When there is a foreign body in the small intestine, which section should be cut into?

A) Proximal

B) Distal 

Answer: DISTAL 

the proximal intestine will be distended, and it would be wiser to cut into undamaged intestinal wall. The distended wall will have disrupted cell wall structure and decreased healing capabilities.

BECAUSE the proximal intestine will be dilated and the distal intestine comparatively smaller. So, the proximal is clamped at a perpendicular angle, where the distal (smaller) is clamped at a strong angle. 

(the angle should leave the omental side shorter) 

1) 

2) suture spacing 

3) Make the small side bigger on the anti-omental side

Do NOT artificially close the big side like you can do in the stomach 

TWO simple continuous patterns.

On the omental side and the anti-omental side

stapling - end to end anasatomosis, or triangulated skin stapling. 

Simple continuous split pattern 

Make an omental patch - 

this will help with leaking, healing, etc.

What is an enteropexy?

Why is it preformed?

It is used to prevent intasusception, 

it involves engaging the submucosa of the small intestine through its entire length (giving an accordian apperance) 

IN the ileum, colon and rectum

The duodenum and jejunum have less # of bacterial colonies 

VIsceral manipulation may cause tachycardia and twisting hypertension.

True or False?

FALSE 

Visceral maipulation may cause BRADYCARDIA and twisting HYPOTENSION. 

What is the "leak test"?

What are the possible outcomes?

Foreign body intestinal instructions where would you expect to have more severe clinical signs?

A) when it occurs more proximally

B) when it occurs more distally 

When it occurs more proximally 

You can use a red rubber catheter - feed in down the length of the foreign body.

This will not work if it has perforated or is embedded into the submucosa.

Which is better technique for cystotomy approach:

Ventral or dorsal?

Why?

Ventral

because there are important structures (like ureters) that enter through the dorsal aspect of the bladder

Stranguria, hematuria, pollakiuria, inappropriate urination.

Can obstruct and become an emergency 

Signs can also be associated with just a urinary tract infection or a tumor 

Which surgical removal is preferred for the removal of urinary stones:

Urethrotomy or Cystotomy?

Cystotomy

Remember to REMOVE ALL STONES (duh)

Calculi analysis 

Calculi (crushed) for culture

Bladder mucosa for bacterial culture

***Radiograph to document post-op that all stones were removed****

Physical exam

rectal exam (can feel for thickened urethra)

Blood work 

urinalysis 

Abdominal radiography, contrast radiography

abdominal ultrasound 

transurethral biopsy 

traumatic catheterization - good at diagnosing

POlypoid cystitis (masses in cranioventral area) 

Urinary tract infection 

urolithiasis 

prostatic disease 

urinary neoplasia

Trauma (HBC- Hit By Car)

Iatrogenic (overagressive catheterization, cut during surgery, etc) 

Neoplasia

Severe cystitis

obstruction causing rupture

Comparing abdominal fluid creatinine to serum creatinine levels.

If the creatinine is higher in the fluids than the serum = uroabdomen!

CYSTOSCOPY

can determine both presence and conformation 

You can use excretory urography but not definitive and cannot determine if intra or extramural

Hydroureter

Hydronephrosis 

Ascending urinary tract infection

Surgical treatment of ectopic ureters.

Ligation of distal ureter, resect and reimplant the ureter into urinary bladder.

about 50% 

30-55% of dogs continue to have incontinence 

and may need medical treatment also 

IF done with a needle - only digital pressure needed

Wedge - mattress suture, monofilament absorbable 

Itis very friable

if you cut a vessel or duct it will be difficult to find and ligate because they retract back into the tissue. 

This makes sharp dissection difficult.

Production of : Coagulation factors, plasma proteins, cholesterol, bile salts

Metabolism and conversion of nutrients and drugs

removal of microbes from circulation (reticuloendothelial)

Factor VIII

(maybe released from glomerular, vascular and tubular endothelium) 

Lowered liver production:

hypoalbuminemia, hypoglycemia, coagulopathies

Anemia

hypokalemia

ascites 

hepatic encephalopathy and seizures

*impaired drug metabolism*

Pre med and induction: Diazepam + Opoid

Maintenance: Isoflurane

Thiobarbituates 

Ketamine (dogs)

Acepromazine 

(metabolism in the liver impeded)

Stunted growth 

thin body condition 

Ascites 

Blood clotting disorders

JAUNDICE 

Seizures 

Sepsis 

Caudate 

quadrate 

right lateral 

left medial 

right medial 

left lateral - BIGGEST

LEFT LATERAL 

it is the largest 

20% is arterial 

80% is venous from PORTAL VEIN

(from pancreas, stomach, spleen, intestines)

Protects systemic circulation from substances that are metabolized by the liver or excreted from the liver to the GI.

