Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Thursday, September 19, 2013

Enterotomy For Intestinal Foreign Bodies Including Surgical Video


Fig. 1 Corn cob foreign body in the intestine of a dog.
Make enterotomy incision at arrow.

Preoperative Care

Fluid therapy is a critical aspect of overall management of the intestinal surgery patient. Correct dehydration and provide maintenance needs with intravenous fluids (such as Lactated Ringers or other balanced electrolyte solution). Correct electrolyte abnormalities such as hypokalemia. Give colloids if the animal is hypoproteinemic or whole blood or packed cells if anemic.
                 
Prophylactic use of antibacterials is indicated since the intestine is contaminated. Broad-spectrum antibiotics are recommended such as one of the cephalosporins (cefazolin, 20 mg/kg IV) Begin the drug before surgery to insure adequate blood levels at the time of the operation. Do not continue the antibiotic postoperatively unless infection (e.g. peritonitis) is present.

Quietly recite the Halsted Chant to prepare yourself for the surgery. (See first blog in the VKP series.)

Surgical Technique for Enterotomy

See previous blog on Intestinal Biopsy for recommendations on instruments and sutures for intestinal surgery. Use meticulous, atraumatic technique and keep the tissues moist. Isolate the affected segment of bowel with moistened sponges and place stay sutures adjacent to the proposed incision.  Have an assistant use their fingers to occlude the bowel on each side of the enterotomy incision. Incise the intestine on the antimesenteric side close to the foreign body and in an area of intestine that is healthy, i.e. the area of bowel that is downstream from the foreign body. (Figs.1,2)
Fig 2: Fragment of rubber ball in the intestine of a dog.
Make enterotomy incision at arrow.


Fig 3: Rubber fragment removed


Use suction to control spillage and minimize contamination of the peritoneal cavity. Do not use electrocautery on the intestine for hemostasis. Extricate the foreign body from the intestine and remove it from the sterile field to avoid contamination. (Fig. 3)

Closure:

Close the intestine with 4-0 PDS, taper RB1 needle in a simple continuous pattern.  Be sure to do full thickness bites of the intestine (Fig. 4) to include the submucosa which is the holding layer.
Fig. 4: Full thickness suture bites of the intestinal wall are required
to be sure of including the submucosa.
Avoid excessively handling the full thickness bowel with thumb forceps even if you are using DeBakey forceps.  Have your assistant maintain tension on the suture line as you are taking the bites of tissues to keep it from loosening. Use the suture needle to guide each suture loop onto the incision to maintain even spacing. (See Video) After completing the simple continuous line, fill in any gaps with the same suture using a simple interrupted pattern. (Fig. 5)
Fig. 5: Completed enterotomy closure with simple continuous pattern
Leak test the incision as described in the blog on Intestinal Biopsy. Lavage the local tissues but not the entire abdomen unless there was gross spillage of intestinal contents or peritonitis is present. Place the omentum on the incision and tack it adjacent to each end of the incision. (The omentum helps seal the incision and provides blood supply and lymphatic drainage.)

See blog on Intestinal Biopsy for postoperative care.

Always save the foreign body and give it back to the owner when the animal is discharged from the hospital. Encourage them to provide safe chew toys for their animal to use.

Video

The video is short but demonstrates some important principles of tissue handling that were mentioned in the text above.