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Surgery Exam 2

STUDY
PLAY
Where does the vein for the left ovary come from?
Comes off of the left kidney's vein
How is doing a Buccal Mucosal Bleeding Time test related to the kidney?
Uremia may impair platelet adhesions/aggregation
What is included in a diagnostic plan for the kidneys?
CVC, biochemistry panel, coag panel, BMBT, UA, urine culture, blood pressure, thoracic rads
Which lateral, R or L, is best to do a abdominal radiograph for the kidneys?
Right lateral
What does an excretory urograph tell you?
The quality of urination rates
What should you note about the contrast given when doing an excretory urograph?
Iodinated contrast is renal toxic
What is the time course of the different shots during an excretory urograph?
Taken at 0 min (base), 5 min (angiograph), 20 min (renal), and 40 min (excretory)
What is pyelography?
Injection of contrast directly into the renal pelvis
What is ultrasound good for when assessing the kidneys?
Good for architectural changes, dilated renal pelvices, US guided biopsy
How can you evaluate the vasculature of the kidneys?
CT angiography is supior to an EU
What is scintigraphy used for when assessing the kidneys?
Glomerular filtration rate
If you are removing a kidney, what is a good test to perform and why?
Scintigraphy; Test the GFR of each individual kidney to assess the impact of removing a kidney
What are the basic preoperative considerations you should make before performing kidney surgery?
Correct pre-existing problems if possible or be aware of them if you cannot, oncotic support, monitor urine output, avoid nephrotoxic drugs, avoid drugs that cause hypotension, may need drugs to of set hypotension, epidurals can reduce anesthetic requirements
How much of CO do the kidneys get and why is this important to note?
25% of CO; they can hemorrhage a lot, and proper blood volume is necessary to keep them properly perfused
What are some post-operative considerations for renal surgery?
Intravenous fluids, analgesia, monitor urine output and weight of the animal, monitor blood pressure, monitor for systemic issues like uremia (biochem, CBC and platelets, etc . . .)
What are the congenital kidney defects discussed in class?
Agenesis or dysgenesis, renal ectopia, fusion, polycystic kidney disease
What is the difference between agenesis and dysgenesis of the kidneys?
Agenesis - ureter absent; dysgenesis - ureter present
Where are the kidneys located when you have renal ectopia?
Originate near the aortic bifurcation and "ascend"
Are the kidneys still functional in cases of renal ectopia?
Position doesn't affect function
Describe kidney fusion:
"Horseshoe" shaped; normal function
What is the main problem with congenital defects of the kidneys?
They are often accompanied with other congenital defects
What breed is polycystic kidney disease common in?
Persian cats; reported in other purebred cats; rare in dogs
Describe the pathogenesis of polycystic kidney disease:
Originate from renal tubular cells, compress surrounding parenchyma and lead to renal failure; treatment unsuccessful
What is the only way of treating polycystic kidney disease?
Kidney transplant
What are the acquired renal disorders talked about in class?
Renal neoplasia, acquired renal cyst, perirenal pseudocyst, renal abscess, renal trauma
How common are primary renal tumors?
Primary renal tumors are rare
Are renal tumors benign or malignant?
Majority are malignant
What is the most common renal tumor in cats?
Lymphoma
What is the most common renal tumor in dogs?
Renal cell carcinoma
What is the treatment of choice for renal neoplasia?
Nephrectomy; partial nephrectomy is the opposite kidney is diseased
Are acquired renal cysts real cysts?
They are epithelial lined
How do you treat acquired renal cyst?
US guided draining and ethanol infusion described
What are perirenal pseudocysts?
Fluid between capsule and parenchyma
What is associated with perirenal pseudocysts?
Linked with chronic renal disease
What species is perirenal pseudocysts more common?
More in cats
What are renal abscesses associated with?
Pyelonephritis, nepholiths, renal biopsy, hyperadrenocorticism, DM
How do you treat renal abscesses?
Supportive care and nephrectomy
What is the best way to treat renal trauma?
Manage them conservatively, better than going to surgery
When should you use renal biopsies?
Only if results will change the course of action
What are the possible techniques at getting a renal biopsy?
Percutaneous (blind), US guided, Key-hole (flank), laparoscopic, laparotomy
If doing a laparotomy to gain a renal biopsy, what should you remember?
Occlude the renal artery to control bleeding;
What are laparotomy renal biopsies used for?
Wedge or incisional biopsies
What size of needle should be used for renal biopsies?
14-18 gauge
When is partial nephrectomy indicated for?
In animals with renal insufficiency or previous nephrectomy, isolated lesion or trauma
Describe the technique of a partial nephrectomy:
Occlude renal artery and vein, excise tissue, close pelvis, cover defect (renal capsule, omentum, or hemostatic sealants (fibrin, aldehyde, cyanoacrylate glue))
What should you always remember about the kidney when doing surgery?
Major bleeding is possible, the kidney has a capsule
What are the indications for nephrectomy?
Trauma, persistent infection, renomegaly, obstructive calculi with persisten hydronephrosis, neoplasia, kidney donation
What are two things to remember about when considering a nephrectomy?
Make sure contralateral side is normal, pay attentions to vascular anatomy (bleeding)
What are the most common type of uroliths?
Calcium oxalate most common
If an animal has azotemia, what does this mean?
Means both kidneys are affected
What is part of a complete workup for uroliths?
Symptoms and lab work changes may be absent, culture the urine, image the entire urinary tract
How successful is medical management alone of uroliths?
66% successful
What is involved in medical management of uroliths?
Diuresis, drugs to induce ureteral relaxation (Calcium channel blockers, glucagon, amitriptyline
In cases of uroliths, what are the indications for renal surgery?
Comprimised renal function, hematuria, pain, UTI, obstruction
What are the surgical options for dealing with uroliths?
Lithotripsy (dogs only), nephrectomy, pyelolithotomy, ureterotomy, ureteral resection and anastomosis, ureteral reimplantation, nephrotomy
Describe the nephrotomy procedure?
Unilateral only (stage if bilateral), release kidney from retoperitoneum, occlude vessels, incise capsule, intersegmental vs bisectional nephrotomy
T or F - There are effects on GFR when performing a nephrotomy:
Inconsistent finding; Basically do this only if there is a strong need to do it
What happens when closing a nephrotomy site?
Digital compression is required for 5-10 minutes while blood flow is restored; then the capsule is closed with a simple continuous pattern but the suturues are not placed through the parenchyma
What is pyelolithotomy?
Removing a stone from the renal pelvis
What is ureteral anastomosis indicated for?
Indicated for ureteroliths or trauma
When dealing with the ureters, what should you remember?
The ureters don't like being handled; react a lot
What are the risks of ureteral anastomosis?
Leakage, obstruction/stricture
How can you combat strictures in ureters?
Spatulate the ureter ends before anastomosis
What is the complication rate of ureteral re-implantation?
Lower complication rate than ureteral R and A
What is the procedure of a Ureteral Re-implantation?
Abnormal portion of ureter removed, distal end spatulated, sutured to the bladder mucosa/submucosa
What are the risks associated with ureteral catheters?
Stranguria, imperfect location, ureteral trauma, UTI
What do ectopic ureters produce?
Urinary incontinence
Who are predisposed to ectopic ureters?
Dogs, females, skye terriers, Golden retrievers, labrodor retrievers, huskies
What other anomalies are ectopic ureters associated with?
Hydroureter, renal dysgenesis, vestibulovaginal abnormalities
What can you do to diagnose ectopic ureters?
Must rule out other disease (Survery rads, UA, and culture), US, contrast-enhanced rads, contrast CT (most sensitive), cystoscopy
What is the difference between intramural and extramural ectopic ureters?
Intramural means the ureter travels in the wall of the bladder and urethra for awhile before opening into the urethra farther down; Extramural is not in the wall
What are the possible options for surgically treating ectopic ureters?
Cystoscopy-guided laser ablation, cystotomy (intramural - incise and suture ureter to bladder mucosa; extra-mural - reimplant ureter into bladder)
Describe the procedure of treating an ectopic ureter?
Identify the ureteral orifice, incise across the bladder wall into the lumen of the ureter, opening of the ureter is sutured to the bladder mucosa, distal ureter is ligated, sutured closed or removed
Why might an animal have postoperative incontinence after ectopic ureter surgery?
Abnormal function of urethral sphincter mechanism
What is a neouretercystotomy?
Basically creating a new hole in the bladder for the ureter to go through
Define a ureterocele:
Prolapse of a ureter into the bladder, may cause an obstruction of urine
What are the advantages of performing a cystoscopically guided laser ablation over open surgery for ectopic ureters?
Reduced postoperative pain and hospitalization
What is the indication for feline renal transplant?
End stage renal disease unresponsive to medical therapy
What is the survival rate of patients receiving a feline renal transplant?