Also many substances are metabolized in the liver, so this prevents them from being in systemic circulation.

Retarded development of the liver 

hepatic insufficiency 

hepatoencephalopathy

Portosystemic shunts 

hepatic abscesses and cysts 

hepatic neoplasia 

hepatic lobe torsion

biliary tract obstruction 

Neoplasia of the liver is often primary.

True or False?

FALSE 

Because the liver is filtering blood from all over the body, it usually a secondary (metastatic) lesion.

Dorsal recumbancy 

HEAVILY SEDATED

it is inexpensive 

easy if guided with an ultrasound 

Sensitive for FOCAL lesions

Not sensitive for diffuse lesions

uncontrollable hemorrhage

surgical biopsy better because it is easier to visualize 

insert metal butting cylinder 

stop when hub contacts liver surface

withdrawl punch 

grab biopsy sample 

trim at base with metzenbaum scissors

use gelfoam sponge to stop bleeding

It is where a suture material (of good knot security - like monocryl) is wrapped around the effected liver lobe. 

This is then pulled tight, crushing thru friable hepatic tissue.  Place overlapping sutures around the margin, cut 5 mm distal to them and excise!

Scapel for CAPSULE ONLY

Then your fingers - or the scapel handle

this sort of blunt dissection will split the parenchyma, 

but will not break the ducts or vessels.

Alternative: use surgical stapling device

Traumatic laceration

AV fistula

torsion 

neoplasia

Gastroduodenal v

Splenic v

Caudal mesenteric v

cranial mesenteric v

Medial and lateral left lobes are easier - because there is a more distinct separation, so its easier to access vessels

Right lateral and caudate lobes need to be freed from caudal vena cava (via umbilical tape tourniquet round cranial and caudal vena cava, portal vein, celiac art, cranial mesenteric art)

Where is the gall bladder located?

(ie. between which lobes)

The liver has good regenerative properties, so function can be restored in most surgeries.

True or False?

TRUE 

(unless there is still underlying disease that is causing the liver not to function or regenerate properly)

Several overlaying mattress sutures are placed around margins (to crush tissue but not cut).

then excise wedge - and more sutures or sponge to stop bleeding

Histopathology 

mineral analysis 

Culture 

Toxin build up 

hepatic encephalopathy

decreased liver size 

hepatic insufficiency 

typically a result of portal hypertension

Often there are multiple shunting vessels 

accounts for 20% of canine portosystemic shunts

Congenital extrahepatic shunts are usually:

singular or multiple?

A extrahepatic shunt redirect blood:

- from systemic to portal circulation

- from portal to systemic circulation

Which is correct?

Portal to systemic 

this causes blood that needs to be filtered to bypass the liver and continue to systemic circulation

What is a more common occurance:

extrahepatic or intrahepatic single shunts?

Extrahepatic = 60% of single shunts 

intrahepatic = 35% of single shunts 

both are usually congenital and are accompanied by abnormalities in other vessels.

Intrahepatic shunts are usually acquired and multiple.

True or False?

FALSE

Usually congenital and single

Getting a dog from the pound is risky because you dont know their genetics, and they are likely to have congenital anomalies like portosystemic shunts.

True or False?

FALSE 

purebreds are more likely to acquire congenital abnormalities like portosystemic shunts

Extrahepatic shunts most commonly effect:

Miniature or large pure bred dogs?

Extrahepatic = MINIATURE/toy pure breds

that are less than a year old

Intrahepatic = Large pure bred dogs 

that are less than a year old 

Stunted growth 

hepatic encephalopathy (lethargy to seizures)

PU/PD

Urinary dysfunction 

ammonum biurate calculi in urine 

prolonged drug effects

CATS: ptyalism, blindness

Nuclear scrintigraphy can confirm the presence of a portosystemic shunt.

