Gastrotomy/Enterotomy Tips & Tricks

Gastrointestinal foreign bodies are commonly encountered in small animal medicine. For gastric foreign bodies, there are several approaches depending on the type and amount of foreign material ingested. Similarly, the degree of clinical signs reflects what was indiscriminately eaten, from no clinical signs to protracted vomiting if the pylorus is obstructed.

Foreign bodies lodged in the pylorus or proximal duodenum may show classic bloodwork abnormalities of gastric outflow obstruction. In these cases, protracted vomiting causes significant loss of gastric secretions. This results in hypochloremic, metabolic alkalosis. Distal gastrointestinal obstruction more commonly results in metabolic acidosis

Options for removal of gastric foreign bodies are 1) let the material or object be digested by gastric acid (e.g., bone), 2) emesis induction, 3) endoscopic retrieval, and 4) surgical removal. Deciding the best approach is dependent on the type of material, equipment availability, level of endoscopic expertise, and cost.

After deciding to take an animal to surgery for gastric or intestinal foreign material, a full abdominal exploratory should be performed after entering the abdomen as there may be additional foreign material in the small intestine. Perioperative antimicrobials are indicated (cefazolin or cefoxitin 22 mg/kg IV q90min).

Gastric foreign bodies are removed through routine gastrotomy:

• Make a generous abdominal approach from the xiphoid past the umbilicus
• Place a Balfour abdominal retractor for improved visualization.
• Perform a full abdominal exploratory as there may be additional foreign material in the small intestine
• Pack off the stomach from the rest of the abdominal cavity using laparotomy sponges or surgical towels
• Place stay sutures at each end of the proposed incision. A typical gastrotomy incision is performed in the ventral body of the stomach between the lesser and greater curvature. Any suture material can be used. Suture ends should be quite long and secured with mosquito hemostatic forceps. An assistant can hold the stay sutures to minimize spillage from the stomach; alternatively, the hemostats can be secured to the surgical drapes or looped over the Balfour if no surgical assistance is available.
• Make a stab incision into the lumen of the stomach with a #15 or #11 scalpel blade. Continue the incision with Metzenbaum scissors to create an opening large enough to remove the foreign material.
• Babcock forceps, sponge forceps, or gloved hands can be used to remove the material from the stomach and place onto a nearby surgical towel, which is then taken away from the surgical area once all material is removed. The pylorus and cardia should be closely evaluated to make sure no foreign material is left behind. Change gloves prior to gastrotomy closure.

For closure of a gastrotomy incision, synthetic absorbable monofilament suture (e.g., 3- 0 or 4-0 Monocryl, Biosyn, or PDS) with a swaged-on taper needle is the material of choice. There are numerous techniques to choose from when deciding how to close the stomach. Regardless of the suture pattern, the common theme for all gastrointestinal surgery is inclusion of the submucosal layer in the closure. Full-thickness purchase of the tissue ensures that this holding layer is incorporated in the suture line. Specific options for gastrotomy closure include:

• Single-layer full-thickness simple continuous pattern
• Single-layer full-thickness simple interrupted pattern
• Two-layer continuous inverting pattern
  • Full-thickness simple continuous pattern followed by,
  • Partial-thickness (seromuscular) Lembert or Cushing pattern
• Two-layer continuous inverting pattern
  • Simple continuous to close the mucosa and submucosa followed by,
  • Partial-thickness (seromuscular) Lembert or Cushing pattern

For simple gastrotomy, a single-layer full-thickness simple continuous pattern is preferred due to increased efficiency and decreased amount of suture material used. A two-layer pattern may be more appropriate if performing a partial gastrectomy or if there is a concern about tissue viability.

• Start the gastrotomy closure at the point of the gastrotomy incision furthest away from you.
• Begin a single-layer, full-thickness simple continuous pattern 2 to 3 mm away from the commissure of the incision.
• Place suture bites 3 mm apart and 3 mm from each edge incorporating all layers. (If the gastric mucosa is markedly everted, suture bites should come up in the middle and redirected instead of taking a suture bite across the incision all at once.) • Trail the suture line towards you such that the suture material is snug against the gastric tissue.
• Finish the suture pattern 2 to 3 mm beyond the edge of the incision. Tie surgical knots securely using 6 throws.
• Assess the suture line for appropriate spacing and tightness. Place additional simple interrupted sutures if necessary.
• Perform a local lavage of the suture line and then remove the abdominal packing.
• Change gloves and use different instruments for routine closure of the abdomen.