77.5% survive to discharge
What may be required in acute renal failure or ethylene glycocl toxicity situations?
Hemodialysis
Describe what is included in feline renal transplant preoperative screening:
CBC, Chem panel, Blood type (and match to donor), thyroid hormone, UA/culture/prot:creat, Abdominal rads and US, Cardiac workup, infectious disease screening: FeLV, FIV, Toxoplasmosis
What things are contraindicated for Feline Renal Transplant?
Neoplasia, CHF, FeLV or FIV, Recurrent/existing UTI, Uncontrolled hyperthyroidism, fractious temperament
What are the three things that make feline renal transplant a long term commitment?
Financial, Emotional, Long-term care
How do you immunosuppress the cats that receive renal transplants?
Cyclosporine and prednisolone; ketoconazole
Why is ketoconazole given along with the immunosuppression drugs for renal transplants?
Inhibits cytochrome P450 so less cyclosporine has to be given (not degraded as fast)
Which kidney is typically transplanted and why?
Left kidney; longer vein
Where is the transplanted kidney typically anastomosed to?
To the caudal aorta and vena cava
What solution aids in preserving organs between transplants?
Phosphate-buffered sucrose organ preservation solution
Why must cyclosporine levels be monitored in a transplant case?
There is a 12 hour trough you have to assess so that the cat doesn't start rejecting the kidney
How are the vein and artery anastomosed to the aorta and vena cave in renal transplants?
End-to-side anastomosis
How small of suture is being used for the anastomosises of the vessels in transplants?
8-0, 7-0
When they remove the ureter of the kidney to be transplanted, what is taken with it?
Part of the wall of the bladder, lessens any risk of stricture when placed in the recipients bladder
Name complications that can occur with renal transplants:
Hemorrhage, graft thrombosis, ureteral obstruction, delayed graft function, acute rejection (13-26%), chronic rejection, hemolytic uremic syndrome, urolithiasis, retroperitoneal fibrosis, immunosuppression complications (infection, Diabetes mellitus, neoplasia)
How more likely is an drug immunosuppressed cat from renal transplant to get Diabetes mellitus? Lymphoma?
5x more likely; 6x more likely
What is a possible complication of laser ablation of ectopic ureters?
You go too far and create a hole in the bladder
Why are dogs not good candidates for renal transplant?
They don't stop rejecting kidneys
What is a main thing to consider when assessing for renal transplants in cats?
If there are signs of problems in both kidneys that point to a systemic issue, a new kidney is not going to help
Where do the transplant donor cats come from?
Cats raised in a pathogen free environment
In order to reduce risk of damage to the donor kidney, how long can the surgery be?
One hour or less
What is one of the main reasons cats only leave the hospital after renal transplants 77% of the time?
Acute rejection
What is one of the most common long term complications of feline renal transplant?
Neoplasia
What are possible diagnostics for assessing the urinary bladder?
Cystocentesis (cytology and culture), Rads, contrast rads, US, contrast enhanced CT, cystoscopy, catheter biopsy
What conditions can cystoscopy be used therapeutically for?
ectopic ureters, cystic calculi, collagen injection
How can you avoid tissue trauma when operating on the urinary bladder?
Stay sutures (not forceps), cold saline for hemostasis (not electrocautery), saline and suction to increase visibility (not gauze sponges)
When doing any body cavity surgery, what should you do when exteriorizing an organ that can leak?
Pack off the cavity
What are indications for a cystotomy?
Calculi, repair trauma, biopsy/resect masses, ectopic ureters
Why is doing a cystotomy good for getting tissue samples and culture?
Can get a full thickness biopsy, culturing the wall of the bladder can identify bacteria that are being harbored there
Why must we engage the submucosa when closing a cystotomy site?
The submucosa is the holding layer
When closing the bladder cystotomy, what is one important thing to note?
Don't go over kill
Name complications associated with cystotomy:
Hematuria, uroabdomen, UTI, stones
How long is hematuria post-cystotomy acceptable?
1-2 days post surgery
When excising a portion of the bladder, what should you remember to do?
Preserve the trigone
What are indications for cystectomy?
Excision of patient urachus/urachal diverticulum, discrete bladder neoplasia or polyp, bladder trauma/necrosis
What is a common side effect or complication of a cystectomy?
Pollakiuria common (>75%); the bladder will regain size with time though
What do you do with ureters if performing a cystectomy?
Can reimplant the ureters
How can you decompress a bladder before a cystectomy?
Use a Foley catheter
What is the basic way of dealing with bladder trauma?
If necrotic, debride the edges and close it like a cystotomy but again, preserve the trigone
What are indications for a cystostomy?
Stabalize (Lower urinary obstruction), bladder or urethral trauma, obstructive disease (neoplasia), neurogenic bladder atony
What are your short term options for a cystostomy?
Foley or mushroom tip catheter
What are your options for a long term cystostomy?
Low-profile silicone gastrostomy tube
Describe the basic technique of placing a cystostomy catheters:
Paramedian position, purse-string suture in bladder wall, catheter passes through purse-string into bladder, Dr. Colopy says never to pexy the bladder because what happens if you want to further surgery
What are some complications of cystostomy catheter placements?
UTI, Cystic calculi
What is the main consideration of dealing with UTIs after a cystostomy catheterization surgery?
Don't want to promote resistant bacteria; culture and treat intermittently, avoid continuous antibiotics
What are the indications for a cystopexy?
Perineal hernia, incontinence (mixed results), cystostomy tube (she says never do it)
What are the three options for performing a cystopexy?
Incisional, tube cystopexy, laparoscopic assisted
Name the congenital conditions of the bladder discussed in class:
Patent urachus, vesicourachal diverticulae (most common), bladder hypoplasia
What is a patent urachus?
Communication between the bladder and the allantoic sac
How do you diagnose the congenital bladder issues mentioned in class?
Contrast cystography
What are ways the bladder can sustain trauma?
neoplasia, trauma, iatrogenic, obstruction
Name symptoms of bladder trauma:
Hematuria, anuria, dysuria, abdominal bruising, abdominal pain, systemically ill
Name the metabolic changes associated with bladder trauma:
Azotemia, dehydration, metabolic acidosis, hyperkalemia
If you do an abdominocentesis and find that the urea and creatinine are higher than serum creatinine, what has happened?
Ruptured bladder (remember though that there is really nothing that points to uroabdomen alone)
How can you determine the source of a uroabdomen?
Cystourethrogram or Excretory Urogram
How do you treat bladder trauma?
If it's a small tear, can catheterize and let it heal on its own; Supportive care, cystostomy tube; possibly surgery; Must be stabilized before surgery; Resect unviable tissue and close; consider wrapping with omentum
What is another name for calcium oxalate?
Struvite
How can you retrieve and remove a cystic calculi?
Routine cystostomy, catheter assisted, cystoscopic, laparoscopic assisted, lithotripsy
What is lithotripsy?
Breaking up of urinary system stones via sound waves
What are the things important to do before and after removing stones form the bladder?
Need pre-op radiographs immediately before surgery; pass a catheter anterograde and retrograde to ensure all removed, post-op radiographs, submit stones for analysis, bladder wall for culture
How polypoid cystitis situations Neoplastic?
No (but must biopsy)
What is polypoid cystitis associated with?
UTI, calculi, etc . . (basically irritation)
What are symptoms of polypoid cystitis?
Hematuria, stranguira, UTI
What is the key with dealing with polypoid cystitis?
Need to treat the underlying disease
How common is polypoid cystitis?
Rare
How common are bladder neoplasias?
Rare
What is the most common bladder neoplasia?
Transitional cell carcinoma
Where do bladder tumors most commonly reside?
Trigone predilection
What diagnostics can you do to look for tumors of the bladder?
Image bladder, biopsy, thoracic rads, pelvic rads, CT, abdominal US
What is included in treatment of bladder tumors?
Possibly surgery, chemotherapy, NSAIDs, radiation
Describe the differences in the urethra between male and female:
Male - long and thin, Female - short and wide
What do you associate an Urinary Tract Obstruction with?
Emergency; uremia within 3-5 days; death within 5-7 days (owners may confuse with constipation)
What are presenting signs of urethral disease?
Stranguria, dysuria, pollakiuria, hematuria, uremia, metabolic acidosis, hyperkalemia (cardiac signs)
What are the signs associated with hyperkalemia?
Bradycardia, Absent or small P waves, prolonged QRS width and PR intervals, Spiked T waves, ventricular arrhythmias; the more and more hyperkalemic they become, the more and more unrecognizable the QRS complexes
What are the consequences of a prolonged UTO?
Increased pressure on the bladder causes loss of detrusor function, bladder necrosis, death (5-7 days post obstruction)
What are possible causes of UTO?
Calculi, stricture, mass lesions, bladder herniation, urethral spasm (not very common)
What is part of initial treatment of an UTO?
