Soft Tissue Surgery: GI surgery

Question 1

What is the duodenal dam manoeuvre?

Answer 1

Grasp the duodenum and retract most of the intestines over to the left to expose the right abdominal roof

Question 2

What is the colonic dam manoeuvre?

Answer 2

Grasp the colon and retract most of the intestines to the left to examine the left abdominal roof

Question 3

1. How can intestines be kept moist during surgery?
2. When are stay sutures indicated?

Answer 3

1. Saline usine a bulb syringe or cover with moistened abdominal swabs
2. Handling tissues- stomach and gall bladder- 3-4 stay sutures

Question 4

What extra instruments can be good for abdominal surgery?

Answer 4

• Self-retaining abdominal retractors
• Malleable retractors
• Suction- essential for lavage
• Debakey thumb forceps- least traumatic
• Doyen bowel forceps or allis tissue forceps
• Crushing forceps to occlude the lumen of gut

Question 5

The least vascular parts of the gut wall should be incised
Where is best?

Answer 5

• Midway between the greater and lesser curvature of the stomach
• Antimesenteric border of the duodenum, jejunum or colon
• Approx 2/3 of the way from mesenteric to antimesenteric border of the ileum

Question 6

How should the GI tract be ligated?

Answer 6

Capillary ooze- small vessels, stops when sutured

Larger vessels- ligate, avoid cautery on gas filled

Oesophagus- ligate and divide segmental BVs as required

SI
* Ligate branches of cranial mesenteric and the terminal arcade vessels running along the mesenteic border

Colon depends on what tissue is being resected

Question 7

How is the liver operated on preventing haemorrhage?

Answer 7

• Check coagulopathies
• Topical haemostatic agents
• Pringle manoeuvre- occlude blood flor for 15m
• Resections- tempory occlusion with combination of ligatures and tourniquets
• Guillotine method- near the border

Question 8

How is a partial lobectomy away from the border or total done?

Answer 8

Finger fracture technique
* Incise liver capsule
* crush/seperate the parenchyma along that line with fingers to expose the large vessels and bile ducts to ligate

Question 9

How is pancreas haemostasis performed?

Answer 9

• Pass ligature around the area containing lesion of haemorrhaging
• Bluntly seperate pancreatic lobules around the lesion, isolate blood vessels and ducts ligate

Question 10

when sectioning intestine what how should it be incised?

Answer 10

30 degrees to the transverse- ensures adequate blood supply

Question 10

when sectioning intestine what how should it be incised?

Answer 10

30 degrees to the transverse- ensures adequate blood supply

Question 11

How can intestine viability be subjectively and objectively?

Answer 11

Subjective
* Colour- healthy pink
* Arterial pulsations
* Peristalsis

Objective
* Pulse oximetry
* Inject fluroescein dye IV

Question 12

Why can thoracic oesophagus tolerate ligation of segmental blood vessels?

Answer 12

• Has a rich submucosal plexus of blood vessels
• Avoid cautery

Similar for the jejunum

Question 13

1. What can resection of the duodenum compramise blood supply to?
2. What needs to be preserved on a splenecomty for the stomach?
3. What needs to be avoided around the pylorus?

Answer 13

1. Pancreatic blood supply
2. Left gastroepiploic artery
3. Cranial pancreaticoduodenal and hepatic arteries

Question 14

How can contamination of the peritoneal cavity be minimalised during surgery?

Answer 14

• Use moistened swabs
• Before opening intestine- milk contents from incision site
• Elevate the oesophagus and stomach with stay sutures
• Discard contaminated instruments and gloves
• After lavage with 1-3L of warm water

Question 15

When should prophylactic ABs be used for GIT surgery?

Answer 15

IV just after induction
* Clavulanate-amoxicillin- common contaminants
* Colonic or hepatic surgery- metronidazole (anaerobes)
* Amoxicillin- bile

Question 16

Where are issues of tension in the GI?

