Surgery of the Small Intestine

Question 1

Importance of small intestinal surgery

Answer 1

It accounts for around 25-64% of all colic disorders- strangulating mostly (60-85% are strang)

Question 2

Assesment of intestinal viability

Answer 2

Flueorescin dye: for ischaemic stang disorder

Surface oximetry: PsO2 has specificity of 100%

Doppler US: haem strang

Histopath

Clinical assesment:

• colour of serosa and mucosa
• Peristalsis or changes in peristalsis
• pulsation of mesnterial artery

Question 3

What is unique about the small intestine?

Answer 3

The villi have a special bs therefore is less tolerant than the Large colon

Strang lesions account for 60-85%

Prestenotic dilation is a concern

Ischaemic wall could be prone to reperfusion injury

Question 4

What are the strang obstructions of the SI

Answer 4

Volvulus

Epiploic foramen

Penunculated lipoma

Tears of the mesentery

Intussusception

Inguinal hernia

Lig gastrolienalis tear- int hernia

Umbilical hernia- Richter’s or Littre’s

Diaphragmatic hernia

Question 5

Volvulus

Answer 5

Usually at 2-4 months of age

Mesnterium turns >180degrees

Volvulus nodosus: when the mesentery forms a know: seen btw 2-7 months of age

Question 6

Foramen epipoicum Winslowi

Answer 6

Left to R

Ileum involvement

Crib biters and wind suckers

Usually requires reoperation

Mostly mild clinical signs, 50% have reflux

Question 7

Itussusception

Answer 7

Jejunojejunal- all ages, long

Ileocaecal <3yrs, small

Question 8

Abdomical hernias

Answer 8

Umbilical

Traumatic

Postop

Prepubic tendon rupture

Question 9

Inguinal hernias

Answer 9

When abd organs found in the ing canal (usually SI loop)

Acquired: Direct vs indirect(real)

Congenital: scrotal (hernial content in the vaginal tunic)

Question 10

Congenital indirect inguinal hernia

Answer 10

Foals

No colic symptoms

Can palpate intestines in the scrotum

Fluctuent swelling

Not painful

Treatment: can outgrow in 3-5 months! Immediate surgery if colic signs do develop

If direct: need to perform surgery!!

Question 11

Acquired indirect inguinal hernias in adults

Answer 11

Clinical symptoms:

Early: rectal palpation of stuctures is v painful!

Indolent: no pain upon palpation- suspect necrotic intestine in this case

Question 12

Acquired indirect intestinal hernias: Diagnosis and Differentials

Answer 12

Diagnosis: History and clinical signs

Palpation

Visual exam

Palpation upon rectal exam

Differentials

• Twisted testicle
• Thrombosis of testicular artery
• Seroma or hematoma
• Pyocele- pus in vaginal tunic
• Orchitis
• Teratomas of testicle or scrotum

Question 13

Acquired indirect intestinal hernias: treatment

Answer 13

Peracute: Pull out rectally, or massage back in whilst under GA and then continue to castrate the animal

Surgical: GA Dors recumbency

• herniotomy- resection of gut if it is necessary
• decompression the prestenotic part of the intestine
• Castration- close ext ing ring
• Should probably castrate other side too
• Laparoscopic closing of vaginal process

Question 14

Acquired direct inguinal hernias: clinical signs, treatment and prognosis

Answer 14

Mild to moderate colic!

Adhesions and inflamm of intestines

Treatment: must act quickly to close the hernial ring

Guarded to good prognosis

Question 15

Non-strangulating obstructions of the small intestine

Answer 15

Impaction of the ileum

Hypertrophy of muscle of ileum

Ascarids- impactions

Duodenitis, prox jejunitis

Neoplasia

Gastroduodenal obstruction

Question 16

Ileal impaction

Answer 16

Up to 90cm

Seasonal: winter-early spring

Anoplocephala perfoliata

Mares and arabians

Enterotomy is contra!!

Jejunocecostomy not usually recommened

Reimpactions are rare

Question 17

Parascaris causing impaction

Answer 17

usually around 5 months of age

Over half after antihelminthic treatment

High mortality in serious cases

• Toxins
• Necrotising enteritis
• Peritonitis, adhesions
• Mechanical obturation etc

Question 18

Duodenitis, prox jejunitis (is this also known as prox entritis?)

