EQUINE ABDOMINAL

SURGERY

K.E. Mwape
Principles of equine intestinal surgery
Perioperative Antimicrobials
Two major indications for antibiotic therapy are
prevention and treatment of infectious
processes.
Specific goals of perioperative antibiotic therapy
in abdominal surgery of the horse are prevention
or treatment of incisional infections,
postoperative adhesions, septic peritonitis, and
the treatment of septic shock.
Wound infection may result from many factors,
including
– patient contribution,
– environmental influences,
– and surgeon's contribution.
Therefore, prophylactic antibiotics are indicated.
Timing Of Surgery

Immediate surgery is mandatory for horses with a

specific surgical lesion or if intestinal viability is
compromised.
Medical management of the surgical patient before
induction of anesthesia is necessary if hypovolemia,
acid-base imbalance, and electrolyte abnormalities
are present.
Fluid therapy should be administered, sometimes
with the aid of a fluid pump (up to 60 to 90 ml/kg/hr).
Antibiotic therapy and supportive drugs such as
flunixin meglumine are administered before surgery,
when necessary.
However, if the horse is suffering from intractable
pain, it may be impossible and, in some instances,
detrimental to delay induction of anesthesia.
Horses with abdominal distention due to large
colon displacement or volvulus may have
impairment of venous return and/or ventilatory
difficulty during anesthesia.
Pre-induction percutaneous gaseous
decompression of the cecum and/or colon can
be beneficial.
Early surgical intervention is likely to increase
the survival rate in most horses with colic,
especially those with volvulus of the large colon.
Rectal palpation of intestinal distention,
moderate to severe abdominal distention,
uncontrollable pain, and identification of
serosanguineous peritoneal fluid should indicate
surgical intervention.
Assessment Of Intestinal Viability
Intestinal viability refers to the capacity of intestine to
survive and function normally after injury and to heal
without residual changes that could cause clinical
problems.
However, the options available for the management of
the intestinal lesion must also be considered in the
decision to resect bowel of questionable viability.
Important considerations are the risk of malabsorption,
accessibility of viable intestinal margins for anastomosis,
complexity of the anastomosis, overall effects of
additional surgery time, and experience of the surgeon.
The final decision should be tempered with the
realization that most types of anastomoses can lead to
adhesions and stenosis, and that these risks may be
greater in a horse with peritonitis, shock, and diffuse
intestinal hypoperfusion
Methods of Predicting Intestinal Viability
Standard clinical criteria
Fluorescein fluorescence
Doppler ultrasonography
Surface oximetry
Thermography
Surgical Considerations
Selection of Surgical Instruments
Besides the standard surgical pack, some additional
instruments are useful in performing intestinal surgery in
the horse.
An impermeable sleeve is useful to prevent strike-
through wetting of the surgeon's arms.
Wound rings (VI-Drape Wound protector) are helpful in
decreasing friction injury to the incised abdominal wall
caused by the surgeon's arms entering and leaving the
abdominal cavity.
Babcock forceps can be used to apply atraumatic
traction before cystotomy or enterotomy.
Surgical stapling devices are useful for vascular ligation,
enterotomy closure, or performing intestinal resection
and anastomoses.
 Glassman intestinal clamps are used for temporary and
atraumatic occlusion of the intestinal lumen.
Another intestinal clamp, a 14-inch long, sel-retaining
atraumatic clamp is used for large intestinal resection or
enterotomy procedures (Scanlan 14-inch intestinal clamp).
A colon tray is helpful during enterotomy and luminal
evacuation of the large intestine

Selection of Suture Materials

A variety of suture materials are now available for
intestinal surgeries, and new materials are
constantly introduced.
An ideal suture should material must be strong and
be able to maintain strength until healing occurs.
For skin, subcutaneous tissue and viscera, 14 to
21 days is sufficient for healing.
Chromic catgut is less popular but still is used by
some surgeons for enterotomy closure and intestinal
anastomoses.
Absorption of catgut suture is unreliable, and the
material is rapidly degraded by enzymatic secretions
from the stomach, duodenum, and colon.
Therefore, for routine enterotomy or intestinal
anastomosis, synthetic absorbable sutures are
preferred.
If delayed healing is expected, polydioxanone,
polyglyconate, or nylon may be preferable.
Closure of equine ventral midline incisions with
catgut increases the risk of herniation 55 times over
other suture material.
At present, size 2 or 3 polyglactin-910 is the suture
of choice for equine abdominal closure in all but dirty
procedures.
Polydioxanone and polyglyconate suture may be
suitable alternatives to polyglactin-910 but have
not been critically evaluated in horses.
A new non absorbable monofilament suture
made of polybutester may have benefits for
abdominal wound closure.
It maintains strength for a longer period of time
than does absorbable suture and is less prone
to suture sinus formation than multifilament,
nonabsorbable suture.
The suture stretches rather than cuts through
tissue when tension increases.
Staples or nonabsorbable monofilament suture
materials are preferred for skin closure.
Selection of Suture Patterns
The goals of successful intestinal surgery are to
obtain a watertight closure without stricture and
to avoid adhesion formation.
There are many different suture patterns, each
leading to an acceptable result.
The submucosal layer provides the strength of
intestinal closure.
Accurate serosal closure is essential for a
watertight seal.
To obtain such a leakproof seal, each suture
should be placed accurately.
Repeated perforation of the intestinal wall with
needle or tissue forceps should be avoided.
Prevention of mucosal protrusion through the
suture line is important.
Mucosal protrusion can cause localized peritonitis
and adhesions.
Everted mucosa should be oversewn.
Serosal surface should be apposed without
excessive inversion.
Excessive tension on the suture line should be
avoided.
Advantages of interrupted suture patterns are
1. the strength of an entire line of closure does not
rest on a single knot,
2. expansion can occur between suture bites, and
3. there is less interference with the local blood
supply.
Suture patterns can be further categorized
into:
– inverting (Cushing, Connel, Lembert, and
Schmieden),
– appositional (Gambee, simple interrupted,
simple con-. tinuous, and simple interrupted
crushing) and
– everting (horizontal mattress) sutures.
 Celiotomy/Laparatomy Approaches
The equine abdomen can be explored through several
approaches, including the ventral midline, ventral
paramedian, inguinal, colpotomy and flank approaches.

