Just say "There". An irreverent look at the world of surgery.

Many years ago when I was a surgical resident my advisor, Dr. Ron Bright, taught me a very important lesson. When something goes wrong in surgery, for example you accidentally cut something you should not have, there is a proper way to respond. What you do not do is say “Whoops!”, or “Oh my god!”, or scream some unprofessional expletive. (although one of my former residents claims that the “f” word has hemostatic properties.) What you do is step back from the operating table, look at the patient, and calmly say: “There”.  In this way, you maintain a stable and professional demeanor and maintain what little respect the surgical assistants may still have for you. Saying “There” makes people think you actually meant to do whatever that stupid thing was you did. Of course, after saying “There”, particularly if there is active bleeding or other potentially catastrophic event happening, quickly step back up to the operating table and correct the problem.

Surgeons are very modest people.

In the first blog we talked about Halsted’s principles of surgery. There are a few other principles that should be recognized by all surgeons:

• Do not cut blood vessels that have names.
• Especially do not cut blood vessels that have short names.
• The worst kind of bleeding is that which you can hear.
• Gelfoam is a wonderful hemostatic agent, but it will not stop hemorrhage from the aorta.
• All bleeding eventually stops.
• The incision heals from side to side, not end to end. (courtesy of Dr. George Wilson)
• Do not use retractors that are bigger than the patient. (see Figure 1)
• The only surgeons who do not have complications are those who are dead.
• The surgeon is allowed to sing in the operating room.
• Most surgery is to remove an SBI (“something bad inside”).
• Pour sugar into an open wound, but not salt.
• Do not cut something unless you know what it is.
• When operating on a chicken around lunchtime, do not use electrocautery to control bleeding in muscle tissue.

Figure 1: This chihuahua and this Balfour retractor do not make a good match.

Case Outcome: Shih Tzu with chronic vomiting

A cranial abdominal mass or enlarged pylorus was seen on  the lateral abdominal plain film. (arrows)
Radio-opaque calculi were present in the urinary bladder.

A filling defect (arrows) in the pyloric antrum was seen on the upper GI barium series.

The filling defect was also seen in this VD projection of the upper GI series. (arrows)

Gastric endoscopy revealed hypertrophied mucosa in the pyloric antrum and pylorus. (arrow)

Abdominal exploratory was performed and the pylorus and antrum incised.
Severe hypertrophy of the mucosa was seen. (arrows)

Full thickness biopsies of the pylorus were obtained and a Y-U pyloroplasty was performed.

A cystotomy to remove the calculi was performed. The dog also had a portosystemic shunt and a gall bladder mucocele. An ameroid constrictor was placed around the shunt and a cholecystectomy was done. (How's that for a abdominal surgery combo?) Histopathology of the pylorus revealed changes consistent with chronic hypertrophic pyloric gastropathy. Gall bladder histopathology was consistent with a mucocele. Calculi analysis was urate and struvite in composition. The Shih Tzu did well postoperatively, lived an additional 1 and 1/2 years, and then died of unknown causes.

For more information on this disease and the surgical treatment see:
Johnson SE, Sherding RG, and Bright RM. Diseases of the Stomach, in Saunders Manual of Small Animal Practice, 3rd edition, eds Birchard SJ and Sherding RG, Elsevier, St. Louis, pg. 664.

How did you do on the case?

Stay tuned for more gastric surgery blogs including some updates on Gastric Dilatation Volvulus. 

What's Your Diagnosis?

This is an 11 year old female spayed Shih Tzu with a 2 month history of intermittent vomiting. The vomitus sometimes looks like coffee grounds. She had a right sided enucleation 2 years ago that was unrelated to her current problem.

Physical examination was unremarkable except for the absent right eye.

A CBC showed mild neutrophilia and serum chemistry profile was normal. A urinalysis was also normal.

