Page 587 - WSAVA2018
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begin suturing at the mesenteric border as this al¬lows adequate visual¬ization of mesenteric vessels and helps prevent encircling these ves¬sels when placing the first few sutures. Any of the appositional suture patterns previously described (i.e., simple continuous or interrupted) will result in a high success rate, both in the short-term (i.e., leakage, breakdown) and long term (i.e., stricture, stenosis).
The following tips may prove helpful when performing an intestinal anastomosis (see the anastomosis video clip at www.videovet.org for detailed description of the surgery tips below:
1) First, place a stay suture to hold the mesenteric border of each segment of bowel in apposition. Tie this suture, leave the ends long, and place a hemostat on the suture end without the needle.
2) Place a second stay suture in the antimesenteric borders of each segment to be sutured to bring the ends of the intestinal segments into apposition. Place a hemostat on the ends of this suture.
3) Place gentle traction on the mesenteric and antimesenteric stay sutures to bring the two intestinal segments into apposition.
4) Using the needled segment of suture from the mesenteric stay suture, begin a simple continuous appositional anastomosis being careful to get a 3 - 4
mm bite in the submucosa and placing each suture no more than 2 - 3 mm apart (2 mm apart in cats). When the anastomosis is complete, tie the suture to the mesenteric stay suture.
5) If a simple interrupted apposing suture pattern is used, be careful to get a 3 - 4 mm bite in the submucosa and place each suture no more than 2 - 3 mm apart.
6) Evaluate the integrity of the anastomosis. The author’s preference for evaluating the integrity of anastomotic closure is to visually examine each suture to be certain that suture placement is no more than 2 - 3 mm apart and that each suture has a 3 mm bite in the submucosa.
Postoperative care
Intravenous fluids to maintain hydration and ensure renal function are continued postoperatively, until the patient begins to eat and drink. Intravenous fluids should then be tapered over a 24 to 48 hour period.
Systemic antibiotics are continued postoperatively for 5-7 days; 10-14 days in cases with peritonitis and/or sepsis.
Feeding: Early return to enteral feeding is best for the overall health of the intestine. Feeding the postoperative gastrointestinal surgical patient is generrally based on the following criteria:
a) preoperative condition of the patient
b) the condi¬tion of the bowel at the time of surgery
c) surgical procedure performed (i.e., enterotomy, anastomosis, pylorectomy)
d) presence or absence of peritonitis
e) postoperative condition of the patient.
The earlier patients can be returned to oral alimenation the better.
Complications
The most common postoperative complication of small intestinal surgery is leakage; leak is either associated with breakdown of the anastomosis or improper surgical technique (i.e., improper suture placement, inappropriate suture material, knot failure, sutures to far apart, inappropriate bite in the collagen laden submucosal layer, suturing nonviable bowel).
A presumptive diagnosis may be accomplished by the following:
1) Body temperature (may be up if acute or down if moribund).
2) Abdominal palpation: periodic, gentle abdominal palpation for pain (gas or fluid?).
3) General attitude (depression anorexia).
4) Incision: examination of the patients incision for drainage (look at cytology if drainage is present)
5) CBC: leukocytosis followed by leukopenia (sepsis), or a degen¬erative left shift may imply breakdown.
6) Glucose: low glucose generally implies sepsis (this occurs early in sepsis and may be used as a screening
test).
7) Abdominal radiographs: generally not helpful, they are difficult to critically assess due to the presence
of postoperative air and lavage fluid. It can take 1 - 3 weeks for peritoneal air to diffuse from the abdominal cavity after routine abdominal surgery. Time variation is dependant upon the amount of air remaining in
the abdominal cavity postoperatively (i.e., large deep chested animal vs a small obese animal).
8) Abdominal tap (paracentesis): a four quadrant abdominal tap is accomplished by aspirating fluid using a 5cc syringe and 20 gauge needle or placing a plastic IV catheter into the peritoneal cavity and allowing fluid to drip onto a slide. This may be the most sensitive diagnostic test for determining the presence or absence of intestinal leak.
9) Peritoneal lavage (if paracentesis is not productive): infuse 10-20cc/kg of sterile physiologic saline solution into the ab¬dominal cavity, then gently pal¬pate the abdomen and repeat the four quadrant paracentesis. This technique increases the sensitivity of paracentesis
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