Evaluate hemodynamic status, correct metabolic derangements (initiate dieresis, LRS better than NaCl), decompress the bladder (Urethral catheter - preffered, cystocentesis - may rupture the bladder due to necrosis, tube cystotomy)
How can you image the urethra?
Plain rads (rarely diagnostic), positive-contrast urethrocystography (filling defects, contrast extravasation), US (only extrepelvic), CT scan or MRI, Urethroscopy
What can you do temporarily alleviate an UTO?
Hyropropulsion
What is hydropropulsion?
Increasing the size of the urethra with fluid and then forcing up more saline to shoot the blockage up to the bladder; always assess with rads
When can you use hydropropulsion?
When the stone or blockage is smaller than the urethral diameter
Where are two places calculi often obstruct the urethra?
Ischial arch, caudal to os penis
When attempting surgery for an UTO, what should you remember?
Avoid anesthesia until patient stabilizes
What are possible ways of diverting urine around a blockage?
Cystostomy or transurethral catheter; intact bowel or isolate segment (high complication rate)
What are the two most common ways to deal with a UTO surgically?
Urethrotomy, Urethrostomy
Describe the general process of a male urethrotomy?
Catherterize the urethra, incise on midline of urethra (move retractor penis muscle laterally), remove calculi, catheterize anterograde and retrograde, leave it open or suture
Why might leaving the incised urethra open during a urethrotomy be a good idea?
Some feel it reduces the risk of stricture; not proven - more complications if you leave it open and let it heal by second intention
What are possible locations for a urethrotomy on a male dog?
Prescrotal (preferred), perineal, prepubic
What are indications for an urethrostomy?
Recurrent obstructions, permanent urethral damage, malignant neoplasia
What are the locations for an urethrostomy in male cats?
Perineal or prepubic
What are the locations for an urethrostomy in male dogs?
Prescrotal, scrotal , perinea, or prepubic
What are the locations for an urethrostomy in female cats and dogs?
Prepubic; No done much in female cats and dogs
What is the prognosis of Transitional cell carcinomas?
Poor
How does performing a perineal urethrostomy help with UTO in male dogs?
Decreases the potential for UTO, less length of urethra, does not eliminate the risk though
Describe the process of a perineal urethrostomy?
Elliptical incision around scrotum and prepuce, perform castration, elevate origin of ischiocavernosus muscles, transect vetral penile ligament, free pelvic attachments to level of bulbourethral glands, retractor penile muscle is transected, sever penis proximal to reflection of prepuce, incise urethra to level of bulbourethral glands; Use tension free closure to attach the urethra to the skin; want a nice wide open urethra (they will shrink down a lot)
Why do we take down the ischiocavernosus muscles and transect the ventral penile ligment when performing a perineal urethrostomy?
Provides a lot of mobility to the urethra; a lot of failures for this procedure are due to not taking down these attachments
When doing a perineal urethrostomy in cats, what should you remember?
Opening should accommodate a mosquito forceps, use figure-8 skin sutures
What are possible complications of perineal urethrostomy procedures?
Hemorrhage, SQ leakage of urine, infection, stricture, urine scalding (dogs), UTI (you are basically turning a male into a female)
What is the main enemy to perineal urethrostomies?
Tension, need to take down urethra attachments enough to allow mobility
Is a perineal urethrostomy in a dog the preferred site?
No, not cosmetically appealing, urine scald
Describe the procedure of scrotal urethrostomy?
Place a catheter retrograde, circumferential incision around scrotum (castrate if needed, leave adequate skin to avoid tension), fix retractor penis muscle laterally, fix SQ tissue to tunic, incise urethra on midline, suture skin to urethra (non-absorbable); penile amputation??
What are complications associated with a scrotal perineal urethrostomy?
Hemorrhage (3-5 days is typical), Stricture (normally reduces 1/3 to ½), urine scald, dehiscence, UTI
Who can have prepubic urethrostomy procedures done?
Male or female cats or dogs
What is a prepubic urethrostomy procedure basically?
A salvage procedure for recurrent peliv obstruction, failed perineal urethrostomy, neoplasia
What are the basics of a prepubic urethrostomy?
Preserve maximal length of functional urethra (innervation runs around there), midline position in female and male cats; Paramedian in male dogs with partial prostatectomy, avoid acute bend in urethra, spatulate urethra and suture to skin (epithelium to epithelium); may lay the urethra along the skin to get the largest opening they can
Name complications with a prepubic urethrostomy:
Skin irritation and necrosis, incontinence, obstruction (kinking of urethra), stricture, bacterial cystitis
Out of 16 cats given a prepubic urethrostomy, how many are euthanized within 2 years?
6 out 16 cats
Name possible causes of urethral trauma:
Motor vehicle accidents, dog bit wounds, urthral calculi, urethral neoplasia, iatrogenic
How do you treat incomplete urethral tears?
Catheterization; leave it in 2-3 weeks, evaluate for infection when catheter removed
What is a complication when dealing with urethra trauma?
Stricture
How do you treat complete tears of the urethra?
Anastomosis
Describe a simple anastomosis of an urethral tear?
Approach from the abdominal, pelvic osteotomy, or perineal region, debride ends, close with single layer, minimize tension, possibly place a urethral catheter
How do you manage an urethral trauma case post-operatively?
Maintain catheter (urethral or cystostomy), dieresis, evaluate at regular intervals until healed, if there are complications - go to salvage procedures
What are the most common neoplasias of the urethra?
Transitional cell carcinoma, Squamous cell carcinoma
What are the treatment options for urethral neoplasia?
Surgery, Tube Cystostomy, Urethral stenting
How do urethral stents work?
Self-expanding metallic nitinol stents, 1 cm cranial and caudal to the obstruction
What is the signalment for urethral prolapses?
Young, male brachycephalic dogs
What are urethra prolapses related to?
Increased abdominal pressure
Name the treatment options for urethra prolapses?
Manual reduction (urethral catheter and purse-string suture), resection and anastomosis (urethral mucosa retracts), Urethropexy
What is one thing to remember when performing surgery to correct a urethra prolapse?
Suture the urethra to the skin ahead of time so you don't lose it
How is a urethropexy performed?
Prolapse is reduced with a groove director; 1-3 full thickness absorbable sutures are passed from the exterior of the penis, into the lumen, and back out
Name the urethral congenital anomalies discussed in class:
Hypospadias, Epispadia, Urethrorectal fistula
What is hypospadias?
Failed fusion of urogenital folds (incomplete closure of urethra in males)
What is epispadia?
Incomplete closure of dorsal urethra
What is urethrorectal fistula?
Failed fusion of urorectal fold so the urethra and rectum are continuous
What conditions contribute to urinary continence?
Tone of smooth and striated muscle, elastic tension within the wall of the urethra, intraabdominal pressure, length of the urethra
What is another name for spay incontinence?
Urethral Sphincter Mechanism Incontinence
How can you medically manage spay incontinence?
Estrogen (Diethylstilbestrol), Alpha agonist (phenylpropanolamine), Anticholinergics (oxybutynin)
What role does estrogen play in urinary continence?
Gives tone to the urethra
What do anticholinergics do for urinary incontinence?
Suppress spastic bladder and urine retention
Describe the side effects Diethylstilbestrol has?
Bone marrow suppression
Describe the side effects Phenylpropanolamine has?
Hypertenstion, diarrhea, hyperexcitability
Describe the side effects Oxybutynin has?
Vomiting, ileus, constipation, urine retention
Does medical management always work for dealing with spay incontinence?
Some dogs fail to respond or become refractory
Why would you want to relocate a pelvic bladder to treat urinary incontinence?
Put intraabdominal pressure on the urethra
What are the three procedures mentioned to relocate a pelvic bladder?
Colposuspension, urethropexy, cystopexy
What can be done surgically to increase urethral resistance to treat urinary incontinence?
Periurethral surgical slings, artificial sphincters, intraurethral bulking agents (collagen most common)
What is done in a colpsuspension?
Cranial vagina is fixed in an intraabdominal position; exposes bladder neck to intraabdominal pressure
What is the success rate of colpsuspension to treat urinary incontinence?
50-70% success
If using collagen for treating spay incontinence, what is one thing to remember?
It has to be repeated so incontinence in a young dog would not be a good situation for this (you can't keep going in there and shooting in collagen without consequence)
What are the basic problems with using artificial sphincters?
Either they are too loose (don't work), or they are too tight (cause an obstruction)
Is a recessed vulva related to early age OHE?
No evidence that dogs with early age OHE are predisposed to recessed vulvas
What are associated problems with recessed vulva?
Perivulvar dermatitis, urinary tract infection, urinary pooling/incontinence
What is the procedure to fix a recessed vulva?
Episioplasty for recessed vulva
What is the basic procedure of an episioplasty for recessed vulva?