Plain film radiographs, abdominal ultrasound, and an upper GI study with barium were performed:

Area between the cross marks in the pylorus

What further diagnostics would you do?
What are your differential diagnoses?
What definitive treatment would you recommend? (hint: it probably involves some kind of surgery.)

Answers in the next blog!

Fine tuning surgical removal of gastric foreign bodies

Today's blog may seem a little basic but it's a good start to what will be several more blogs describing gastric surgical techniques such as debridement and closure of full thickness ulcers, incisional gastropexy to prevent gastric dilatation volvulus, and pyloroplasty for pyloric hypertrophy.
Gastric surgery requires adequate surgical exposure.  The ventral midline abdominal approach should begin at the xyphoid cartilage and extend beyond the umbilicus.  Self-retaining retractors (e.g. Balfour) are very helpful in the exposure. 

Contamination of the abdomen with stomach contents can be minimized by isolating the stomach from the remainder of the abdomen with laparotomy sponges, using stay sutures to elevate the gastrotomy incision, and using suction to remove stomach debris and fluid.  If an upper GI radiographic contrast study was performed preoperatively, prevent spillage of barium into the peritoneal cavity.

Always do a thorough examination of all abdominal organs. Besides the stomach, pay particular attention to the intestines, liver, and pancreas.  In cases of gastric neoplasia, close examination of regional lymph nodes and liver must be done to check for metastatic disease.

Indications for gastrotomy include gastric foreign body, distal esophageal foreign body, or gastric biopsy.  Figures 1-4 are from a dog whose owners discarded turkey drippings onto the gravel driveway on Thanksgiving Day. That was the tastiest driveway the dog had ever eaten. (Yes, the gravel was removed from the stomach using a sterile teaspoon.)

Make the gastrotomy incision in a relatively avascular area, halfway between the lesser and greater curvature.  Traditional gastrotomy closure is a two-layer inverting pattern such as a Cushing (Fig 5) followed with a Lembert pattern (Fig 6).  Absorbable sutures such as Monocryl or PDS on taper needles are acceptable for closure. Be sure to penetrate the submucosal layer of the stomach with the suture. After taking a bite of the tissue, if you can see the suture through the tissue the submucosa has probably not been included in the suture bite. Some surgeons prefer to close the gastrotomy incision with a simple continuous of the full thickness gastric wall followed by a Cushing pattern of the seromuscular layer. Dr Becky Ball, also a surgeon at Circle City Veterinary Specialty Hospital, prefers that technique.

Figures 1 and 2

Figures 3 and 4

Figure 5

Figure 6

            

                        

                                                                           

The Halsted Chant!

When I was on the faculty of the College of Veterinary Medicine at Ohio State, I taught the "Instruments and Tissue Handling" lecture to the 2nd year veterinary students. I tried to emphasize the importance of the surgical principles developed by Dr. William Halsted, a great surgeon who is considered one of the patriarchs of modern surgical technique in humans. His principles were:

Gentle handling of tissues

Meticulous hemostasis

Close dead space

Maintain blood supply to the organs and tissues

Maintain asepsis

Do not suture tissue under tension

Accurately align the tissue layers when closing

Rather than have the students memorize that list of principles, I modified them into a silly but fun exercise we called the "Halsted Chant".  I had one member of the class stand in front of his or her fellow students and yell the first part of each line with the students responding with the second half of each line.

I have to say each time we did it I found it to be a wonderful experience. If it helps you remember the most important principles of surgery, commit the Chant to memory and say it out loud before beginning the intended surgery.

Chorus:

When in doubt . . . cut it out!

A chance to cut . . . a chance to cure!

Above all else . . . do no harm!

Verses:

Tight stitches . . . incision itches!

Unhappy tissues . . . healing issues!

Leave dead space . . .    seroma in place!

Hemostasis . . . bloodless spaces!

Handle rough . . . inflamed stuff!

Asepsis . . . no abscess!

Layers aligned . . . healing sublime!

Repeat the Chorus