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Getting the Most Out of Exploratory Laparotomy In Dogs and Cats

Stephen J. Birchard, DVM, MS Diplomate, ACVS Department of Veterinary Clinical Sciences The Ohio State University Columbus, Ohio Introduction Exploratory laparotomy is a frequently used diagnostic and therapeutic technique in veterinary medicine. In some clinical cases, exploratory laparotomy is the most expeditious and efficient method for making or confirming a diagnosis. Valuable information can be obtained if the procedure is properly performed. A systematic examination of all abdominal organs is a key element of the surgery. Obtaining biopsies of appropriate tissues is indicated in most animals, and can add greatly to the information gained by the procedure. Surgical Anatomy and Methods of Organ Exposure Abdominal Wall The abdominal wall is made up of 4 muscles, the transversus abdominus, internal abdominal oblique, external abdominal oblique, and rectus abdominus.1 The aponeuroses of all of these muscles join at the ventral midline to form the linea alba. The linea is easily identified in the cranial and middle aspects of the abdomen, but is quite narrow and more difficult to delineate in the caudal abdomen in both dogs and cats. Peritoneum and Omentum The peritoneum is a serous membrane made up of mesothelial cells that lines the abdominal cavity and covers the abdominal viscera. The peritoneum is a very smooth lining that produces a small amount of fluid in the normal animal. This fluid allows friction-less movement of visceral surfaces against each other. The peritoneum is closely adherent to the transversus abdominus and, as opposed to humans, is difficult to separate from the tranversus muscle in dogs and cats and cannot easily be sutured as a separate layer of tissue. The kidneys, ureters, pelvic urethra, abdominal aorta, iliac lymph nodes, and adrenal glands

are considered retroperitoneal structures. This is an important fact when evaluating these structures on abdominal radiography and when considering surgical approaches. In some situations, lateral or flank approaches to the abdomen may be a more convenient method of exposing retroperitoneal structures. The falciform ligament is a thin sheet of mesentery that is filled with fat in well-nourished animals. It is found in the cranial aspect of the ventral body wall. It may be necessary to remove this ligament during cranial abdominal exploratory since it may interfere with exposure and complicate the closure of the abdominal wall. Ligation of an artery at the most cranial aspect of the ligament will be necessary if it is removed. The omentum is the large, lacy membranous structure that extends from the stomach to the urinary bladder. The omentum is divided into the greater and lesser components. The lesser omentum, located cranial to the stomach, has 2 leaves which enclose the omental bursa. This bursa communicates with the epiploic foramen. The epiploic foramen is dorso-cranial to the stomach, medial to the caudate process of the liver, and bounded by the caudal vena cava dorsally and portal vein ventrally. Extrahepatic portocaval shunts can frequently be found entering the caudal vena cava at the epiploic foramen. Other important segments of the omentum are the hepatoduodenal ligament and gastrosplenic ligament. Stretching of the hepatoduodenal ligament in large breed dogs has been implicated as one factor predisposing to gastric dilatation/volvulus. The greater omentum is the large sheet of tissue that covers the majority of the abdominal viscera. The omentum is sometimes referred to as the "surgeon's friend". It has the ability to provide blood supply and lymphatic drainage to injured or healing tissues. The omentum can also be lengthened to allow placement into distant sites such as areas of resected body wall or into non-healing wounds of the skin. The omentum can also be used to treat prostatic abscesses and cysts. Gastrointestinal tract The mesentery of the gastrointestinal tract is divided into the mesoduodenum, mesojejunoileum, and mesocolon. The mesoduodenum can act as a retractor by elevating the duodenum and pulling it to the left side during abdominal exploratory. This maneuver allows exposure of the right kidney, adrenal gland, ovary, and abdomenal "gutter". Similarly, the colon can be pulled to the right and the mesocolon used to expose the left side of the abdominal cavity and associated organs. The root of the mesentery is located mid-abdomen and dorsally. The duodenum descends caudally and then forms the duodenal flexure around the caudal aspect of the root of the mesentery. At this flexure, the surgeon will notice the duodenocolic ligament, a normal structure that is sometimes incorrectly thought to be an adhesion. This ligament may impede exteriorization of this portion of the duodenum from the abdominal cavity.

