SAMS 1 Flashcards
(373 cards)
1
Q
Sterilization
A
process of destroying all microorganisms
chemical, heat or radiation
2
Q
T/F: only inanimate objects can be entirely sterile
A
true
3
Q
disinfectants vs. antiseptics vs decontamination
A
Disinfectants- on inanimate objects
antiseptics- antimicrobials on LIVING TISSUE
decontamination- cleaning & disinfecting/ sterilizing processes to make contaminated things safe to handle
4
Q
Asepsis vs sterile
A
asepsis- absence of pathogenic microorganisms
sterile- free off ALL microorganisms
sterility- surgery suite!
asepsis- whole hospital
5
Q
T/F: infection rate doubles for every hour of surgery
A
TRUE!!!
6
Q
clean wound
A
Non- traumatic
ELECTIVE PROCEDURE
no acute inflamamtion
no break in aseptic technique
no entry into nasty organs (GI, urinary or respiratory)
INFECTION RATE IS 2.5-6%
7
Q
clean contaminated wound
A
entry into GI, urinary or urogenital tract WITHOUT significant contamination
minor break in asepsis
INFECTION RATE- 2.5-9%
8
Q
contaminated surgery
A
fresh traumatic wound (less than 4 hours old)
leakage from GI or urogenital tract
MAJOR BREAK IN ASEPSIS
INFECTION RATE 5.5-28%
9
Q
dirty surgery
A
infected
traumatic wound over 4 hours old OR TISSUE IS DEVITALIZED OR FOREIGN MATERIAL
perforated viscus encountered
acute bacterial inflammation or purulent material (pus)
“clean” tissue transected for access to an abscess
INFECTION RATE 18-25%
10
Q
whats the difference between eyed and swaged needles
A
eyed: MORE TRAUMATIC! unreels easily
swaged on: expensive, much less traumatic
11
Q
Cutting suture needles
A
FOR FIBROUS TISSUE (periosteum, fascia, skin)
12
Q
standard cutting needle vs. reverse cutting needle
A
standard: cutting edge toward incision -> larger hole and more risk of suture pull through
reverse cutting: edge away from incision -> less risk of bigger hole and pull through; also doesn’t get dull as fast apparently
13
Q
taper needles
A
DELICATE TISSUES (bladder, GI, muscle, fat)
anything w. a lumen or a subq layer
14
Q
natural vs. synthetic suture
A
natural (cat gut or silk) has an intense inflammatory reaction in the tissue and synthetic doesnt
15
Q
absorbable vs. non-absorbable
A
absorbable: loses strength in 60-90 days using enzymatic or hydrolytic degradation
16
Q
faster degradation of suture
A
urine (sterile): PDS- loses all strenght in 3 days; 1 day if proteus is in the urine
PDS, monocryl, maxon and biosyn lose all strenfht in tissues in 7 days if proteus is present
17
Q
PH and suture degradation
A
faster in Alkaline: Monocryl, Maxon, Biosyn, Vicryl, Dexon
ACIDIC: pds, vicryl and non-absorbable nylon
18
Q
which type of suture is resistant to loss of strength regardless of tissue ph
A
polypropylene- non-absorbable suture
19
Q
monofilament suture
A
single strand, less drag through the tissues, MEMORY, resists harboring microorganisms, more susceptible to breaking
20
Q
multifilament suture
A
multiple strands
stronger and more pliable
less memory
more drag and increased risk for infection
21
Q
what is the most common antibiotic coating for sutures
A
triclosan
inhibits bacterial FA synthesis
22
Q
suture creep
A
the tendency to slowly and permantly deform under constant streess
23
Q
suture memory
A
tendency to return to og shape after deformation
when you take out of the package and it just wants to coil back up
24
Q
PDS suture
A
monofilament
absorbable
coated or uncoated
use for:
body wall/ fascia and muscle
ligatures (spay and neuter
stay sutures
small dog- 3-0
md dog: 2-0
lg dog: 0 to 2-0
25
Maxon suture
similar to PDS
monofilament, absorbable, uncoated
body wall/ fascia & muscle, ligatures, stay sutures
26
monocryl suture
monofilament, absorbable, coated/ uncoated
SUBCUTANEOUS TISSUE
SKIN
small dog: 3-0 to 5-0
md: 2-0 to 4-0
lg dog: 2-0 to 3-0
27
biosyn suture
monofilament, absorbable
uncoated
similar to monocryl
SUBCUTANEOUS OR SKIN ONLY
sm dog: 3-0 to 4 or 5-0
md: 2-0 to 3 or 4-0
lg: 2-0 to 3-0
28
vicryl suture (polyglactin 910)
BRAIDED, absorbable
coated
SOFT TISSUE APPROXIMATION/ LIGATION, OPTHALMIC SX, INTRAORAL SX
29
nylon suture
braided or monofilament
NON-ABSORBABLE
SKIN, DRAINS/ TIE-OVERS, TUBES
INTENTIONAL SHUNTS
SKIN:
sm: 3-0 to 4-0
md: 2-0 to 3-0
lg: 2-0 to 3-0
30
polypropylene suture
similar to nylon
monofilament
non-absorbable
SKIN (sm: 3-0/ 4-0 md & lg: 2-0/3-0)
DRAINS/ TIE-OVERS/ TUBES
INTENTIONAL SHUNTS
VASCULAR: LEAST THROMBOGENIC OF ANY SUTURE
31
which suture type is the least thrombogenic
polypropylene
32
list suture types you would use for skin
polypropylene
nylon
biosyn
monocryl
33
list sutures you would consider for ligatures or stay sutures
PDS
maxon
34
what suture type would you use for subcutaneous tissue
biosyn
monocryl
35
what suture type would you use for the body wall or fascia
pds
maxon
36
what suture would you use for opthalmic or oral surgery
vicryl
37
T/F: interrupted suture patterns provide a better seal
false!
continuous is better
38
list some examples of appositional interrupted suture patterns
simple interrupted
cruciate
gambee (I/C)
39
list some inverting suture patterns
Halsted
Lembert
Cushing: partial thickness
Connell: full thickness (L is for lumen)
INVERTING: TURNS TISSUE EDGES TOWARD CENTER OF HOLLOW ORGAN
40
list examples of everting/ tension relieving suture patterns
Quilled/ stented: I
Far- Near- Near-Far: I
Vertical Mattress: I/C
Horizontal Mattress: I/C
TURNS TISSUES AWAY FROM THE PATIENT AND TOWARD THE SURGEON
41
chinese finger trap for a drain
secures tubes in place
repeated loops around the tube
42
purse string suture patterns
to secure a tube that's exiting the body
Contraindicated:
GI or any organ that can stricture
43
where should tissue adhesive (vetbond) NEVER GO
never ever put it in the subcutis or inside the body
44
t/f: the knot of a suture does not reduce tensile strength
FALSE
KNOTTING REDUCES STRENGTH BY 10-40%
45
when you hand a surgeon a curved kelly hemostat which way should the tips point?
UP
so they are ready to be used!