Answer 16

Oesophagus and proximal colon

Question 17

What is required for accurate tissue apposition of the GI?

Answer 17

Submucosa
* High collagen content
* Must be incorporate into suture line

Question 18

What are the two closure techniques of the GI for longitudinal incisions

Answer 18

• Longitudinal closure- general purpose
• Transverse- maintains lumen diameter, small patients

Transverse incisions may cause stricture

Question 19

How is section of intestine sutured together?

Answer 19

End to end appositional anastomosis

Question 20

What suture material is used for most intestinal surgery?

Answer 20

2 metric or 1.5 monofilament, synthetic absorbable

Can use nonabsorbable for colonic surgery

Question 21

What suture patterns are used in GI sugery?

Answer 21

• Simple interupted or continuous
• Oesophagus- single later blosure
• Stomach- 2 layer closure- simple then inverting cushing
• 3-4mm from cut edge and 3mm apart
• Check by injecting sterile saline

Question 22

How can luminal disparity be dealt with?

Answer 22

Different diameters
* Eliminate gaps by spacing sutures further apart on the larger side

Question 23

How is the mesentery closed?

Answer 23

Simple continous synthetic monofilament

Question 24

How can the omentum be used to an advantage of GI surgery?

Answer 24

Omental wrapping: * protects GI incisions * Increases local tissue O2 * Promotes angiogenesis * Phagocytic immunity * Seal * Or serosal patching- suture intestine to itself

Question 25

What fluid and electrolyte imbalance is acceptable before GI surgery?

Answer 25

Correct to 50-75% before

Question 26

What are complications of GIT surgery?

Answer 26

* Peritonitis * Adhesions * Small bowel syndrome * Strictures

Question 27

1. What causes primary and secondary peritonitis? 2. What are the clinical signs? 3. What is the pathophysiology?

Answer 27

1. Primary- rare- FIP, secondary chemical (bile), septic (necrosis/perforation) 2. Variable- depression, anorexia, abdominal pain, ileus, pyrexia, shock 3. Hypovolaemia- decreased fluid intake, losses from vomiting/diarrhoea, metabolic acidosis form decreased tissue perfusion, electrolyte imbalance, endotoxic shock

Question 28

How is peritonititis diagnosed?

Answer 28

* Radiography- loss of abdominal detail * Haem- left shift * Biochem- azotaemia * Abdominal paracentesis- US * C&S

Question 29

How is peritonitis treated?

Answer 29

* Correct fluid and acid/base imbalance * Broad spec ABs * Correct cause * Lavage * Drainage

Question 30

What causes adhesions?

Answer 30

Tissue anoxia, serosal injury, FB Can be restrictive Minimise with appropriate tissue handling, removing blood clots

Question 31

What is short bowel syndrome? How is it medically managed?

Answer 31

Removal of about 80% SI * Maldigestion- reduced pancreas secretions * Malabsorption- reduced SA * Bile salt deficiency- enterohepatic circulation Medical managment * Frequent small low fat meals * Diet supplements * Medium chain triglyceride oil * Oral antidiarrhoeals, ABs, antacids Poor prognosis

Question 32

What is ileus? What are the clinical signs? What is the treatment?

Answer 32

1. Inadequate peristaltic activity of the entire GI, functional obstruction 2. Vomiting, diarrhoea, fluid and gas retention 3. Difficult- address cause, correct fluid and electrolyte imbalance, normalise motility

Question 33

How can the oesophagus be approached?

Answer 33

* Access to level of second rib via a cervical midline * Access the intrathoracic via intercostal thoracotomy

Question 34

How is the terminal colon, rectum and anus approached?

Answer 34

Ventral approach * split pelvis- colorectal junction Anal approach * Suitable for foal lesions close to anus- every anus Pull through approach- distal colonic or mid-rectal lesions * evert rectal wall through anus and transect distal rectum Dorsal- caudal or middle rectum * Inverted U incision dorsal to anus Lateral- between external anal sphincter and levator ani