The mesenteric lymph nodes are present in the mesentery, adjacent to the ileocecocolic junction. The nodes lie very close to the cranial mesenteric artery and vein. Biopsy of these lymph nodes must be performed with great care to avoid damage to the vascular structures. The major intestinal lymphatic trunks are also located in this area although are usually not visible unless the animal has recently eaten a fatty meal. The liver consists of 6 lobes, the right and left medial, right and left lateral, quadrate, and caudate. The gall bladder lies between the quadrate and right medial lobes. The liver has a dual blood supply, receiving blood from both the hepatic arteries and from the portal vein. The majority of the liver's oxygen supply is derived from portal blood flow. The hepatic arteries are branches of the celiac artery and lie within the hepatoduodenal ligament along with the common bile duct. A cystic artery also branches off one of the hepatic arteries and supplies the gall bladder. The surgeon must therefore be very careful in manipulating or incising the hepatoduodenal ligament to avoid trauma to these important structures. The pancreas is divided into right and left limbs. The right limb is exposed by retracting the duodenum to the right, the left limb is exposed by caudal retraction of the transverse colon. The right limb shares arterial blood supply with the duodenum from the cranial and caudal pancreaticoduodenal artery. The splenic artery and vein lie very close to the distal aspect of the left limb. Urinary Tract The right kidney is more cranial than the left and relatively fixed in position. The left kidney is more mobile and easier to biopsy from a ventral midline approach. The ureters are dorsally located and exposed by retracting the bowel cranially or exteriorizing the intestines from the peritoneal cavity. The distal ureters are found by identifying the lateral ligaments of the bladder and exposing the small tubular structures within the ligaments. The ureters can be followed dorsally to the bladder trigone. If the urinary bladder is full, it should be emptied by manual expression or catheterization before the exploratory is begun. It can be emptied intraoperatively via suction using a small needle attached to a syringe or suction tubing. The bladder can be used as a "handle" for retraction in order to gain better exposure of the prostate gland or urethra. Stay sutures are placed at the apex of the bladder to retract it cranially. Approaches to the Abdomen Ventral Midline The ventral midline abdominal approach is the most versatile for abdominal exploratory

surgery. The incision is made through the linea alba. A frequent problem with the initial incision is missing the linea alba and inadvertently making an incision that is off the midline. This is not a serious problem for exposure of abdominal viscera, but can cause increased bleeding if the rectus muscle is sharply incised. A most common reason for missing the linea alba during the abdominal approach is poor positioning of the animal on the surgical table. If the animal is leaning even slightly to one side or the other, the tissues will be shifted and the linea will be harder to find. V-trough positioning devices can help keep the animal in perfect dorsal recumbency to avoid this problem. The abdominal approach should allow inspection of all abdominal viscera. Therefore, make the incision from the xyphoid to the brim of the pelvis. Remember, the "incision heals from side to side, not end to end." One of the most common mistakes made in abdominal surgery is inadequate exposure. Self-retaining abdominal retractors, such as the Balfour retractor, facilitate exposure by holding the abdominal wall apart. This frees up the hands of the primary and assistant surgeon to manipulate the organs rather than retract the abdominal wall. Use moistened laparotomy sponges to pad the abdominal muscle prior to placing the Balfour retractor. Paramedian A ventral paramedian approach can be performed instead of the midline. The paramedian approach is useful for caudal abdominal exposure in male dogs to avoid the prepuce. For example, a paramedian approach can be used for removing retained testicles in cryptorchid dogs. This is especially helpful if the surgeon is unsure if the retained testicle is located in the inguinal region, or in the abdomen. If the initial dissection over the inguinal canal fails to expose the testicle, the incision can be extended cranially and entrance to the abdominal cavity made via a paramedian approach. Paramedian approaches can also be used for routine cystotomy or prostatic biopsy in dogs. Exposure of the bladder for cystostomy tube placement can also be done via a paramedian approach. To avoid excessive bleeding during this approach, bluntly separate the fibers of the rectus abdominus muscle rather than sharply incising them. Paracostal A ventral paracostal incision is occasionally a useful adjunct to the ventral midline approach to gain more exposure of the right or left cranial quadrant of the abdomen. The incision is made 3-4 cm caudal to the costal arch, from the xyphoid to lateral abdominal wall. Examples of situations where this additional exposure would be helpful are: adrenalectomy, nephrectomy, partial hepatectomy, and biliary surgery. Flank

Although the flank approach is not frequently recommended for abdominal surgery in small animals, it can be a useful approach in certain situations, such as adrenalectomy, or emergency cystostomy or gastrostomy. A "grid' incision is recommended by many surgeons, and is performed by using blunt dissection through each muscle layer of the abdominal wall. These muscles can also be sharply incised. The major disadvantage of the flank approach is inability to examine all abdominal organs due to lack of bilateral exposure. Instruments Proper surgical instruments are essential to good surgical technique. In the Table is a list of instruments for doing routine abdominal procedures ("must have"), and those instruments that are not essential but helpful ("nice to have") A typical general surgical pack is also described in the table. Biopsy Techniques An integral part of exploratory laparotomy is the examination of tissues, and obtaining samples for analysis. Obtain biopsy samples from abnormally appearing organs. Even normal tissues sometimes warrant biopsy, depending on the nature of the animal's disorder. A variety of safe, easily performed biopsy techniques are available. Kidney Operative biopsy of the kidney can be performed via either wedge incision or using a needle biopsy device (e.g. Tru-cut needle, or Ancor soft tissue biopsy device). Needle biopsy devices are used by stabilizing the kidney with one hand, and penetrating the renal cortex with the other hand using the needle. Be sure to place the needle parallel to the greater curvature of the kidney to ensure sampling of the cortex rather than the medulla. Control bleeding by placing Gelfoam on the puncture site. Liver Guillotine biopsy of the liver is a simple and quick method of biopsy. Place absorbable suture around the tip of a liver lobe and tie tightly to occlude vessels within the parenchyma. Sharply excise the tissue sample. Place Gelfoam over the cut surface of the liver if needed for hemostasis. Skin punch biopsy devices can also be used to obtain liver tissue samples. Place Gelfoam in the in the parenchymal defect to control bleeding. Intestine Biopsy of the intestine should be done carefully to avoid contamination of the peritoneal

