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at the site of the proposed incision, gently retract the wall of the stomach until you can feel the mucosa and submucosa ‘slip’ out of your thumb and finger. The tissue remaining between your thumb and finger is the sero- muscular layer of the antral wall. With a straight or curved pair of Metzenbaum scissors cut all the tissue remaining in your thumb and finger resulting in a perfect depth of the sero-muscular incision.
Once the antral incision is completed remove the Balfour retractors. When selecting the location on
the transversus abdominus m for the gastropexy, it is important to first visualize the location of diaphragmatic muscle fibers as they radiate into the abdominal cavity and attach near the costal arch. It is important that the gastropexy site be at least 2cm caudal to the diaphragm muscle insertion. After identifying the attachment of the diaphragm, the bleeding surface of the antral incision
is brought to the right body wall. With the stomach in a normal position, the bleeding antral surface is touched
to the peritoneal wall approximately 3-4 cm deep to the abdominal wall incision and 2cm caudal to the insertion of the diaphragm. A blood mark is created on the peritoneum at this proposed location. This will be the site for the permanent gastropexy. The peritoneum and transverses abdominus muscle are then incised creating a mirror image defect of the antral incision. The incisional defect in the stomach is then sutured to the incisional defect in the abdominal wall. The defects are sutured in two layers using a simple continuous pattern with 2-0 or 3-0 monofilament or multifilament synthetic absorbable suture.
Belt Loop Gastropexy: This technique is based on the construction of a sero-muscular antral flap attached around a segment of transversus abdominus muscle. A horseshoe shaped incision is made in the serosal layer of the antral portion of the stomach with its base at the greater curvature. The sero-muscular portion of the stomach is identified by grasping full thickness antral wall between the thumb and index finger and “slipping” the mucosal and submucosal layers away so only the sero-muscular portion of the wall remains between thumb and finger. The sero-muscular layer is incised with scissors and the horseshoe shaped sero-muscular antral flap is dissected and elevated of the submucosal layer. The stomach is replaced in the abdominal cavity in normal position and the sero-muscular flap lined
up with the transversus abdominus muscle. Once this optimal location is discovered, two longitudinal incisions (along the fibers of the transversus m.) are made in
the transversus abdominus m. The segment of muscle between the incisions is undermined. The sero-muscular flap from the stomach (i.e., belt) is passed through the transversus abdominus m. (i.e., loop) and sutured to itself to complete the “Belt-Loop” gastropexy. 2-0 or 3-0 monofilament absorbable synthetic suture in a simple interrupted or continuous pattern is used to secure
the flap in place. Advantages of belt loop gastropexy include: it is relatively easy to perform alone and in the middle of the night, it can be performed quickly, and it is an effective means of permanent gastropexy.
Postoperative management:
In most cases 3 to 4 days of intensive monitoring is necessary for the successful management of GDV patients. Postoperative considerations are listed below:
a. Shock is a postoperative possibility and the patient should be monitored and treated accordingly.
b. Patients are generally held off food and water for 24 hours fol¬lowing surgery. During this time maintenance fluids should be supplied using polyionic isotonic crystalloid fluid. Vomiting may occur following surgery; the NPO period should be extended accordingly. Gastritis and gastric motility disorder may be seen in post op GDV patients.
c. After 24 hours of no vomiting, oral alimentation should begin gradually with
a sequence of ice cubes, water, and finally canned dog food. This should occur over a 2-3 day period.
d. Antibiotics should be continued for 7 - 10 days.
e. Routine surgical complications such as infection, dehiscence, seroma, etc. should be watched for and treated accordingly.
f. EKG monitoring: the most common severe postoperative complication is cardiac arrhythmia. Ap¬proximately 75% of GDV patients will develop arrhythmia’s in the immediate postoperative period. Arrhythmia’s can be present at the initial time of presentation but most often occur within 24 - 72 hours after surgery. Ventricular premature contractions, progressing to ventricular tachycardia is most common. Etiology is unknown but shock, hypoxia, acid base alterations, endotoxins, myocardial depressant factor (MDF), reperfusion injury, release of free radicals, and hypokalemia have been identified. Occurrence of
a total body potassium deficit has been proposed. Etiology of the hypokalemia includes anorexia, vomiting, tremendous outpouring of potassium rich fluids into a dilated stomach, and use of potas-sium poor fluids in treatment of shock. For this reason, ad¬ding 20-30 mEq of potassium chloride per liter of maintenance fluids during and after surgery are recommended.
g. Gastric motility: occasionally GDV patients will develop postoperatove gastric motility abnormalities. Patients with gastric hypomotility or gastric stasis should be treated with a motility modifier (i.e., metaclopramide, erythromycin, etc).
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