ALSO SLAM IT INTO THEIR HAND
46
What labwork must be done prior to a spay/neuter
CBC, Chem
MUST HAVE PCV/TP AND GLUCOSE
47
An ovariohysterectomy will decrease the risk of mammary neoplasia. What is the risk of cancer if they are spayed after their 1st heat
BEFORE 1ST: 0.05%
after 1st heat: 8&
after 2nd heat: 26%
48
list the gutters for an ovariohysterectomy
kidneys
ureters
urinary bladder
49
what are the biologic retractors for an overiohysterectomy
descending duodenum - right side
descending colon- left side
50
describe the surgical approach for an ovariohysterectomy
caudoventral midline approach
dogs: middle of the cranial 3rd to the middle of the middle 3rd
cats: middle 3rd
51
ovariohysterectomy anatomy in dogs vs. cats
DOGS: short ovarian pedicle, long uterine body
CATS: long pedicle, short body
52
if you cant get the uterine body out with the spay hook what should you do next
gently lift the bladder up
the uterine body is between the bladder and the colon
53
list the steps for an ovariohysterectomy after you have made the incision and disected through the linea alba
1. use snook OHE hook to get the uterine horn out then follow that to the ovary
2. place a mosquito hemostat on the proper ligament
3. exteriorize the ovary by plucking the suspensory ligament (can cut it too)
4. make a window in the broad ligament (watch out for the ovarian artery and veins)
5. place 1st hemostat proximal to the pedicel
6. place 2nd hemostat just proximal to the ovarian bursa
7. circumferential ligature just underneath the 1st hemostat
8. replace the hemostat distally (toward the ovary)
9. circumferential ligature proximal to the hemostat
10. flash the hemostat when tightening
11. transect the pedicle above the hemostat using a scalpel blade
12. controlled release
13. same on other pedicle
14. tear broad ligament parallel to the uterine horn to the cervix (both sides)
15. clamp distal to the cervix (dogs only)
16. place 2nd hemostat 5mm distal to the 1st
17. place a 3rd hemostat further distal
18. circumferential ligature proximal to the 1st hemostat and remove hemostat while tightening
19. transfixation ligature
20. transect uterine body
54
when closing what is the holding layer
external rectus fascia
55
describe a 3 layer closure
abdominal wall (linea alba) using simple interrupted pattern w/ PDS or Maxon
subcutaneous tissue simple continuous pattern using monocryl or biosyn
skin closure using intrademal pattern with monocryl or biosyn
56
when do we hot pack/ cold pack
cold pack for the first 3 days then hot pack for the next 3 days
57
describe the prescrotal closed orchiectomy approach
dont go into the peritoneal cavity
ligature may be more likely to slip
58
describe an open prescrotal orchiectomy
opens the peritoneum
more direct exposure of the cord
some people prefer this for larger dogs
59
list the principles of urinary tract surgery
GENTLE TISSUE HANDLING (stay sutures, debakey forceps or fingers)
magnification
hemostasis
60
suture selection for urinary tract sx
absorbable monofilament suture: PDS or monocryl
3-0 to 5-0
AVOID CONTACT W/ URINE
61
list the anatomomic retractors for the upper urinary tract
mesoduodenum
mesocolon
62
what is the blood supply to the kidney
renal artery (10% have miltiple L renal arteries and only one R renal artery)
renal vein ( left ovarian/ testicular vein drains to it; cats usually have multiple)
lumbar lymph nodes
63
describe renal neoplasia
usually malignant
renal carcinoma in dogs
lymphoma in cats
bilateral in 30% of dogs w. primary neoplasia (PN is uncommon)
mets to: liver, adrenals, lungs, LN's, bone and brain
64
renal biopsy
rarely done bc it damages the kidneys
helps w. diagnosing
only get cortical tissue
65
nephrotomy
cutting into the kidney
removing OBSTRUCTIVE nephroliths or neoplasia
AVOID: severe hydronephrosis
may compromise renal fxn by 25-50%
midline celiotomy approach
make sure to occlude the vessels using a tourniquet or a clamp
close w/ simple continuous pattern (absorbable suture)
66
nephrectomy
removing the kidney
midline celiotomy
reflect medially for better visualization of vessels
ligate and transect arteries and veins seperately
triple ligate with 2-0 or 3-0 PDS
isolate the ureter at the bladder and double ligate the bladder as close to the bladder as possible with 3-0 PDS
pull on kidney to remove the ureter from the retroperitoneum
67
pyelolithotomy
removing part of the renal pelvis
if its obstructed by renal or ureteral calculus
68
what is the blood supply to the ureter
renal artery Cranially
prostatic or vaginal artery caudally
69
describe an ectopic ureter
one or both of them dont empty into the dorsovental bladder wall (uusally enter at the neck or lower)
more in females
huskies, goldens, labs, mini poodles, terriers
JUVENILE ANIMAL THAT HAS BEEN INCONTINENT SINCE BIRTH
70
INTRAMURAL ectopic ureter
enters bladder normally
+/- ureteral orifice at the trigone
ureter CONTINUES BEYOND THE PAPILLA (submucosal tunnel)
empties caudal to the trigone
MOST COMMON IN DOGS
71
EXTRAMURAL ectopic ureter
completely misess the bladder
CATS
72
URETEROTOMY
usually for a stone
find the stone then make a longitudinal incision over it
flush the ureter then close longitudinally or transversly
73
ureteral R&A
sharp transection
spatulate the ends (widens the anastomosis and decreases stricture risk)
close w/ interrupted or 2 continuous lines
absorbable suture (PDS or monocryl; 4-0 to 5-0)
consider stenting to prevent stricture
74
neoureterostomy
intramural ectopic ureters
ventral midline celiotomy
ventral cystotomy- possibly extend into the urethra
Catheterize ureter
incise over the cather in trigone/ ureteral papilla area
suture mucosa together (make new stroma)
ligate distal to the new stoma
75
neoureterocystostomy
ureteral re-implantation for extramural E.U., distal ureteral injury, neoplasia
ventral midline celiotomy
ligate & transect near the bladder/ urethra
tunnel through body then make stab incision into mucosa
spatulate the ends then suture to the bladder mucosa with 3-5 simple interrupteds w/ 4-0 to 5-0 PDS or monocryl
76
what are some post-op considerations after upper urinary tract sx?
persistent incontinence in 30-55% of patients (especially in huskies)
77
what are some potential complications with kidney sx?
renal failure
hemorrhage
urianry leakage
hematura
hydronephrosis
78
what are some potential post op complications with ureteral sx?
stricture
79
what is the blood supply to the bladder
supply is dorsolaterally to the bladder (via lateral ligaments)
cranial vesicular artery
caudal vesicular artery-\> MAJOR BLOOD SUPPLY; branch of the urogenitial artery
internal pudendal vein
sublumbar LN's
80
describe the innervation to the bladder
sympathetic: hypogastric nerve (L1-4)
parasympathetic: pelvic n (S1-3)
somatic: pudendal n (L7-S3)
81
describe the healing process of the nladder
100% strength is regained by 14-21 days
complete re-epitheliazation by day 30
82
describe the healing process of the urethra
heals by 7 days
have to divert urine to prevent complciations)
complete transection often leads to stricture (can place catheter to help)
83
describe retrograde hydropulsion
patient anesthetized to relax the urethra the best
catheterize to the stone
2nd person puts a gloved finger in the rectum and occludes the urethra proximal to the stone
flush w/ saline to distend urethra
assistant quickly released the urethra to let the stone pass
84
describe voiding urohydropulsion
very tiny stones or grit
anesthetize patient
catheterize
fill bladder w/ saline
hold ptnt upright and express bladder
DO NOT RUPTURE THE BLADDER
85
Cystotomy
caudal abd midline or parapreputial celiotomy
exteriorize the bladder; use stay sutures at the apex and pack off the bladder
stones: pass a catheter before cutting into the bladder to prevent them from falling down into the urethra
incise at ventral midline and mid body
stab incicion then suction urine out
extend incision w/ metzenbaums
place stay sutures to hold it open
goal of closure: watertight seal without impinging ureters
SUBMUCOSA IS THE HOLDING LAYER
single layer closure is preferred (3-0 PDS/ monocryl with simple interrupted or simple continuous)
86
t/f: a small amount of hemorrhage up to 1 week post op is normal after a cystotomy
true
87
cystostomy
opening into bladder for urine diversion
mini-celiotomy over bladder
stay sutures
stab incision through bladder wall
place a tube, then tighten a purse string suture pattern, pass tube through body wall ( seperate incision), inflate the balloon
close and suture catheter to the skin
88
urethrotomy
catheterize
incise the urethra over the catheter
extend incision w. iris scissors
closure is preferred ( simple interrupted or simple continuous using 3-0 or 4-0 PDS/ monocryl)
can leave to heal by 2nd intention and can bleed for several days
remove catheter
89
urethrostomy
permanent hole in the urethra
scrotal, perineal, prescrotal, prepubic
scrotal is preferred for dogs
perineal is preferred for cats
90
scrotal urethrostomy
dogs!
urethra is widest and most supf here
castration w/ scrotal ablation
catherize
ventral midline incision over urethra
mobilize and retract the retractor penis muscle
make a 2-3cm long urethral incision over the catheter
suture urethral mucosa to the skin (simple interrupted or continuous 3-0 or 4-0 monocryl
91
perineal urethrostomy
CATS!
catheterize
incise around scrotum and prepuce
mobilize penis/ urethra to the level of the bulbourethral glands (dissect laterally and ventrally; minimal dorsal dissection; release ischiocavernosus muscle)
incise @ bulbourethral glands (widest at this point in cats)
amputate the penis
suture the urethral mucosa to the skin w. 4-0 monocryl using a simple interrupted patter
92
where is the widest point of the urethra in the male dog? what about cats?
