Bovine surgery 2

Question 1

Surgical Approaches

Answer 1

Flank
- Paralumbar fossa celiotomy
> Left
> Right
- Mid to low
> Right paracostal approach
> Left oblique celiotomy
- Ventrolateral oblique
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Right paramedian celiotomy
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Ventral midline

Question 2

Flank: paralumbar fossa celiotomy
- what can we access from the left?

Answer 2

• Left side: access rumen, reticulum, spleen, diaphragm, reproductive tract, bladder, left kidney, abomasum (LDA)

Question 3

Flank: paralumbar fossa celiotomy
- what can we access from the right?

Answer 3

• Right side: access pyloric part of abomasum, small & large intestine, reproductive tract, urinary bladder, kidneys

Question 4

Flank: paralumbar fossa celiotomy
- landmarks for initial cut

Answer 4

Landmarks:
* 6-8cm ventral to transverse processes
* 4-6cm caudal to last rib
* Dorsoventral direction for approx. 25cm

Question 5

Flank: paralumbar fossa celiotomy
- is the approach the same from R and L side? what if we anticipate a pyloropexy or c-section, how will we change our landmarks?

Answer 5

• R & L approach the same
• If pyloropexy anticipated (R side), go closer to last rib
• If c-section (L side), incision more caudal and lower in flank

Question 6

Flank: paralumbar fossa celiotomy
- Layers of incision:

Answer 6

Layers of incision:
* Skin
* Subcutaneous
* External abdominal oblique muscle ( points diagonally from head to udder)
* Internal abdominal oblique muscle (points diagonally from brisket to tailhead)
* Transversus abdominis muscle with attached peritoneum (up and down)

Question 7

what are the muscular layers of the abdominal wall and where do they run?

Answer 7

• External abdominal oblique (ribs > tuber coxae, prepubic tendon, linea)
• Internal abdominal oblique (hip, lumbar vertebrae > linea, ribs)
• External & internal abdominal oblique fuse to aponeurosis (= external sheath of rectus abdominis) > linea
• Transversus abdominis (lumbar vertebrae, ribs > forms aponeurosis=inner sheath of rectus abdominis > linea)
• Rectus abdominis > only ventral (sternum, ribs ®cranial pubic ligament)

Question 8

Flank: paralumbar fossa celiotomy
- what is our strategy for closure? what layers do we close and what type of suture and patterns?

Answer 8

• 4 layers:
• Peritoneum & transversus abdominis
• Internal abdominal oblique
• External abdominal oblique
• Skin
  ()
• Peritoneum & transverse abdominis
• Internal abdominal oblique
• External abdominal oblique
  > simple continuous, #2, absorbable
  ()
• Skin > Ford interlocking, #1, nonabsorbable, simple interrupted ventral
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  o Peritoneum & transversus abdominis, No. 1 or 2 absorbable, simple continuous
  o Internal abdominal oblique, No. 1 or 2 absorbable, simple continuous
  o External abdominal oblique, No. 1 or 2 absorbable, simple continuous
  o Skin, non-absorbable suture, No. 1 , Ford interlocking pattern and a few simple interrupted sutures at the ventral aspect to allow for drainage if necessary

Question 9

Flank: paralumbar fossa celiotomy
- advantages and disadvantages

Answer 9

Advantages: good for exploration, viscera in normal position

Disadvantages: not always adequate exposure eg for evaluating gravid uterus, or small intestine; cow may go down

Question 10

what is the use of the right paracostal approach?

Answer 10

• Good for access to abomasum in calves or adult cattle
• More thorough examination of intestines possible through this approach in calves due to more mobile intestinal tract than adults
• Left lateral recumbency under GA

Question 11

Right paracostal approach - where / what do we cut?

Answer 11

• Parallel and caudal to last rib (5-10 cm in adults)
• Aponeurosis of external abdominal oblique
• muscular layer of internal abdominal oblique dorsally, and aponeurotic portion ventrally
• Transversus abdominis and peritoneum together, tented

Question 12

Flank: Mid to Low approach
- advantages and disadvantages?

Answer 12

Advantages:
* standing or recumbent
* good access to intestines if recumbent
* good access to gravid uterus animal

Disadvantages:
* increased potential of spillage of organs
* increased tension on sutures

Question 13

Mid flank: Left oblique celiotomy
- when is it reccomended?

Answer 13

o Recommended for cows with c section
o Extends further cranial and ventral than classic flank approaches so better for
uterus exteriorisation
o Standing or recumbent

Question 14

Mid flank: Left oblique celiotomy
- landmarks for incision? how do we cut?

Answer 14

o Skin incision starts 10cm ventral to transverse process and angles forward to
finish at level of costochondral junction
o Abdominal oblique muscles incised in same direction as skin
o Transversus and peritoneum tented as other approaches

Question 15

Low flank: Ventrolateral Oblique
- when would we use this approach?

Answer 15

• C-section in recumbent animal (fetal abnormalities)

Question 16

Low flank: Ventrolateral Oblique
- what is the surgical technique?

Answer 16

• Lateral recumbency
  > Usually sedation & local
• oblique incision (30-40 cm)
  > Ventral to flank fold, dorsal to udder
• extends cranioventrally
• Mark milk vein!
• Incise along edge of rectus abdominis
• External sheath is holding layer of the closure

Question 17

Flank: Ventrolateral Oblique
- advantages

Answer 17

Good access to uterus > good exteriorization > less contamination

Question 18

Flank: Ventrolateral Oblique
- disadvantages

Answer 18

• Requires good restraint
• Difficult to enlarge incision
• less access to other organs
• Tension & movement on incision

Question 19

Right paramedian celiotomy
- when do we use? what is it good for?