cavity. Place stay sutures on the antimesenteric surface of the intestine and isolate the segment of bowel from the remainder of the abdomen with laparotomy sponges. Make a small elliptical incision with a #15 scapel blade. Be sure to obtain a full thickness sample of intestinal wall. Alternatively, use a 4 or 5 mm skin biopsy punch to obtain the sample. Close the incision with 40 PDS or polypropylene in a simple interrupted pattern. Polypropylene is preferred in animals that may have delayed healing. Cover the incision with greater omentum to help prevent leakage. Other tissues The prostate gland and lymph nodes are easily biopsied by simply making an elliptical incision in the tissue and excising the sample. Closure can be done with absorbable suture in a mattress or cruciate pattern. Biopsy the pancreas in a similar manner as the liver. Carefully dissect a small section of the tip of either the right or left limb. Using absorbable suture such as 4-0 PDS, encircle a small section of the tip of the pancreas and tie the suture tightly to occlude vessels. Then excise the sample. Handle the pancreas very gently to prevent postoperative pancreatitis. Abdominal Closure Closure of the ventral midline incision is simple, especially if the incision was directly on the linea alba. If a paramedian incision was performed (that is, slightly off the linea), research has clearly shown that suturing the external leaf of the rectus fascia alone provides similar strength and healing as suturing both the internal and external fascia.2 Also, the author routinely closes the fascia in a simple continuous pattern using a strong suture such as monofilament polypropylene (Prolene) or polydioxanone (PDS). One study showed that there is no correlation between suture types and degree of inflammation in cats.3 However, many surgeons, myself included, avoid chromic catgut for abdominal closure because of problems with excessive inflammation or seroma, and because of the rapid loss of strength of the gut suture. It has also been shown in many studies that closure of the peritoneum is not necessary and may even be detrimental by encouraging adhesion formation.4 Conclusion Using basic prinicples of surgery, abdominal exploratory is a valuable method of diagnosis and treatment in small animal practice. One study found that exploratory laparotomy allowed the establishment of a diagnosis and prognosis in a high percentage of animals.5 The key features of the procedure are: achieve adequate exposure, handle tissures properly, do a thorough examination of all organs and tissues, obtain biopsy and culture samples for analysis, and

perform closure using accepted sutures and patterns.

References 1. Evans HE, Christensen GC. Miller's Anatomy of the Dog, 2nd ed, W.B. Saunders Co., Philadelphia, pp 324-331. 2. Rosin E, Richardson S. Effect of fascial closure technique on strength of healing abdominaol incisions in the dog. A biomechanical study. Vet Surg 1987;16:269-272. 3. Freeman LJ, Pettit GD, Robinette JD, et.al. Tissue reaction to suture material in the feline linea alba. A retrospective, prospective, and histologic study. Vet Surg 1987;16:440-445. 4. Peacock EE. Wound Repair, third ed., W.B. Saunders Co., Philadelphia, pp 441-443. 5. Boothe HW, Slater MR, Hobson HP, et. al. Exploratory celiotomy in 200 nontraumatized dogs and cats. Vet Surg 1992;21:452-457. Study Questions 1. Why should the surgeon use a paramedian abdominal approach for certain conditions in dogs and cats?

2. Which blood vessel(s) provide the majority of blood flow to the liver?

3. Which abdominal structures are retroperitoneal?

4. Why is the omentum called the surgeons friend?

5. When performing a renal biopsy, what is the proper orientation of the needle to the renal cortex?

Table
Surgical instruments necessary for exploratory laparotomy in small animals. Typical general surgery pack 1 Bard-Parker scapel handle 1 Metzenbaum scissors 1 Mayo scissors (blunt-sharp) 1 Mayo-Hegar needle holders 4 Pean hemostats 4 Carmalt hemostats 1 Kelly clamp (straight) 1 Kelly clamp (curved) 1 Crile clamp (straight) 3 Mosquito clamps (straight) 3 Mosquito clamps (curved) 4 towel clamps 1 Brown-Adson tissue forcep 1 DeBakey tissue forcep 1 Saline bowl and bulb syringe Additional Must Have Equipment 1. Balfour retractors (with blade) 2. Abdominal sponges 3. Suction 4. Formalin and containers. for biopsy samples 5. Culture tubes or swabs 6. Appropriate selection of suture material Additional Optional Equipment 1. Malleable retractors 2. Deaver retractor 3. Biopsy tools a. true cut b. Vim-Silverman c. Ancor soft tissue biopsy device 4. Hemostatic clips (Versaclips) 5. Electrocautery 6. Glass slides and cover slips 7. Gelfoam