Surgical Procedures

Question 1

Temporary Tracheostomy

Answer 1

1. Clip the ventral neck and aseptically prep
2. Make a ventral midline incision from the cricoid cartilage, extending 2-3 cm caudally
3. Separate the sternohyoid muscles
4. Make a horizontal (transverse) incision through the annual ligament between the 3-4 or 4-5 tracheal cartilages
   Do not exceed 50% of the tracheal circumference
5. Place cartilage-encircling sutures using 2-0 Prolene around the adjacent cartilages to separate the edges and allow for tube insertion. Label the suture loops with tags “cranial” and “caudal”
6. Insert the tracheostomy tube
7. Facilitate tube placement by opening a hemostat in the incision, or depress the cartilages cranial to the horizontal incision
8. Alternatively place tension on the caudal suture to open the incision
9. Appose the sternohyoid muscles in a simple continuous pattern with a 3-0 or 4-0 absorbable suture (PDS, monocryl, maxon, vicryl, biosyn), then close subcutaneous tissue, and skin cranial and caudal to the tube
10. Secure the tube in place using gauze or a collar

Question 2

Tracheal Laceration (small)

Answer 2

1. Can be repaired primarily with a simple interrupted suture pattern at the junction of the tracheal ring and trachealis muscle
2. Can often be medically managed

Question 3

Tracheal Laceration (large)

Answer 3

R&A – can remove 20-50% of the trachea in an adult dog

1. Expose the involved trachea via a ventral cervical midline incision, lateral thoracotomy, or median sternotomy
2. Mobilize only enough trachea to allow anastomosis without tension, and preserve as much of the segmental blood and nerve supple to the trachea as possible
3. Place stay sutures around the cartilages cranial and caudal to the resection sites before transecting the trachea
4. Resect the diseased trachea by splitting a healthy cartilage adjacent to the intact cartilages
5. Use a #11 blade to split the tracheal cartilages as their midpoint
6. Transect the dorsal tracheal membrane with Metzenbaum scissors
7. Preplace and then tie 3-4 simple interrupted sutures with 3-0 or 4-0 Prolene or PDS in the dorsal tracheal membrane
   - Retract the endotracheal tube into the proximal trachea during resection and placement of sutures
8. Remove blood clots and secretions from the lumen and advance the tube distal to the anastomosis
9. Complete the anastomosis by apposing the split cartilage halves or adjacent intact cartilages with simple interrupted sutures beginning at the ventral midpoint of the trachea
   Space additional sutures 2-3mm apart
10. Place 3-4 retention sutures to help relieve tension on the anastomosis, placing them so that they encircle an intact cartilage cranial caudal to the anastomosis, crossing external to the anastomotic site
11. Lavage the area and appose the sternohyoid muscles in a simple continuous pattern
12. Close the SC tissues and skin routinely

Question 4

Gastrotomy

Answer 4

With the patient in dorsal recumbency, (If male place a towel clamp on the prepuce and clamp it to the skin on one side of the body. make a ventral midline incision from the xiphoid process extending caudally to the pubis.
Sharply incise the subcutaneous tissues until the external fascia of the rectus abdominis muscle is exposed. Ligate or cauterize small subcutaneous bleeders and identify the linea alba
Tent the abdominal wall and a make a sharp incision into the linea alba with a scalpel blade.
Use scissors to extend the incision cranially or caudally (or both) to neat the extent of the skin incision
Digitally breakdown the attachments of one side of the falciform ligament to the body wall, or incise it completely
Use Balfour retractors to retract the abdominal wall and provide adequate exposure of the gastrointestinal tract
Inspect the entire abdominal contact before incising the stomach.
To reduce contamination, isolate the stomach from remaining abdominal contents with moistened laparotomy sponges
Place stay sutures to assist and manipulation of the stomach and help prevent spillage of gastric contents
Make the gastric incision in a hypovascular area of the ventral aspect of the stomach between the greater and lesser curvature
Make sure the incision is not near the pylorus or closure of the incision may cause excessive tissue to be unfolded into the gastric lumen, resulting in outflow obstruction
Make a stab incision into the gastric lumen with a scalpel and enlarge the incision with Metzenbaum scissors
Use suction to aspirate gastric contents and reduce spillage
Close the stomach with 2-0 or 3-0 absorbable suture (PDS) in a two layer inverting seromuscular pattern
Include serosa, muscularis, and submucosa in the first layer, using a Cushing or simple continuous pattern then follow it with a Lembert or Cushing pattern that incorporates the serosal and muscularis layers
As an alternative, close the mucosa and a simple continuous suture pattern as a separate layer to reduce postoperative bleeding
Before closing the abdominal incision, substitute sterile instruments and gloves for those contaminated by gastric contents
Whenever you remove gastric foreign material be sure to check the entire gastrointestinal tract for additional material that could cause an obsessional obstruction
Lavage and suction the abdomen
Close the abdomen
On each side of the incision, incorporate 4-10 mm of fascia in each suture.
Place interrupted sutures 5-10 mm apart depending on the animal’s size
Incorporate full thickness bites of the abdominal wall in the sutures if on midline, through the linea alba. If the incision is lateral to the midline, close the external rectus sheath without including muscle in the sutures
Close SC with simple continuous pattern of absorbable material
Use nonabsorbable sutures in a simple interrupted or continuous appositional pattern to close the skin.

Question 5

Pringle maneuver

Answer 5

Compress the hepatoduodenal ligament, which contains the portal vein and hepatic artery

Hepatoduodenal ligament = portion of the lesser omentum that attaches the liver to the descending duodenum and forms the ventral border of the epiploic foramen

Can be compressed with a vascular clamp or digitally

Question 6

Cystotomy

Answer 6

Clip from xiphoid to pubis and aseptically prep
Perform a caudal ventral midline laparotomy
Isolate the bladder by placing moistened laparotomy pads underneath the urinary bladder
Place two full thickness monofilament stay sutures: one in the bladder apex for retraction and one in the trigone
Make a longitudinal incision in the ventral aspect of the bladder, away from the ureters and urethra, and between major blood vessels
Remove any intraluminal urine with a Poole suction tip
Extend the bladder incision with Metzenbaum scissors
If calculi are present, remove gently with a bladder spoon
Flush and suction out the bladder
Verify that the urethra is patent by placing a red rubber catheter retrograde or antegrade through the urethra
Flush through the catheter as it is withdrawn
Repeat flushing and scooping at least three times
Explore the interior of the bladder and trigone to verify there are no calculi remaining after urethral catheterization and flushing
Also, check the bladder apex to ensure there is no evidence of a diverticulum, and if there is one present, excise it.
Excise a small section of the bladder mucosa adjacent to the incision to submit for aerobic culture
Close the incision in a single layer with a simple continuous appositional pattern with absorbable suture, including the submucosa in each bite
If the bladder wall is thin, close the incision with a rapid two-layer inverting pattern
Close routinely
Take an abdominal radiograph to ensure there are no stones remaining