Dogs: scrotal section of the urethra
cats: bulbourethral glands
93
list potential complications of a urethrostomy
stricture formation
urine leakage (uroabdomen or subcutaneous tissue)
ascending bacterial infection
hematuria/ hemorrhage
urinary/fecal incontinence
94
urethral prolapse is most common in
english bulldogs, bostons, and yorkies
95
urethral prolapse treatment
conservative: reduce the prolapse and place purse string sutures for 5 days
surgical: resect the prolapsed tissue, suture mucosa to the penis w/ simple interrupted 3-0 or 4-0 monocryl
urethropexy: mattress sutures to hold it in the penis
96
t/f: a urethral prolapse will recur if the animal doesnt get neutered
TRUE!!!!!!
97
t/f: hemorrhage is common after a urethral prolapse
true
hemorrhage for 1-2 weeks
98
List the primary components of brachycephalic airway syndrome
stenotic nares
elongated soft palate
hypoplastic trachea
nasopharyngeal turbinates
99
list the secondary components of brachycephalic airway syndrome
everted laryngeal saccules
laryngeal collapse
100
list some signs of brachycephalic syndrome
stertor
stridor
gagging
snoring
increased Resp effort
exercise intolerance
hypoxemia
hyperthermia
101
what are treatment options for stenotic nares
alaplasty (resecting the nares)
can be vertical, horizontal or dorsolateral
most people do vertical
102
describe an elongated soft palate
overlaps the epiglottis by more than 1-2 mm
normal caudal border is the caudal margin of the pharyngeal tonsils
soft palate helps to occlude the nasopharynx while swallowing
103
what is the name for resecting an elongated soft palate (surgical procedure)
staphylectomy
104
list some complications of a staphylectomy
post op swelling -\> dyspnea
overshortening -\> nasal reflux or aspiration
hemorrhage
105
how do everted laryngeal saccules form?
2ndary effect of increased negative pressure
eversion of mucosal tissue lateral to the vocal folds
contributes to upper airway obstruction
tx: sharp excision following extubation
106
what is a hypoplastic trachea
congenital issue in brachycephalic breeds (bulldogs esp)
decreased ratio of tracheal diameter: thoracic inlet height
NO SURGICAL TX AVAILABLE
107
laryngeal collapse
2ndary to negative pressure in airway
no good tx for severe cases: artenoid lateralization, partial laryngectomy, permanent tracheostomy
108
while nasal cavity surgery is not common, what are some approaches
dorsal rhinotomy
ventral rhinotomy
109
describe laryngeal paralysis
congenital issue in 4-6 mo old huskies or bouvier des flandres
acquired in large breed dogs (labs) and usually bilateral
traumatic -\> usually bilateral
110
what are c/s of laryngeal paralysis
inspiratory stridor worse w/ exercise
voice change
exercise intolerance
resp distress/ hyperthermia
coughing when eating/drinking
111
how do we surgically correct laryngeal paralysis
"tie back"
UNILATERAL arytenoid lateralization (bilateral increases risk of asp. pneumonia)
112
what are the landmarks for arytenoid lateralization
caudodorsal part of cricoid cartilage
cricoarytenoid dorsalis muscle
muscular process of the arytenoid cartilage
113
list some complications of arytenoid lateralization
aspiration pneumonia (20% of ptnts)
dysphagia
suture breakage
cartilage fracture intra-op
114
temporary tracheostomy
* upper airway obstriction
* long-term ventilation
* ventral midline cervical incision
* seperate sternohyoideus muscles
* incise annular ligament between cartilage rings between rings 3 &4 or 4&5
* no more than ½ circumference of the trachea
* stay sutures proximal and distal in the trachea
* insert and maintain tube
115
what are some indications for permanent tracheostomy
upper airway obstriction
SALVAGE PROCEDURE
116
permanent tracheostomy
* ventral midline cervical incision
* seperate sternohyoideus muscles
* appose sternohypodeus muscles dorsal to the trachea
* excise rectangular segment of tracheal wall
* LEAVE MUCOSA INTACT
* suture mucosa to skin
117
what are the indications to tracheal R&A
neoplasia (rarely)
severe trauma
118
how much of the trachea can be resected
up to 50%
119
what are some complications of a tracheal R&A
stenosis
dehiscence
120
T/F: the intercostal space is 4 times as wide as the ribs
False
2-3 times
121
What is the main source of blood supply to the thoracic wall
intercostal arteries (caudal to ribs w/ vein and nerves)
internal thoracic artery runs at the ventrum
122
what intercostal muscle is involved in expiration (internal or external)
INTERNAL
123
What intercostal muscle is involed in inspiration (internal or external)
EXTERNAL
124
LIST THE MUSCLES INVOLVED IN INSPIRATION
scalenus
serratus dorsalis cranialis
levatores costarum
diaphragm
125
why would you perform a lateral (intercostal) thoracotomy
lung lobestomy, cardiac dx, thoracic duct ligation, esophageal/ tracheal sx
126
list some reasons why we may do a median sternotomy
thoracic exploratory
mediastinal mass resection
127
list some reasons why we may do a thoracoscpy
thoracic exploratory
pericardial window
lung lobectomy
thoracic duct ligation
mediastinal mass resection
128
how would you perform a lateral thoracotomy
incise from the costovertebral junction to the sternum
use a finochietto retractor
place a chest tube at caudorsal thorax
pre-place sutures: circumcostal w/ monofilament suture, remove air, appose muscles and skin, remove air again
129
which muscles are involved with a lateral thoracotomy
latissimus dorsi (elevate and retract DO NOT CUT)
scalenus (5th rib)
serratus ventralis seperate between muscle fibers)
intercostal muscles (seperate)
pleura
130
describe a median sternotomy procedure
incise at ventral midline over the sternum
through the pectoral musculature
transect the sternum (oscillating saw, avoid internal structures, leave 2-3 cranial or caudal sternebrae intact)
close: chest tube subcostal lateral to midline
ortho wire in an firgure 8 pattern
close normally
131
typical exploratory thoracoscopy
paraxyphoid camera portal w/ 5-10mm rigid scope
1-2 intercostal instrument portals
132
what is the purpose of a thoracocentesis
to remove fluid/ air
DO IT BEFORE RADS OR PLACING A CHEST TUBE
133
What sedation do you use for a thoracocentesis
opiod + benzodiazepine
134
which intercostal spaces do you perform a thoracocentesis in
7th,8th or 9th
135
t/f: most patients w/ a pneumothorax will resolve without surgery
true!
136
where do you incise for a trocar- style chest tube vs a large bore silicone chest tube?
trocar style: cut at 10th or 11th space then advance tube 3-4 spaces
Lg bore: pull incision cranially so incise directly over the entry space (`6/7th) then pop through intercostals w/ a curved hemostat. advance tube cranially then secure to animal
137
list some potential causes of a SPONTANEOUS PNEUMOTHORAX
ruptured bullae or blebs
commone in large breed dogs (HUSKIES!!!)
