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58 Cards in this Set

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How can you tell that a fluid is from a body cavity when performing a tap?
• If free blood in body cavities it shouldn't clot so if do a tap and then put in tube and doesn't clot then you know you're in a body cavity bc the platelets aren't there
-Platelets are removed from the peritoneal surface w/in 45 minutes
What are the 5 natural openings in the abdominal cavity?
1) Esophageal hiatus
2) Caval hiatus
3) Aortic hiatus
4) Inguinal canals
5) Vascular femoral lacunae
How long can pneumoperitoneum persist after a laparotomy?
2-3 weeks post-op
What is the general approach for an exploratory laparotomy?
Ventral midline incision
-reserve flank or alternative approaches for surgical goals (ovariectomy, adrenalectomy etc)
What approach is used for an adrenalectomy?
Paracostal approach
What is involved in the surgical preparation for an exploratory laparotomy?
-Dorsal recombency
-Prep xyphoid to pubis
-4 corner drape: drape for disaster
-Count sponges
When performing a ventral midline celiotomy for an exploratory laparotomy, what can you do to get the penis out of the way?
repuce gets in the way with males so he hooks the prepuce with a towel clamp and clamp it to some skin located laterally so if need to continue ventral midline caudally you can
-curve happens with the skin but still stay on the linea alba when enter the abdominal cavity
What should you remember to do when making your primary ventral midline incision for an exploratory laparotomy (or any ventral midline celiotomy)?
Apply tension with your fingers!
Why do you want to make sure not to clear too much space when cleaning up the linea alba during a ventral midline celiotomy?
Too much dead space---> seroma formation
Explain the thickness/thinness of the linea alba cranially and caudally.
o linea alba means white line, thinner and wider cranially, caudally by inguinal area the muscles come together and obscure it so can't see it well, but its quite thick
What do you cut through if you make your incision just lateral to the linea alba when performing a ventral midline celiotomy?
Rectus abdominis muscle- avoid, it hurts much worse to cut through muscle
What muscle do you only see cranially when performing a ventral midline celiotomy?
internal abdominal oblique pretty much ends caudally, but do see cranially
What technique should you use when using metzenbaums to clean off the linea alba?
Push-cut technique: close a little bit as pushing but the sharp scissors just cut when push the scissors
Explain the surgical technique for performing a ventral midline celiotomy?
o tent up the linea alba (adson's, brown adson's)
o invert blade
o insert blade parallel to linea and lift up
-forceps will have to release to allow blade to lift up
Why should you always palpate right after making your skin incision during a ventral midline celiotomy?
Check for adhesions- if fat break down with fingers, if important and stuck don't apply blunt force then may just go off midline and cut through muscle and give extra pain meds
What are 2 ways to protect viscera from injury when incising into the abdominal wall?
-blade vs scissors
•robust animals use mayos, cats can use metzenbaums
-grooved director (or forceps), make sure stay on linea alba
Where is the falciform ligament located ventrally?
falciform ligament starts at umbilicus and goes cranially- usually not an issue w/ spay
What do you do if you encounter the falciform ligament during a ventral midline celiotomy?
Usually removed for improved exposure
-may split down the middle and pack off sides w/ moist sponges
What are 2 things to remember about your method of exploration during an exploratory laparotomy?
1) Be systematic, thorough and consistent
2) Balfour retractors are pivotal
What do you do to inspect the liver during an exploratory laparotomy?
• lift up lobes, look b/w live & diaphragm
• Gall bladder: squeeze make sure not obstructed, look at bile ducts
What do you do to examine the stomach during an exploratory laparotomy?
• palpate for foreign bodies
• retract caudally w/ left hand and run right hand up along greater curvature and check the cardia (if right handed), pull fundus caudally and tenses up cardia so can run hand up the curvature
• follow long pylorus and to duodenum
• palpate so don't miss foreign bodies
• act like you're going through an anatomy book and look at greater and lesser curvatures etc.
What do you do to examine the duodenum during an exploratory laparotomy?
• Lift and evaluate pancreas (don't palpate--> pancreatitis)
• palpate thickness of entire SI tract (get used to normal thickness)
What do you have to make sure to examine when looking at the cecum during an exploratory laparotomy?
o While lifting cecum--> mesenteric LNs (a whole cluster right there)
What do you need to make sure to examine while lifting the duodenum during an exploratory laparotomy?
o While lifting duodenum --> right kidney: mesoduodenum is a sling and pulls all viscera to midline so can look down to retroperitoneal space and see kidney, adrenal gland(usually can't see right) which should feel like a peanut
What do you do to examine the spleen during an exploratory laparotomy? What else should you look at while at the spleen?
oSpleen (head on left side)
•Gently exteriorize
•while retracting to midline and the right--> left kidney and adrenal gland
What structures do you need to remember to examine when in the caudal abdomen during an exploratory laparotomy?
Caudal abdomen including urinary bladder (palpate and make sure wall isn't thickened and no stones, if full of urine can empty-most commonly use a sterile 20g needle and do a cysto and suck with syringe, but don't keep poking bladder, keep needle in) and ureters (trace ureters- can see exiting the kidneys)
*What is the holding layer of a laparotomy closure?
External rectus sheath
-make sure to include when closing linea alba by taking wide bites
-sheath= outer most layer of peritoneal space
• Cranial two thirds linea alba is thinner so have to take a meatier bite, but don't take too much bc muscle necroses and can get space, but don't want too little bc will pull out
• Caudal two thirds, linea is thinner but thicker so avoid more of the muscle (a mm of musle)
What is the first layer closed during a ventral midline celiotomy?