Foreign bodies located in the small intestine are approached through a longitudinal incision aboral to the obstruction.

• Exteriorize the section of obstructed small intestine and pack off the rest of abdominal cavity using laparotomy sponges or surgical towels
• Ingesta can be held back by assistant or minimally traumatic instruments such as Doyens. An assistant can also provide traction across the segment; alternatively small stay sutures can be placed at each end of the proposed incision; the hemostats can be secured to the surgical drapes or looped over the Balfour.
• Using a #15 or #11 scalpel blade, make a stab incision on the antimesenteric border into the lumen of the small intestine aboral to the obstruction. Continue the incision longitudinally with Metzenbaum scissors to create an opening large enough to remove the foreign material.

Following removal of the foreign material, the intestine is evaluated for viability. If there are any concerns about the health of the small intestine, a resection and anastomosis should be performed. Otherwise, the enterotomy incision is closed with a single-layer appositional pattern using 4-0 monofilament absorbable suture (e.g., Biosyn, PDS). Options for simple enterotomy closure include:

• Single-layer simple interrupted approximating pattern
• Single-layer simple continuous approximating pattern
• Begin a single-layer, full-thickness simple continuous pattern 2 to 3 mm away from the commissure of the incision.
• Place suture bites 2 mm apart and 2 mm from each edge incorporating all layers. (If the mucosa is markedly everted, suture bites should come up in the middle and redirected instead of taking a suture bite across the incision all at once.)
• Trail the suture line towards you such that the suture material is snug against the intestinal tissue.
• Finish the suture pattern 2 to 3 mm beyond the edge of the incision. Tie surgical knots securely using 6 throws.
• Assess the suture line for appropriate spacing and tightness. Place additional simple interrupted sutures if necessary.
• Consider leak testing.
• Perform a local lavage of the suture line and then remove the abdominal packing.
• Change gloves and use different instruments for routine closure of the abdomen.

Prior to closure, an elective right-sided gastropexy should be considered in breeds at risk for GDV. Postoperative pain management following gastrointestinal surgery can be challenging, as nonsteroidal anti-inflammatory drugs should be avoided. Local analgesia is advocated through the use of incisional blocks. Feeding is no longer delayed in the postoperative period, and the animal should be offered food once fully recovered from anesthesia.

Frequently Asked Questions

1. What gastrointestinal medications do you use preoperatively and postoperatively?
2. What postoperative pain medications do you use following gastrointestinal surgery?
3. What suture material and suture pattern do you use for gastrointestinal closures?
4. Do I leak test enterotomy closures?
5. How do I monitor for dehiscence of gastrointestinal closures?
6. What is my perioperative and postoperative antimicrobial protocol for gastrointestinal surgery?
7. Does prophylactic gastropexy have any complications?
8. What is your preferred gastropexy technique?

References

• de Battisti A, Toscano MJ, Formaggini L. Gastric foreign body as a risk factor for gastric dilatation and volvulus in dogs. J Am Vet Med Assoc 2012;241(9):1190-3.
• Hayes G. Gastrointestinal foreign bodies in dogs and cats: a retrospective study of 208 cases. J Small Anim Pract 2009;50:576-83.
• Hobday MM, Pachtinger GE, Drobatz KJ, et al. Linear versus non-linear gastrointestinal foreign bodies in 499 dogs: clinical presentation, management, and short-term outcome. J Small Anim Pract 2014;55:560-5.
• Strelchik A, Coleman MC, Scharf VF, et al. Intestinal incisional dehiscence rate following enterotomy for foreign body removal in 247 dogs. J Am Vet Med Assoc. 2019 Sep 15;255(6):695-699.
• Zersen KM, Peterson N, Bergman PJ. Retrospective evaluation of the induction of emesis with apomorphine as treatment for gastric foreign bodies in dogs (2010-2014): 61 cases. J Vet Emerg Crit Care 2020;30(2):209-212.