138
DESCRIBE MEDICAL MANAGEMENT VS SURGICAL OPTIONS FOR A SPONTANEOUS PNEUMOTHORAX
Conservative: continuous drainage over 2-3 days
surgical: complete or partial lung lobectomy (many dogs have multiple lesions and are bilateral so a thoracoscopy or median sternotomy)
139
describe an exudate
protein \> 3g/dL
specific gravity is \>1.025
nucleated cell count \>7000
so protein, sp gravity and nucleated cell count is high
140
describe a modified transudate
protein \> 2.5 but less = 5
specific gravity \>1.015 = 1.025
nucleated cell count \>1500 = 7000
141
describe a transudate
protein = 2.5
sp. gravity \<1.015
NCC = 1500
142
what causes a chylothorax
anything that can increase hydrostatic pressure in the cranial vena cava
trauma, neoplasia, IDIOPATHIC IS MOST COMMON
143
describe a chylothorax (typical signalment and c/s)
afghans, shiba inus, siamese and himalayan cats
c/s: coughing &/or resp distress
144
what are some diagnostics you can do for a chylothorax
milky fluid w/ pink hue
fluid triglyceride \> serum triglyceride
fluid cholesterol \< serum cholesterol
chylomicrons → sudan black
145
describe medical management for a chylothorax
periodic thoracocentesis (can result in dehydration and loss of lipids, protein & fat soluble vitamins)
low fat diet
rutin (neutraceutical)
146
describe surgical management for a chylothorax
divert lymphatic flow from the thorax
METHYLENE BLUE IMPROVES INTRA-OP VISUALIZATION
thoracic duct ligation or pericardiectomy→ thoracoscopy or thoracotomy
cisterna chylii ablation → abdominal incision
147
what is the prognosis for a chylothorax
fair to guraded (53-100% success)
recurrence is most common complication
salvage procedures: pleuroperitoneal shunt or a pleuroport
148
describe the inital theraoy for acute traumatic diaphragmatic hernias)
assess for other injuries
treat for shock
resp support
emergency surgery if gastric herniation, unable to stabilize patient or uncontrollable pain/ hemorrhage
149
how would you surgically correct a diaphragmatic hernia
ventral midline celiotomy
replace abdominal contents
extend hernia if you need to
if there are adhesions (chornicity) then divide and possibly do a partial lung/ liver lobectomy; may need to do a caudal median sternotomy; be sure to debride edges if it is chronic
simple continuous duture (begin dorsally)
then suck the air out
85% or better chance of survival
150
what are some differentials for a mediastinal mass
thymoma
dogs more common
labs and goldens
10.5-12 years old
lymphoma
cats more common
~6 years old
151
what are some signs of a mediastinal mass
weakness, anorexia, lethargy, coughing, dyspnea, weight loss, tachypnea, vomiting, regurgitation, PU/PD
152
what is a common paraneoplastic syndrome with thymomas
myasthenia gravis (~50%)
and secondary megaesophagus
hypercalcemia
153
what is a common paraneoplastic syndrome with lymphoma
hypercalcemia
154
what are some further diagnostics that you can do for a thymoma to check for paraneoplastic syndrome (myasthenia)
AChR→ acetylcholine receptor antibody test
Tensilon test → edophonium chloride
155
what test would you run to check for hypercalcemia associated with a lymphoma or thymoma
ionized calcium
156
what is the median survival time for animals with mediastinal mass
cats ~5 years
dogs \> 2 years
157
what is the signalment for a primary lung timor
no breed/ sex predilection
usually 11-12 years old
larger breeds
158
what are the main primary lung tumors we see
bronchoalveolar carcinoma
adenocarcinoma
these make up over 95% of primary lung tumors
159
describe a partial lung lobectomy
removing focal lesions of the peripheral ½ to ⅔ of the lobe
or biopsy
1. place clamps proximal to the lesion
2. place 2 continuous overlapping suture patterns proximal to the clamps
3. excise the tissue
4. oversew the lung
5. leak test
160
how would you perform a total lung lobectomy
1. lateral thoracotomy
2. clamp bronchus near the hilus
3. isolate the lobe
4. blunt dissection to isolate the artery w/ 3 suture technique
5. ligate vein in same way
6. place 2nd clamp and transect bronchus
7. continous horizontal mattress and oversew
161
what are some complications of a mediastinal mass lobectomy
pneumothorax
hemorrhage
insisional complications
persistent discomfort
162
describe a lung lobe torsion
UNCOMMON
young pugs (about 4.5) → left cranial lobe
older, lg breed dogs
males predisposed
cats → around 9
lobar sign on rads
MOST COMMON ON RIGHT MIDDLE AND LEFT CRANIAL
163
where is a lung lobe torsion most likely to occur
left cranial or right middle lung lobes
164
how would you treat a lung lobe torsion
lung lobectomy WITHOUT DEROTATING IT
prognosis fair to gaurded (50-60%)
pugs are more favorable to live… which is so weird
165
t/f: rib fractures require surgery
false
usually conservative management
166
what is flail chest
multiple consecutive rib fractures that can cause paradoxical thoracic wall motion
usually not treated
can tx w/ external splints
167
list the 2 primary rib tumors
osteosarcoma
chrondrosarcoma
168
how would you do an en bloc excision with chest wall reconstruction for a thoracic wall tumor
can excise up to 6 consecutive ribs
up to 8 in cats
169
what is the prognosis for primary thoracic wall tumors
chrondrosarc: 1-3 years
osteosarc- 8 mos (surgery+ chemo)
170
describe a pectus excavatum
developmental defect of sternum/ caudal ribs
many patients asymptomatic
easier to tx when young
external splinting or internal fixation
171
which breed/ species are predisposed to pectus excavatum
burmese and bengal cats
172
what is the most important thing when performing cardiac surgery
ATRAUMATIC TISSUE HANDLING AND GOOD SX TECHNIQUE!
173
how would you close after cardiac sx
3-0 to 6-0 tiny suture w. taper point (atraumatic)
polyproylene, polytetraflouroethylene, braided polyester
silk for ligatures
174
what is the signalment for a PDA
purebreds
females \> males
poodles, keeshonds, maltese, bichon frises, yorkies, cocker spaniels, pekingese, collies, shelties, poms, corgis
**heritable→ poodles and corgis**
hypoplasia & segmental asymmetry of the ductus muscle mass → failure of ductus contraction
175
desceribe the pathophys of a Left → Right PDA
**\*\*\*MOST DIE BEFORE 1 YEAR OLD\*\*\***
aorta → pulmonary artery
left side volume overload
L ventricular and atrial dilation
progressive deterioration
L sided CHF
progressive functional mitral regurge → more overload of left ventricle
A-fib
176
Describe the pathophys of a R → L PDA
late development or shortly after birth
pulmonary a→ aorta
suprasystemic pulmonary hypertension → reverses shunt
differential cyanosis → hypoxemia & cyanosis more intense caudally
exercise intolerance, varying hypoxemia, polycythemia
177
how would you diagnose a L→ R PDA
cardiac murmur → continuous, left heart base +/- thrill
femoral pulses → bounding or hyperkinetic *from low diastolic pressure that causes shunting of blood through ductus during diastole*
Thoracic rads
**ECG- confirmatory diagnosis**
178
what would you see on an ECG with a patient that has a L→ R PDA
tall R waves on lead 2
a fib or ventricular ectopy
LA enlargement
LV chamber dilatation
increased aortic ejection velocity
reverse turbulent flow in pulmonary artery on Doppler
179
how would you diagnose a R→ L shunt (PDA)
cyanosis (hallmark)→ more severe in caudal mucus membranes; due to postition of ductus in relation to bifurcation of the brachycephalic trunk
femoral pulses are NORMAL
no cardiac murmur
thoracic rads
180
What are the indications for surgery for a L→ R shunt (PDA)
ALL CASES BC OF POOR LONG TERM PROGNOSIS W/OUT CORRECTION
**exceptions:**
surgical ligation (not until 8 weeks but before 16 weeks;
CHF: tx w/ diuretics before surgery (sx 24-48 hours post op)
supresystemic pulm. hypertension
181
what are the indications for surgery to repair and R → L shunt (PDA)
**DONT DO IT!!!!!!!!!!!!!!!!!**
182
how would you perform a L→R shunt (PDA) surgery
left 4th intercostal thoracotomy (dogs)
left 4th-5th (cats)
blunt dissection, deep and parallel to the ductus
ligate with 2 sutures using 2-0 silk; place suture closest to aorta 1st
BRANHAM REFLEX: INCREASED BP DECREASED HR
183
what is the branham reflex
increased blood pressure
decreased heart rate
184
what are some potential complications after a PDA shunt repair
rupture of PDA or great vessels (most severe and most common cause of mortality)
residual flow but rarely hemodynamically significant; another sx not needed
185
describe the general outcome of L→ R shunt sx
curative for most cases if performed \<6 mos of age
mitral regurge and 2ndary myocardial failure generally reversible post op
low risk of surgical mortality (\<7%)
CHF increases risk of post op mortality
186
what is a vascular ring anomaly
developmental issue of the great vessels that encirlce the esophagus/ trachea by an incomplete or a complete ring of vessels
embryo: paired dorsal and ventral aortas
6 interconnecting pairs of aortic arches correspond to 6 brachial arteries
187
What breed is most commonly assoc. w/ persistent right aortic arch (PRAA) w/ left ligamentum arteriosum
BONUS: where does it usually occur
german shepherds, irish setters
persians or siamese cats
BONUS: usually at right 4th aortic arch
188
what is the most common clinical vascular ring anomaly
persistent right aortic arch w. left ligamentum arteriosum
189
when are persistent right aortic arch cases typically diagnosed?
