
Q

Define laparotomy

A

Surgical incision through the flank

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3
Q

List the major indications for abdominal surgery

A
  1. Diagnostic purposes, e.g. inspection of organs or tissues, biopsies etc.
  2. Assessment of prognosis, e.g. establish feasibility of surgical correction of a disease
  3. Therapeutic purposes, e.g. trauma, haemorrhage, infection/source control
  4. Prophylactic procedures, e.g. gastropexy
  5. Neutering, e.g. desexing procedures
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4
Q

What are the 5 levels of ASA classification?

A

1 = normal healthy patient

2 = mild systemic disease

3 = severe systemic disease

4 = severe systemic disease with constant threat to life

5 = moribund patient of whom is not expected to survive without surgical intervention

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5
Q

What factors may affect perioperative nutritional status of a patient?

A
  • anorexia
  • weight loss
  • recent trauma, surgery or sepsis
  • physical impairments to prehension, mastication and deglutition
  • vomiting and diarrhoea
  • oedema, ascites, open or draining wounds
  • catabolic medications, e.g. glucocorticoids
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6
Q

What methods of providing perioeprative and postoperative nutritional support exist?

A
  1. Enteral nutrition - increase oral intake, assisted oral feeding, chemical stimulation of appetite, tube feeding (naso-oesophageal, oesophagostomy, gastrotomy and enterostomy tubes)
  2. Parenteral nutrition - total parenteral nutrition or partial parenteral nutrition
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7
Q

What is the difference between total parenteral nutrition (TPN) and partial perenteral nutrition (PPN)?

A

With TPN all essential nutrients are administered parenterally. With PPN nutrients are administered parenterally to SUPPORT enteral feeding

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8
Q

What factors affect perioperative risks?

A
  • pre-existing medical disease
  • age
  • emergency procedures
  • anaesthetic management
  • surgical procedure performed
  • duration/length of procedure
  • haemodynamic stability
  • experience of the veterinary surgeon
  • availability of adequate postoperative monitoring
  • inadequate analgesia
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9
Q

Give examples of abdominal conditions in which the benefit of surgery may (1) outweigh the risks, (2) requires further study, and (3) risks outweigh the benifit

A

(1) Benefits > risks = penetrating abdominal trauma, septic peritonitis, eviseration
(2) Further study = intraabdominal malignancy, haemoperitoneum in haemodynamically stable patient
(3) Risks > benefits = persistent or intermittent vomiting that has not been localised with non-surgical diagnostic methods, nephroliths or ureteroliths NOT obstructing urinary outflow, FLUTD, persistent or intermitted diarrhoea that has not been localised with non-surgical diagnostic methods, ascites that has not been localised with non-surgical diagnostic methods

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10
Q

What are the 4 levels of prognosis?

A

(1) Excellent - minimal potential for consequences of procedure, with high probability of resolution of problem

(2) Good - low potential for complications of procedure and high probability of successful surgical outcome

(3) Fair - serious complications are possible but uncommon, recovery may be prolonged and the animal may not return to presurgical function

(4) Guarded/poor - expected to have a prolonged recovery, high likelihood of death during or after the procedure, or the animal unlikely to return to presurgical form

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11
Q

When should referral be offerred?

A

Always, especially when primary clinician experience is limited or appropriate level of perioperative care is not available with primary clinician

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12
Q

What are the potential complications of aspiration?

A
  • hypoxia
  • interstitial oedema
  • alveolar haemorrhage
  • atelectasis
  • airway obstruction
  • chemical pneumonitis
  • bronchospasm
  • postoperative aspiration pneumonia
  • death
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13
Q

How does can regurgitation or vomiting lead to death in the context of surgery?

A

High gastric contents –> increases risk of regurgitation, vomiting and gastro-oesophageal reflux (GOR) at induction of anaesthesia or during procedure or recovery –> oesophagitis and potential stricture, larygospasms –> poor protection of airways –> damage to airways –> lack of oxygen movement into blood stream –> death

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14
Q

What factors of aspiration affect the pulmonary outcome?

A
  1. Volume of aspirated material
  2. pH of aspirated material
  3. Amount of particulate matter in the material
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15
Q

List common risk factors for regurgitation, aspiration and gasto-oesophageal reflux (GOR)?

A
  • recent ingestion of food
  • pregnancy or obesity
  • hiatal or diaphragmatic hernia
  • laryngeal paralysis
  • megaoesophagus or oesophageal motility disorders
  • oesophageal, gastric or intestinal surgery
  • anaesthetic drugs that reduce lower oesophageal sphincter pressure
  • opioids delaying gastric emptying
  • vomiting
  • abdominal masses or gross ascites
  • gastric or bowel obstruction
  • recumbency or mental depression
  • head-down surgical position
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16
Q

What is the principle behind mechanical bowel preparation (MBP)?

A

Reduces risk of surgical site infections and anastomotic leakage following surgery of the large intestine

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17
Q

What is the purpose of a preoperative enema?