True or False?

TRUE 

***but it will NOT indentify the shunting vessel!!!

Abdominal ultrasound 

positive contrast portography 

nuclear scinitigraphy

Which is the preferred method of portosystemic shunt occulsion:

Acute or Gradual? Why?

GRADUAL 

because there is a higher incidence of complications with the acute - the liver has to adjust to doing its job again and handling all that blood.  

Complications include portal hypertension - death

Ameroid ring constrictor 

cellophane banding 

Portal pressure!

Because the liver needs to adjust to all the new blood it is receiving, the pressure needs to be measured and be cautious of hypertension.

Hemorrhage

seizures

ascites 

portal hypertension

recanalization 

acquired shunting (compensatory to hypertension)

Although there is a 10% mortality rate, 

many that survive the perioperative period have excellent long term prognosis.

Some may need continued medical managment 

Trick question

You cant use an occulsion device IN the liver for the most part, it would be weird.

Acute or staged ligation - 20% mortality rate 

percutaneous caval stent and coil embolism - may be better 

Extrahepatic biliary obstruction (benign or malignant)

Biliary mucocele

Biliary tract rupture causing bile peritonitis

(can be caused by trauma or necrotizing cholecystitis)

BENIGN: 

Cholelithiasis, biliary sludge, pancreatitis/pancreatic abscess, stricture

MALIGNANT:

Pyloric, duodenal, pancreatic, hepatic, biliary tract 

How can EHBO be surgically corrected?

(extrahepatic biliary obstruction)

Choledochotomy (if duct dilated and obstuction can be removed adequately)

Biliary diversion 

surgical stapling (GIA stapler)

It is where there is rupture or leakage of the biliary tract into the abdomen, causing peritonitis.

This needs to be addressed immediately and patients will recover quickly if the peritonitis remains sterile.

septic bile peritonitis has 73% mortality rate

SPLENECTOMY

why? because patients do fine without a pancreas, and since you are going in there (for a biopsy or partial slenectomy) you might as well just remove the whole thing - prevent having to go back in.

Diffuse splenomegaly (from torsion, congestion, infarction)

neoplasia

trauma - rupture

immune mediated disease

Splenic a: distal to last branch to pancreas AND 

where is courses towards short gastrics

Left gastroepiploic a

short gastric arteries

Then the vessels to the omentum need to be ligated as well

Parallel to greater curvature of the stomach 

connected by the gastrosplenic ligament (part of the omentum)

The branches just prior feed the pancreas.

If these are ligated instead, blood flow to pancreas would be compromised.

HISTOPATH 

FNA, ultrasound, CT scan do NOT determine malignancy

HEMANGIOSARCOMA

70% 

At this time there is often metastasis - esp in the right atrium.

Ruptured tumor puts cancer cells in the abdomen.

POOR 

even with Chemo 

Surgery does NOT effect prognosis 

Surgical removal of hemangiosarcomas improves prognosis, especially if chemo is used post-operatively.

True or False?

FALSE 

Prognosis of hemangiosarcomas are VERY POOR, with or without chemo.  And surgical removal does not improve these poor chances. 

<10% sruvive past 12 months.

Partial removal of the pancreas is indicated only if it involves the distal portions of the limbs.

True or False?

TRUE

This distrupts the least amount of vasculature

The left limb

Which lesions benefit the most from pancreatic surgery?

a) insulinoma

b) Pancreatic abscess 

c) adenocarcinoma

B) pancreatic abcesses 

as well as pseduocysts 

Both are non-neoplastic diseases where surgery is curative.

Usually a consequence of pancreatitis 

but contain NO bacterial components

Almost always these are sterile.

Drain 

Debride fibrous wall of pseduocyst/

remove necrotic or purulent areas of abscess

OMENTALIZE (tack down to pancreas with sutures)

Treatment of Pancreatitis is be done:

medically or surgically?

MEDICALLY - it is not a true surgical disease 

and should always be agressively treated medically.

Surgery can help diagnose, and may be needed from consequences of pancreatitis. 

**Jejunostomy feeding tube - tx of pancreatitis that bypasses inflammed area and can replenish lost proteins.

JEJUNOSTOMY feeding tube

by placing a feeding tube distal to the inflammed region there is a way to replenish lost proteins