To half moon incisions in skin (one right above the vulva and one out farther), then move the skin basically (a skin flap move)
What are some considerations you want to cover when doing diagnostics in the chest?
Is something in the chest the problem, what can be done to help the problem, if there is something even resectable (is surgery even worthwhile)
What is the most common approaches to entering the thorax?
Intercostal thoracotomy
What can you see on a left sided intercostals thoracotomy? Right sided?
Left - left side of heart, PDA, pulmonary artery, caudal esophagus, Right - trachea, cranial esophagus
What is the basic procedure for entering the thorax laterally?
Skin, Latissimus dorsi and pectorals, scalenus (or ext. abdominal oblique), serratus ventralis, intercostals muscles and pleura, finochietto retractor
How do you re-establish negative pressure after opening up the thorax?
Thoracotomy tube (one way valve)
What is the advantage between intercostals sutures and transcostal sutures when re-establishing correct orientation of ribs after thoracic surgery?
Transcostal sutures may have less pain involved (don't impinge on vessels and nerves)
What is median sternotomy good for?
Preferred approach for exploratory surgery
What is lying directly under the pericardium on a median sternotomy approach?
The right ventricle
What can you get good access to with a median sternotomy?
heart and pericardium as well as both hemithoraxes
What is used to repair a sternotomy?
Wire (figure-8 pattern for superior mechanical strength
When closing thoracic approaches, what should you remember?
All the muscle layer and skin are closed separately
How long is a thoracic drain maintained after thoracic surgery?
12-24 hours; checked every hour until negative and then every 4 hours or so
What are possible ways to provide analgesia for a thoracotomy?
Systemic opioids, NSAIDs and such, Epidural, intercostals nerve blocks, intrathoracic bupivacaine
What are the surgical conditions of the thoracic wall mentioned in class?
Pectus excavatum, trauma, infection (bacterial or fungal), foreign body/migrating grass awn, neoplasia
What is pectus excavatum?
Developmental defect with concave caudal sternabrae (can be asympotomatic or restrict thoracic volume)
What is conservative way to treat pectus excavatum?
Suture the sternabrae to an external splint
When correcting restriction to the lungs and thorax, what is one important thing to remember?
When you have a chronic lung collapse, re-expansion upon correction can lead to fatal pulmonary edema
What can impair respiratory function after trauma?
Pulmonary contusions or lacerations, hypovolemia, myocardial contusion, pleural fluid/air, diaphragmatic hernia, rib fractures/flail chest
Which is more serious, damage to lungs or rib fractures?
Damage to lungs
When dealing with thoracic trauma, what is an indication to go to surgery?
Ongoing hemorrhage, pneumothorax, sepsis
Do you have to surgically repair rib fractures?
No, most don't require repair
When dealing with fractured ribs, what indicates surgery is necessary?
Devitalized (remove), laceration of underlying lungs, functional defect (flail chest)
How can you treat flail chest?
External brace attached to the broken ribs
T or F; Most thoracic wall neoplasias are benign:
False; most are malignant
What tumors were listed for thoracic wall neoplasia?
Chondrosarcoma, osteosarcoma, fibrosarcoma, nerve sheath tumors (these are all often firm and immobile), cutaneous or subcutaneous mast cell tumors
What is the survival time for thoracic wall osteosarcoma? Chondrosarcoma?
Osteosarcoma - 290 days; Chondrosarcoma (LONG time)
What are the rules for resection of masses in the thoracic wall?
3 cm margins, ribs if boney involvement, entire rib if marrow involvement; ligate intercostals vessels, max of 6 ribs
What are your options for thoracic wall reconstruction?
Apposition of remaining ribs, rotation of muscle and skin flaps, placement of mesh
When placing mesh over a thoracic area, what should you cover it with?
Cover with muscle (if available), don't just place over skin; use omental pedicle flap to pad/protect mesh
Why should the mesh be covered on a thoracic reconstruction?
The mesh is permeable and if exposed to the air (if skin dehisceses), you have an immediate pneumothorax
What muscles can be used for muscle flaps in a thoracic wall reconstruction?
Latissimus dorsi, external abdominal oblique, transverses abdominis, diaphragm
What are potential consequences of using a mesh on the chest?
Source of infection and have to be removed, may work through the skin and cause a pneumothorax
Define the parameters for a transudate, modified transudate, and an exudates?
<2.5 protein, <1500 cells; 5>x>2.5, 7000>x>1500; >3, >7000
What are possible causes of a pure transudate?
Hypoprotienemia, CHF
What are possible causes of a serosanguinous transudate?
Lung lobe torsion, diaphragmatic hernia, neoplasi
What are possible causes of sanguinous fluid?
Trauma, neoplasia, coagulopathy, actue lung torsion
Why is a sanguinous fluid like an body cavity hemorrhage not going to clot?
All the clotting factors have already been used up (unlike frank blood from hitting a vessel)
What type of effusion is an inflammatory effusion?
modified transudate, or exudates
What are some common causes of a septic inflammatory effusion? Nonseptic?
Trauma, tracheal or esophageal rupture, foreign body; diaphragmatic hernia, neoplasia, chronic chylothorax, FIP, lung lobe torsion
What does a chylous effusion look like?
Milky white, possibly a pink hue
What is a basic clinical picture for pleural effusion?
Hard time expanding their lungs, respiratory function is diminished
What does a pleural effusion chest rad look like?
loss of detail basically
What do you do with a thoracocentesis fluid?
Sample in EDTA, and clot tubes, sterile sample for culture, and cell counts, SpGrav, TP, triglycerides, cholesterol
How do you do a thoracocentesis?
Sternal recumbency, ventral 3r-7th rib space, aseptic prep, insert at oblique angle
When placing a thoracostomy tube, why do you tunnel under the SQ or latissimus dorsi?
Limits tracking of air
Where in the chest is a thoracostomy tube placed?
7th or 8th ICS; in a cranioventral direction (if fluid is in there)
When done placing a thoracostomy tube, what should you always do?
Take a radiograph to ensure proper placement
How can you control evacuation of a thoracostomy tube?
3-way valve, Heimlich valve, or constant suction
Why might a thoracostomy tube not be able to be aspirated?
Pleural space evacuated, valve not open, tube kinked, tube obstructed with clots or fibrin, fenestrations within subcutaneous space
What are the common pathogens found in a pyothorax of dogs?
Actinomyces or Nocardia
Who commonly has idiopathic chylothorax?
Afghan hounds
How treatements of chylothorax are ineffective?
Dietary management (usually ineffective), Benzopyrones (Rutin - stimulates macrophage removal of fat), pleurodesis (obliterates pleural space)
What can be done surgically to treat chylothorax?
Thoracic duct ligation, cistern chili ablation, pericardectomy
What is the success rate of treating a chylothorax with thoracic duct ligation?
50-60%
T or F - Combining several surgical procedures to treat chylothorax may be more successful than just one alone:
True; Pericardectomy and cistern chili ablation may increase success of surgical therapy over thoracic duct ligation alone
What is an interesting thing about a hemothorax?
You can collect the blood sterilely and autotransfuse it back into the patient
When dealing with a pneumothorax, when is surgical exploration warranted?
If air leaks fail to seal in 24-48 hours
What is the cause of tension pneumothorax?
Underlying mechanism of tension pneumothorax remains unknown
What is restrictive pleuritis?
Inflammation of the pleura; may have to remove the thickened pleura - Restrictive pleuritis
What should you note when considering a partial lung lobectomy?
Isolated lesions, limited by proximity to bronchi and vessels
Describe the process of a partial lobectomy:
Isolate with vascular forceps, resect and oversew, surgical staples
Describe the process of a complete lobectomy:
Isolate vessels and double ligate, apply forceps to bronchus and oversew, use surgical staples
How many layers do you oversew a bronchu?
Two layers - running horizontal mattress pattern oversewn with a simple continuous pattern
What is a complication of a complete lobectomy when oversewing a bronchus?
Dehiscence or necrosis can cause bronchopleural fistula
Which is more preferable, Ligate the vessels or use staples, for a lobectomy?
Surgical staples
How much lung tissue can be removed without consequence?
Can remove up to 2/3 entire lungs if staged
What is thoracoscopy good for?
Lung biopsy, pericardectomy
What are the cardiac procedures mentioned in class?
Pericardial effusion, pacemakers, patent ductus arteriosus, subaortic stenosis, atrial septal defect, ventricular septal defect, tetralogy of fallot, valve replacement, pulmonic stenosis
What procedures can they do trans-cather?
Pacemaker, L-R PDA, pulmonic stenosis, ASD
What are the clinical signs of pericardial effusion?
Decreased CO, exercise intolerance, coughing, ascites, high venous pressure, muffled heart sounds, low aortic pressure, depressed QRS voltage
What are the top three things they do surgery on for pericardial effusion?