A

To decrease faecal bulk

They DO NOT decrease the bacterial load in the remainin faeces

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18
Q

Has preoperative shampooing been shown to reduce the risks of surgical site infections?

A

No

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19
Q

What are the consequences of pain for patients undergoing abdominal surgery?

A
  • enhances fear, anxiety and stress response, leading to a catabolic state
  • delays wound healing
  • predisposes to intestinal ileus
  • reduces food intake
  • leads to wound interference and self-trauma
  • prolongs anaesthetic recovery, leading to increased morbidity
  • reduces cardiovascular function
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20
Q

How do opioids affect the gastrointestinal tract?

A
  • increase smooth muscle and sphincter tone
  • decrease peristalsis, reducing propulsive activity
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21
Q

Consequences of NSAIDS?

A

No clear evidence for withholding NSAIDS in UNCOMPLICATED gastrointestinal surgery.

Can cause gastrointestinal irritation or ulceration, nephrotoxicity and hepatopathy.

Potential for neophrotoxicity in anaesthetised patients - specifically hypotension which may reduce renal blood flow

Increase bleeding at the surgical sites by inhibition of thromboxane A2 - however uncommon with therapeutic dose, with the exception of aspirin

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22
Q

What is the overall risk of developing a surgical site infection (SSI)?

A

5%

Encompasses all infections local and regional to surgical wound, including superficial and deep tissues, and organs or visceral space infections.

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23
Q

What species of bacterial are most commonly isolated from SSIs?

A

endogenous skin flora

Staphylococcus spp., e.g. pseudintermedius and aureus

Eschericia coli

Pasteurella

Bacteroides

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24
Q

What bacteria are most commonly encountered in organ or visceral space infections?

A

Enterobacter spp.

Enterococcus spp.

Clostridium spp.