Question 7

C-Section

Answer 7

Clip from xiphoid to pubis and aseptically prep
Empty urinary bladder
Administer prophylactic antibiotics
If >30kg, tilt the patient 10-15 degrees to the side to remove weight on the CVC
Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
Exteriorize the uterus and isolate it from the abdomen with moistened laparotomy sponges
Make a ventral midline incision in the uterine body
Bring each fetus to the incision by external peristaltic motion on the uterine horn
Once at incision, grasp the fetus intraluminally and exert gentle traction
If the placenta readily separates from the uterus, remove with the neonate
If the placenta is difficult to separate or bleeds, leave in place and clamp and cut the umbilicus, and remove the neonate alone
Place neonate in a sterile towel and hand off to assistants for resuscitation
After removal of all apparent fetuses, thoroughly palpate the uterus from ovaries to cervix to ensure there are no remaining fetuses
Using 3-0 or 4-0 absorbable suture on a taper needle, close the first layer in a simple continuous pattern (avoiding penetrating the lumen), and then a continuous Cushing’s pattern oversew on the second layer
Lavage the abdomen with warm saline or a balanced electrolyte solution
Close the abdominal wall and skin routinely

Question 8

Lateral Thoracotomy

Answer 8

2. Locate the approximate intercostal space (typically 4-6)
3. Sharply incise the skin, subcutaneous tissue, and cutaneous trunci muscle
   a. The incision should extend from just below the vertebral bodies to near the sternum
4. Deepen the incision through the latissimus dorsi with Metzenbaum scissors, then palpate the first rib by placing a hand cranially under the latissimus dorsi muscle. Count back from the first rib to verify the correct intercostal space
5. Transect the scalenus and pectoral muscles with Metzenbaum scissors perpendicular to their fibers, then separate the muscle fibers of the serratus ventralis muscle at the selected intercostal space
6. Incise the external and internal intercostal muscle
7. Notify the anesthesiologist before penetrating into the thorax
8. Use closed scissors or a blunt instrument to penetrate the pleura, allowing the lungs to collapse away from the body wall
9. Extend the incision dorsally and ventrally to achieve the desired exposure
10. Identify and avoid incising the internal thoracic vessels as they course subpleurally near the sternum
11. Moisten laparotomy sponges and place along the exposed edges of the chest incision
12. Use a Finochietto retractor to spread the ribs
13. Place a thoracostomy tube through an intercostal space one to two spaces caudal to the incision prior to closing the thorax
14. Close the thoracotomy by preplacing 4-8 sutures of heavy monofilament absorbable or nonabsorbable suture (3-0 to 2, depending on the size) around the rubs adjacent to the incision
15. Approximate the ribs with a rib approximator or have an assistant cross two sutures to approve the rubs then tie the remaining sutures.
16. Tie all sutures before removing the rib approximator
17. Suture the serratus ventralis, scalenus, and pectoralis muscles in a continue pattern with absorbable suture.
18. Appose the edges of the latissimus dorsi muscle similarly
19. Remove residual air from the thoracic cavity using the preplace thoracostomy tube or an over the needle catheter
20. Close the subcutaneous tissue and skin routinely

Question 9

Lung Lobectomy

Answer 9

1. Identify the affected lobe(s) and isolate it from the remaining lobes with moistened sponges
2. Identify the vasculature and bronchus to the lobe
3. Using blunt dissection, isolate the pulmonary artery supplying the affected lobe and pass a ligature of nonabsorbable or absorbable suture (2-0 or 3-0) around the proximal end of the vessel
4. Place a second ligature in a similar fashion distal to the site where the vessel is to be transected
5. Transect the artery between the two distal ligatures
6. Ligate the pulmonary vein in a similar fashion
7. Identify the main bronchus supplying the lobe and clamp it with a pair of Satinsky or crushing forceps proximal and distal to the selected transection site
8. Sever the bronchus between the clamps and remove the lung lobe
9. Suture the bronchus proximal to the remaining clamp in a continuous horizontal mattress pattern
   a. In cats and small dogs, can place a transfixing ligature around the bronchus
10. Before removing the clamp, secure a suture in the bronchus distal to the clamp
11. Remove the clamp
12. Oversew the end of the bronchus in a simple continuous pattern
13. Fill the thoracic cavity with warm saline
14. Inflate the lungs and check the bronchus for air leaks. Check the lungs that have been “packed off” to make sure they reinflate and are not twisted.
15. Suction the lavage fluid
16. Close routinely

Question 10

Esophageal Foreign Body Removal (Cranial cervical esophagus)

Answer 10

a. Position the patient in dorsal recumbency
b. Incise the skin on midline, beginning at the larynx and extending caudally to the manubrium
c. Incise and retract the platysma muscle and subcutaneous tissue
d. Separate the paired sternohyoid muscles along the midline to expose the underlying trachea
e. Retract the thyroideus ima vein with the sternohyoid muscle or ligate it
f. If access to the caudal cervical esophagus is needed, separate and retract the sternocephalicus muscles
g. Retract the trachea to the right to expose the adjacent anatomic structures including the esophagus, thyroid glands, cranial and caudal thyroid vessels, the recurrent laryngeal nerve, and the carotid sheath
h. Pass a stomach stube or esophageal stethoscope to facilitate identification of the esophagus and lesion
i. After the FB is removed, lavage the surgical site with warm sterile and return trachea rot its normal position
j. Close the incision by apposing the sternohyoid muscles using absorbable suture )3-0 or 4-0) in a simple continuous pattern
k. Apposed subcutaneous tissue in a simple continuous pattern with 3-0 or 4-0 absorbable suture and use nonabsorbable suture to appose the skin

Question 11

Esophageal Foreign Body Removal (Cranial thoracic esophagus)