Neoplasia, idiopathic, infection
What is the most sensitive and specific test for pericardial effusion?
US
What are the options for treating a pericardial effusion surgically?
Repeated centesis (palliative), pericardiectomy
What do pacemakers really do?
Treat symptomatic heart block resulting in exercise intolerance or syncope
What is the differences between epicardial pacemakers, and transvenous pacemakers?
Epicardial are placed in the abdomen; transvenous pacemakers a placed through the veins and the generator is placed in the subcutaneous tissue of the neck
What is the typical rate set on dog pacemakers?
Typically 100 bpm in dogs
How often do you check up on pacemaker patients?
At least every 3 months
What does the heart murmur of a PDA sound like?
Washing machine
Name radiographic signs associated with a PDA?
Pulmonary overperfusion, left heart enlargement, dilatation of descending aorta
Which PDA is untreatable surgically?
R-L PDA, the lungs have hypertension and if you occlude the PDA, severe pulmonary edema occurs (in reverse PDAs the caudal part of the body gets unoxygenated blood)
What is the prognosis of PDA?
Untreated, PDA causes heart failure and 64% of dogs without treatment die within 1 year of diagnosis
What is the most common PDA?
Hemorrhage; reverse PDA uncommon
What is the most common cause of a subvalvular aortic stenosis?
Usually from a ring of fibrous tissue withing the LVOT immediately below the aortic valve
What is the prognosis of untreated subvalvular aortic stenosis?
Sudden death common in first 3 years of life
What is interesting about surgical treatment of subvalvular aortic stenosis?
Balloon dilation doesn't help, surgical resection reduces pressure gradient, but rate of sudden death is not reduced
What is required to surgically treat AD?
Cardiopulmonary bypass
How common is VSD?
Relatively common in the dog, most common congenital cardiac defect in cats
What can VSD lead too?
Pulmonary overcirculation, left sided volume overload, congestive heart failure; But frequently small and well tolerated
On an echocardiogram, what do Doppler signals indicate?
High velocity - small opening and restrictive; Low velocity - large hole and needs to be corrected
What has to be used inorder to correct a VSD?
Cardiopulmonary Bypass
What are the four parts of Tetralogy of Fallot?
Pulmonic stenosis, overriding aorta, VSD, right ventricular hypertrophy
What is the main goal of surgical treatment of a Tetralogy of Fallot?
Increasing pulmonary circulation
What are the two things that you have to correct together to fix a Tetrology of Fallot?
Closure of VSD, Correction of pulmonic stenosis
What are the two types of replacement valves?
Mechanical, bioprosthetic valves
What is wrong with mechanical valves?
Thrombogenic
What is a bioprosthetic valves?
Glutaraldehyde -fixed xenograft from bovine pericardium or porcine aortic valve mounted on synthetic framework
What is a murmur associated with a pulmonic stenosis like?
Systolic murmur over left heart base
What radiographic signs are associated with pulmonic stenosis?
Right heart enlargement, post-stenotic dilation of MPA
What are indications for surgical treatment of pulmonic stenosis?
Failed balloon valvuloplasty, too small to attempt balloon valvuloplasty (<10 kg), Sub or supravalvular stenosis
What are two reasons that a dog may fail balloon vavuloplasty for a pulmonic stenosis?
Thickened dysplastic valve leaflets, significant muscular contribution to outflow tract obstruction
How do you surgically treat a pulmonic stenosis?
Patch graft (give more room in the area of the stenosis)
Why might using cardiopulmonary bypass be best in some cases of pulmonic stenosis?
Allows ample time for treating all the aspects of some complicated cases of PS (valvular, valve annular and muscular components)
What are the two ways to work on the heart with a pulmonic stensos?
Inflow occlusion, cardiopulmonary bypass
How long does the body tolerate inflow occlusion?
4 minutes (normothermia), 8 minutes (mild hypothermia); but want to cut these times in half so that you have plenty of time to get things done
What three vessels are occluded when performing inflow occlusion on the heart?
Cranial vena cava, caudal vena cava, azygous vein
What is the main problem with cardiopulmonary bypass?
Initiates a systemic inflammatory response
What is different about the esophagus from the rest of the GI tract?
Doesn't have a serosa; some believe it hinders healing and sealing (mucosa, submucosa, muscularis, adventitia)
What nerves supply the esophagus?
Pharyngoesophageal n, Recurrent laryngeal n, Vagus n
What arteries supply the esophagus?
Thyroid a, Bronchoesophageal a, Aorta, Left Gastric a
What is the most common cause for esophageal surgery?
Foreign body
List some diseases of the esophagus that need surgery?
Foreign bodies, vascular ring anomalies, strictures, achalasia, neoplasia
What is a common cause of an esophageal stricture?
Regurgitation of gastric contents that causes damage
What happens when you have cricopharyngeal achalasia?
The upper esophageal sphincter won't open (just transect the muscle)
What species can have a leiomyosarcoma in the esophagus?
The cat (has smooth muscle in its esophagus
Name some neoplasia of the esophagus?
Squamous cell carcinoma, Fibrosarcoma, leiomyosarcoma
What are the three approaches to get to the esophagus?
Cervical - ventral midline; Cranial thoracic - right third intercostals; Caudal thoracic - left eight intercostals
What esophageal procedures were mentioned in class?
Endoscopic foreign body retrieval, balloon dilation, esophagotomy, resection and anastomosis
How many times does it take to balloon the esophagus?
Sometimes 4-5 times
Some name some priniciples for esophageal surgery?
Note the poor healing of the esophagus, use perioperative antibiotics, preserve blood supply, avoid contamination, close esophagus in two layers, avoid excessive tension, consider patch over esophagus if closure comprimized, utilize gastrostomy tube if necessary
What layer is the holding layer of the esophagus?
Submucosa
What patterns do you use to close the esophagus?
SC or SI
What size of suture do you use on the esophagus?
4-0 o 3-0 monofilament
What should you note about doing your first layer of closure on the esophagus?
Knots within lumen, grab the submucosa
What is an important part of postoperative care for esophagus surgery?
Want to NPO 24 to 48 hours post surgery, start on water slowly and then give food over 7-10 days
Why give H2 antagonists to an esophagus surgery patient?
Limit acid that can be refluxed and cause damage
Name the blood supply to the stomach:
Gastric and gastroepiploic arteries
What nerve supplies the stomach?
Vagus
What are some diseases of the stomach that may require surgery?
Foreign bodies, GDV, pyloric hypertrophy, neoplasia, ulcers, hernias and intussusceptions
What is the signalment for a muscular pyloric hypertrophy and stricture?
Younger, brachycephalic breeds, Siamese cats
What is the signalment for mucosal pyloric hypertrophy and stricture?
Older, small breeds
What is the procedure to relieve the stricture of pyloric hypertrophy?
Incise the pyloris longitudinally and close it transversely
What are the approaches to the stomach?
Ventral midline laparotomy (most common), flank laparotomy
What are some preoperative things to remember to do before gastric surgery?
Correct metabolic abnormalities, withhold food for 8-12 hours, perioperative antibiotics
What should you do during stomach surgery?
Use stay sutures or Babcock forceps, pack-off stomach, have suction available, incise Avascular area, inspect stomach carefully
How do you close the stomach after surgery?
Close in 2 layers, SC in mucosa and inverting in submucosa and seromuscular layer, lavage abdomen, consider jejunostomy tube
What are two inverting suture patterns?
Cushing and Lembert
What size and type of suture do you use on the stomach?
4-0 or 3-0, monofilament, absorbable, avoid chromic gut (breaks down quite fast in stomach)
What surgical procedures were mentioned for the stomach?
Gastrotomy, partial gastrectomy, managmenet of GDV (gastropexy), pyloromyotomy/pyloroplasty, partial gastric resection, pyloric resection
How much increase in size do you gain for the pylorus when performing a pyloroplasty?
30-40% increase
What are two ways to increase the size of the pylorus?
Longitudinal-to-transverse, Y-U pyloroplasty
How long do you have to hold off food for surgery on the stomach?
12-24 hours, small amounts of water and then soft food over the next 10 days, gradually increasing, feed via jejunostomy tube
What is the most common postoperative complication associated with the stomach?
Dehiscence
Define the process of Gastric Dilitation Volvulus:
Life-threatening emergency, dilation of stomach with gas, food and fluid, rotation on mesenteric axis, progressive gastric distention, gastric necrosis, obstructive shock, collapse
What are some possible risk factors for GDV?
Exercise after eating, over eating with aerophagia, anatomic predisposition, delayed gastric emptying, gastroesophageal sphincter dysfunction, change of environment, stress
Which direction does the stomach rotate in a GDV?
Clock-wise (90-360 degrees); pylorus moves ventrally and to left near cardia
What can also occur along with a GDV?
Splenic enlargement or torsion
What are complications of a GDV?
