SURGERY TIP 13: ADHESIONS … Natures own booby TRAP!

Adhesions .. are bands of fibrous scar tissue that form on organs in the abdomen. They can cause organs to stick to one another or to the wall of the abdomen.

They rarely form without some kind of prior inflammation or surgery.

Adhesions of the intestine can kink, twist, pull, or compress the intestines causing symptoms of abdominal discomfort and vomiting if severe enough. However in most patients, adhesions do not cause any clinical signs.

This patient required a caesarean section but had one performed previously. I was aware of this and was cautious entering the abdomen, as I have learned this the hard way before. Previously I almost transacted a piece of intestine adhered to the linea alba I was so close to spilling intestinal contents everywhere.

Adhesions… If need be can be broken down manually or with surgical instruments via a mix of blunt and surgical dissection.

This patient had several adhesions from a prior C-section, I slowly dissected them in order to gain access to the uterus.

If your patient has had abdominal surgery before… Keep adhesions in mind and enter the abdomen carefully, as it could save you a MAJOR head ache!

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Removing the Falciform Ligament

While simple for some I didn’t do this for years!!! Why? Because I didn’t know how! I only needed to see it once for me to be comfortable doing myself. 🤯🤯 Ever since then it has made a significant difference in increasing my ability to visualise inside the abdomen. Especially the cranial abdominal structures. It is also super helpful in large and overweight patients.
So how do you do it!? 💥 The falciform ligament is attached to xiphoid as it extends caudally towards the umbilicus it is attached to the body wall on either side of linear alba. It is fed by blood vessels that arise from where it is attached near the xiphoid. 💥 After you have made your ventral midline incision from xiphoid to pubis. You cut through the thin reflections on either side of the linea alba with either electrosurgery or with scissors otherwise you can tear through it after clamping down and crushing the tissue with Carmalt clamps. When you get to the xiphoid area the fat is generally thicker and it contains the blood vessels. You can place a circumferential ligature around this and then when you tighten the ligature it can cut through the fat and ligate these vessels. Otherwise the fat can be crushed first with a Carmalt then a ligature placed. After ligature is placed you can transect the fat. If you use electrosurgery you can slowly cut and cauterize the fat and vessels, however, you must make sure you allow time for the vessels to cauterize.
After it has been removed make sure you look under to see if there is any bleeding.

If you found this useful, share it with your friends!

Cutting into the small intestine!!


Ok, this may be simple for some but some of you have not done it or even seen it. So here we go!


After isolating the segment with moist laparotomy sponges (see previous Surgery Tips) and pushing the ingesta away from that site and you can holding it back with either Doyon intestinal forceps or your assistant fingers (see previous Surgery Tip).


I usually make that incision in the aboral (or rectal) end of the object as this is usually the healthiest part of the intestine. I generally cut over normal intestine, but if the foreign body cannot be moved then at least half the of the incision through the normal intestine and half over the foreign body. An incision directly over the foreign body is not recommended because the intestine may be devitalised and therefore can impact the ability to heal which can lead to increased risks of breaking down later.


I use a scalpel to create a stab incision then I lengthen the incision with Metzenbaums, as I feel like I have more control over the incision compared to extending it with the scalpel. I also always put the instruments that enter the gastrointestinal tract (or a dirty area) into a tray to keep dirty instruments away from clean.

Want to know how to take the guesswork out of getting the temperature of your lavage fluid right? That is getting the temperature as close to body temperature as possible.

If YES then you have to thank the team at @perthvetemergency for this one. IT BLEW MY MIND when they showed me!

You can USE a LASER temperature reader to measure the temperature of your lavage fluid …. it is super quick, easy and sterile. You get them from the hardware store. Too hot?? … then add some cold, too cold … add some hot. I aim for 38.5 celcius or 101.3 fahrenheit.

Gauging the temperature of the lavage fluid by swirling your magic thermometer fingers in the bowl of lavage fluid or assessing it as it flows over your fingers into the abdomen can be subjective… Sure it might it be BUT it is still subjective.

Too hot you are inflicting pain and also giving the liver, kidneys, spleen, and gastrointestinal tract a light poach … Too cold… Then you drop the core body temperature, which leads to prolonged recovery and altered metabolism of drugs.

We are in COVID times…. All those laser forehead temperature readers you have NOW have another use after this pandemic!
Tip: You can also use it to measure how warm your hotties after too!

Your colleagues will want to know this one!. So share and tag as you see fit!

Enjoy team, G

Knowing how to occlude the intestine to help minimise leakage of intraluminal contents is critical for any surgery that involves entering the intestinal tract.

Despite the fact that most of the intestinal contents accumulate behind the obstructive process there can be fluid in the aboral end of the site of interest that can leak backward. So occluding both the oral and aboral ends is important.

While having your assistant occlude the intestine with their fingers is likely the least traumatic way of occluding the bowel, Doyen clamps (or forceps) or others that serve a similar function are really useful instruments especially when you are doing intestinal surgery by yourself.

