01 power point exploratory laparotomy
Post on 10-Apr-2015
658 Views
Preview:
TRANSCRIPT
11/9/2008
1
Abdominocentesis, Abdominocentesis, Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage
d E l Ld E l Land Exploratory Laparotomy and Exploratory Laparotomy (celiotomy), in Small Animals(celiotomy), in Small Animals
Presented by Dr. Ali BaniadamPresented by Dr. Ali Baniadam
Abdominocentesis• Yields useful information in cases of abdominal injury,
peritonitis or ascitesp• Physical and radiographic examinations should proceed
abdominocentesis• Cytologic, microbiologic and biochemical examination
of aspirated fluid may help to establish the diagnosis• Diagnostic peritoneal lavage (using a dialysis catheter) is
the most reliable and accurate method for early ydetection of the intraabdominal injuries
11/9/2008
2
Indications
• Intraabdominal injuries following blunt trauma d i f h bd i l iand penetration of the abdominal cavity
• Shock without apparent cause• Sever thoracic trauma• Determining the cause of pain• Sign of disease involving peritoneal cavity• Suspicion of postoperative GI dehiscence
• Moderate leukocytosis in peritoneal fluid is normal following uncomplicated abdominal surgery ) up to 1000 cells/µL
• Toxic or degenerative cells occur withToxic or degenerative cells occur with overwhelming peritonitis
• Presence of intracellular bacteria is an indication for surgery
• Abdminocentesis is not indicated when there is a good physical or radiographic evidence of the need for exploratory laparotomy
11/9/2008
3
Estimating intraabdominal blood volume
• Observing the lavage sample• The amount of blood can be estimated using the• The amount of blood can be estimated using the
following equationX=(LV) / (P-L)
X= the amount of blood in the abdominal cavityL= the PCV of the returned lavage fluidV= the volume of lavage fluid infused into the abdominalV= the volume of lavage fluid infused into the abdominal
cavityP= the PCV of the peripheral blood before IV infusion of
fluids
• Surgical intervention is indicated when the PCV f i d l l k i hi 5 20of aspirated lavage samples taken within 5-20
min increases to a PCV of over 5%• If an animal in shock does not respond to
aggressive fluid therapy• Retroperitoneal or diaphragmatic injuries mayRetroperitoneal or diaphragmatic injuries may
give false-negative results
11/9/2008
4
Diagnosis
• Microscopic examination of the aspirate’s sediment: detection of injury to the viscussediment: detection of injury to the viscus
• Cytologic examination: abdominal neoplasia• Chemical analysis: biliary tract injuries (bilirubin
test), pancreatitis (amylase activity), urinary tract injuries (creatinine and Urea concentration),
f i f ll i i (Alk liperforation of small intestine (Alkaline phosphatase), significant liver trauma (Glutamic-pyruvic transaminase)
Catheter placement
• Preparation of the skin 2 cm caudal to the umblicus, local anethesia containing epinephrinelocal anethesia containing epinephrine
• A 3 mm incision is made through the skin • The bladder should be emptied• Left lateral recumbency• Insertion of catheter with the aid of a metal stylet• If organ enlargement or adhesion is suspected: dorsal
recumbency and insertion of catheter with direct visualization
11/9/2008
5
• Warm, balanced solution is infused by gravity flow at 22 ml/kg
• The patient is rolled gently from side to side• A small amount (20ml) of fluid is removed • The skin is closed• Strict hemostasis • The catheter may be left in place
11/9/2008
6
Exploratory laparotomy indications
• Abnormal accumulation within the peritoneal cavity of abdominal viscera
• Nonresponsive pain• Major organ disruption• Nonresponsive dystocia• Abnormal discharge from abdominal tissue• Inspection and palpation of organs
b b• Microbiologic testing, biopsy, or histopathological analysis
• Trauma and neoplasia
Timing
• Surgery should be timed to maximize the potential for diagnostic and therapeutic successpotential for diagnostic and therapeutic success while minimizing patient insult.