Answer 11

a. Position the patient in right lateral recumbency over a roller towel placed perpendicular to the long axis of the body
i. Choose the appropriate intercostal space incision based on the radiographic location of the abnormality
b. Identify the esophagus in the mediastinum dorsal to the brachiocephalic trunk
c. Identification may be aided by passage of a stomach tube or by palpation
d. Dissect the mediastinal pleura overlapping the esophagus to just above and below the proposed surgical site
e. Preserve the branch of the intercostal thoracic vein and costocervical vein that cross the cranial esophagus

Question 12

Esophageal FB Removal (at heart base via right lateral thoracotomy)

Answer 12

a. Incision is made through the right 4th or 5th intercostal space
b. Identify the esophagus located just dorsal to the trachea in the mediastinum
c. Dissect and retract the azygos vein from the esophagus to allow adequate exposure
d. Ligate the azygos vein if necessary to adequately expose the esophagus

Question 13

Esophageal FB removal (caudal esophagus via caudal lateral thoracotomy)

Answer 13

a. Patient is positioned in lateral recumbency, and a caudal lateral thoracotomy is performed
b. Make the incision in either the left 8th or 9th intercostal space
c. Expose the caudal esophagus by transecting the pulmonary ligament and packing the caudal lung loves cranially
d. Identify the esophagus which is just ventral to the aorta
e. Identify the dorsal and ventral vagal nerve branches on the lateral aspect of the esophagus and protect them

Question 14

Esophagotomy

Answer 14

a. Pack off the esophagus from the remainder of the field with moistened lap pads
b. Suction material from the cranial esophagus before making the esophagotomy incision to minimize contamination of the surgical site
c. Place stay sutures adjacent to the propped incision site to stabilize, aide manipulation, and avoid trauma to the esophageal edges
d. Make a stab incision into the lumen of the esophagus and extending the incision longitudinally as necessary to remove the foreign body
e. Make the incision over the FB if the wall appears normal
f. Remove the FB with forceps to avoid additional trauma
g. Incision may be closed with one or two later closure
i. Place each suture approximately 2 mm from the edge and 2 mm apart
ii. Incorporate the mucosa and submucosa in the first layer of the two layer simple interrupted closure
iii. Place sutures so that the knots are within the esophageal lumen
iv. Incorporate the adventitia, muscularis, and submucosa in the second layer of the sutures with the knots tied extraluminally
v. When a one layer closure is used, pass each suture through all layers of the esophageal wall and tie the knots on the extraluminal surface
vi. Check closure integrity by occluding the lumen, injecting saline, applying pressure, and observation for leakage between sutures

Question 15

Enterotomy

Answer 15

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
3. Identify location of the foreign body
4. Exteriorize the intestinal segment and pack off with moistened laparotomy sponges
5. Gently milk chyme (intestinal contents) from the lumen of the identified intestinal segment.
6. To minimize spillage of the gastrointestinal contents, either:
   a. Have an assistant occlude the lumen at both ends of the isolated segment by using a scissor like grip with the index and middle fingers 4-6 cm on each side of the proposed enterotomy site
   b. If an assistant isn’t available, use non crushing intestinal forceps (Doyen) or a Penrose drain tourniquet to occlude the intestinal lumen
7. Using a No 11 scalpel blade, make a full thickness stab incision in the intestinal lumen immediately distal/aboral to the foreign body on the antimesenteric border of the intestine
   a. The length of the incision should be only slightly larger than the distance from the mesenteric border to the antimesenteric border
   b. If in the ileum, the incision will be between the antimesenteric and mesenteric borders as the presence of ileal vessels on the antimesenteric surface precludes an incision in this region
8. If necessary  Obtain full thickness biopsy samples 2-3 mm wide by either making a second longitudinal incision parallel to the first with the scalpel blade or by removing an ellipse of intestinal wall at one margin of the first incision with Metzenbaum scissors
9. If the incision you made needs to be lengthened, use Metzenbaum scissors or the scalpel blade and remove the foreign body
10. Trim the everted mucosa so that its edge is even with the serosal edge (in necessary) or use a modified Gambee suture.
11. Suction the isolated lumen
12. Close the incision with gentle appositional force in a longitudinal or transverse direction using simple interrupted sutures or simple continuous appositional pattern using a monofilament synthetic absorbable material (3-0 or 4-0 PDS)
    a. Incorporate the submucosal layer
    b. Place sutures through all layers of the intestinal wall 2 mm from the edge and 2-3 mm apart with extraluminal knots.
    c. Angle the needle so that the serosa is engaged slightly far from the edge than the mucosa to help reposition everting mucosa back into the lumen
13. Once the intestinal closure is complete, while maintaining luminal occlusion near the enterotomy site, moderately distend the lumen with sterile saline, applying gentle digital pressure, and observe for leakage between sutures
14. Lavage the isolated intestine and abdomen. Place omentum over the suture line before closing the abdomen
15. Replace contaminated instruments and gloves before closing the abdomen
16. Close routinely

Question 16

Intestinal R&A

Answer 16

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
3. Explore the abdomen routinely
4. Isolate the affected intestinal segment with moistened laparotomy sponges
5. Assess intestinal viability and determine the amount of intestine needing resection.
6. Milk intestinal contents away from the proposed resection site if possible
7. Atraumatically clamp the intestines 3-5 cm beyond the proposed transection sites with either Doyen forceps, Penrose drains, or an assistant’s fingers (as previously described above for enterotomy)
8. Double ligate and transect the mesenteric vessels from the cranial mesenteric artery that supplies the affected intestine
   a. Make windows in the mesentery around the vessels to the affected segment, and double ligate and transect the vessels
   b. To ligate the terminal arcuate vessels running along the mesenteric attachment to the intestines, take suture bites of the mesentery adjacent to the intestinal wall at the proposed sites of transection
9. Transect the mesentery along the segment to be removed
10. Place Carmalt or Kelly forceps across the proposed ends of the intestinal segment to be resected
11. Transect the intestine near the Carmalt or Kelly forceps adjacent to the arcuate ligatures (along the outside of the forceps.
12. Make the incision either perpendicular or oblique to the long axis
13. Gently suction or wipe the intestinal ends with a moistened gauze sponge to remove any debris
14. Appose the intestinal ends by first placing a simple interrupted suture at the mesenteric border, and then placing a second suture at the antimesenteric border (approximately 180 degrees from the first suture)
15. If the ends are equal diameter, space additional sutures between the first two approximately 2 mm from the edge and 2-3 mm apart
    a. If the luminal sizes of the intestinal ends are unequal, use a perpendicular incision across the intestine with the larger luminal diameter and an oblique incision across the intestine with the small luminal diameter to help correct size disparity
    b. Make the oblique incision such that the antimesenteric border is shorter than the mesenteric border
    c. If further correction is needed, space sutures around the larger lumen slightly further apart than around the smaller lumen or remove a wedge from the antimesenteric border of the smaller intestine
16. Inspect the anastomosis and check for leakage
17. Remove the clamps and close the mesenteric defect with 4-0 rapidly absorbable suture in either a simple continuous or interrupted pattern, avoiding any blood vessels
18. Lavage and suction the abdomen
19. Wrap the omentum over the anastomotic site before closing the abdomen
20. Close routinely