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25
What classifications of factors exist that contribute to the susceptibility to and incidence of SSIs?
1. Host factors - ASA > or = 3 - age - severe malnutrition - neoplasia - pre-existing illness - local surgical site factors 2. Operative factors - surgical time (number 2 factor - 90 mins 2 x greater risk than 60 minutes) - wound contamination (number 1 factor) - suture materials - blood loss - tissue trauma/cautery - hypothermia - tissue dessiccation 3. Microorganism factors - infective dose of obligate or facultative aerobic bacteria = 10^5 bacteria per gram of tissue
26
What main factors exist to reduce SSIs?
- adequate preoperative assessment of patient to treat or stabilise host factors - careful perianaesthetic monitoring, BP, TEMP etc. - appropriate surgical site preparation - appropriate preparation of surgical team - maintaining asepsis in surgical theatre - adhering to Halsted's principles of surgery - limiting the use of foreign material - suture, mesh or drains - providing ongoing care in the postoperative period Antibacterial prophylaxis should never replace appropriate aseptic technique.
27
Describe the wound classification categories?
28
What is the optimal time for parenteral administration of prophylactic antibiotics?
30-60 minutes before surgical incision
29
What manoeuvres exist to aid in abdominal examination/exploration?
30
What are the five major regions of the abdominal cavity? (for the purposes of exploration)
(1) Cranial abdomen - liver - gall bladder/bile ducts - hepatic hilus - epiploic foramen - spleen (2) Gastrointestinal tract - stomach - intestinal tract - pancreas - region LNs (3) Right paravertebral region - hepatic portal vein - caudal vena cava - coeliac artery - hepatic LNs - right adrenal glands - right kidney and proximal ureter - right ovary and uterine horn (4) Left paravertebral region - aorta - left adrenal gland left kidney and proximal ureter - left ovary and uterine horn (5) Caudal abdomen - bladder and distal ureters - proximal urethra - prostate gland and ductus deferens - uterine body and proximal vagina - regional LNs Other regions include: (6) Greater peritoneal cavity - peritoneal fluid (7) Abdominal wall, peritoneal surface and mesenteries - diaphragm - oesophageal hiatus - aortic and caval hiatus - greater and lesser omentum - internal inguinal rings
31
List Halsted's principles of surgery
32
How can inadequate incision length or positioning lead to increased tissue trauma?
Inadequate incision length or patient positioning --> decreased surgical exposure --> excess tissue traction --> excess tissue trauma
33
List the principles of abdominal lavage?
- use warmed, sterile isotonic fluid (saline) - removed as much lavage fluid as possible via suction prior to closure - volume not clearly defined, but 200-300 ml/kg have been recommended
34
What should be done to swabs/sponges during abdominal surgery?
Moistening - reduce tissue desiccation and trauma when handling
35
What methods exist to control haemostasis during abdominal surgery?
1. Pressure - digital, fluid or swab 2. Sealing devises - cautery, ligasure (up to 7 mm) 3. Stapling devices and ligating clips - haemoclips, TA staplers, GIA and EEA staplers, skin staplers, ligating clips, LDS staplers 4. Haemostatic agents - cellulose, collagen, gelatin, micoporous polusaccharide beads
36
What is the rate of perioperative complications following elective procedures?
between 10 and 20% Severe complications are reported between 1 and 5%
37
Complication rate of exploratory ceoliotomy
25-30% perioperative
38
Anaesthetic-related complications rate
7-9%
39
List complications following abdominal surgery within the context of anaesthesia, abdominal wall and abdominal cavity.
40
What factors affect the speed of recovery from general anaesthesia and surgery?
- duration of the procedure - breed - systemic illness - temperature - anaesthetic drugs administered and route of administration
41
What are the minimum monitoring requirements following an abdominal procedure?
- temperature - pulse rate and quality - respiratory rate and quality - mucous membrane colour and CRT - mentation and level of analgesia (pain scoring) - position of the patient - wound mangement - drug therapy Also can measure: - urine production (normally 1-2 ml/kg/hr for adequate renal perfusion) - PCV and TP/TS - BG, electolytes and other biochemistry
42
How can not moving/turning a patient post surgery negatively affect the patient?
Can increase the risk of hypostatic congestion in the dependent lung. Should rotate if has not moved in 30 minutes.
43
What is the tensile strength of fascia by 3 weeks postoperatively?
20% tensile strength at 20 days
44
When should a cutting needle, taper-cut needle, taper-point needle and blund-pointed needle be used?
(1) Cutting needle - tougher tissues, e.g. skin (2) Taper-cut needle - round body with cutting point - dense tissues such as tendon (3) Taper-point needle - round body with sharp point, for delicate tissues such as intestine or fascia (4) Blunt-pointed needles - round body with blund point, used for friable tissues such as liver or spleen
45
Describe the minimum surgical instrumentation for a general soft tissue surgical pack
46
47
What are the four major muscle layers of the abdominal wall from external to internal?
(1) External abdominal oblique (2) Internal abdominal oblique (3) Transversus abdominis (4) Rectus abdominis
48
What direction do the fibres of the abdominal wall muscles run in?
49
What are the origins and insertion points of the abdominal wall muscles?
50
Describe the ventral view of the abdominal muscles
51
What are the 'natural openings' into the abdomen?
(1) Femoral canals - vascular lacunae caudolateral to the superficial inguinal ring, bounded cranially by the internal abdominal oblique muscles and inguinal ligament and medially by the rectus abdominis muscles, seperated from the internal ring of inguinal canal by inguinal ligament. Femoral artery and vein, lymphatics and saphenous nerve pass through here. (2) Inguinal canals - openings in the caudoventral abdominal wall forming a natural slit, lateral to the rectus abdominis muscle and aponeuroses of internal abdominal oblique and external abdominal oblique muscles. There are technically two canals - internal and external openings with a short oblique canal between them. (3) Umbilicus - middle of linea alba where umbilical vessels, vitelline duct and allantoic stalk pass in the foetus.
52
What are the two common surgical approach terms to the abdominal wall? What are the common surgical approaches?
(1) Coeliotomy = common ventral midline approach (2) Laparotomy = flank approach to the abdomen --------------------------------------- (1) Midline approach (2) Paramedian approach (3) Flank laparotomy (4) Paracostal approach
53
List the causes of postoperative incisional hernias in abdominal surgery
54
Describe the treatment of an incisional hernia
- initial stabilisation - protective bandage/dressing until surgery - determine the causal factors for dehiscence and herniation - approach hernia through original incision, removing all suture material - examine herniated viscera for evidence of strangulation or vascular compromise - assess edges of fascia - minimal debridement of torn or inflamed fat - tissue culture if inspection suspected - primary musculofascial repair using standard technique - supplement with horizontal mattress or cruciate sutures - routine SC and skin closure
55
Define hernia
Hernia = protrusion of internal structure (i.e. organ) through a defect in the wall of an anatomical cavity in which it normally lies
56
What typically forms the hernial sac in abdominal hernias?
Peritoneum
57
What is the difference between a true and false hernia?
False hernias are the protrusion through a rupture in the body wall - therefore will have no peritoneal lining. Most acquired hernias are false hernias resulting from trauma. Many true hernias are congenital defects of embryogenesis.
58
What are the possible differential diagnoses for body wall masses?
59
What are the 3 main aims of hernia repair?
1. Reduction in hernia contents 2. Anatomical reconstruction of the defect without tension 3. Closure of the dead space resulting from reduction of the hernia, and high amputation of the hernial sac
60
What approach can be made to most hernias?
Incision directly over the hernia sac - assessment of the hernia contents and excision of necrotic or ischaemic tissue in strangulated hernias prior to reduction May need to be enlarged May need concurrent ventral midline approach
61
How should the hernial ring be closed?
Direct appositional suture repair Some cases may need stabilisation
62
What are the complications of hernia repair? List some common causes of these.
1. Seroma 2. Infection 3. Recurrence
63
What are the most common sites for traumatic abdominal hernia?
Paracostal region - especially cats Ventrocaudal or prepubic regions
64
What percentage of body wall ruptures that are contaminated become infected?
50%, e.g. dog bite injuries

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