Compression on the CVC, decreased cardiovascular function (CO, CVP, CV, MAP), obstructive shock, gastric necrosis, metabolic derangements, cardiac arrhythmias
What is a definitive sign on rads for a GDV?
Compartmentalization of the stomach (gas in wrong part of stomach on a lateral - gas in pylorus when in right lateral and visa versa), "Double Bubble"
How can you tell the difference between gastric dilatation and GDV?
Look for "Double bubble" in right lateral radiograph
How do you medically manage a GDV?
All things IV (catheter, fluids, antibiotics, analgesia, gastroprotectants, possibly corticosteroids and lazaroids)
What is an important thing to note about catheter placement in a GDV patient?
Can't use the hind leg because the GDV is blocking blood return to the heart
Describe the basics of GDV surgery:
Ventral midline laparotomy, decompression of stomach, derotate, give the tissue time to regain circulation before deeming it comprimized, examine stomach, spleen, and intestines for injury, look for potential cause, perform splenectomy if devitalized,
Describe a belt-loop gastropexy?
Cut a flap off the serosal surface of the stomache, make an incision envelope in the abdominal wall, pass the stomach flap through the envelope and resuture it to the stomach
What are some postoperative complications associated with GDV?
Cardiac arrhythmias, sepsis, peritonitis, hemorrhage, DIC, recurrence
What is the mortality rate of a GDV surgery?
15-60%
What is the recurrence rate of a GDV after surgical resection?
5% (gastric dilation may still occur)
What are the four layers of the GI tract (minus the esophagus)?
Mucosa, submucosa, muscularis, serosa
What supplies blood to the small intestines?
Celiac and cranial mesenteric arteries
When there is a linear foreign body, where does a perforation occur in the SI?
Along the mesenteric border of the SI
On an abdominal radiograph, what is classic for a foreign linear body?
Comma shaped air pockets
When looking for SI problems, what do you look for on a survey rad?
Opaque foreign bodies, distended loops of bowel, two different populations of bowel, plicated or bunched loops of bowel, free air or fluid in abdomen
What does an intussusceptions look like on US?
Like a bulls-eye
What are the limitations of endoscopy in looking at the SI?
Can't reach the jejunum
When inside the abdomen and concerned with SI, what should you do?
Perform complete exploratory and palpate entire length of intestines (go through 2x to make sure you didn't miss anything); handle gently with fingers or Doyen forceps
What suture material should you use to close the intestines?
3-0 or 4-0 monofilament, absorbable suture on taper needle
How do you close the SI?
Preplace a sutures at mesenteric and antimesenteric borders, place sutures 4-5 mm away from edge and 3-4 mm apart; need solid apposition but very slight crushing tension on knots; use SI or SC apposition pattern; avoid inverting or double layer closure
What happens with inversion on SI closures?
Constriction
How do you deal with luminal disparity when anastomosing two section of bowel?
Oblique resection or antimesenteric incision
What surgical diseases of the SI were mentioned in class?
Foreign bodies, intussusceptions, neoplasia, intestinal volvulus, intestinal trauma
When cutting open the SI to remove a foreign body, what determines where you incise?
You want an area that is healthy, so your sutures hold
What are the neoplasias of the SI?
Lymphosarcoma, adenocarcinoma, leiomyosarcoma, fibrosarcoma
How much SI can you remove safely?
Up to about 80% of the SI
When dealing with opening and then closing the SI, what should you do after you close?
Check the closure for leakage using injected saline
Which part of the SI should be closed first and why?
The mesenteric side because of the fat that can obscure areas around there
Why would you want to omental wrap an enterotomy?
Helps promote fibrin seal and reduce risk of dehiscence (wrapped and tacked down to serosa)
Describe serosal patching:
Adjacent loops of bowel are carefully arranged and sutured over enterotomy site to promote fibrin seal and support adjacent intestine
How long is NPO for in SI surgery?
12-24 hours
How long do you need antibiotics postoperatively from SI surgery?
Really only a few days unless there is known contamination and leakage
When is dehiscence most common post SI surgery?
Most likely in the first 2-5 days
Why is it ideal to use only one layer of closure in the SI?
Reduce risk of stricture
Describe how surgical staples connect the SI together:
Basically you have the two open ends running parallel to each other; staple the to sides touching together, then tyou pinch the two open ends together and staple again; makes a loop
What do you do if there is peritonitis present when you perform SI surgery?
Culture and lavage the abdomen
What is the average blood volume of a dog per kg?
80-90 ml/kg
What is the equation to calculate the volume of blood needed to increase the PCV of a patient?
Volume needed = BW kg x 90 x ((PCV desired - PCV recipient)/ PCV donor)
What is the general rule for raising blood PCV?
1 ml of whole blood per lb of body weight will raise the PCV 1%
What is the basic anatomy of the spleen?
Parenchymal organ with thin capsule of elastic fibers and smooth muscle
What supplies blood to the spleen?
Splenic artery and vein
What innervates the spleen?
Vagus and celiac nerves
What are the functions of the spleen?
Blood storage, blood filter, hematopoesis, Iron metabolism, immunoglobulin production
What is the one thing that can be affected if the spleen is removed?
Hematopoesis; depends on the level of dependence of the patient on the spleen for hematopoesis
What is the one thing that can occur in response to splenic issues that is not explainable?
Cardiac arrhythmias
When palpating the abdomen, where can you commonly feel an enlarged spleen?
Cranioventral abdomen
What can US help you with when looking at the spleen?
The echogenicity or cellular consistency of the spleen
List the surgical diseases of the spleen mentioned in class:
Neoplasia, hematoma, traumatic rupture, torsion, abscess
What are the two most common tumors of the spleen?
Hemangiosarcoma, hemangioma (both are large cavitative masses)
Where should you look for a primary hemangiosarcoma when one is seen in the spleen?
Heartbase or right atrium
What is the difference between hemangiosarcoma and hemangioma?
HSC is malignant and hemangioma is benign
If you see a large bloody mass in the spleen, what are your DDx?
Hemangiosarcoma, hemangioma, hematoma
What is the key to getting back good results from a splenic biopsy?
Large tissue sample with possibly several representative areas
When there is a splenic torsion, what is the common treatment?
Splenectomy; unless caught early enough
How is a splenic abcess diagnosed?
US, FNA, cytology
How do you treat a splenic abscess?
Splenectomy; culture and continue systemic antibitiotics
With Splenic surgery what is the main things to watch and be aware of?
The systemic signs associated with splenic disease (Hypotensive shock, anemia, thrombocytopenia, icterus, cardiac arrhythmias, coagulopathy)
What are two things to note about splenic surgery?
Handle spleen carefully to avoid rupture, have plenty of hemostasis available
How do you perform a splenectomy?
Isolate spleen and identify vascular pedicle; pack off spleen with moist lap sponges, double ligate vessels with absorbable or non-absorbable material, may use hemoclips (Must be secure)
How do you perform a partial splenectomy?
Double ligate vessels that supply portion of spleen to be removed; gently compres spleen before clamping, transect spleen and oversew cut edge with two continuous rows; monitor suture edge for hemorrhage
What suture material do you use for a partial splenectomy?
3-0 or 4-0 absorbable suture on taper needle
What is the main thing to watch post operatively after splenic surgery?
PCV; need to monitor for hemorrhage
What is one of the main issues or complications post splenectomy?
Reduced ability to tolerate hypotensive crisis
What are possible causes for seizures?
Neoplasia, hepatic encephalopathy, hypoglycemia, toxins, infection, encephalitis, epilepsy
Name the blood supply to the pancreas?
Branch of splenic and cranial and caudal pancreaticoduodenal arteries
What are the two ducts of the pancreas?
Pancreatic and accessory ducts
What are two things to avoid when handling the pancreas?
Handle the pancreas gently to avoid iatrogenic pancreatitis, indentify the common bile duct to avoid injury
When exploring the abdomen when you suspect pancreatic cancer, what is something you should check for metastasis?
The gastric lymph nodes (just under the pancreas)
How do you stabilize a patient you suspect has an insolinoma?
Frequent feedings, glucocorticoids, and dextrose; monitor blood glucose
What are the surgical diseases of the pancreas noted in class?
Neoplasia, abscess, trauma, pseudocysts
What is another name for an insulinoma?
Beta cell tumor
What is the common signalment for an insulinoma?
Older, large-breed dogs
What is a blood level indicator of insulinoma?
Increased insulin:glucose ratio
What do insulinomas look like?
Usually small tumors within parenchyma of pancreas
What do glucocorticoids do for insulinoma?
Increase blood glucose??
What does diazoxide do for insulinoma?
Decrease insulin secretion
What is the difference from the insulinoma and adenocarcinoma of the pancreas?
Insulinoma - from endocrine pancreas, small masses; Adenocarcinoma - from exocrine pancreas, usually fairly large size before clinical signs; Both metastasize
What are possible causes of a pancreatic abscess?