Answer 18

Cause unknown- Clostr toxins, parasites?

Fever, incr WBCs, reflux!- can produce 48L in 24hrs!- has reddish discolouration

Colic signs

Decompression offers improvement (decr HR)

Peritoneal fluid normal

Rectal exam: distension

Treatment: decompression, electrolytes

AB’s and PREVENT LAMINITIS

Question 19

Enteritis and Fibrosis

Answer 19

Eosinophilic gastroenteritis: local or generalised

Question 20

Anastomosis of the SI

Answer 20

End to end using continuous Lembert

Side to side: seen with jejunocaecostomy?

Question 21

Disorders of the caecum

Answer 21

1. Impaction
2. Caecocaecal invagination
3. Caecocolonal invagination
4. Volvulus, torsion
5. Infarction

Question 22

Caecum impactions

Answer 22

Type 1: hard: mechanical?

Type 2: semi-solid/fluid: paralytic?

Question 23

What can cause caecocolic or ileocaecal intussusception?

Answer 23

Anoplocephala perfoliata

Question 24

Diseases of the ascending colon (the L and R ventral and dorsal colon)

Answer 24

Large colon tympany- most common cause of colic!

Impaction- try to trat conservatively

Sand colic

Enterolithiasis

Large colon displacement: because the suspension is loose

Torion or volvulus

*displacement occurs more frequently than torsion

Question 25

Tympany

Answer 25

Together with displacement Decompress: * through the caecum- with marek trocar or 12G IV catheter * or through rectum

Question 26

Pelvic flexure enterotomy

Answer 26

Requires a colon tank Suture in 2-3 layers \*I think indicated for RDD?

Question 27

LEft dorsal displacement

Answer 27

Also known as Nephrosplenic entrapment Conservative treatment 90% successful Phenylephrine for splenic contration In recurrent cases: Laparoscopic closure of the NSS Prophylaxis: * ablation of the space laparoscopically * coloplexy * large colon resection

Question 28

Volvulus

Answer 28

Also known as torsion Strang vs non-strang (90-360degrees) Usually seens in prev colic cases (esp broodmares) Post foaling Sever pain Characterised by direction and point of twist: bad if \>90degress clockwise

Question 29

Treatment of Volvulus

Answer 29

Resection: must assess the viability of the colon * clinically: mucosa, pulse * Intraluminal P (by Doppler) * Histopath!! * Pre-op lactate in the plasma * Post-op colon wall thickness- measure on US Colopexy

Question 30

Desc colon

Answer 30

Colon tenue Has broad antimesenteric taenia Long, fatty mesocolon

Question 31

Diseases of the descending colon

Answer 31

Miniature breeds esp!! Impaction/obstipation Tooth problems Lesions of vessels Lipoma pedulans Enteroliths

Question 32

Diseases of the descending colon: complications of conseervative treatment

Answer 32

Thrombophlebitis

Question 33

Diseases of the descending colon: complications of surgery

Answer 33

Paralytic ileus Wound infection Colic!! because of adhesions Thrombophlebitis

Question 34

Rectal tears and prolapse

Answer 34

Tear: I, II, IIIa and IIIb, IV Prolapse: I-IV

Question 35

Non intestinal colic diseases

Answer 35

1. CV: thrombus in iliac artery, pericarditis 2. Thorax: pleuritis and pleuropneumonia 3. Abdomen: neoplasia, abscess, peritonitis, haematoma 4. Liver: cholelithiasis, cholangiohepatitis 5. Spleen: abscess, splenomegaly 6. Urinary tract: nephrolith, pyelonephritis, cystits, bladder rupture 7. Mare genital tract:ovulation, theca or gran cell tumour, uterine torsion 8. Stallion genital: testicle torsion, orchitis 9. Muscle-bone: laminitis, rhabdomyolysis 10. NS: tetanus, botulismus, EMND

Question 36

Muscle hypertrophy of the ileum

Question 37

Lecture notes on inguinal hernias

Answer 37

Congenital vs acquired Indirect: * Intact peritoneum covering the hernial sac * Recurrence is frequent * Adult stallions: acute, aggressive colic * V. hard vaginal tunic * Won't see SI loops in this case? Dircect * Rupture of vaginal tunic - SI can come out through and this is visible under the skin OR tear just next to the inguinal canal