Enterotomy in Cats (Felis) | Vetlexicon
felis - Articles

Enterotomy

ISSN 2398-2950


Introduction

  • Common surgical procedure to:

Uses

Advantages

  • Removal of intestinal foreign bodies.
Full thickness intestinal biopsies have a higher diagnostic yield potential compared to endoscopic intestinal biopsies Enteroscopy.


Disadvantages

Alternative techniques

  • Endoscopic intestinal biopsies.
  • Obstructing non-passing small intestinal foreign bodies will have to be retrieved surgical.

Time required

Preparation

  • 15-30 minutes.

Procedure

  • 60-90 minutes.

Decision taking

Diagnostics

  • Hematology, biochemistry Blood biochemistry: overview, electrolytes and blood gasses. If animal is unstable and/or GI perforation is suspected, stabilize patient for shock Shock.
  • Radiographs Radiography: digital to assess for obstructive pattern. Ultrasound depending on experience for further localization of obstruction and characterization as well as free fluid in abdomen. CT Computed tomography (CT) has been shown to be rapid and accurate for the diagnosis of intestinal obstruction.
  • If free abdominal fluid perform abdominocentesis Abdominocentesis for cytology, lactate and glucose measurements. Compare to peripheral measurements.

Pre-operative treatment

  • If animal is unstable and/or GI perforation is suspected/confirmed, stabilize patient for shock. Correct/stabilize any electrolyte imbalance as appropriate.

Requirements

Personnel

Veterinarian expertise

  • Medium.

Anesthetist expertise

  • Medium.

Nursing expertise

  • Medium.

Materials required

Minimum equipment

  • Basic surgical pack Surgical instruments.
  • DeBakey forceps.
  • Doyens intestinal forceps Enterectomy: Doyens forceps (if no assistant available).

Ideal equipment

  • Suction.
  • Self-retaining retractors (Gossets, Balfour, Alexis).
  • Assistant to hold intestines.
  • Bipolar electrocautery.

Minimum consumables

  • 3-0 to 4-0 absorbable monofilament suture (polydioxanone, polyglyconate) Suture materials: absorbable with a swaged on taper point needle.
  • Scalpel blade.
  • Gauze sponges with radiopaque line.
  • Warmed saline for abdominal lavage after enterotomy.
  • Suture to close enterotomy and abdomen - size dependent on size of patient. Skin staples or cyanoacrylate glue also an option.

Preparation

Dietary preparation

  • Fast 6 h prior to elective surgery of adult patient.
  • Water must be available at all times.
  • Pediatric patients should preferably be starved for no more than 4-6 h.

Site preparation

Restraint

Technique

Approach

Step 1 

  • Ventral midline incision from immediately caudal to xyphoid to immediately cranial to pubis with no 10 scalpel blade.
  • Identify the linea alba.
  • Tent the linea alba with Adson thumb forceps.
  • Perform small stab incision through the linea alba with a no 11 scalpel blade.
  • While tenting the abdominal wall with forceps continue the linea alba incision with Mayo scissors. Ensure there are no adhesions as you go along by inserting your finger to palpate ahead of where you are cutting.

Step 2 

  • Remove the falciform fat by cutting it away from its lateral attachments with Metzenbaum scissors. Here bipolar diathermy can be useful for hemostasis of the small vessels. When the cranial pedicle is reached just caudal to the xiphoid ligate with 3-0 absorbable monofilament suture before amputating the fat.

Step 3 

  • Place moistened lap swabs on either side of the incision and insert a self-retaining abdominal retractor (Balfour or Gosset). Take care not to entrap any organs or tissue between the retractor and abdominal wall.

Core procedure

Step 1 

  • Full abdominal exploratory examination. This will allow the surgeon to identify any further issue which may need to be addressed and planned into the procedure.
  • Pack off the identified section of bowel where the enterotomy is planned with moist laparotomy swabs to protect the abdominal cavity from potential spillage of intestinal contents. Exteriorize the loop if possible.
  • Assess viability of the section of intestine. Consider enterectomy Enterectomy if you have concerns about the viability of the intestine.

Step 2 

  • Gently milk away additional intestinal contents from the site of the enterotomy. When performing foreign body removal, the incision into the intestine should be performed aborad to rather than directly over the distended section. Incise into healthy tissue and gently traction the foreign body out from the intestine. Do not place too much tension or you risk damaging the intestinal wall and risk breakdown later. If you need to, make the incision longer.
  • Gently clamp intestines either with atraumatic intestinal forceps (eg Doyens forceps) or digitally, via an assistant.
  • Make a stab incision with a no 11 scalpel blade on the anti-mesenteric side.
  • Extend the incision on anti-mesenteric side parallel with the intestine with Metzenbaum scissors Surgical instruments: dissecting scissors - Metzenbaumto length appropriate for foreign body removal or intestinal biopsy.
  • When performing full thickness intestinal biopsies, a trick is to place a stay suture in the tissue to be removed. Place the suture on the anti-mesenteric border parallel to the intestine. Take a 3-5 mm bite. Make the stab incision adjacent to the stay suture which can be used to place tension on the tissue and allow improved ease of intestinal incision. Once the stab incision has been made continue to either end of the stay suture with Metzenbaum scissors and then connect to the other side of the stay suture. Be aware not to take too large of a section at the risk of stricture. This technique also allows minimal handling of the biopsied tissue without repeated grabbing with forceps thereby improving tissue preservation for histopathology.
  • If retrieving a singular foreign body, use Babcock forceps, Allis tissue forceps or hemostats to grasp the foreign body and milk foreign body out of enterotomy site. Take care not to grasp mucosal lining of intestine.
  • Multiple enterotomies may be needed in cases with linear foreign bodies. In these cases, cutting the linear foreign body can ease in its retrieval. Do not place overt tension through the linear foreign body as it is removed at the risk of cheese wiring through the tissue or causing other damage. This is most often seen on the mesenteric border that might not be readily visible. This can develop into necrosis and leakage of intestinal content.

