Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Friday, September 6, 2013

Incisional Gastropexy: Detailed description and video!


Fig. 1: The letters and arrow indicate where the gastric incision
is made for incisional gastropexy
A critical part of the operative treatment for GDV is to perform a gastropexy. Creating a permanent adhesion between the pyloric antrum and the right side of the abdominal cavity prevents recurrence of rotation of the stomach. Many options for gastropexy are available, including tube gastrostomy, circumcostal gastropexy, belt loop gastropexy, or incisional gastropexy. Because of its simplicity, incisional gastropexy has gained popularity among surgeons in recent years. Creating a seromuscular incision in the pyloric antrum and a similar incision in the interior abdominal wall starts the incisional gastropexy. These two incisions are sutured to each other to create the permanent adhesion. Incisional gastropexy is a straightforward technique and studies have shown it to be very effective at preventing gastric volvulus in dogs.
            
In addition to performing the procedure for dogs that have already developed GDV prophylactic gastropexy is also indicated in dogs that may develop GDV sometime in their life. (see previous blog on risk factors for GDV)

Towel clamps are placed on the edge of the right body wall and held by an assistant to increase exposure. A simple interrupted suture of 2-0 PDS (taper needle) is placed at the lesser curvature of the pyloric antrum ("a" in Fig. 1) and sutured to the interior of the abdominal wall just caudal to the last rib. A second suture is placed at the greater curvature of the antrum ("b" in Fig. 1) and then sutured to the interior of the abdominal wall at a point approximately 4-6 cm caudal to the first suture depending on the size of the animal. (Fig. 2) The needles are left on these initial sutures since they will be used to suture the stomach to the abdominal muscle after incisions are made.

Fig. 2 The pyloric antrum has been tacked to the interior of the
body wall on the right side.
(R: right, L: left, Cr: cranial, Ca: caudal)         
A seromuscular incision is made in the pyloric antrum being careful not to enter the stomach lumen. The incision is perpendicular to the long axis of the stomach. (arrow in Fig. 1) To start this incision, the stomach wall can be pinched between the thumb and first finger. Allow the gastric mucosal layer to slip through the fingers and thus not be included in the incision. Metzenbaum scissors or scalpel are used to incise the tissue being held by the fingers which amounts to a seromuscular incision. This incision is then lengthened by using the Metzenbaum scissors to undermine the seromuscular layer and separate it from the mucosal layer. The scissors are then used to incise the seromuscular tissue to complete the stomach incision. A corresponding incision is then made in the interior abdominal musculature the exact same length as the stomach incision. (Fig. 3)


Fig. 3 Incisions have been made in both the stomach and body wall.
Use the previously placed PDS sutures to appose the stomach incision to the abdominal incision. Suture the lateral aspect of the stomach incision to the dorsal aspect of the abdominal incision with one suture line. (Fig. 4) 


Fig. 4 The lateral aspect of the stomach incision has been sutured
to the dorsal aspect of the body wall incision.
Then suture the medial aspect of the stomach incision to the ventral aspect of the abdominal incision with the other suture line. (Fig. 5)


Fig. 5 the medial aspect of the stomach incision has been sutured
to the ventral aspect of the body wall incision.


Video:



Acknowledgement: Thank you to my good friend and colleague Dr. Gary Ellison for his help in developing this incisional gastropexy technique.

Note: The surgical description and photos are also published in the May/June, 2013 issue of The California Veterinarian. Here is the link: http://www.cvma.net/images/cvmapdf/GastricDilatation.pdf