between 2-6 mos old
190
what are the c/s of Persistent RIght Aortic Arch
usually normal until weaning
postprandial regurge once starting solid food
esophageal obstruction
191
what would you see on p/e for a PRAA pup?
malnourished but always hungry
megaesophagus (especially noticebale cranially)
192
where would you cut for a PRAA in a dog
left side
4th intercostal thoracotomy
193
Where would you cut for a PRAA in a cat
left 4th-5th intercostals
194
what suture would you use for ligation for a PRAA
two sutures
2-0 sillk
195
why do you use a stiff balloon for a PRAA
breaks down fibrous bands
196
t/f: signs usually resolve after a PRAA
true
megaesophagus may not resolve fully
197
what is the most common complication with PRAA surgery
persistent regurgitation
→ aspiration pneumonia and death
198
why would you do a pericardiectomy
chronic or recurrent pericardial effusion (idiopathic or neoplastic)
or cardiac tamponade
or multiple pericardiocenteses
199
what are the types of a pericardiectomy
total → rarely done
subtotal
200
describe the main points of a subtotal pericardiectomy
4th-5th intercostal thoracotomy
can be left or right
median sternotomy
fillet= alternative
201
how would you perform a subtotal pericardiectomy
cut ventral to the phrenic nerve
incise AROUND caval vessels
retract heart and cut opposite side ventral to phrenic nerve
divide the sternopericardial ligament
202
how would you perform a pericardiectomy thorascopically
make a pericardial window → subtotal pericardiectomy
dorsal or lateral recumbency
3 portal technique
window in pericardium ( \>3x3 cm)
203
what is the most common cardiac neoplasia
right auricular hemangiosarcoma
204
what is the prognosis for a right auricular hemangiosarcoma
bad
highly metastatic
sx & chemo→ 6 mos
sx alone → 6 weeks
pericardiectomy alone wont help increase survival
205
how would you resect a right auricular hemangiosarcoma
pericardiectomy
mass resection
206
what is the most common aortic body tumor
chemodectoma
207
what breeds are more commonly assoc w/ a chemodectoma
BRACHYCEPHALICS!!! (boxers, bostons, english bulldogs)
locally invasive
not resectable
208
what happens with a chemodectoma
leads to pericardial effusion
MST w/ sx= 22 mos
MST is 4 mos without sx
209
list the most common oral tumors in the dog
epulides
malignant melanoma
squamous cell carcinoma
fibrosarcoma
210
list the most common oral tumors in the feline
squamous cell carcinoma
fibrosarcoma
211
what are epulides
most common benign oral tumor → smooth surfaced nodular gingival mass
originates from periodontal ligament → local excision is curative
if originating from odontogenic epithelium→ acanthomatous ameloblastoma; needs more aggressive dissection; can become malignant; radiation is effective
212
describe melanoma in the oral cavity
ALWAYS MALIGNANT
gingiva. buccal/ labial mucosa \> palate \> tongue
firm brown-black color
amelanotic is usually less differentiated
locally invasive
mets to regional LN's early on (80% of time)
213
what should you do with a malignant melanoma patient
surgery +/- radiation
MST: 8-9 mos
better w/ LN removal and vaccine
AMELANOTIC MELANOMA→ WORSE PROGNOSIS
214
describe a squamous cell carcinoma in the oral cavity
usually gingival, tonsils & base of tongue
ulceration is common, red friable mass
prognosis worsens as it is more caudal
gingival: locally invasive but mets later: rostral mass w/ wide resection is possibly curative
tonsilar: very aggressive; nearly alwayw metted at diagnosis and usually not resectable
HAVE TO RESECT W/ WIDE MARGINS AND DO PHOTODYNAMIC THERAPY IF \<1CM DEEP
215
Fibrosarcoma oral tumors
large breed dogs
usually on maxillary gingiva and hard palate
pink, red, firm, smooth, multi-lobulated masses
locally invasive and aggressive in younger animals
WIDE SURGICAL RESECTION W/ RADIATION THERAPY (LOCAL RECURRENCE COMMON)
216
what is a high-low fibrosarcoma
golden retrievers
usually low grade histologivally and come back as benign and inflammatory
BUT THEY ARE BIOLOGICALLY A HIGH GRADE!!!
VERY LOCALLY INVASIVE AND LOW RISK OF METASTASIS
respond to radiation
217
describe a feline oral SCC
MOST COMMON ORAL TUMOR IN THE CAT
guarded → poor prognosis
extensive bony involvement
local recurence is common
check FeLV and FIV status
SX, radiation, chemo, photodynamic therapy
218
what are some surgical treatment options for oral tumors
debulking
wide resection w. maxillectomy or mandibulectomy
219
what are some advantages of oral surgery
ADVANTAGES:
blood supply is huge
saliva is bacteriostatic
heals fast
220
what are some disadvantages with oral surgery
contaminated
high motion and high tension
hard to maneuver in
221
what is the blood supply to the maxilla
major palantine
minor palantine
222
what is the blood supply to the mandible
mandibular alveolar artery
mental arteries
223
what are some ways you can perform a partial maxillectomy
1. hemi
2. rostral
3. bilateral rostral
4. central
5. caudal
224
how would you perform a partial maxillectomy
incise oral mucosa 1 cm beyond mass (2-3 if fibrosarcoma)
seperate soft tissues
save 1 canine tooth if you can
maxillectomy cut
MAKE SURE YOU HAVE A GOOD SEAL FROM THE NASAL CAVITY
labial mucosa-submucosa flap
225
describe the direct apposition technique for an oronasal fistula
elevate & mobilize
close mucosa to mucosa
absorbable suture
TENSION→ FAILURE
226
describe the buccal flap technique for an oronasal fistula
release mesially and distally
incisions diverge into buccal mucosa
elevate palatal margin
suture corners first
TENSION → FAILURE
227
describe the double flap technique for an oronasal fistula
create palatal incisions
elevate
digital pressure on ROSTRAL PALATAL ARTERY
invert
create buccal flap and suture over the palatal flap
228
t/f: a cleft palate revision is usually only performed once
FALSE!
MULTIPLE PROCEDURES W. ADEQUATE HEALING TIME IN BETWEEN
229
describe a cleft palate repair
repair at 3-4 mos old
after 1st round of shots, stronger mucosal tissues and they are a little bigger so its easier to move around in there
outpatient sx: owner management
multiple procedures with 3 weeks in between
230
how long should you have in between cleft palate surgery
3 weeks to allow for adequate healing
231
where should rostral mandibulectomies be?
between 2nd and 3rd premolars
TO AVOID CANINE ROOTS
232
DESCRIBE A CHEILOPLASTY
total hemimandibulectomy
level of premolar 1 or canines
remove mucocutaneous junction
prevents drooling or tongue hanging out
233
what are the main points of oral surgery?
