Page 585 - WSAVA2018
P. 585

of strength in the small intestine; this layer must be incorporated into any small intestinal closure.
5) It may be difficult to visualize the submucosal layer due to mucosal eversion. Visualization of submucosa may be enhanced if everted mucosa is trimmed away.
6) Intestinal contents should be “milked” away from the anastomosis site. Intestinal clamps (e.g., Doyen intestinal clampS, Alice tissue forceps with a rubber feeding
tube interposed, hair clips, or Penrose drains) may be used to prevent intestinal contents from contaminating the surgical site whilst manipulating intestine during anastomosis.
7) The anastomosis should be irrigated prior to its return to the abdominal cavity and instruments and gloves changed prior to abdominal closure.
8) Abdominal lavage with 2-3 liters of body
temperature, sterile, physiologic saline solution should be ac¬complished prior to closure. The ob¬jectives of repeated abdominal lavage include dilution of bacteria and endotoxin and mechanical removal of fibrin and necrotic debris. The fluid of choice is body temperature, sterile, physiologic saline solution with no additives
(i.e. betadine solution, chlorhexidine, antibiotics, etc). Lavage solution is poured into the abdominal cavity using a sterile stainless steel bowl, the abdominal viscera gently aggitated, and fluid and debris suctioned out
with a suction device and a Poole suction tip. Injecting antimicrobials or other products into the abdominal cavity is not recommended.
Suture Material
Absorbable suture
Catgut. Catgut is NOT recommended for any visceral organ surgery. Its unpredictable absorp¬tion and rapid loss of tensile strength in such situations may result in an unacceptably high number of anastomotic leaks and /
or breakdowns. Use of catgut suture in gastrointestinal surgery is not recommended.
Dexon, Polysorb, and Vicryl. Synthetic absorbable braided suture (i.e., polyglactin, poly-glycolic acid) have become very popular. The braided nature however does result in increased tissue drag and difficult knotting ability.
Biosyn and Monocryl. These sutures have similar properties to Dexon, Polysorb and Vicryl however
they are monofilament. They were developed to overcome the problem of tissue drag and knot slipping found in the braided synthetic absorbables. Their predictable hydrolytic absorption is unaffected by their immediate environment (i.e., in¬fection, contam-ination, hypoproteinemia). They retain high tensile strength for
a long period of time (2 3 weeks) and have very good handling characteristics. These suture materials are ideal
for use in gastrointes¬tinal surgery. These sutures are the authors choice for gastrointestinal surgery.
PDS and Maxon. PDS and Maxon, are synthetic absorbable monofilament suture materials with similar properties to that of Dexon and Vicryl. They have
been shown to retain approximately 70% of their
tensile strength at 3 4 weeks, and are absorbed by hydrolysis (unaffected by infection, con¬tamination, hypoproteinemia). These suture materials are ideal for use in gastrointes¬tinal surgery. Possible disadvantages include stiffness, a tendency to kink and prolonged absorbtion time.
Nonabsorbable suture
Nylon, Polypropylene. Monofilament, nonabsorbables are excellent suture materials for use in contaminated or infected surgical sites. They have a high tensile strength, are relatively inert in tissue, noncapillary, and do not act as a nidus for infection. These materials pas¬s through tissue with essentially no tissue drag and have ex¬cellent knot tying security at sizes 3 0 to 5 0.
Silk, Mersilene, Bronamid, Vetafil. Multifilament nonabsorbable sutures should NEVER be used in gastrointestinal surgery. They may harbor infection for years and may result in suture related abdominal abscesses or draining tracts.
Suture size
For the majority of small intestinal surgical procedures in dogs, 3 0 or 4 0 size suture material is adequate; in cats, 4-0 is recommended. The tensile strength of this size suture is greater than the tensile strength of the tissues that are being sutured (i.e., intestinal wall). Larger size suture may contribute to anas¬tomotic failure by increased trauma to tissues and its effect on the blood supply of tis¬sue margins.
Needles
Swaged-on “atraumatic” reversed cutting, narrow taper point, or fine taper cut needles can all be used for gastrointestinal surgery. The author prefers a narrow taper point needle. Needle diameter should approach the diameter of the suture.
Suture Placement
When suturing intestine, sutures should be placed 3-4 mm from the cut edge of the intestinal serosa and no more than 2 -3 mm apart. It is important to recognize everted mucosa and be sure the 3 - 4 mm bite in the intestinal wall is not just in mucosa but engages all layers of the intestinal wall. Measure your intestinal wall bite from the cut edge of the serosa.
Suture Patterns
Your Singapore, the Tropical Garden City
        583
            

































































   583   584   585   586   587