The Doyen Forceps have some key design features:
1) Lightweight which minimises the trauma to the intestine
2) Non-crushing flexible blades with a gap in between the blades so they do not completely close when clamping down
3) Longitudinal groves to help stop slipping which minimises the amount of pressure required to keep them in place.

These features help it to occlude the lumen without crushing the intestinal wall.

Here are some tips for using them:
1) When closed the tips of the blades should not close down on or traumatise the blood vessels that are feeding the intestine of interest.
2) When clamping down, only ratchet down enough so that you have occlusion without excessive crushing
3) When manipulating and moving the intestine and/or the clamps be mindful of not traumatising the intestinal blood vessels.
4) When you remove the clamps the impressions left by the grooves should disappear after a couple minutes, if they persist for too long then the clamps may have been applied too tightly, so remember this the next time.

While Doyen clamps can be super useful, you still have to make sure you have protected the rest of the abdomen from spillage with lap sponges.

I hope you found this tip useful and helps you feel more confident using them in the future!

G.

SURGERY TIP 3: TESTING FOR LEAKS! 🤔

Do I test for leaks after closing the intestine? …. Not always

Leak testing is a bit CONTROVERSIAL. 🤔

There isn’t any specific association established between leak testing and any risk of leakage in dogs or cats. 🐕😸 I am not saying you should not do it. It may be important when you first start so that you get an idea of how well your intestinal suture placement was, but you have to be careful that you are not generating too much intraluminal pressure.

Mimicking intraluminal pressures generated during normal peristalsis is VERY DIFFICULT. Generally, you occlude a piece of intestine and inject some saline in the lumen and apply pressure to see if it leaks HOWEVER if you want to be more accurate it has been suggested that: 🤓 – Occluding off a 10cm segment of the intestine
– Injecting 12ml of saline
– Via 25g needle into the intestinal lumen
– Without applying extra pressure ….generates approximately the same intraluminal pressures that are generated during normal peristalsis. You could apply GENTLE pressure and if it leaks then apply another suture. If it doesn’t then all good. 👍👍 If we generate too much pressure we are actually SQUEEZING FLUID out of the intestinal incision line leading to unnecessary extra suture placement. Correct suture placement is the key and should be the focus, with leak testing as the backup.

If you want to leak test then sure go ahead, I can see the value in doing it, just be mindful about what you are trying to achieve.

Do you test for leaks?
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SURGERY TIP 2: KEEPING THE ABDOMEN STERILE – try a fenestrated drape!

What?? Another drape?… YES!

Let’s say you have an intestinal foreign body with a large amount of fluid accumulated behind it.

An additional method of protecting the abdomen from leakage is to use another fenestrated drape on top of your first set of drapes.

You pass the intestinal segment through the fenestration, then pack around the exteriorised intestine with moist lap sponges as per usual.

The combination of the drape which prevents large spillage from entering the abdomen and the lap sponges which absorb any local leakage help to significantly reduce any contamination from gastrointestinal contents spreading to the rest of the abdomen.

At the end, after focal lavage, you slowly remove layer by layer looking for any leakage or abdominal contamination.

Give it a go! 👍

SURGERY TIP 1: HOW BIG DOES AN EX-LAP INCISION NEED TO BE?😷 I am a firm believer that the incision must extend from the xiphoid to the pubis. The reason being is that you need to be able to assess all the organs and palpate the entire gastrointestinal tract from the stomach to the colon.

Just because you see a rock on radiographs doesn’t necessarily mean that is the only pathology present. There could be: – Two foreign bodies eg. one in the stomach that you can’t see on with imagery
– Pathology in another organ eg. spleen or liver mass, pancreatitis etc.
You definitely can’t assess all the organs properly if the incision you make is only half the length of the xiphoid to pubis. 🤓

I have seen the consequences of small ex-lap incisions:
– Missed second foreign body
– Longer surgery times and trauma to organs trying to work through small incisions with limited access to organs, one of my own cases several years ago where I caused a splenic mass to bleed more as I tried to pull it through an incision that was in hindsight, too small.

I get it might take longer to close the abdomen, but I would rather make sure I visualise and assess everything rather than miss something AND have the appropriate space and exposure to properly do what I need to do.

Nothing is more satisfying than watching your patient wake up from a procedure smoothly. Postoperatively, I always make sure the patient is covered with appropriate levels of pain relief and often opt for multimodal analgesia.
When it comes to wound healing, it occurs ‘cut edge to cut edge’ so from side-to-side, not from one end to one end. This means that an incision line that is 10cm long will heal in the same time as one that is 5cm long, so why not make it easier for yourself, and allow yourself the working space to do a thorough job.

Tip: Always warn owners how long the incisions will be before going to surgery and then again when they come down for a visit as it can be a shock to them as they are often used to keyhole incisions.

Comment and share to your friends if you found this useful!👍

This is the first of a series of VLOGS where I take you along a weekend at work. First, we tackle a Fussy Puppy on live talkback radio that is streamed across Queensland. I also learned the secret lingo of cat owners. Provided clinical advice on a lung ultrasound video from a case that @drbrookschampers was managing at @perthvetemergency. Enjoy!