WIDE MARGINS
avoid electrosurgery on oral mucosa
minimal tissue handling
TENSION FREE CLOSURE: best if over bone
appose mucosa
suture w. PDS in subq and monocryl over mucosa (some people like braided vicryl)
234
which veins make up the external jugular
lingual facial and maxillary
235
where are salivary mucoceles most commonly located
mandibular or sublingual
236
describe the potential locations of a salivary mucocele
cervial
sublingual or RANULA
pharyngeal
237
what are the clinical signs of a salivary mucocele
swelling (usually not painful)
dysphagia
dyspnea
exopthalmos
238
how do you find the correct gland for a salivary mucocele
ask which side came firs
place in dorsal and see where it falls (falls to affected side)
239
T/F: you should NOT repeatedly drain a salivary mucocele because it can lead to an abscess
TRUE
240
Describe the procedure for a mandibular or sublingual salivary mucocele
incise over mandibular gland
CRANIAL TO CAUDAL
penetrate capsule
blunt and digital dissection rostrally
ligate @ lingual nerve
241
describe the procedure for a ranula or pharyngeal mucocele
MARSUPIALIZATION FOR RANULA:
incise the “roof” of the ranula
suture the lining of the ranula (pocket under the tongue) to the sublingual mucosa with monocryl → allows for drainage and heals via 2nd intention
sialoadenectomy later if it recurs
242
where is the most common place for an esophageal foreign body
narrowest places:
thoracic inlet
base of heart
diaphragm
243
how would you do surgery to remove a foreign body in the esophagus
90% removed via endoscopy
push into stomach and perform gastrotomy
esophagotomy: SUBMUCOSA IS THE HOLDING LAYER→ no serosa and you avoid trauma to the esophageal edges
244
what are the clinical signs and treatment options for an esophageal stricture
dysphagia 6 weeks aftger anesthesia/ surgery
tx: balloon catheter dilatation or R&A
245
describe the vascular supply to the cervical portion of the esophagus
thyroid and subclavian br
246
describe the thoracic vascular supply to the esophagus
bronchoesophageal and aorta br
247
describe the abdominal vascular supply to the esophagus
LEFT gastric and phrenic br
248
describe the location of the esophagus
cervical and thoracic: LEFT OF MIDLINE
tracheal bifurcation to stomach: RIGHT OF MIDLINE
249
what are some complications of esophageal surgery
aspiration pneumonia
esophagitis→ regurge → aspiration
dehiscence → mediastinitis
stricture
250
describe a cervical esophageal surgery
ventral midline approach
find recurrent laryngeal n
esophageal stethoscope helps us find it
use gelpi retractors
251
how would you perform an esophagotomy for a foreign body
isolate site w/ damp lap pads
suction
stay sutures
incise over or caudal to the foreign body
2 layer closure:
1st layer: intraluminal
2nd layer: extraluminal
252
describe a partial esophagectomy
remove 20-50% (3-5cm)
partial (circumferential) myotomy
support or patching techniques
place stay sutures then anastomose with an intraluminal and extraluminal closure
253
what is the arterial blood supply to the lesser curvature
left gastric (from celiac)
right gastric (from the hepatic)
254
what is the arterial blood supply to the greater curvature
left gastroepiploic (from splenic)
short gastric (from splenic)
right gastroepiploic (from gastroduodenal)
255
what is the holding layer for the esophagus/ stomach?
SUBMUCOSA!
256
what foreign bodies must be removed
if there is a pyloric outflow obstruction
toxic/ caustic or sharp objects (batteries, pennies minted after 1983)
nondigestible objects
things that are large enough to cause intestinal obstruction
linear foreign bodies
257
what acid-base and electrolyte abnormalities are common in foreign body patients
hypokalemia
metabolic ALKALOSIS
258
how would you perform a gastrotomy
ventral midline celiotomy
explore abdomen
pack off stomach w/ moistened lap sponges
stay sutures at each end of the planned site (3-0 PDS on a taper needle; full thickness bites)
incise @ ventral body of the stomach between lesser and greater curvatures (less vascular here)
stab incision into the lumen then extend with metzies
remove FB
CLOSURE:
one or two layer
holding layer→ submucosa
continuous or simple interrupted pattern w/ 3-0 PDS (SC in mucosa/ submucosa and cushing or lembert in seromuscularis)
LAVAGE LAVAGE LAVAGE
259
T/F: medical management is the mainstay of treating a gastric ulcer
true!
260
when would you take a gastric ulcer patient to sx
full-thickness biopsy needed
resection or a deep/ perforated ulcer
intractable bleeding
261
how would you operate on a gastric ulcer
local resction of ulcerated tissue
OR
partial gastrectomy:
isolate w/ stay sutures ans Doyen forceps
ligate blood supply
Resect
close w/ TA stapler or 2-layer inverting suture pattern (3-0 PDS simple cont. in mucosa/ submucosa and cushing/ lembert in seromuscularis); holding layer→ submucosa
262
what is the most common gastric neoplasia in dogs
adenocarcinoma
263
what is the most common neoplasia in cats
lymphoma
264
how would you diagnose gastric neoplasia
endoscopy or incisional biopsy
265
how would you surgically treat polyps or benign masses in the stomach
submucosa or marginal excision
266
how would you surgically treat stomach cancer that is a solitary, malignant mass
wide surgical excision
| (partial gastrectomy)
267
how would you surgically treat pyloric involvement of a gastric neoplasia
partial gastrectomy w/ pylorectomy
(bilroth 1 or 2)
268
what is a bilroth 1 procedure
**PYLORECTOMY W/ GASTRODUODEONOSTOMY**
so you resect the pylorus and attach the stomach to the duodenum
can be sutured or stapled together
**BILIARY DIVERSION USUALLY NOT NEEDED**
269
what is a bilroth 2?
**PYLORECTOMY W/ GASTROJEJUNOSTOMY**
so you take out the pylorus and the duodenum and attach the stomach to the jejunum
side-side anastomosis of the jejunum to the stomach (sutured or stapled)
**BILIARY RE-ROUTING NECESSARY (CHOLECYSTOJEJUNOSTOMY)**
**guarded to poor prognosis**
270
what are some other names for a benign gastric outflow obstruction
pyloric stenosis
chronic antral mucosal hypertrophy
chronic hypertrophic pyloric gastropathy
271
what is the common signalment for a benign gastric outflow obstruction
brachycephalics (boxers, bulldogs, bostons)
siamese cats
usually present at a young age
272
what are the clinical signs of a benign gastric outflow obstruction
vomiting
regurgitation
273
what diagnostics would you perform for a benign gastric outflow obstruction
upper GI series (contrast rads)
gastroduodenoscopy
biopsy (rule out neoplasia or pythiosis
274
how would you surgically correct a benign gastric outflow obstruction
Y-U pyloroplasty or Bilroth 1
they provide the widest diameter
good prognosis
275
what are the indications for a gastrostomy tube
inappetence
gastric decompression
276
how would you place a gastrostomy tube
open or endoscopically
place tube after making a stab incision in the gastric body after purse-strings are placed
LEFT ABDOMINAL WALL GASTROPEXY
LEAVE TUBE IN FOR 14 DAYS FOR THE STOMACH TO MAKE A STOMA; EVEN IF THEY START EATING AT LIKE DAY 2
277
What is the common signalment for a GDV
large → giant breeds (great danes, german shepherds, standard poodles)
middle aged or older
great danes can be younger
278
list some possible risk factors for a GDV
relative w. history of GDV
deep chested
underweight
rapid eaters
large volume of food SID
heavy exercise right after eating
eating from raised bowls
stress
279
what happens to a GDV patient after the volvulus happens
gastric distention is progressive due to cardia and pyloric obstruction
280
what do GDV patients usually present with (history)
non-productive retching
anxiety
depression
abdominal distention
281
how would you diagnose a GDV
RIGHT LATERAL RADS
POP-EYE ARM/ BOXING GLOVE SHAPE ON RADS
282
Describe the cardiovascular effects on a GDV patient
* increased Intra Abd pressure → decreased venous return → decreased output and decreased splanchnic perfusion
* hypovolemic shock
* cardiac arrythmias
* VPC's and V-tach
283
what are the respiratory effects on a GDV patient
* decreased tidal volume 2ndary to abd distention
* hypercapnia leads to metabolic ACIDOSIS
284
what are the gastrointestinal effects on a GDV patient
decreased perfusion bc of the distention and volvulus
285
what are the metabolic derangements that happen in a patient with a GDV
cellular hypoxia → metabolic acidosis (hyperlactatemia)
free-radical formation and repurfusion injury
endotoxemia
286
how would you treat a GDV patient when they come in shocky
* 2 cephalic IV catheters
* blood for PCV/ TP, glucose and lactate
* save some for CBC/Chem
* shock doses of fluids (90ml/kg crystalloids or 20ml.kg hetastarch)
* ¼ dose at a time
287
how would you perform gastric decompression for a GDV patient after atabilizing them
orogastric tube (w/ heavy sedation or anesthesia!)
