Gastrointestinal surgery: reducing mortality and morbidity: part I and II

Gastric surgery

Gastric surgery is commonly performed to remove foreign bodies and to correct gastric dilatation-volvulus. Gastric ulceration or erosion, neoplasia, and benign gastric outflow obstruction are less common indications. Gastric disease may cause vomiting (intermittent or profuse and continuous) or just anorexia. Dehydration and hypokalemia are common in vomiting animals and should be corrected before induction of anesthesia. Alkalosis may occur secondary to gastric fluid loss; however, metabolic acidosis may also be seen. Hematemesis may indicate gastric erosion or ulceration or coagulation abnormalities. Peritonitis arising from perforation of the stomach caused by necrosis or ulceration often is lethal if not treated promptly and aggressively. Aspiration pneumonia or esophagitis may also occur in vomiting animals. If possible, severe aspiration pneumonia should be treated before induction of anesthesia for gastric surgery.

Gastrotomy

The most common indication for gastrotomy in dogs and cats is removal of a foreign body. Make a ventral midline abdominal incision from the xiphoid to the pubis. Use Balfour retractors to retract the abdominal wall and provide adequate exposure of the gastrointestinal tract. Inspect the entire abdominal contents before incising the stomach. To reduce contamination, isolate the stomach from remaining abdominal contents with moistened laparotomy sponges. Place stay sutures to assist in 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 curvatures. Make sure the incision is not near the pylorus, or closure of the incision may cause excessive tissue to be enfolded 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 material (e.g., polydioxanone, polyglyconate) 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 in 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 a gastric foreign body, be sure to check the entire intestinal tract for additional material that could cause an intestinal obstruction.

Small intestine

Surgery of the small intestines is most often indicated for gastrointestinal obstruction (i.e., foreign bodies, masses). Other indications include trauma (i.e., perforation, ischemia), malpositioning, infection, and diagnostic or supportive procedures (i.e., biopsy, culture, cytology, feeding tubes).
Diagnosis of small intestinal disease is based on the history, clinical signs, physical examination, radiographs, ultrasound scans, laboratory data, endoscopy, and/or biopsy. Diet, medications, stressful events, and response to prior therapy should be ascertained from owners. Clinical signs of small intestinal disease vary and are nonspecific, although weight loss, diarrhea, vomiting, anorexia and/or depression are the most common. Pain and shock may result from trauma, vascular occlusion, or complete intestinal obstruction. Severe vomiting, shock, or an acute abdomen suggests intestinal malposition, ischemia, perforation, or upper intestinal obstruction. Visual examination provides information about the animal’s mental state, temperament, nutritional state, and comfort. Abdominal palpation may identify pain, thickened intestine, abdominal masses, or malpositioned organs.

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