Gastrointestinal (GI) surgery is commonly performed in both first opinion and referral practices. There are a number of common indications for gastrointestinal surgery including neoplasia, mechanical obstruction (due to neoplasia, intussusception or a foreign body), abnormal positioning (eg gastric dilatation and volvulus) or failure of motility (eg megacolon). This article will focus on basic surgery, and specifically suturing, of the stomach and intestines.
The small and large intestines are accessed via a ventral celiotomy. Access to the rectum may require pelvic symphysiotomy or a perineal approach depending on the location of the lesion. The abdomen should be clipped from mid-thorax to the level of the pelvis and four quarter draping performed to allow room for an adequate length of celiotomy incision.
Ease of surgical exploration is aided by the use of self-retaining abdominal retractors (such as Balfour retractors), suction and a Poole suction tip and good lighting. The edges of your incision should be covered with moist laparotomy swabs prior to placement of your retractors.
The precise order of exploration of the abdomen is up to the individual surgeon but should be consistent and ensure all structures are examined and palpated. With respect to the intestine, it makes sense to run the gut from either the proximal or distal end, paying attention to regional lymph nodes and gut wall thickness. Waves of peristalsis should be apparent during examination.
For all gastrointestinal surgeries consider changing gloves and kit if there has been contamination of these by intestinal contents or if there is a neoplastic aetiology. If there has been spillage of intestinal contents, the abdomen should be lavaged prior to closure of the celiotomy.
Indications: foreign body removal, gastric biopsy
Note: a how-to gastrotomy video is available here.
The stomach can be closed in a single- or two-layer closure (the author usually performs a two-layer closure as the layering of the stomach wall is usually clearly visible) ( Figure 2).
Indications: foreign body removal, full thickness biopsy
Once the location of the lesion has been identified, the affected loop of bowel should be isolated using moist swabs to reduce the risk of contamination. The lumen of the intestine orad and aborad to the lesion should be occluded to reduce the risk of leakage of intestinal contents. This can either be achieved using the fingers of an assistant or using atraumatic bowel clamps (Doyens).
Make your incision into a healthy-looking area of bowel ( Figure 3) on the anti-mesenteric border using a number 11 blade ensuring the length of the incision is suitable for your needs (eg if for a foreign body removal, the incision should be long enough to permit removal without tearing the incision further). Have the assistant stretch the bowel out between their fingers as this will make it easier for you to suture.
The intestine is most commonly sutured using a full thickness simple continuous or simple interrupted pattern and swaged on suture material. One cadaveric study suggested avoiding the use of conventional cutting needles (Mitsou et al., 2018). It is not necessary to use inverting suture patterns nor to do a two-layer closure. Sutures should be placed 3 to 5mm from the edge of the tissue and around 3mm apart. Minimise how much you handle the edges of your tissue with forceps ( Figure 4A) and use Debakey forceps rather than rat tooth forceps. The submucosa must be included in the closure. The author prefers to use simple interrupted sutures of 4/0 USP polydioxanone in the small intestine ( Figure 4B) unless the tissue is very thick (in which case 3/0 USP polydioxanone is used). Surgical sites should be wrapped with omentum after suturing. This can be tacked in place depending on personal preference.
Serosal patching can be utilised in cases where there are concerns regarding the strength of your repair if resection of the affected section of the intestine is not feasible.
The author usually performs a leak test of any intestinal incision as it allows for peace of mind. Saile et al. (2010) reported that for canine jejunum, saline volumes of 16.3 to 19ml (digital occlusion) and 12.1 to 14.8ml (Doyen occlusion) could be used to achieve intraluminal pressures of 34cm water during leak testing of a 10cm segment containing a closed biopsy site. Bearing in mind we are not usually able to assess intraluminal pressures in surgery, the lumen of the intestine either side of the incision is occluded by an assistant’s fingers and 10ml of sterile saline introduced into the lumen using a 24 gauge needle (volume depending on the length of the bowel you are testing). The incision is checked visually for any signs of leakage and extra sutures placed as required.
Enterectomies are indicated for the removal of devitalised intestine, resection of neoplastic lesions ( Figure 5A), management of intestinal wound dehiscence and irreducible intussusception ( Figure 5B).
Nutrition is a significant consideration in the post-operative period and a plan should be in place for feeding before the surgery. Enteral intake of food is important both for nutrition of enterocytes (and thus wound healing) and also for stimulation of peristalsis. Thus, food should be offered at the earliest opportunity.
Placement of a feeding tube (usually oesophagostomy or gastrostomy tube) should be considered at the time of surgery if the patient has been inappetant prior to surgery or you feel the patient may have specific requirements for feeding post-operatively (eg in septic peritonitis).
A full review of post-operative drug therapy is not in the scope of this article, but the most common time for intestinal incisional dehiscence, the most concerning complication seen after intestinal surgery, is reported to be three to five days post-operatively. Rectal temperature is usually monitored three times daily to check for pyrexia, and body weight can be monitored to assess for the accumulation of ascites, seen as an increase in body weight.
| Mitsou, K., Papazoglou, L. G., Savvas, I. and Tzimtzimis, E. | 2018 | Investigation of leakage holes created by four needle types used for closure of canine enterotomies. Open Veterinary Journal, 8, 411-414 |
| Saile, K., Boothe, H. W. and Boothe, D. M. | 2010 | Saline volume necessary to achieve predetermined intraluminal pressures during leak testing of small intestinal biopsy sites in the dog. Veterinary Surgery, 39, 900-903 |