gastric trocarization w. a 16 or 18 gauge needle or catheter
288
how would you surgically correct a GDV
midline celiotomy
decompress stomach
**derotate by pulling the pylorus ventrally and caudally while pushing body of stomach dorsally**
explore rest of abdomen
check for necrosis
**check the spleen for infarction (artery pulses; it will decrease in size really fast if it is not infarcted)**
partial gastrectomy if needed
splenectomy if infarcted
**gastropexy (incisional preferred)**
289
WHAT ARE THE 4 P'S OF A HEALTHY GUT
PINK
PERFUSION
PERISTALSIS
PULSE
NECROSED: gray to black, no peristalsis, thin walled compared to normal and no gastric slip
290
how would you perform an incisional gastropexy
5-6cm seromuscular incision in pyloric ANTRUM
5-6 cm incision caudal to the last rib on RIGHT SIDE (through peritoneum and transversus abdominal m)
suture stomach to body wall with **2 continuous lines** of 0 or 2-0 PDS or Prolene
**SUTURE SEROMUSCULARIS ONLY**
291
What are the most common complications of a GDV post op
arrythmias
hypotension
DIC
peritonitis (gastric rupture)
sepsis
recurrence (rare if you pexy it correctly)
292
how can you PREVENT a GDV in an at-risk animal
prophylactically gastropexy it
open, lap assisted, endoscopic assisted, total lap
can be done at the same time as you neuter them
293
what breeds are pred isposed to a hiatal hernia
english bulldogs and shar peis
294
what are the common signs assoc. w/ a hiatal hernia
regurgitation mostly
can be vomiting, hypersalivation, dysphagia, resp distress, anorexia, weight loss, hematemesis
some are asymptomatic
295
how would you treat a hiatal hernia
herniorrhaphy w/ esophagopexy
avoid the vagal trunks and esophageal vessels
LEFT sided gastropexy
296
which vascular structures provide blood to the spleen
short gastric aa
left gastroepiploic aa
splenic aa
297
list some indications for a splenectomy
hemoabdomen
splenic mass (hemangiosarcoma, lymphoma, etx)
splenic torsion
immune-mediated dz (not common)
298
list some indications for a partial splenectomy/ incisional biopsy
diffuse or focal disease (not a tumor)
trauma
299
what is the most common cause of hemoabdomen
splenic hemangiosarcoma
300
how would you perform a splenectomy
ligate the splenic hilar vessels→ saves the short gastrics
ligation of splenic artery and vein → HAVE TO PRESERVE THE BRANCHES TO THE PANCREAS but not the short gastric a & left gastroepiploic a.
301
how would you perform a partial splenectomy and what is the most common reason for doing it?
ligate hilar vessels, place mattress sutures in the splenic parenchyma
TRAUMA NOT FOR TUMORS
302
What are some common complications with splenic surgery
hemorrhage
arrythmias (VPC's, V-tach)
GDV→ reported as early as 5 days to 6 mos postop; gastropexy at risk puppers
303
describe the afferent blood supply to the liver
portal vein provides 80% → drains stomach, intestines, pancreas, spleen
arterial system provides 20% (hepatic a) →branch of the celiac artery
304
describe the efferent blood supply to the liver
hepatic veins
caudal vena cava
305
describe hepatic insufficiency
\>70-80% loss of hepatocytes
* decr protein synthesis
* hypoglycemia
* incomplete or delayed detoxification
* decr. drug clearance
* incr. coag times (PT/PTT)
306
what are some indications for hepatic sx
diffuse hepatic dz → incisional biopsy
focal hepatic dz → incisional biopsy, liver lobectomy, partial lobectomy
vascular abnormalities → PSS
307
list some indications for a liver lobectomy
hepatic neoplasia
hepatic abscess
liver lobe torsion
hepatic trauma
308
what are the most common forms of hepatic neoplasia in the dog
**hepatocellular carcinoma**
massive→ good prognosis
nodular/ diffuse → poor prognosis
Bile duct carcinoma
very bad
309
what is the most common form of hepatic neoplasia in the cat
**benign tumors more common:**
hepatocellular adenoma
hepatobiliary cystadenoma
SX TYPICALLY CURATIVE
310
describe hepatic sx for a liver abscess
hepatic abscesses are rare
lobectomy indicated for solitary abscesses
guarded prognosis
disemminated → very very poor prognosis
311
describe a hepatic lobar torsion
RARE
large breeds
non-specific signs
dx: ultrasound
**tx: lobectomy without untwisting the necrosed lobe**
good prognosis
312
would you take a patient w/ hepatic trauma to surgery?
not usually → can usually control w/ supportive care
unless there is uncontrollable hemorrhage or biliary leakage
313
list some tests you would run before liver surgery
minimum database (CBC/Chem/ UA)
coagulation profile
bile acids
ammonia tolerance test
314
how much of the liver can you remove at one time
\< or equal to 70%
hepatic insufficiency can happen if you take more than this
315
incisional liver biopsy
indicated for diagnosis of diffuse hepatic dz
cholangiohepatitis, fibrotic liver dz, diffuse neoplasia, microvascular dysplasia
non surgical- tru-cut biopsy w/ US guidance
surgical: laparotomy (guillotine, wedge, punch biopsy) or laparoscopy
316
partial liver lobectomy
peripheral lesions, masses
methods: fracture method (incise capsule→ crush overlying parenchyma, and ligate large and cauterize small vessels, overlapping sutures, staples
317
complete liver lobectomy
“hilar resection”
for masses at or near the hilus
ligate arterial, venous, portal and biliary supply at the hilus
technically more challenging
more complete resection
**better hemorrhage control**
318
stapling method for liver surgery
partial and complete liver lobectomy
TA stapler (55 or 90mm)
319
what are some complications of liver surgery
hemorrhage
recurrence
cardiac arrythmias (large mass)
320
describe the flow of bile
liver canaliculi→ interlobular ducts → lobular ducts → hepatic ducts → Gallbladder via cystic duct → common bile duct → bile salts reabsorbed in ileum and transported back to the liver
321
what is the purpose of bile? What is excretion stimulated by?
fat emulsification
stimulated by:
cholecystokinin, motilin and cholinergic pathway
322
list some indications for extrahepatic biliary sx
biliary obstruction
* GB mucoceole
* tumor
* stricture (trauma)
* 2ndary to pancreatic swelling
biliary rupture
* bile peritonitis
neoplasia
323
list c/s of biliary obstruction
icterus (cholestasis; serum bili \>1.5-2)
324
t/f: a bile duct r&a is commonly performed
FALSE
not unless there is severe dilatation
325
describe a cholecystectomy
indicated for: trauma, neoplasia, cholecystitis, obstruction, biliary mucocoele, cholelithiasis (very rare)
free the GB from the hepatic fossa, ligate the cystic duct above the hepatic duct
326
describe biliary diversion sx
cholecystoduodenostomy (Bilroth 1)
cholecystojejunostomy (bilroth 2)
indicated for: common bile duct obstruction; GB HAS TO BE FREE OF DISEASE
free GB from fossa, appose to guts, make a 3-4cm stoma, then 1 or 2 layer closure
327
what are some complications and the prognosis for the following extrahepatic biliary surgeries: cholecohotomy, bile duct R&A, or biliary stenting
complications: dehiscence, septic bile peritonitis (usually fatal \>50%)
prognosis: high mortality (20-30%). high morbidity
328
what is the basic definition of a portosystemic shunt
an anomalous vessel that allows portal blood to bypass the liver
329
what are the 2 main types of extrahepatic shunts
portocaval
portoazygos
330
which breeds are most commonly associated with an EXTRAHEPATIC PSS
small breeds
yorkies, maltese, shih-tzus
331
what is the most common breed of dog that gets INTRAHEPATIC PSS
large breeds
Irish wolfhounds, goldens, australian cattle dogs
332
what is the gender and age predisposition of PSS patients
no gender predisposition
usually \<1 year old
portoazygos usually present older
333
what is the most common history of a PSS dog
failure to grow, anorexia, depression
neuro signs: hepatic encephalopathy (ataxia, stupor, head pressing, circling, seizures/coma); worse after meals
urinary signs: PU/PD, hematuria, stranguria, urinary obstruction, cystoliths (ammonium biurate, radiolucent)
GI signs: vomiting, diarrhea
334
what are the common signs of a cat with a PSS
ptyalism (drooling)\
blindness
aggression/ behavior changes
Hep. encephalopathy
copper colored irises
335
t/f: a PSS dog on PE will usually have enlarged kidneys due to increased GFR
true
336
what will you see on bloodwork with a dog with a PSS
increased ALT, AST, ALP
hypoproteinemia
hypoalbuminemia
low BUN
hypoglycemia
microcytosis w/ normochromic anemia
coag is usually normal
liver fxn: increased ammonia & increased Bile Acids (don't do if bili is high)
337
describe portal scintigraphy for a PSS
minimally or non-invasive
only need sedation
enema- TC99
trans-splenic
hard to tell different types of shunts apart
338
list some advatages and disadvantages of portal scintigrpahy
**Advantages:**
* non-invasive
* very and specific
**disadvantages:**
* isolation bc of radioactive substances
* surgery- wait time after scan
* 60 hours → transcolic
* 1 hour→ trans-splenic
339
what is the gold standard of diagnosing a PSS with diagnostic imaging
CT ANGIOGRAPHY
340
Why is a CT Angiogram the gold standard of diagnosing a PSS
non-invasive
a**llows for accurate localization** of intra/extra hepatic shunts!