• Diagnostic peritoneal lavage is useful in abdominal trauma cases
• There are no absolute rules to guide the surgeon• It should be performed when the patient is not
responding sufficiently to therapy
11/9/2008
7
Technical consideration
• Preparation: Patient preparation should maximize surgical optionsAn incompletely prepared ventral abdomen is no excuse for in complete surgical evaluation
Surgical Approaches
• Ventral midline Th i i i h ld t d f th i h id t– The incision should extend from the xiphoid process to immediately cranial to the pelvis
• Paracostal extension of a midline incision• Paracostal
– incision begins at the xiphoid process, continues parallel and three to four cm caudal to one costal arch and extends to athree to four cm caudal to one costal arch, and extends to a point level with the end of the last rib
11/9/2008
8
Views of the abdomen of the dog showing the common sites for incision
11/9/2008
9
Equipment Needed
• A standard soft tissue surgical pack• Noncrushing intestinal forceps• Electrocautery device• Vascular tourniquet• Intestinal forceps
Surgical technique• Exploratory laparotomy techniques are
essentially the same regardless of the clinical signs of the patientsigns of the patient
• After entry into the peritoneal cavity, microbiologic samples of peritoneal fluid are collected
• Isolation and control of serious hemorrhage and active gastrointestinal leakage should be the first g gstep
• A thorough, systematic exploration of the abdomen, size, shape, location, consistency, surface contour
11/9/2008
10
Ventral view of dog after removal of ventral abdominal wall and the
greater omentum
Ventral view of dog after the removal of the ventral body wall, stomach and intestines
11/9/2008
11
Exploration of the peritoneal cavity
• The cranial extent of the abdomen is evaluated first: • Diaphragm (transection of triangular ligament betweenDiaphragm (transection of triangular ligament between
the liver and diaphragm, although often unnecessary), • Liver lobes, gall bladder, hepatic hilus• Inspection and palpation of the stomach• Spleen and greater omentum (exteriorization)• After replacement of the spleen, mesentric arterial
p l ti d p ri t lti ti it h ld l bpalsation and peristaltic activity should also be evaluated
• The duodenum and pancreas• The use of mesoduodenum as an anatomic
retractor gently improves visulaization of the right paraverteral regionPortal vein, caudal vena cave, celiac artery, hepatic lymph nodes, right kidney and proximal ureter, right ovary and uterine horn
• Duodenum is traced to the dudenocolic ligamentg
• Jejunum, cecum, descending colon
11/9/2008
12
• The mesocolon as a rtractor enable the surgeon to examine the left paravertebral area
• Left kidney and proximal ureter, aorta, left adrenal gland left ovary and uterine hornadrenal gland, left ovary and uterine horn
• Distal colon, urinary bladder, distal urter, proximal urethra, prostate gland, ductus deferens or uterine body and vagina
Biopsy techniques
• During exploratory laparotomy, gross evaluation d i i l f d idand interpretation alone often do not provide a
definitive diagnosis• Frequently: Liver, intestines, lymph nodes,
kidneys, prostate gland• Less commonly: stomach spleen urinaryLess commonly: stomach, spleen, urinary
bladder, grater omentum
11/9/2008
13
Liver
• Finger of instrument fragmentation technique• Wedge resection technique: two rows of full-
thickness horizontal mattress suture• Use of cutaneous punch: hemostasis is achieved
by inserting a topical hemostatic agent or omentumomentum
11/9/2008
14
11/9/2008
15
Small intestine
• Obtain full-thickness intestinal wall sampleI i i h• Incision transverse to the mesentery
• The biopsy incision should not exceed 20% of the intestinal circumference
• The incision is closed in a single layer using appositional suture pattern with synthetic absorbable or monofilament nonabsorbable suture material
• Protection by greater omentum
Lymph nodes
• Fine-needle aspiration technique: cytological l ievaluation
• Excisional biopsies: morphologic interpretation
11/9/2008
16
Kidneys and prostate gland
• Needle biopsy techniqueTh dl i i d h h h l lThe needle is inserted through the renal capsule at the caudal aspect of the kidney and is directed within the cortex toward the cranial pole.Digital pressure to achieve hemostasis
• Wedge resection biopsies: After excision a wedge-shaped segment the defect is closed with mattress suture
11/9/2008
17
Other tissues
• An elliptical section of gastric wall from one side f h d dof the gastrotomy wound edge
• Partial splenectomy• Partial pancreatectomy• Urinary bladder biopsies after cystotomy• Excising a section of omentum
11/9/2008
18
Therapeutic intervention
• Hemorrhage control• Correction of the source or sources of
contamination and pain• Removal of mass lesions or intestinal
obstructions• Eli i ti f b liti• Elimination of abnormalities
Intraoperative peritoneal lavage
• Peritoneal lavage using one to three liters of warm isotonic solution is beneficial because itwarm, isotonic solution is beneficial because it facilitates aspiration of such contaminations as soft tissue fragment, bacteria, blood clots and fat.
• Lavage also warms the patient• It is important to suction the lavage fluid p g
completely before closure of the wound• Antibiotics, antiseptics and anticoagulants
(heparin: 100 µg/kg) can be added to peritoneal lavage
11/9/2008
19
Wound closure
• Sutures are placed approximately 3 to 10 mm from the wound edgewound edge
• The sutures should only incorporate the linea alba and external sheath of the rectus abdominis muscle
• Closure of a paramedian approach( 5 mm lateral to the linea alba) is accomplished by suturing the external sheath only
• Closure of the internal sheath of the rectus abdominisis unnecessary
• The peritoneum heals quicker and with fewer complictions if it has not been sutured
• The simple continuous pattern using p p gnonabsorbable synthetic sutures has been demonestrated to be efficient and effective clinically
11/9/2008
20
11/9/2008
21
top related