Question 17

GDV

Answer 17

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis; take care when incising the linea alba to prevent trauma to the stomach
3. Place Balfour retractors to increase exposure
4. Decompress the stomach before repositioning by using a large bore needle attached to suction or by having an assistant pass an orogastric
5. Standing on the right side of the dog
6. For a clockwise rotation, once the stomach is decompressed, rotate it counterclockwise by using your right hand to grasp the pylorus (usually found below the esophagus) and using your left hand to grab the greater curvature of the stomach
7. Retract the pylorus ventrally and toward the right side of the abdomen (toward yourself or the incision) while simultaneously using your left hand to exert downward pressure on the visible portion of greater curvature (or fundus) of the stomach to encourage it to move dorsally
8. Ensure that the spleen is in the normal position in the left abdominal quadrant (15.7-21% of dogs with GDV)
   a. If there is splenic necrosis or significant infarction, perform a partial or complete splenectomy
9. Once the stomach is de-rotated, if it still remains dilated, an orogastric tube and be passed again. You can also palpate the intraabdominal esophagus to ensure that the stomach is derotated
10. Assess the stomach for evidence of necrosis (9.3-41% of dogs)
    a. Greater curvature and the junction of the fundus and the body are the most common sites of necrosis
    b. Palpate gastric vessels for evidence of pulses or thrombi
    c. If necrosis is present, perform a partial gastrectomy
    i. Pack the stomach off from the rest of the abdomen with moistened laparotomy sponges
    ii. Place stay sutures using 2-0 or 3-0 polypropylene in the healthy stomach wall
    iii. Ligate any intact blood vessels supplying the area to be resected
    iv. Sharply excise the affected portion of the stomach using a scalpel blade until the cut edges are actively bleeding
    v. Close the stomach in two layers using 2-0 or 3-0 PDS
11. Close the mucosa and submucosa with a simple continuous pattern
12. Close the seromuscular layers with a continuous or interrupted pattern, which may be appositional or inverting
13. Can be reinforced by oversewing with a Cushings or Lembert pattern
14. Perform gastropexy (incisional) (also included on own card if prefer to study two procedures separately)
    a. Make a 5cm long seromuscular incision longitudinally in the gastric antrum
    i. Penetrate only the serosa and muscle layers; the submucosa should be intact; if the submucosa is inadvertently incised, it should be closed with a simple interrupted or continuous suture pattern before continuing
    b. Make a corresponding stab incision into the right ventrolateral abdominal wall caudal to the last rib extending 3-4 cm in length through the peritoneum and transverse abdominal muscle on the right body wall; the incision should be 1/3 of the distance from the ventral to dorsal midline
    c. Using 2-0 PDS, the edges of the gastric wall incision are sutured to the edges of the body wall incision with two simple continuous patterns
    i. The first suture is started dorsally at the cranial border of the gastric wall and body wall incisions and these are then apposed
    ii. A second suture is started dorsally at the caudal border of the incisions and these are then apposed
    iii. Make sure the muscularis layer of the stomach is in contact with the abdominal wall muscle
15. Lavage the abdomen
16. Close routinely

Question 18

Incisional Gastropexy

Answer 18

1. Make a 5cm long seromuscular incision longitudinally in the gastric antrum
   i. Penetrate only the serosa and muscle layers; the submucosa should be intact; if the submucosa is inadvertently incised, it should be closed with a simple interrupted or continuous suture pattern before continuing
   a. Make a corresponding stab incision into the right ventrolateral abdominal wall caudal to the last rib extending 3-4 cm in length through the peritoneum and transverse abdominal muscle on the right body wall; the incision should be 1/3 of the distance from the ventral to dorsal midline
   b. Using 2-0 PDS, the edges of the gastric wall incision are sutured to the edges of the body wall incision with two simple continuous patterns
   i. The first suture is started dorsally at the cranial border of the gastric wall and body wall incisions and these are then apposed
   ii. A second suture is started dorsally at the caudal border of the incisions and these are then apposed
   iii. Make sure the muscularis layer of the stomach is in contact with the abdominal wall muscle
2. Lavage the abdomen
3. Close routinely

Question 19

Colonotomy and colopexy

Answer 19

1. Expose and explore the abdomen
2. Locate the descending colon and isolate it from the remainder of the abdomen
3. Pull the descending colon cranial to reduce ethe prolapse.
4. Verify reduction of the prolapse by an assistance performing a rectal examination
5. Make a 3-5 cm longitudinal incision along the antimesenteric border of the distal descending colon through only the serosal and muscularis layers
6. Make a similar incision on the left abdominal wall several centimeters (>2.5 cm) lateral to the linea alba through the peritoneum and underlying muscle
7. Appose each edge of the colonic and abdominal wall incisions with two simple continuous or simple interrupted rows of sutures using 2-0 or 3-0 monofilament, absorbable suture or non-absorbable suture.
8. Engage the submucosa as each suture is placed but not penetrating the colonic mucosa
9. Lavage the surgical site and surround it with omentum before closing the abdomen

Question 20

Repairing body wall hernia (including for paracostal hernias)