341
describe pre-op management of a PSS patient
stabilize
**manage medically for 2-4 weeks before sx:**
**low protein diet**
**lactulose**→ acidifies colon and traps ammonium; cathartic → increases GI motility and trapped ammonium gets out the body faster; CAN GIVE AS AN ENEMA FOR AN EMERGENCY
**antibiotics (Neomycin, metronidazole or ampicillin**) → decreases ammonium producing bacteria and decreases absorption of those toxins
**anticonvulsants (keppra**)→ may help decrease risk of post-attenuation seizures/ decrease severity of them if they do happen; 20mg/kg PO Q8
342
describe how a PSS would be performed
ventral midline celiotomy
abdominal exploratory (small liver, large kidneys, bladder stones, find shunt)
ligate the shunt
liver biopsy
343
how do you identify a PSS in surgery
left and right gutters:
epiploic foramen: portal vein ventral, caudal vena cava dorsal, hepatic artery is usually pulsing→ MOST SHUNTS ENTER HERE
omental bursa → LEFT SIDE OF STOMACH
cranial to the liver→ PORTOAZYGOS SHUNT
**ANY VESSEL CRANIAL TO THE PHRENICOABDOMINAL VEINS IS ABNORMAL**
**SHUNTS ENTER IN AT RIGHT VENTRICLES AND THERE IS ALWAYS TURBULENT FLOW**
344
How would you attenuate an extrahepatic shunt
attenuation: ameroid constrictor, cellophane banding or gradual occlusion (decr. risk or portal hypertension and decr. risk of multiple acquired shunts)
ligation: silk suture, acute ligation (complete may be possible, portal hypertension/ multiple acquired shunts may be possible)
345
what is an ameroid constrictor and how does it work for a PSS
outer: stainless steel ring
inner: casein ring
stainless steel key
casein will swell and lead to fibrosis (inflammatory reaction) and thrombosis
takes 2-5 weeks for occlusion (faster if thrombosis happens); may not be complete
346
what is cellophane banding and how does it work for a PSS
cellulose NOT POLYPROPYLENE
leads to an inflammatory rxn (fibrosis) and thrombosis
time to occlusion: 4-6 weeks; may not be completely occluded
347
describe a silk ligation for a PSS
partial or complete ligation
MUST MONITOR PORTAL PRESSURES→ DETERMINES AMOUNT OF CLOSURE
2ND SX MAY BE NEEDED
348
describe intrahepatic shunt ligation
harder to identify→ feel liver lobes and there is a soft spot
procedure depends on location:
left lobe: ligate left hepatic vein
right and central: ligate supplying portal vein branch; sometimes can dissect and attenuate shunt
some cannot be attenuated → abnormal development of portal system
349
list some methods for intrahepatic shunt ligation
suture ligation (partial or complete), ameroid constrictor, cellophane band, thrombogenic coil placement
350
what are some intra-op complications of a PSS
hemorrhage
portal hypertension
misidentification of the shunting vessel
anesthesia → poor/ prolonged drug metabolism
351
what are some post-op considerations after a PSS
**portal hypertension → higher likelihood w/ acute ligation**
H.E. → will continue until shunt attenuated
seizures (status epilepticus) → propofol CRI; Keppra IV
hemorrhage
persistent shunting
acquired multiple extrahepatic shunts
352
why does portal hypertension occur and what are some intraoperative & postop signs during PSS sx?
back up of pressure in the portal vasculature
**intraop:**
hyperperfusion of mesenteric and intestinal vessels; marked increase in GI motility, +/- signs of hypovolemic shock
**Postop**:
abd. pain, abd distention, bloody vomit/ diarrhea, hypovolemic shock
353
what do you do after a PSS sx for follow up
continue med management after surgery while the shunt gets attenuated→ until b/w is normal; min. of 2-4 mos to the rest of their life
serial b/w:
start 2-3 mos postop if doing well
serum chem
bile acids (pre and post)
354
what is the prognosis for extrahepatic and intrahepatic PSS after sx
extra: 94% good→ excellent
intra: 60% 1 yr survival
355
what is the cause of multiple acquired shunts
**chronic portal hypertension** (chronic liver dz; arteriovenous malformations; shunt attenuation/ ligation)
**vestigial fetal vessels:** multiple, tortuous, extrahepatic; connect portal system to the renal veins or caudal vena cava near the kidneys
356
what is the prognosis and surgical procedure for multiple acquired shunts?
DO NOT DO SURGERY!!!!!! (CONTRAINDICATED BC VESSELS ARE RELIEVING PORTAL PRESSURE)
poor prognosis w/ liver dz
may be asymptomatic if 2ndary to PSS attenuation
medical management: low protein diet, lactulose, antibiotics
357
describe the prognosis in cats w/ PSS
higher complication rate (up to 77%)
neuro complications common (blindness/ seizures)
prognosis: up to 75-80% have excellent outcome
358
describe microvascular dysplasia
“portal vein hypoplasia- microvascular dysplasia” (PVH-MVD)
typically no portal hypertension
small intrahepatic portal veins → microvascular shunts in the liver
breeds: cairn terriers and yorkies
359
which breeds are predisposed to microvascular dysplasia
cairn terriers and yorkies
360
describe the signs of microvascular dysplasia with PSS or alone
**w/ PSS:**
often have concurrent MVD
NEED LIFELONG MEDICAL MANAGEMENT
**MVD alone:**
present older in life
less severe c/s
better long term prognosis w/ med management
361
describe c/s, work up and treatment for microvascular dysplasia
**C/S:**
similar to PSS
maybe less severe
**work up:**
similar to PSS
no shunt found
liver biopsy→ findings similar to PSS
**tx:**
medical management like w/ PSS
362
how do you diagnose a septic abdomen
intracellular bacteria on abdominocentesis
363
when should you never use barium for rads?
IF YOU SUSPECT A PERF!
364
what are the principles of SI SX
early dx and good techniques prevent most complications
perform sx asap after dx for perforation, strangulation, obstruction
approximating suture patterns→ simple interrupted, simple continuous, monofilament, absorbable suture (PDS)
SUBMUCOSA ENGAGED in all sutures (submucosa is holding layer)
non-traumatic forceps (Doyens) or fingers to prevent leakage
debakey forceps (less traumatic than Brown-Adson's or Rat tooths)→ do not pinch the tissue with these!
cover sx sites w/ omentum or serosal patch
replace contaminated instruments and gloves before closing
local lavage of anastomosis
perioperative abx
optimal healing→ good blood supply, mucosal apposition, minimal trauma
365
which factors delay healing and increase the risk of dehiscence for Small intesinal SX
hypovolemia
shock
**_HYPOPROTEINEMIA_**
debilitation
infection
366
list some indications for an enterotomy
FB
full thickness biopsy
longitudinal incision
longitudinal vs. transverse closure: transverse usually not needed; only for teeny tiny patients
leak test
wrap omentum (patch)
complete exploratory→ mesenteric border
367
describe a serosal patch
uses ANTI-mesenteric borders
loose loop of intestines
avoid sharp bends
368
how much small intestine can you remove during surgery
up to 70-80% without complication
short bowel syndrome: proximal resection is better than distal
369
how would you perform a small intestine R&A
equal diameter→ 60-90 degree incision→ **MESENTERIC SIDE LONGER**
unequal diameter→ 45-60 degree incision
tapered needles
3-0 to 4-0 suture
can use simple interrupted or 2 lines of simple continuous with 50% of circumference each
**mesenteric suture line placed 1st (hardest to place and the first to leak)**
close the mesenteric rent→ avoid damaging blood supply to the remaining bowel
370
what is a radiogaphic dx of a small intestinal FB
SI loops greater than 1.6-2X the height of the body of L5
371
when should you not do a FB surgery
if its in the colon
stomach→ can possibly do endoscopy
progressive movement w/ serial rads
partial obstruction
372
when should you take a FB dog to sx
severe vomiting/ dehydration
debiliatated
suspect peritonitis
complete obstruction/ markedly distended bowel (rupture risk)
**linear FB**
**failure to pass in 36 hours**
**no movement on serial rads in 8 hours**
373
what electrolyte and metabolic abnormalities do you expect with a FB
hypokalemia
metabolic alkalosis