Answer 19

• Cranial abdomen access
• Mostly used for correction of abomasal
  displacement or volvulus, or access to reticulum
• Restrained in dorsal recumbency

Question 20

Right paramedian celiotomy
- where to do the incision? how large?

Answer 20

Landmarks:
* 4-6cm lateral to ventral midline
* 6-8cm caudal to xiphoid
* 15-20cm incision

Question 21

Right paramedian celiotomy
- what layers do we cut through? what is the holding layer?

Answer 21

• Skin, subcutaneous
• Ext.sheathof rectus abdominis mm (holding layer), rectus abdominis mm, int. sheath of rectus abdominis mm (thumb forceps to tent)
• Sometimes in cranial portion aponeurosis of pectoral mm is present

Question 22

Right paramedian celiotomy
- advantages and disadvantages

Answer 22

Advantages:
* good access to forestomachs, abomasum and urinary bladder in male

Disadvantages:
* requires good restraint
* dorsal recumbency!!!
* general exploration limited
* not as strong as midline

Question 23

indications for ventral misdline incision

Answer 23

• umbilicus problems
• calves
• urogenital diseases
• C-section

Question 24

Surgical technique for ventral midline incision

Answer 24

• dorsal recumbency
• Sedation & local or GA
• incision through linea alba

Question 25

ventral midline closure technique

Answer 25

- linea > simple continuous, #1 or 2, absorbable - subcutaneous > simple continuous, #0 or 2.0, absorbable - skin > simple continuous or ford interlocking, #0 or 2.0, non-absorbable

Question 26

Ventral Midline approach - advantages and disadvantages

Answer 26

Advantages: * good exposure (young calves) Disadvantages: * dorsal recumbency * gravid uterus less easily exteriorized > Can tilt cow * exploration may be difficult in adult * increased tension on sutures

Question 27

Indications for rumenotomy

Answer 27

* Metallic foreign objects traumatic reticulitis or reticuloperitonitis * Removal of foreign material that may obstruct reticulo- omasal orifice * Removal of foreign bodies lodge in distal esophagus * Removal of ruminal content following overload, or ingestion of toxic plants * Rumen impaction * Impaction or atony of omasum or abomasum

Question 28

Rumenotomy - where do we incise, then what do we do? what do abscesses feel like and where would we look?

Answer 28

surgical exploration in left paralumbar fossa * Incision caudal to last rib * Abdominal exploration before opening rumen * Caudal & central part first * Abscesses firm & spherical, usually right side of reticulum or cranial to omasum * Palpate for adhesions

Question 29

Rumenotomy - where do we anchor rumen? why? how?

Answer 29

* Rumen is anchored to skin to prevent contamination of peritoneal cavity when abdomen opened: * Exteriorise as much of rumen as possible * Continuous inverting suture pattern to close rumen to skin over entire incision, use non- absorbable No1 or 2, cutting needle needed for skin

Question 30

when doing a rumenotomy and anchoring the rumen to the skin, what must we ensure?

Answer 30

* Ensure rumen projects well over skin at ventral aspect to prevent contamination

Question 31

alternative to suturing rumen to skn in rumenotomy, and disadvantage

Answer 31

Alternatively, can use rumenotomy board, but is more easily displaced

Question 32

rumenotomy incision - what should we stay away from? how do we remove contents?

Answer 32

* Good seal important * Stay away from anchoring sutures during incision *Remove fluid with hose, solid contents scoop out *Explore

Question 33

rumenotomy - how do we find the reticulum? what can we do to help find foreign bodies?

Answer 33

Follow dorsal wall (through gas cap) to reach reticulum * To locate foreign bodies, reticulum can be gently picked up

Question 34

during rumenotomy, how do we drain an abscess?

Answer 34

Abscess can be drained into reticulum by carrying in scalpel blade attached to umbilical tape

Question 35

Rumenotomy - closure method? how to stay clean?

Answer 35

* Closure of rumen with No. 1 or 2 absorbable material in 2 rows of continuous pattern, with second row using an inverting suture pattern * Following closure of first row, suture line is thoroughly lavaged * surgeon regowns, redrapes and uses a clean surgical kit * Rumen-fixation suture removed prior to closure of second row of rumen sutures

Question 36

when do we perform a rumenostomy? general strategy?

Answer 36

* chronic vagal indigestion, space occupying lesion, idiopathic * commercial device or suturing rumen to skin

Question 37

muscles of flank - what is our holding layer? where is it? - how do the fibers of each muscle run? - how do we incise?

Answer 37

- External abdominal oblique o Incised in same direction as skin incision - Most extensive muscle of flank, ‘holding layer’ - Originates on 4th or 5th rib, terminates on tuber coxae, prepubic tendon and linea alba - Fibres run in caudoventral direction - Aponeurosis of external abdominal oblique blends with aponeurosis of internal abdominal oblique to form external sheath of rectus abdominis muscle - Internal abdominal oblique o Incised in same manner as external abdominal oblique - Originates on tuber coxae, transverse processes and thoracolumbar fascia, terminates on costal cartilages or aponeurosis joining external abdominal oblique - Fibres run in cranioventral direction - Transverse abdominis o Tent using thumb forceps and use Mayo scissors to cut along length to prevent damage to viscera o Thinnest layer o Arises from transverse processes of lumbar vertebrae and last ribs o Forms aponeurosis at lateral edge of rectus abdominis muscle o Becomes internal sheath of rectus abdominis muscle and ultimately inserts on linea alba o Covered on inside by transverse fascia and peritoneum