Answer 20

1. For most abdominal hernias, perform a ventral midline abdominal incision to allow the entire abdomen to be explored
   a. Assess the extent of visceral herniation
   b. Reduce the herniated contents and amputate or excuse necrotic or excised tissue around the hernia.
   c. Close the muscle layers of the hernia with simple interrupted or simple continuous suture.
   d. If a large area of devitalized tissue is removed, use synthetic mesh such as Marlex or Prolene to close the defect (obviously don’t place the mesh in infected sites).
   e. Fold the edges of the mesh over and suture the folded edges to viable tissue using simple interrupted sutures
   i. Injuries to the cranial pubic ligament can be difficult to repair
2. If necessary, drill holes in the pubic bone to anchor the sutures

For paracostal hernias:
a. Make a midline incision or make one directly over the hernia
b. Explore the hernia and suture the torn edges of the transverse, internal, and external abdominal oblique muscles.
c. Incorporate a rib in the suture if muscle has been avulsed from the costal arch

Question 21

DH Repair

Answer 21

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
3. Remove falciform fat if it hinders visualization
4. Ex lap
5. Reduce abdominal organs from the thoracic cavity into the peritoneal cavity
   a. Gently manipulate the liver and spleen from the cranial aspect when possible, to avoid fracture and further trauma
   b. If unable to reduce, enlarge rent in diaphragm
   c. If unable to reduce after enlarging rent, a median sternotomy may need to be performed (28% of chronic herniations)
6. Examine entire diaphragm for multiple rents, edge of the rent(s), and blood supply
7. Appose the edges of the rent(s), maintaining the natural openings for the aorta, esophagus, and vena cava; use synthetic absorbable or nonabsorbable monofilament suture (PDS) in a simple continuous pattern
   a. Repair from dorsal to ventral
   b. If the rent cannot be repaired primarily (rare), a transversus abdominis muscle flap or synthetic mesh can be used
   i. Also call a fucking surgeon you have no business doing this surgery
   c. If the defect is avulsed from the ribs, incorporate a rub in the continuous suture for added strength
8. +/- Place a thoracostomy tube
   a. Can be performed prior to closure of the rents to allow visualization of tube placement
   b. If not placing a tube, pass a red rubber catheter through the herniorrhaphy site to evacuate remaining air in the pleural space
9. Close the skin routinely as previously prescribed

Question 22

Liver lobectomy

Answer 22

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
3. Remove falciform fat
4. Identify lobe to be removed
5. Pass umbilical tape around the portal vein, celiac artery, cranial mesenteric arteries, and caudal vena cava in front of and behind the liver
6. Left lateral and medial
   a. Left lateral and left medial maintain separate near the hilus more than the other lobes, so can often be removed in small dogs and cats with a single encircling ligature
   b. Crush the parenchyma near the hilus with fingers or forceps
   c. Place an encircling ligature around the crushed area and tie
   d. Isolate the blood vessels and biliary ducts near the hilus and ligate them
   e. Double ligate or oversew the ends of large vessels
   f. Resect the parenchymal tissue, leaving a stump of tissue distal to the ligatures to prevent retraction of hepatic tissue from the ligatures and subsequent hemorrhage
   g. Remove umbilical tape
   h. Close routinely
7. Left lateral
   a. Isolate, ligate, and divide the left lateral lobar hepatic and biliary duct
   b. Retract the left lateral lobe laterally, and retract the left medial lobe medially
   c. Expose the left lateral portal vein and hepatic vein, the latter being cranial and to the left
   d. Isolate, ligate, and divide the left lobar portal vein, then separate the parenchyma of the left lateral lobe from the left hepatic vein using the inner cannula of a Poole suction tip
   e. Divide the annular ligament and ligate and divide the left lateral lobar artery
8. Left medial
   a. Use cranial retraction for hilar exposure
   b. Isolate, ligate and transect the left medial lobar portal vein
   c. Isolate, ligate, and transect the left medial lobar hepatic artery and biliary duct individually where they are located in the fibrous tissue dorsal to the transected portal vein
   d. Retract the left medial liver lobe to the left and the quadrate lobe to the tight to dissect the parenchyma from the hepatic veins using the inner cannulas of the Poole suction tip
   e. Use ligation and cauterization to separate vessels extending from the left lateral liver lobe
   f. Ligate the hepatic veins as they are identified
9. Central division
   a. Use Lahey gallbladder forceps to bluntly dissect the base of the quadrate lobe
   b. Isolate and divide the quadrate lobar portal vein, biliary duct, and artery, and ligate and divide them en bloc
   c. Perform the same dissection and transection of the right medial liver lobe portal vein, artery, and biliary duct
   d. Bluntly separate the parenchyma between the quadrate and right medial liver lobes using the inner cannula of a Poole suction tip
   e. Retract the lobes to expose the diaphragmatic surface
   f. Isolate the accessory right hepatic vein with blunt dissection on the diaphragmatic surface of the liver and ligate it
   g. Retract the quadrate lobe to the right, and separate the praenchyma joining it and the left medial liver lobe to locate, isolate, and transect the central hepatic vein
   h. If the gallbladder has not been removed, suture it to the diaphragm or the left medial liver lobe to prevent it from twisting
10. Right lateral
    a. Expose the right lateral liver lobe by retracting the duodenum and the central division of the liver to the left
    b. Transect the left triangular ligament and create a window in the peritoneum
    c. Isolate, ligate, and transect the right lateral lobar portal vein, hepatic artery, and biliary duct, taking care to avoid the portal vein of the central division
    d. Approach the right lateral lobe hepatic veins in the cranioventral liver for ligation
11. Caudate process of the caudal lobe
    a. Approach via incision of the hepatorenal ligament
    b. Create a window in the overlying hilar peritoneum and ligate the supplying artery and draining biliary duct
    c. Isolate, ligate, and transect the portal vein after its branching from the right portal vein
    d. Identify the caudate lobar hepatic vein cranial and dorsal to the portal vein and isolate it using blunt dissection for suture or thoracoabdominal stapling device ligation
    e. Approach the papillary process of the caudal liver lobe after opening the omental bursa
    f. Retract the stomach caudally and ligate the papillary lobar artery ventral to the papillary lobar portal vein
    g. Carefully identify, isolate, and ligate the papillary lobar portal vein
    h. Identify, ligate, and transect the papillary lobar biliary duct, then bluntly separate parenchymal attachments to the caudate process
    i. Expose and ligate the associated hepatic vein

