Decision Making in GI Obstruction

Question 1

what is a gastronomy

Answer 1

incision in stomach

Question 2

what is enterotomy

Answer 2

incision into intestine

Question 3

what is enterectomy

Answer 3

removal or portion of intestine

Question 4

how do you limit contamination in GI surgery (8)

Answer 4

1. isolate using moistened swabs
2. exteriorize intestine when possible
3. dirty area of trolley
4. change gloves + intruments after closed GI tract
5. perform local lavage
6. perform general lavage
7. milk contents away from incision lines
8. occlude intestines: doyen intestinal clamps, assistants hands

Question 5

what forceps should you use to hand the intestines

Answer 5

atraumatic forceps

plain thumb forceps

debakey vascular forceps

Question 6

what do you need to do when you are suturing the intestines

Answer 6

engage the submucosa

fibrous suture holding strong layer

Question 7

what suture materials are appropriate

Answer 7

1. monofilament
2. synthetic
3. absorbable

must be synthetic material

cat gut matieral is not acceptable –> it will be digested by proteases

poliglecaprone 25 (monocril)

glycomer 631 (biosin)

polydioxanone (PDS 2)

Question 8

what suture patterns can be used

Answer 8

appostitional patterns

simple interrupted or continuous

Question 9

how far apart should simple interrupted sutures be

Answer 9

3mm bites 3mm apart

Question 10

what is the cushing pattern be used for

Answer 10

invert seromuscular layer in the stomach

produces early serosal seal

Question 11

what are the benefits of serosal seal (5)

Answer 11

1. reduce leakage
2. increase blood supply
3. speed up healing
4. increase drainage
5. increase local host defences

Question 12

what is an omental wrap

Answer 12

wrap omentum around intestine

adhere to incision line and bring in a good blood supply and drain material away

don’t necessarily need to suture into position but you can put a tacking suture proximally and distally

Question 13

when should you feed postoperatively

Answer 13

early feeding recommended

Question 14

why is early feeding recommended

Answer 14

1. little distention of intestine with feeding
2. water tight seat
3. enteral feeding crucial for mucosal health

Question 15

what are common presentations of gastric foreign bodies

Answer 15

1. incidental finding
2. obstruction: intermittent or persistent vomiting

Question 16

what are the treatment options for gastric foreign bodies (3)

Answer 16

1. induce emesis
2. endoscopic retrieval
3. gastronomy

Question 17

where is a gastronomy done

Answer 17

between the lesser and greater curvature

in the body of the stomach

Question 18

how do you begin your incision into the stomach

Answer 18

stay sutures to lift the area you want to incise up

the liquid sits at bottom and gas at the top

easier to control contamination

Question 19

what scissors should you use to extend your incision in a gastronomy

Answer 19

metzenbaum

mayo scissors are too blunt and will crush tissue

Question 20

how do you close a gastronomy (2)

Answer 20

1. first layer: simple continuous mucosa and submucosa
2. second layer: cushing in seromuscular layer

Question 21

what is a non viable area of intestine

Answer 21

wall thinning

green

grey

black

Question 22

what is a compromised area of intestine

Answer 22

avulsed vessels

red

hemorrhagic

Question 23

what is viable intestine

Answer 23

active hemorrhage from nick

pulse

peristalsis

Question 24

what are key things to remember when performing an enterotomy

Answer 24

1. do not incise over the foreign body as this area is compromised
2. extend incision to avoid stretching and tearing as foreign body is removed
3. use instruments to handle foreign body
4. sutures must engage the submucosa

Question 25

describe how to perform an enterotomy (5)

Answer 25

1. pick site proximal or distal to foreign body 2. linear incision 3. antimesenteric surface 4. no 11 blade 5. extend with scapel or metzenbaum scissors

Question 26

how is an enteronomy closed

Answer 26

submucosa is holding layer simple, full thickness appositional pattern (interrupted or continuous)

Question 27

how do you perform a leak test in enterotomy

Answer 27

occlude intestine 25 guage needle 5ml saline gentle pressure

Question 28

how do you perform an enterectomy (5)

Answer 28

1. identify areas to resect including healthy margin --\> make incision between two arcuate vessels 2. ligate vessels 3. incise mesentery 4. curshing clamps on portion to excise 5. non crushing clamps on portion to suture

Question 29

how do you close an enterectomy

Answer 29

suture 1: mesenteric border suture 2: anti-mesenteric border fill in between: 3mm apart close mesentery

Question 30

how do you deal with luminal disparity

Answer 30

adapt narrower end of intestine so it matches the larger loop extend incision on anit mesenteric surface so length along the intestine matches the loop get a triangular edges and can help to trim those off

Question 31

what is an intussesception

Answer 31

proximal telescoping inside the distal loop causes obstruction, adhesion and pressure buildup and vascular comrpomise leading to necrosis

Question 32

when are intussusceptions common

Answer 32

in puppies and kittens spontaneous possibly secondary to worms or enteritis

Question 33

where is the most common location for intussusceptions

Answer 33

jejunocolic at ileocecocolic junction

Question 34

how do you diagnose an intussusception (3)

Answer 34

1. clinical signs in young animal 2. palpable sausage in abdomen 3. ultrasound distinctive

Question 35

how do you treat an intussusception (2)

Answer 35

1. reduce intussusception +/- enteroplication in young patients 2. enterctomy if there is non viable tissue or in old patients

Question 36

how do you reduce the intussusception

Answer 36

squeeze base of intussusception distally whilst applying cranial traction

Question 37

when should you perform an enterectomy with an intussusception (4)

Answer 37

1. adhesions prevent reduction 2. tissue non-viable 3. tissue tears 4. neoplasia

Question 38

what is an enteroplication and what are the risks

Answer 38

suture adjacent loops of small intestine together on antimeseteric surface prevents recurrce but there is risk of perforation and death reserve for reccurent cases

Question 39

how do linear foriegn bodies travel through intestines

Answer 39

usually gets trapped at base of tongue string becomes taught in intestine intestines bunch up around FB string cuts into mesenteric border

Question 40

what can linear foreign bodies cause

Answer 40

perforation peritonitis death common