Step 3 - Enterotomy closure

  • 3-0 or 4-0 absorbable monofilament suture (such as polydioxanone, polyglyconate) Suture materials: absorbable on taper point swaged on needle Close the enterotomy in a single appositional layer with full thickness sutures either in a simple interrupted pattern, simple continuous pattern, or a modified Gambee pattern Suture patterns. Bites should be 2-4 mm from the edge of the incision and 2-4 mm apart. Take care to maintain even tension along the suture line while suturing a simple continuous pattern. In any repair it is important that the submucosal layer is engaged as this is the tension holding layer.
Take care not to let the mucosa become everted through the enterotomy closure. If eversion is excessive and cannot convincingly be inverted into the lumen, then trim away mucosal tissue with Metzenbaum scissors prior to suture placement.

Exit

  • Routine three-layer abdominal closure Suture materials: absorbable Suture materials: non-absorbable Suture patterns.
  • Abdominal closure:
    • 2-0 or 3-0 such as polydioxanone or polyglyconate (PDS, Maxon) simple continuous or simple interrupted.
  • Subcutaneous closure:
    • 3-0 or 4-0 such as poliglecaprone 25 (Monocryl) simple continuous.
  • Cutaneous closure:
    • Intradermal layer with 3-0 or 4-0 such as poliglecaprone 25 (Monocryl).
    • Skin staples, skin sutures 3-0 Nylon simple interrupted, cruciate or Ford interlocking pattern or cyanoacrylate glue can be used instead of or in conjunction with the intradermal closure.

Aftercare

Immediate Aftercare

Monitoring

  • Post-operative monitoring includes regular temperature readings hourly until return to normothermia (37.5°C-38.5°C/99.5°F-101.3°F).
  • Encourage food intake as soon as the patient is awake and sufficiently conscious to swallow.
  • Feed little and often. Ideally a gastrointestinal wet diet. The daily ration should be divided into 6-8 potions to be fed at regular intervals. When the cat goes home, feeding 4-6 times a day for the first 2 weeks as this might be more manageable for the owner.
  • If the cat has had prolonged inappetence prior to surgery then start at 33% of the daily energy requirement, then 66% the following day to then end at 100% full ration 3 days after to prevent refeeding syndrome.

Fluid requirements

  • Ensure the cat is normohydrated. Correct any fluid deficiency.
  • Keep on maintenance intravenous fluid Fluid therapy: overview until eating and drinking or until substituted via a feeding tube if one has been placed.

Analgesia

  • Opioids for at least 12-24 h Analgesia: opioid.
  • Ketamine Ketamine infusion can be added in cases that need additional analgesia.
  • NSAID Analgesia: NSAID is a contentious drug choice in these cases and an individual risk assessment should be carried out. The use of intra-operative locoregional analgesia techniques can have a significant positive impact on the post-operative pain relief requirements.

Antimicrobial therapy

  • Intra-operative antimicrobials Therapeutics: antimicrobial drug are indicated in open gastrointestinal surgery. Post-operative antimicrobials are not indicated unless there has been a breach of sterility, the patient is septic or other individual patient factors apply.

Other medication

  • Not indicated unless complicating factors are present.

Wound Protection

  • Elizabethan collar.
  • Limited activity confined to a small room or crate without the ability to run or jump.
  • Primapore for the first 8-12 h or until any wound oozing has stopped.

Potential complications

  • Post-operative complications range from mild to devastating including, but not limited to:
    • Dehiscence.
    • Abscess Abscess.
    • Septic peritonitis Peritonitis.
    • Incisional seroma  Seroma.
    • Short-bowel syndrome.
    • Ileus Ileus.
    • Adhesions.
    • Surgical site infection.

Outcomes

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Mullen K M et al (2021) Evaluation of intraoperative leak testing of small intestinal anastomoses performed by hand-swen and stapled techniques in dogs: 131 cases (2008-2019). JAVMA 258 (9), 991-998 PubMed.
  • Winter M D et al (2017) Ultrasonographic and computed tomographic characterization and localization of suspected mechanical gastrointestinal obstruction in dogs. JAVMA 251 (3), 315-321 PubMed.

Other source of information

  • Giuffrida M A & Brown D C (2017) Small Intestine. In: Veterinary Surgery Small Animal. 2nd edn. Eds: Johnston S A, Tobias K M. Elsevier, USA. pp 1730-1761.