Question 23

Splenectomy

Answer 23

2. Perform a ventral midline laparotomy, incising from the umbilicus to the pubis
   a. If hemoperitoneum is present, insert a Poole suction tip through a small linea incision first and remove as much fluid as possible before extending the incision
3. Insert Balfour retractors
4. Explore the abdomen, exteriorize the spleen and place moistened abdominal sponges or lap pads around the incision under the spleen.
5. Ligate the splenic vessels  double ligate and transect all vessels at the splenic hilus with absorbable or nonabsorbable suture
   a. Identify the splenic artery and vein at the tip of the left pancreatic lobe, proximal to the origin of the left gastroepiploic artery
   b. Isolate the splenic artery and vein by dissection parallel to the vessels through the surrounding mesentery
   c. Triple ligate each vessel separately and transect between the distal two ligatures
   d. Ligate and transect the short gastric arteries and veins and any anastomosing gastroepiploic vessels that might provide backflow to the transected tissues
   i. If possible, preserve the short gastric branches supplying he gastric fundus
6. Ligate and transect any attached omentum, and remove the spleen from the surgery area
7. Examine the abdominal cavity for evidence of metastasis
8. Close routinely

Question 24

OHE

Answer 24

2. Perform a ventral midline laparotomy, incising from the pubis to midway between the umbilicus and xiphoid
   a. In dogs, make the incision just caudal to umbilicus in the cranial third of the abdomen
   b. In puppies, make the incision in the middle third of the caudal abdomen
   c. In cats, the body of the uterus is more caudal and difficult to exteriorize so make the incision in the middle third of the caudal abdomen
3. Once you excise through the skin and subcutaneous tissue, exposing the linea alba, grasp the linea alba tenting it outward and make a stab incision into the abdominal cavity. Extend the linea incision cranially and caudally using Mayo scissors.
4. Slide the OVE hook (Snook) with the hook against the abdominal wall, 2-3 cm caudal to the kidney.
5. Turn the hook medially to ensnare the uterine horn, broad ligament, or round ligament, and gently elevate from the abdomen
6. Anatomically confirm the identification of the uterine horn by following it to either the uterine bifurcation or ovary
7. With caudal and medial traction on the uterine horn, identify the suspensory ligament by palpation at the taut fibrous band at the proximal edge of the ovarian medical
8. Stretch or break the suspensory ligament near the kidney without tearing the ovarian vessels to allow exteriorization of the ovary
   a. To do this, use the index finger to apply caudolateral traction on the suspensory ligament while maintaining caudomedial traction on the uterine horn
9. Make a hole in the broad ligament caudal to the ovarian pedicle. Place one, two, or three Mosquito, Crile, or Rochester-Carmalt forceps across the ovarian pedicle proximal (deep) to the ovary
10. Place an encircling or figure 8 ligature proximal to (below) the ovarian pedicle clamps using 2-0 to 4-0 PDS, Maxon, Monocryl, Biosyn, or Vicryl
    a. For figure 8 ligatures, direct the needle through the middle of the pedicle, loop the suture around one side of the pedicle, then redirect the needle through the original hole from the same direction and loop the ligature around the other half of the pedicle
    b. Place a second circumferential ligature proximal to the first to control hemorrhage that may occur
11. Place a Mosquito hemostat on the suspensory ligament near the ovary
12. Transect the ovarian pedicle between the two remaining clamps, or proximal to the most distal clamp.
13. Remove clamps and observe for hemorrhage
14. Perform the identical procedure on the other side
15. Trace the uterine horn to the uterine body
16. Make a window in the broad ligament adjacent to the uterine body and uterine artery and vein
17. Place a Carmalt across the board ligament on each side and transect
18. Triple clamp the uterine body above the cervix
19. Place a figure 8 suture (0 to 3-0) absorbable suture through the body using the point of the needle and encircling the uterine vessels on each side
20. Place a circumferential ligature, modified Millers knot.
21. Transect the uterine body between the top two clamps before ligation
22. Remove the uterus from the surgical area
23. With a 0, 2-0, or 3-0 monofilament absorbable suture, place an encircling ligature at least 2cm below the clamp and tie two knots, starting with a surgeon’s throw
24. Loosen the clamp as the first throw is tightened
25. Place one or two transfixing-encircling ligatures above the first ligature and below the clamp, using a similar suture material
26. Wipe the stump clean of any discharge and monitor for hemorrhage
27. Lavage and suction the abdomen
28. Close routinely

Question 25

Transpalpebral enucleation

Answer 25

1. Copiously lubricate the eye(s). Clip periocular area, 2 in wide area around the eyelid with a No 40 blade clipper and prep with 0.5% povidone-iodine
2. Confirm that the procedure is being performed on the correct eye
3. Start with the closure of the eyelids with Allis tissue forceps or suture the lids closed with a simple continuous 3-0 or 4-0 suture leaving the ends left long, these may be used to position the close.
4. Circumferentially incise the anterior skin orbicular layer of the eyelids parallel to and 4-5 mm from the lid margins with a No 15 Nard Parker Scalpel or electrocautery.
5. From the initial skin incision, bluntly dissect the subcutaneous tissues with a small curved Metzenbaum scissor around the globe while keeping the plane of dissection outside the conjunctival sac.
6. Use Allis tissue forceps on the subcutaneous tissue inside the incision to keep the eyelids open dorsally and ventrally.
7. Cut the medial and lateral canthal tendons with Mayo scissors to free up the canthal area.
8. Palpate the bony dorsal orbital rim so it can be used as a landmark.
9. At the level of the dorsal orbital rim, deepen the incision by bluntly and sharply dissecting with the top of the scissors in the tissue the tissue until the yellowish sclera and extraocular muscle tensons are exposed.
10. Bluntly and sharply dissect 360 degrees around the globe, making the incision parallel to the limbus.
11. Don’t pull the eye because you can put traction on the optic nerve and cause trauma to the optic chiasm, resulting in blindness of the remaining eye.
12. Clamp the tissues at the posterior pole of the globe then remove the hemostat.
13. With enucleation scissors (strong curved ideally) or curved Metzenbaum scissors, cut the optic stalk halfway between the back of the eye and posterior orbit.
14. Remove the block of tissue containing the globe, lid margins, orbital lacrimal gland, conjunctiva, and third eyelid gland
15. Flush orbit
16. Close the orbital septum with 3-0 or 4-0 PDS in a horizontal mattress pattern, 3-0 or 4-0 polyglactin 910 suture for the subcutaneous tissue and then the skin, and place local anesthetic.