Secondary to pancreatitis or ascending infection from GI tract
What is important to do particularly to the pancreas after trauma?
Ligate any exposed or lacerated ductal tissue
What is a pancreatic pseudocyst?
Collection of pancreatic secretions in fibrous sac, not true cysts
How do you diagnose a pancreatic pseudocyst?
US
What are the surgical procedures for the pancreas were mentioned in class?
Pancreatic biopsy, partial pancreatectomy
What is an important thing to remember to do when biopsying the pancreas?
Carefull dissect between pancreas and duodenum to avoid damage to common blood supply
What can cause exocrine pancreatic insufficiency post operatively?
>90% removed or both pancreatic ducts ligated
What can cause endocrine pancreatic insufficiency post operatively?
>90% of pancreas removed
What are the possible causes of icterus?
Hemolytic anemia (IMHA, toxins, parasites), Liver disease (toxin, hepatitis, hepatic trauma), Choleostasis (bile duct obstruction, pancreatitis)
What do we need to know about the anatomy of the liver for surgery?
Parenchymal organ, six lobes (Right lateral, right medial, quadrate, caudate process of the caudate lobe, papillary process of the caudate lobe, left medial lobe, left lateral)
What vessels supply blood to the liver?
Portal vein and hepatic artery (hepatic veins to CVC)
What surgical diseases of the liver were mentioned in class?
Hepatic neoplasia, portosystemic shunts, trauma, abscesses, cysts
What is the most common primary tumor of the liver?
Hepatocellular carcinoma/adenoma
What two tumors cause diffuse enlargement of the liver when they have invaded it?
Lymphoma, mast cell tumor
What things on the liver and spleen that can confuse you?
Regenerative nodules
When you see liver abscesses, what should you be thinking?
They came from somewhere else; there is a nidus somewhere else
What are hepatic cysts?
Benign epithelial adenomas (fluid filled)
When considering to do surgery on a possible liver issue, what should you especially pay attention too?
Coagulation panel - the liver makes coag components
On a survey rad, how can you make a general assessment of the size of the liver?
Based on the orientation of the caudal margin of the liver (or stomach) to the ribs (want them to be parallel)
What is important about US on the liver?
Can tell you the cellular consistency and texture inside
How worried should you be about bleeding when taking a biopsy of the liver?
Not that worried as long as you take a small sample, have checked the coagulation panel, and have held off the area long enough and assessed for bleeding
What is important thing about liver disease and surgery?
Severe hepatic disease may affect anesthesia, blood glucose, wound healing, coagulation and neurologic status
What types of antibiotics should you select for post operative coverage after liver surgery?
Aerobic and anaerobic coverage
How can you deal with the fragility of the liver when performing surgery on it?
Take relatively large bites and follow curve of the needle, use tapered needle
The liver oozes blood, how can you deal with this?
Hemostatic agents like Gel-foam or collagen sponge
Why does the liver ooze blood when cut?
The vessels draw back into the parenchyma and can't be ligated or pinched off
What are the surgical procedures for the liver discussed in class?
Liver biopsy, partial lobectomy, total lobectomy
What are the different techniques for taking a biopsy of the liver?
Suture technique, punch biopsy technique, guillotine technique
Describe the suture technique for liver biopsy?
Take suture and create loops with full thickeness bites that allow you to cut off an area, and then you cut out that area for biopsy
What do you have to do to the punch site after punch biopsy of the liver?
Plug the hole with gel foam
What is the basic process of liver lobectomy?
Blunt-sharp dissection and ligation or automatic stapling device
What are primary things to monitor postoperatively after liver surgery?
Monitor for hemorrhage and check PCV/TS (the biggest thing), monitor blood glucose and albumin levels
What are complications of liver surgery?
Hemorrhage, hypoglycemia, portal hypertension, ascites
What is the typical type of portosystemic shunt?
Porto-caval
What two vessels does the portosystemic shunt generally drain into?
CVC, Azygous vein
Why does the liver atrophy in cases of portosystemic shunts?
Hepatotrophic substances from the pancreas and intestines are not processed by the liver resulting in hepatic atrophy
What substances abnormally elevated in the systemic blood due to a portosystemic shunt cause clinical signs?
Ammonia, mercatans, aromatic amino acids, branched chain amino acids, GABA
How are portosystemic shunts classified?
Congenital vs acquired, single vs multiple, intrahepatic vs extrahepatic
What are congenital shunts typically?
Single, extrahepatic more than intrahepatic
What are acquired shunts typically?
Multiple, extrahepatic
What are two signalments for acquired shunts?
Middle to older aged animal with chronic liver disease; Young animals with congenital hepatic fibrosis (basically something that makes blood shunt through other vessels)
What is the signalment for extrahepatic congenital PSS?
Typically purebred small or toy breed dogs, DSH cats
T or F; there should be only one large vessel entering the CVC cranial to the kidney veins?
False; should be no large veins entering the CVC cranial to the kidneys
What is the signalment for intrahepatic congenital PSS?
Typically purebred, large breed dogs
Why are there urinary signs associated with PSS?
Lack of kidney medullary hypertonicity from lack of urea metabolism by the liver
What are PE findings that suggest PSS in cats?
Ptyalism, copper colored eyes
What are your differentials for hepatic insufficiency?
PSS, cirrhosis, AV fistula, microvascular dysplasia
What are you differentials for neurologic signs?
PSS, epilepsy, hydrocephalus, toxic exposure, hypoglycemia
What are your differentials for causing urinary signs?
PSS, UTI, renal failure
What are CBC findings that are consistent with a PSS?
Mild non-regenerative anemia (microcytic), poikilocytes, target cells
What chemistry panel findings are consistent with PSS?
Decreased TP, albumin, BUN, cholesterol, blood glucose; Mildly elevated serum ALP and ALT
Is bile acid test a good test for diagnosing a PSS?
Good test for liver function, just suggestive of PSS
Is US good for detecting a PSS?
Useful (may miss it but if you see the shunt, that's good)
What does nuclear scintigraphy used for?
Test useful for evaluating hepatic blood flow; compares blood flow in the heart to the liver (normally want more activity in the heart than the liver)
What does a nuclear scintigraphy tell you?
That you have or do not have a PSS; won't tell you if its intra or extra hepatic
What is a jejuna portovenogram?
Contrast injected into jejuna vein to assess portal circulation
What is indicative of a extraheptic shunt upon exploratory laparotomy?
Any vessel from mesentery entering the CVC or azygous vein
What is indicative of an intrahepatic shunt during an exploratory laparotomy?
Soft spot within a liver lobe
Why reduce the amount of dietary protein in a PSS case?
Reduce the amount of protein break down products that lead to ammonia
Why give oral antibiotics for medical management of a PSS?
Reduce breakdown of the ammonia in the intestines to reduce ammonia levels being absorbed
How does lactulose help with treatment of PSS cases?
Acidifies colonic contents (ammonium trapping) and decreases intestinal transit time
What are the three things to do to medically manage a PSS?
Low protein diet, oral antibiotics, lactulose
Name the three techniques for surgically correcting a PSS?
Ligation of the shunt with suture, ameroid ring, cellophane banding
What is the important thing about correcting a PSS?
Need to understand that portal hypertension can be a hindrance to fixing this; only want to have a portal pressure increase at the top of 20-23 cm of water above baseline - may only be able to ligate the shunt partially
How do ameroid rings occlude vessels?
They swell over time due to absorption of body fluids (50% occlusion in first 2 weeks followed by gradual final occlusion over 3-5 weeks
Why might you get portal hypertension when occluding a PSS?
If done to fast, the liver can't accommodate fast enough and portal hypertension can occur
How long should you continue to treat PSS patients post surgery?
2-3 months, plan to completely ligate partially ligated shunts in 3-6 months if possible
What is the prognosis of surgical treatment of PSS?
Long-term prognosis is good with successful surgical closure of shunt
What would be the likely causes for the persistent bleeding and failure to clot in a cat with icterus and possible biliary obstruction?
Decreased production of coagulation factors II, VII, IX, X due to decreased absorption of vitamin K secondary to the biliary obstruction
What could you have treated the cat with the bleeding and icterus?
Treat with SQ vitamin K prior to surgery
What is the cystic duct?
The neck of the gall bladder before the hepatic ducts connect to it to create the common bile duct
What supplies blood to the gall bladder?
Cystic artery
Between what two liver lobes does the gall bladder sit?
Quadrate and right middle liver lobes
What is one major deciding factor in how severe and acute of clinical signs a disease of the gall bladder may present as?
If the gall bladder is infected or not
What are some classic CBC, chem panel, UA, and coag panel findings associated with the biliary system?
