Earl F. Calfee, III (Trey) DVM, MS

Diplomat American College of Veterinary Surgeons

CSU Surgical Oncology Fellow

Nashville Veterinary Specialists, PLLC

Abdominal Exploration and GI Surgical Techniques

Thanks to our sponsorsPfizer IDEXX

Thanks to Becky DanCoordinator of all things

detailedResource to your clinics

bdan@nashvillevetspecialists.com

Marketing materialsCo-marketing magnets

Recycling2 hour talk – break around 8PM

Logistics first

To explore or not to explore?Anatomic ReviewEquipmentSurgical techniquesPeri-operative managementQuestions

Stop me at any point.

Goals of presentation

VomitingRetchingAbdominal distensionAbdominal painGeneralized discomfort/restlessnessOwner reports ingestion of somethingPalpation of mass effectMass identified on rads or U/S

Situations leading to exploratory celiotomy

Often obviousMass identified with palpation or imaging

Pre-op diagnosticsCBC // Serum chemistryThoracic radiographsAbdominal ultrasoundFNA with cytology - lymphoma

GDVUsually clear indication for surgeryDiscussion of prognosis with ownerMentation is keyPre-operative prognostic indicators

Plasma lactate

To explore of not to explore

Septic abdomenClear indication to explore Owner communication key

Sick animalsHigh mortality – 40-70%High costsIntensive case managementProlonged hospitalization

To explore or not to explore

The “cloudy ones”StableInconsistent

vomiting, anorexia, lethargy

Variable historyVariable signalment

To explore or not to explore

How do you decide on “cloudy cases”What we know

Lots of differentialsForeign body, inflammatory bowel disease, non-specific

gastroenteritis, liver or kidney failure, toxicity, pancreatitis, viral enteritis, GI neoplasia, intussusception, esophageal foreign body, IVDD, pyelonephritis etc., etc., etc.

If you do much surgery you will wait too long on some and go in too early on others

What are we trying to avoid?Operating patient that has readily identifiable non-

surgical conditionPyelonephritis, Addison’s disease, IVDD, etc.

To explore or not to explore

How do you decide on “cloudy cases”Multifactorial decision

Signalment // HistoryPhysical examDiagnostics

To explore or not to explore

SignalmentTypically young but can be older with polyphagia

from concurrent disease (i.e. hyperadrenocorticism)History

Owner missing somethingOwner witnessed chewingAlready vomiting foreign materialFrequent chewer – maybe operated previouslyMedically induced polyphagia

HyperadrenocorticismEpileptic on medsExogenous corticosteroid admin.

To explore or not to explore

History (cont.)Frequency and duration of vomiting

Increased suspicion of need for surgeryHigh frequency = upper GI obstructionChronic intermittent vomiting combined with anorexia,

possible diarrhea, weight loss = lower GI obstructionDecreased suspicion of need for surgery

Chronic, intermittent – possible IBD candidate

To explore or not to explore

Physical examGeneral exam

Overall conditionConcurrent diseaseCats – look under tongueStable patient?

Abdominal palpation is keyPalpable mass = surgery

Watch out for kidney in sight hounds

Make sure not fecesSevere splinting in calm or

depressed animals highly suspicious for peritonitis

To explore or not to explore

Radiographs alone = “Let’s go to surgery”1 – 2 – 3 –4 -

To explore or not to explore

Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material2 – 3 –4 -

To explore or not to explore

Radiographs alone = “Let’s go to surgery”1 - Visible foreign material2 – GDV3 – 4 -

To explore or not to explore

Radiographs alone = “Let’s go to surgery”1 - Visible foreign material2 - GDV3 – Pneumoperitoneum4 -

To explore or not to explore

Radiographs alone = “Let’s go to surgery”1 - Visible foreign

material2 - GDV3 –

Pneumoperitoneum4 - Massive

generalized dilation IntussusceptionMesenteric torsion

To explore or not to explore

Radiographs alone = maybe “Let’s go to surgery”GI distention can be

confusingConcurrent gastric and

small intestinal distention without volvulus

Generalized pure gas distention most consistent with paralytic ileus

To explore or not to explore

To explore or not to exploreGI distention can

be confusingDifferentiation of

paralytic ileus from obstructionNormal

intestinal diameter Dogs - height

of mid-body of L2

Cats – 12-mm

Radiographs alone = maybe “Let’s go to surgery”Evidence of obstruction

Segmental mixed gas dilation patternMid-abdominal intestinal mass effectComma shaped gas patterns

To explore or not to explore

Contrast radiography Who uses here?I basically do not use (ultrasound)

Contrast studies sent here are typically difficult to interpret

Can be very time consumingDon’t over-interpret gastric retention of

contrast

To explore or not to explore

UltrasoundGoals depend on case specifics

If mass identified pre-U/S then evaluating for: Diffuse diseaseTumor originating organFree abdominal fluid

If U/S for non-specific GI signsEvidence of obstruction

Non-propulsive peristalsis Fluid filled bowel loops Visible linear foreign material Free abdominal fluid

User dependent and potential for misinterpretation

To explore or not to explore

Additional diagnosticsCBC/Serum chemistry

WBC countNormal vs mild to moderate leukocytosis vs leukemoid

reactionMajor organ functionThrombocytopeniaHypoalbuminemia

SNAP PLISerum lactate levels

Tissue hypoxia Normal values

<2.5 mmol/L

To explore or not to explore

Additional diagnosticsAbdominocentesis

Paired serum and effusion samples of glucose and/or lactateLactate > 2.5 mmol/LBlood to fluid glucose

difference - >20 mg/dL

Cytology on cytospinBacteria and

neutrophil status

To explore or not to explore

Let’s go to surgery

AnesthesiaMachine // Drugs // Fluids // Monitor

Patient tableInstrument tablePatient prep solutionSterile patient and table drapingInstrument pack with suture

Equipment