Question 26

IO Catheter

Answer 26

1. The most commonly used sites are the flat medial surface of the proximal tibia (1 to 2 cm distal to the tibial tuberosity), the tibial tuberosity itself, and the trochanteric fossa of the femur
   a. Alternative approachable points can be considered, such as the wing of the ilium, the ischium, and the greater tubercle of the humerus
   b. The tibia and the humerus are safe sites for IO access in neonates; however, care should be taken to avoid the epiphyseal plates
2. A preemptive skin stab incision over the site of penetration of the catheter may prolong the life of the needle.
3. For placement in the medial tibia, the needle must be directed into the bone slightly distally and away from the proximal growth plate. To prevent sciatic nerve injury during placement in the femur, the needle should be walked off the medial aspect of the greater trochanter into the trochanteric fossa, with the hip joint in a neutral or slightly extended and internally rotated position. Once the desired orientation of the needle is reached, firm pressure should be applied in clockwise and then counterclockwise rotation.
   a. This procedure normally generates a small depression that seats the needle in the bone; the pressure is then increased while the same rotation pattern is maintained, and the needle should proceed through the near cortex.
   b. A sudden loss of resistance indicates that the needle has fully penetrated the cortex. Before fluids or drugs are administered through an IO catheter, verification of correct placement is required. One of the most frequently reported causes of failure of IO catheterization is an error in identifying landmarks.
   c. A well-positioned catheter should be firmly seated in the bone and should move with the limb without being dislodged.
   d. Gentle aspiration should bring bone marrow into the syringe, although in older animals this may not always be possible. A bolus of heparinized saline solution should flow easily, and there should be no palpable accumulation of fluid in the subcutaneous tissue.
   e. If resistance is encountered, the needle can be rotated 90 to 180 degrees to move the beveled edge away from the inner cortex. IO catheters without a stylet may get a cortical bone that makes those unusable.
4. The subcutaneous tissue must be observed for fluid extravasation. If extravasation is detected, the needle should be removed to prevent further complications and an alternative bone should be used for catheter placement.
5. Once correct placement of the needle is verified, administration of fluids or drugs can be administered by syringe or use of a standard intravenous administration set. To maintain patency during intermittent usage, an infusion plug can be placed, and the catheter flushed with preservative-free heparinized saline solution.
   a. Initial infusion of fluids under pressure causes pain in conscious human patients and lasts approximately 1 to 2 minutes. It is therefore recommended to withdraw a small volume of bone marrow, and then slowly inject 1% lidocaine over 60 seconds before the infusion is initiated in people.

Question 27

Cutdown and catheterization of a central vein

Answer 27

1. A venous cutdown is indicated when the veins are small (a small patient or a patient that is severely hypovolemic) or when the veins are obscured (e.g., due to obesity, subcutaneous edema, or hematoma)
2. Following aseptic skin preparation, awake animals will require local anesthesia of the region, which should be done with care so as not to inject any agent intravenously
3. A 1- to 2-cm incision is then made through the skin parallel to the vessel, with care exercised to avoid lacerating the vein.
4. The vessel is isolated using blunt dissection to free it from the surrounding tissue.
5. An encircling suture (absorbable) is placed around the vein proximal and distal to the intended venotomy site.
6. The catheter can be inserted directly through the superficial vessel wall or, if a catheter is to be used without a needle stylet, an incision can be made into the vein while traction is applied on the preplaced sutures.
7. If an incision is made, then once the catheter is inserted, both sutures are tied proximally to prevent bleeding
8. The skin is closed, and the catheter site is bandaged.

Question 28

Placement of thoracotomy tube - Seldinger technique

Answer 28

1. The lateral thorax is clipped in a wide area around the tube insertion site and surgically prepared
2. For large-bore thoracostomy tube placement or an open insertion technique, the animal is ideally anesthetized and placed in lateral recumbency, provided ventilation and oxygenation are sufficient in this position
3. For the Seldinger technique, light sedation and local anesthesia are usually sufficient, and the animal can remain in sternal recumbency for the procedure
4. Once the area is prepared and appropriate anesthesia or analgesia has been provided, the area is draped
   a. Seldinger
   i. In this technique the chest tube is advanced into the thorax with the use of a guidewire that has been inserted through a small needle or catheter
   ii. The length of the chest tube to be inserted in the thorax should be first determined by estimating the distance from the insertion site to the second rib
   iii. An over-the-needle catheter (or hypodermic needle) is inserted through a small skin incision over the seventh, eight, or ninth intercostal space, angled cranioventral in the direction desired for the chest tube
   iv. A guidewire is inserted through the intravenous catheter in a cranioventral direction
   v. The catheter is removed, leaving the guidewire in place. At this time a dilator can be passed over the guidewire to widen the tunnel through the tissue, although it may not be necessary when larger introducer catheters are used.
   vi. The small-bore thoracostomy tube is advanced over the wire to the desired length. If there is resistance to passage of the tube through the intercostal tissues, it may be prudent to use the dilator, if it has not already been utilized.
   vii. Once the tube is placed, the guidewire is removed and the tube is secured
   viii. Care is taken not to compromise the lumen of the catheter if a finger-trap suture is used.
   ix. The insertion site is covered with sterile gauze, and a bandage is applied to secure the thoracostomy tube to the chest wall and minimize risk of accidental removal