Elevated WBC, elevated liver enzymes, elevated total bilirubin, elevated pancreatic enzymes, bilirubinuria, coagulopathy
What is a good imaging method for assessing the gallbladder?
US
What does a loss of layering mean when you US the gall bladder?
Indicates or suggests cholecystitis
What is another name for the appearance of a mucocele in the gall bladder on US?
Kiwi gall bladder
How useful is cholecystocentesis?
Good for culturing and cytology but comes at a cost; Obligated to monitor for signs of leakage, peritonitis or hemorrhage
When performing abdominocentesis, how can you test to see if the gallbladder has a role in the fluid found there?
Compare total bilirubin of fluid to serum levels; look for bilirubin crystals on cytology
When working with the gall bladder, what is one major thing to note?
Leakage of infected bile can cause life-threatening septic peritonitis; greatly increased when the gall bladder is infected
Is it alright to ligate a single hepatic duct?
collateral flow to other hepatic ducts prevents problems
What should you always do when performing surgery on the gall bladder?
Make sure the common bile duct is patent; catheterize it
What size of suture should be used on the gall bladder?
4-0 to 5-0 monofilament, absorbable , taper needle; close with two layers
What are the 4 basica surgical diseases of the gall bladder?
Biliary obstruction, cholecystitis, mucocele, rupture
What are the surgical procedures of the gall bladder mentioned in class?
Cholecystotomy, cholecystectomy, cholecystoenterostomy, choledochotomy, management of bile peritonitis
What do patients become once a cholecystectomy is performed?
They become obligate bile secreter; you have to make sure the common bile duct is patent or otherwise the bile will have absolutely no where to go
What are indicationed for a cholecystectomy?
Neoplasia, mucocele, cholecystitis, recurrent cholithiasis
What is a cholecystoenterostomy?
Anastomosis of the gall bladder to a segment of duodenum or jejunum ( to bypass an obstruction of the CBD)
What are complications associated with a cholecystoenterostomy?
Reflux, cholecystitis, gastric ulceration (the main one is reflux that can cause issues if its constantly occurring)
What is a choledochotomy?
Removal of a cholelith from the common bile duct; better to try and flush the stone to the gall bladder and remove it from there
How should the total bilirubin respond after surgically treating a biliary obstruction?
The level of Total bilirubin should decrease by half every day after surgery
What are complications of gall bladder surgery?
Peritonitis, bile leakage, stricture, recurrence of cholelithiasis or cholecystitis, ascending cholangiohepatitis
What is the cause of megacolon?
Idiopathic in older cats
What must you rule out to diagnose megacolon in cat that is constipated/obstipated?
Pelvic fracture, mass stricture
What do you do surgically to correct a megacolon?
Subtotal colectomy
Why is peritonitis such a big issue with leakage from the colon?
There is by far more bacteria in the colon than the SI or stomach
What is a common complication of a subtotal colectomy?
Either too much colon is left so you get recurrent constipation or not enough colon is left to properly absorb water and you get diarrhea
Define perianal fistulae?
Multiple ulcerated fistulous tracts in perianal region
Who most commonly has perianal fistulae?
Middle aged, German shepherd dogs
What is the cause of perianal fistulae?
Unknown, but most likely immune-mediated
What do you have to rule out for perianal fistulae?
Anal sac rupture, perianal neoplasia, focal trauma
How can you medically treat perianal fistulae?
Cyclosporine
What do you have to be careful with when performing surgery in the perianal region?
The anal sphincter
What are the different types of anal sac diseases?
Infection, impaction, abscessation
What is the typical signalment for anal sac tumors?
Older, female dogs
What is a common presenting sign associated with an anal sac tumor?
Hypercalcemia
What can cause anal stricture?
Proctitis, trauma, surgery, neoplasia
What are three treatments for anal strictures?
Bougienage, anoplasty, rectal pull-through
What is rectal prolapse secondary too?
Tenesmus (straining)
When treating a rectal prolapse, what is the main thing to do?
Treat the primary cause (purse string suture for 3-5 days)
What are the three types of recto-anal tumors mentioned in class?
Rectal polyps, adenocarcinoma, lymphoma
What is a perianal gland tumor?
Perianal gland adenoma, testosterone dependent; smooth mass, single or multiple, may become ulcerated
Who gets perianal gland adenoma?
Older, intact male dogs (testosterone dependent)
What are the different types of anal atresi?
Type I - congenital stricture; Type II - imperforate membrane; Type III - rectum ends as blind pouch; Type IV - more severe form of type III
What is the Golden Rule of trauma?
Treat the most life threatening problems first
When dealing with an emergency over the phone, what is the main thing you are trying to determine?
Does this animal need to be seen or not?
What is the number one thing when helping an owner with their emergency dog or cat over the phone?
Client safety
What is basic mouth to nose resuscitation?
2 initial breaths:30 chest compressions
How should you transport a head injury animal?
Minimize motion, leve or elevated head for transport (15-20 degree elevation)
List the signs of shock:
Tachycardia, pale mm, off CRT, weak pulses, tachypnic, obtunded, cool extremities
What are the four categories of shock?
Hypovolemic, Distributive, Obstructive, Cardiogenic
Why might a shocky patient have <1 CRT?
Compensatory shock
What does hyperkalemia do to the heart?
Bradycardia
What is the minium data based for trauma?
Varies, always do big 4 (PCV/TP, Azo, Glu), always do thoracic x-rays
What is flail chest?
2 or more consecutive ribs with multiple fractures
How do you tell a pneumothorax on a rad?
Elevated cardiac silhouette, vessels do not extend to periphery
What is the rate of IV fluids for shock?
90 ml/kg for a dog, 60 ml/kg for cat, ¼ given at a time 5-10 min time span
What are the top things you need for ER diagnostics?
PCV/TP, Glu, Azo, EKG
What is A CRASH PLAN?
Airway, CV, Respiraotry, Abdomen, Spine, Head, Pelvis, Limbs, Arteries, Nerves
When dealing with an emergency patient, what shouldn't you do?
Palpate the bladder
What is a way to assess the peritoneal cavity for trauma?
FAST - Focused Abdominal Sonogram for Trauma
What are the four sites for FAST?
Subxiphoid, Bladder midline, Right and left flank
What are the main things when dealing with trauma?
Expect the unexpected, prepare for everything, set owners up for unexpected
What are possible causes of hypovolemic shock?
Hemorrhage, neoplasia, GI losses, urinary losses, 3rd space losses
What are possible causes of Obstructive Shock?
Pericardial disease, pulmonary thromboembolism, bloat
What are possible causes of cardiogenic shock?
Cardiomyopathy, valvular disease, arrhythmia
What are possible causes of Distributive shock?
SIRS, Sepsis
For proper fluid therapy, what do you need to know?
Knowledge of pathophysiology of shock, fluid compartments and distributions, dynamics of fluid movement
What is part of the neuroendocrine response to shock?
SNS, RAAS, ADH
What is the general process of transition of clinical signs from compensated shock to late decompensated shock?
Heart rate goes from high to low, MM goes from pink to gray, white; CRT goes from short to long; Pulse amplitude goes form increased to severely decreased; pulse duration goes from mildly reduced to severely reduced; MT pulse goes form palpable to absent, mentation goes from obtunded to severe obtunded/stupor
What is the basis of late decompensated shock?
Central pathology blunts compensatory response
Whats the problem with shocky cats?
Cats rarely exhibit compensated shock
What is SIRS?
Systemic Inflammatory Response Syndrome - wide spread response to insult
What is sepsis?
SIRS due to infection
What is septic shock?
Sepsis syndrome and hypotension despite adequate IV fluid resuscitation
What is the key to successful treatment of sepsis and septic shock?
Early appropriate antibiotics
What are the 4 parts of fluid resuscitation?
Determine where fluid deficit lies, select fluid for patient, determination of resuscitation end-points, determine the resuscitation technique to be used
What are signs of deficits in the intravascular compartment?
Changes in HR, pulse intensity, CRT, MM color
What are signs of deficits in interstitial and intracellular spaces?
clinical signs of dehydration, dry mm, skin turgor, eye moisture
How long do crystalloids stay in the vascular space?
within 30 minutes ¾ of the fluid is out of the IV space
What are doses for colloids?
5-10 ml/kg for dogs; 2.5-5 ml/kg for cats
When are colloids recommended for patients?
TP <4.0 g/dl or trending downward
What are the resuscitation end-points?
Individualized for the patient; reflect the perfusion status of the animal
How much fluid do you give a hypovolemic animal?
Large amounts
How much fluid do you gie a closed cavity hemorrhage, pulmonary contusion, or head trauma patient?
Small volumes
What is the general technique to resuscitate a cat?
Larger volumes of fluid, crystalloid plus colloid, active warming
What are causes for failure to reach resuscitation end-points?
Inadequate volume administration, continued hemorrhage, third spacing of fluids, heart disease, severe vasodilation