Part Three: Surgery Tips
Recently in my GDV blog series, I discussed releasing the pressure and decompression, this time I want to focus on surgery.
Make the abdominal incision large – from the xipoid to the pubis. You cannot perform a proper exploratory laparotomy without proper visualisation. Additionally, when it comes time to re-rotate the spleen, you will need all the space you can get. Remove the falciform fat to help improve exposure.
The degree of rotation is variable from 90 to 360 degrees, so not all GDV surgeries will be the same. If the omentum is draped over the stomach then this is pathognomonic for GDV.
When derotating, stand on the right side of the patient as all descriptions are based with the surgeon on that side. During volvulus the pylorus rotates ventrally then to across to the left side of the body. To derotate, with one hand (usually your right) reach down the left abdominal wall and firmly grab the stomach down where the spleen normally resides and then pull towards you. At the same time, use your other hand to apply downward pressure (or pressure in the dorsal direction) on the right side of the stomach. This simultaneous pulling on the left side of the stomach and push on the right side of the stomach is generally successful.
The main point is identifying that all the things have gone back to their normal place:
– Pylorus is to the right and you are able to track it through to the duodenum and pancreas
– Fundus is to the left
– Omentum hanging off the caudal aspect of the stomach
– Spleen is derotated [as well]
– Sometimes passage of a stomach tube can help you identify the oesophagus and you can feel it running along the inside of the gastric cardia and fundus.
If the stomach is still distended and it is hard to manipulate then reducing the size of the stomach can make derotation significantly easier. Pass the stomach tube again or aspirate more gas out of the stomach using a 18g needle, extension set, 50ml syringe and 3 way tap.
Assessment of the Stomach:
Gastric necrosis is most likely going to occur along the greater curvature of the body and fundus. Lifting up the stomach and looking at the dorsal aspect of these areas is important. Allow 5 or 10 minutes after derotation before resecting the affected areas to see if it regains colour and pulsations.
I personally perform incisional gastropexy, I find them easier and also very effective. I find an area on the pyloric region of the stomach that, when brought to the lateral body wall, there is minimal tension. Ensure that you do not accidentally incise into the diaphragm; the muscle fibres of the diaphragm radiate out and insert at the costal arch. Identify the transverse abdominal muscles and pexy the stomach to here. I also ensure muscularis to abdominal muscle contact to increase the strength of the pexy once it is healed.
The spleen is almost always engorged in GDV cases, but this does not necessarily mean that it needs to be removed. Always assess the splenic blood supply as it is not uncommon for splenic vessels to tear or thrombose during the volvulus. If there is any concern that the splenic arterial flow is compromised then I would perform a splenectomy.
What if the stomach is still dilated after pexy?:
What if the stomach appears to be still dilated? Generally once the stomach is derotated and normal anatomy has been achieved and the pexy is performed then the remaining food and gas will pass with time. You can try to empty more via a stomach tube or aspiration with a large needle but generally this is not required. I would not perform a gastrotomy to remove contents.
Next week we will cover common postoperative complications!