Question 29

Large Bore thoracostomy tube

Answer 29

i. The key point is the generation of a subcutaneous tunnel by pulling the skin cranially prior to placement of the thoracostomy tube in the seventh, eight, or ninth intercostal space
ii. The length of tube to insert into the thorax is estimated prior to starting the procedure by holding the chest tube alongside the chest with the tip aligned to the second rib, without compromising sterility
iii. A small skin incision, slightly larger than the diameter of the tube, is made overlying the desired intercostal space midway between the dorsal midline and the center of the lateral thorax
iv. The subcutaneous tissue and muscle layers are bluntly dissected with a hemostat
v. The pleura is then penetrated bluntly using a large hemostat or Carmalt forceps
vi. During this maneuver, the anesthetist is asked to stop ventilation to minimize injury to the lung
vii. Also, injury to the underlying organs is minimized by holding the hemostat close to the tip with the nondominant hand to avoid overpenetration
viii. Once the pleura is penetrated, the tips of the hemostat are opened, which creates an opening for the thoracostomy tube
ix. Before insertion, the trochar (if present) can be retracted slightly so that the sharp tip is protected by the tube
x. The tip of the tube is introduced into the thorax and is then advanced toward the uppermost elbow
xi. Once the tip of the tube is well inside the thorax, the hemostat can be removed
xii. The thoracostomy tube should be inserted so that the tip is roughly at the level of the second rib
xiii. It is essential that all tube fenestrations be within the thoracic cavity.
xiv. The stylet is then withdrawn and a tube clamp (Carmalt forceps if a tube clamp not available) can be used to occlude the tube
1. Alternatively, the tube can be connected directly to the suction device
xv. As the skin is released and retracts caudally over the tube, a subcutaneous tunnel is created
xvi. The Mac technique can be used to rule out kinking of the tube: the tube is twisted 180 degrees in each direction and then released. If the tube spins back into its position, this is indicative of kinking
xvii. Depending on the urgency of pleural evacuation, suction is instituted before or after securing the tube
xviii. A purse-string suture is placed around the skin incision if the fit is not firm
xix. The tube is then fixed using a finger-trap suture pattern
xx. A single interrupted suture is placed through the skin at the site of insertion
xxi. This suture may pass through the periosteum of the rib (this requires additional local anesthetic) and is tied in a gentle loop, leaving equal and long suture tags
xxii. The suture tags are used to create the finger-trap pattern by placing a single knot on top of the tube, crossing underneath the tube, and then placing another single knot on top of the tube, and so on
xxiii. The tube is then connected to the suction system of choice
xxiv. The insertion site is covered with sterile gauze, and a bandage is applied to secure the thoracostomy tube to the chest wall and minimize risk of accidental removal
xxv. If no assistant is available to pull the skin forward, the subcutaneous tunnel can be made with a large hemostat or Carmalt forceps
1. The skin incision is made more caudally (eighth to tenth intercostal space), and the hemostat is tunneled cranially through the subcutaneous tissues by the length of two intercostal spaces to the desired insertion point at the level of the sixth to eighth intercostal space
2. Then the pleural space is entered, and the tube is inserted as described earlier

Question 30

Cystotomy Tube Placement

Answer 30

1. Cystostomy tube placement is performed by a stab incision in the abdominal wall in a paramedian position convenient to positioning of the external tubing
2. A purse string suture of absorbable material is placed in the bladder and a small stab incision made within it
3. Following the stab incision into the bladder, the internal end of the cystostomy tube is placed within the bladder and secured
4. Commonly, three to four sutures are placed around the cystostomy site and the abdominal wall to facilitate adhesion between bladder and abdominal wall
5. The external tube is secured to the body wall
6. The urinary bladder should be emptied via cystostomy tube three to four times per day
7. Minimizing contamination of the tube and stoma by careful handling and daily cleaning is essential.
8. Removal of cystostomy tubes may be performed under sedation 14 days following placement once a robust stoma has formed
9. Rate of complications are high, occurring in 49% of patients, and most included inadvertent removal or displacement from the bladder, chewing on the tube, tube breakage, and fistula formation
   a. Minor complications may include irritation or inflammation around the tube exit site, or urine leakage, hematuria, tube obstruction, or complications with fixing the construct to the skin

Question 31

Wound Dressings: Type, Uses, Contraindications, Examples

Answer 31

Question 32

Esophagostomy Tube Placement

Answer 32

1. Patient anesthetized, intubated, and placed in right lateral recumbency
   + Mouth held open with oral speculum
2. Surgical field prep – mandibular ramus to the thoracic inlet extended to the dorsal and ventral midlines
3. Feeding tube premeasured from caudal to the larynx to the 8th/9th intercostal space
   + Tip will lie in distal esophagus
   + Long enough to allow several cm to remain exterior to the skin
   + Sizing:
   + 12-14 Fr cats
   + 20 Fr Dogs
   + Variety of materials available
   + Red rubber, polyurethane, or silicone tubes
4. Curved forceps placed in the mouth and advanced to the mid-cervical esophagus, distal to the hyoid apparatus – forceps are pushed dorsally to tent the skin until able to be externally palpated
5. Jugular is identified to avoid injury
6. Incision made over tented skin through the esophageal wall then exteriorized by blunt dissection
7. Grasp tube with forceps and pull through incision and out of the mouth
8. Lubricate end of the tube, retroflex, and push down esophagus while proximal end is slowly retracted a few cm
9. Proximal end of tube will rotate cranially as tube straightens – slide to pre-marked site
10. Inspect oropharynx to confirm tube is not present
11. Clean incision site and secure tube with finger-trap and non-absorbable suture
12. Confirm placement radiographically
13. Place non-adherent pad over surgical site and lightly wrap
14. Mark tube at exit site to monitor for migration
15. Flush with sterile saline and assess for cough – cap tube when not in use

Question 33

Gastrostomy Tube Placement

Answer 33

• PEG
  1. Patient anesthetized and placed in right lateral recumbency
  2. Left flank is clipped and surgically prepped from costal arch to mid-abdomen in cranial and caudal direction, and from the transverse processes of the lumbar vertebrae to the level of the ventral end of the last rib
  3. Endoscope passed into stomach which is insufflated
  4. Location of G-tube placement in area of gastric body away from the pylorus – identified externally via transillumination
  5. Assistant pushes into abdominal wall with finger – endoscopist observes indentation with the endoscope  confirmation of no organs between gastric and abdominal wall
  6. Stab incision with scalpel blade at this site
  7. Large bore needle passed through incision into stomach
  8. Long suture fed through needle by assistant – firm grasp of external end
  9. Suture inside stomach grabbed by endoscopic forceps and suture is pulled from stomach while retracting endoscope out of the mouth
  10. Mouth end of suture is looped and knotted to swaged on suture of the feeding tube
  11. Feeding tube is lubricated
  12. Assistant pulls on suture at the abdominal wall  pulling feeding tube through the esophagus and into the stomach then out of the body wall  may need to widen stab incision
  13. Mushroom end of tube laid firmly against abdominal wall  checked with endoscope
  14. Tube secured to abdominal wall using flanges in the kit
  15. Endoscope removed after confirmation of ideal placement. End of tube is cut to suitable length. Placement of feeding adaptors.
  16. Sterile dressing applied to stoma site and tube is secured to body with a wrap or stockinet