Body wall
What type of suture do you want to use when closing up the body wall when using a ventral midline approach?
-Long term absorbable is best (PDS & maxon)
-Short term absorbable (monocryl) ok in select circumstances
-Non-absorbable (polypropylene) in other situations
How do you approximate what size of suture to use when closing up the body wall?
want strength to approximate strength of tissue- if pull on suture what will break first muscle or suture? but don't want too big of suture bc takes up more space, want smallest can get away with that's a little bit stronger than tissue you put in
What suture size do you want to use when closing up the body wall when using a ventral midline approach?
Dog: 2-0 to 0
Cat: 3-0 to 2-0
What suture pattern do you want to use to close the body wall when using a ventral midline approach?
•Simple interrupted or simple continuous
•Bites 5-10 mm from incised edge and 5-10 mm apart
What is the second layer you have to close during a ventral midline celiotomy?
Subcutaneous
What type of suture material do you want to use to close the second layer of a ventral midline approach?
Suture material: short or long term absorbable (usually can get away with short term, most use PDS)
What size of suture do you want to use to close the subcutaneous layer when using a ventral midline approach?
4-0 to 3-0
What is the difference b/w a subcuticular and intradermal closure of the subcutaneous?
subcuticular takes more vertical bites, but intradermal is horizontal- involves parts of subq
-if patient has a decent amount of subq space do intradermal - kind of a skin closure- horizontal bites
What suture patterns can be used to close the second layer when using a ventral midline celiotomy?
-Simple continuous
-subcuticular
-intradermal
What is the third layer closed during a ventral midline celiotomy?
Skin
What type of suture do you use to close the skin?
Non-absorbable (nylon or prolene)
OR staples
What size of suture do you use to close the skin when performing a ventral midline celiotomy?
4-0 to 3-0
What suture pattern do you use to close the skin when performing an exploratory laparotomy?
-Simple interrupted
-Cruciate
-Ford interlocking (disliked in small animals)
How common is primary peritonitis?
Rare
Maybe more common in cats
-FIP is another consideration..
What are 2 types of secondary peritonitis?
Aseptic peritonitis: not common
Septic peritonitis
What are 3 examples of aseptic peritonitis?
1) Mechanical
e.g. rub a bunch of gauze
2) Glove powder
3) Parasitic
e.g. kidney worms
Septic peritonitis is most commonly from the _____ (60%).
Gi tract
In up to 50% of cases of septic peritonitis the animal has concurrent ________.
Pancreatitis
Urogenital sources of septic peritonitis are rare but reported, why are they so rare? Why do some cases cause septic peritonitis and some don't?
•sterile urine not particularly irritating
•in healthy normal patient w/o infection, not irritating
•if infected urine then irritating
When does bile cause septic peritonitis?
•Bile, if septic---> extremely severe peritonitis!
•sterile bile not particularly irritating
•bile often is septic, think of common bile duct- superhighway from GI
What are some diagnostics used to diagnose septic peritoniits?
1) Abdominocentesis**
2) Abdominal radiographs
3) ultrasound, CT, and or MRI
What method should you use when performing an abdominocentesis in a suspect septic peritonitis case?
4 quadrant tap- like a cysto but use 4 needles
What do you do with the fluid collected from an abdominocentesis in a case that you suspect septic peritonitis?
-Cytology, fluid analysis and culture/sensitivity
-Fluid analysis depends on what you are looking for (Creatinine vs total bilirubin vs glucose)
What is the point of measuring glucose on fluid collected from an abdominocentesis in an animal that you suspect has septic peritonitis?
If septic can use a glucometer and run peripheral sample and if there's more than a difference of 20 with peritonitis fluid being lower by 20 compared to blood e.g. 80 blood and 60 in fluid or 50 in fluid then even more suggestive of peritonitis**** influences therapy
What should you measure during fluid analysis when you think septic peritonitis was caused by bile? Urine?
-Bile measure Total bilirubin
-if think urine measure creatinine
How can you tell if an animal has septic peritonitis by examining neutrophils? Is it normal for there to be neutrophils in fluid collected from an abdominocentesis?
normal to see neutrophils but if its septic they will look degenerate*** maybe even see intracellular bacteria
-toxic= blood, degenerate= peripheral
What are the 2 components to treating an animal with septic peritonitis?
1) Stabilize the patient prior to surgery
-fluids, electrolytes, acid/base
-antimicrobials (empirical first but base on culture and sensitivity)
2) Surgery
-find & eliminate the source
What are 3 things to consider when surgically trying to find and eliminate the source of septic peritonitis?
1) If GI source, consider simple interrupted suture and a serosal patch
2) Omentalize abscesses and intestinal surgery sites
3) Consider primary closure w/ drains vs open peritoneal damage
What are 3 components of post-op treatment of septic peritonitis?
1) Intensive monitoring and supportive care for any problems identified
•continuous EKG and BP monitoring
•Electrolyte and Big 4, CBC/chem/ UA every 24-48 hours
2) Low dose heparin? (check PT/PTT/platelets
3Nutritional support
Penetrating injuries usually heal on their own, but what are 7 indications for an immediate exploratory due to a penetrating injury?
1) Ongoing hemorrhage
2) Obvious abdominal wall defects
3) Hematemesis
4) Non-resolving hematuria/ hematochezia
-if doing well otherwise do not rush into surgery as it may be resolving
5) Bilirubin or creatinine in fluid > serum
6) Gunshot wounds
7) Bacteria