Ventral Midline Approach

Briefly, the ventral abdominal wall is composed of the
paired rectus abdominis muscles encased between the
external and internal rectus fascia, both layers of which
fuse at the midline creating the linea alba.
Depending on the site of ventral midline incision in a
caudal to cranial direction, the thickness of the linea alba
decreases from 1.0 cm or more at the pubis to 0.2 to 0.3
cm in thickness near the xiphoid.
A standard incision for abdominal exploration
begins at the umbilical scar and extends
cranially for 30 cm.
The location of the incision can vary, more
cranial or caudal, depending on the anticipated
lesion.
The incision can be extended in either direction
as necessary after the procedure is initiated.
The ventral midline is the most useful approach,
but because of the positibility of colic
postoperatively, alternative approaches become
necessary necessary.
Ventral midline celiotomy allows direct inspection of
more than 75% of the length of the digestive tract in
adult horses, and an even greater amount in foals.
The limiting variable is the depth of the abdominal cavity
in adult horses.
The long mesentery of the jejunum and small colon allow
for extensive exteriorization of each respective segment
for direct visual inspection, palpation, and surgical
manipulation.
Much of the cecum and large colon can be mobilized
through the midline incision and made available for
inspection, palpation, or surgical manipulation.
The mesenteric and ligamentous attachments of the
cecal base, right ventral and dorsal colon, the transverse
colon, oral and aboral small colon, and that of the
rectum, limit complete mobilization of these portions of
these segments.
 Similarly, the suspending ligaments of the
stomach and the comparatively short
mesoduodenum allow for palpation of these
organs only during exploratory surgery.

Ventral Paramedian Approach

A paramedian approach is made 8 to 10 cm
lateral to the ventral midline,12 on either side,
more cranial or caudal to the umbilicus as
desired.
This approach allows is visualization of the
individual layers of rectus fascia, external and
internal to the rectus abdominis muscle
Cutting through this muscle produces more
bleeding than a midline incision.
Identification of the individual layers of fascia is
important for wound closure.
Right or left paramedian approaches are seldom
used but may be chosen because of the
configuration of some operating tables.
As with the ventral midline approach, a complete
evaluation of the intestinal tract can be
performed from the paramedian approach.
A caudal paramedian, approach parallel to the
penile shaft and prepuce is preferred to access
the urinary bladder in adult males with cystic
calculi.
 Pathophysiology of Intestinal
Obstruction

Any interference, mechanical or functional, with

the progression of intestinal contents constitutes
obstruction.
The obstruction is said to be simple when the
process is not complicated by vascular
compromise of the bowel.
In strangulating obstruction there is obstruction
to both blood supply and the intestine.
Simple obstruction
Small intestine
Physical obstruction of the SI occurs by
impacted food materials, stricture.
This prevents passage of large volumes of fluid
produced in the upper AT.
This is either sequestered or lost by nasogastric
reflux.
Prime concern of SO is depletion of plasma
volume, reduction in cardiac output and acid
base disturbances.
Static medium enhances gas production by
bacteria.
Secretion of fluids and build up of gas increases
the intraluminal hydrostatic pressure (IHP) thus
distending the bowel.
Stretch receptors in the distended intestinal wall
are activated and hence increasing the pain and
making it continuous.
Peristaltic waves diminish and then cease as
intestinal lumen is progressively filled, leaving an
atonic rapidly distending tube.
Increased IHP stops absorption of water and
water starts to flow fro the mucosa into the
lumen.
The increasing pressure and build up of fluid
caused reflux into the stomach.
Increased vascular hydrostatic pressure in the
bowel promotes leakage of protein rich plasma
into the peritoneal fluid.
Initially there are few leucocytes and
erythrocytes in the PF but become more
numerous with the progressing degenerative
changes.
Damage may allow absorption of endotoxins
and cause production of PGs further
compromising CV function.
However hypovolemic and altered blood
electrolytes are the usual causes of CV collapse.
Severity of clinical signs associated with a SO of the SI
depends on the degree of obstruction (partial or
complete) and the level of obstruction (proximal or
distal).
Proximal obstructions have a more acute onset,
produce greater pain generate a greater volume
of gastric fluid sequestration and have a more
fatal course than distal obstructions.
Clinical signs resulting from distal SI
obstructions develop more slowly and are
generally less severe due to the compliance of
the intestine and the ability to continue some
fluid absorption until IHP initiates secretion.
Distal SI obstructions are characterized by
metabolic acidosis with low serum HCO3.
Large intestine
SO of the LI is usually due to impactions with
food material, enteroliths or other intraluminal
masses or a change in position of the colon e.g.
nephrosplenic entrapment.
The obstruction may be partial or complete.
In general clinical signs or rate of systemic
degeneration are much less dramatic in SO of
the LI than SO of the SI.
Incomplete obstruction allows some passage of
small amounts of ingesta and gas.
Dehydration is mild at first because water still
passes into the caecum where it is readily
absorbed.
The production of VFA and gas by bacteria is
reduced due to decreased amounts of ingesta.
If the obstruction becomes complete, ingesta
and gas accumulate very rapidly.
Distension becomes marked and may become
so great as to exert pressure on the diaphragm
and vena cava.
The result is impaired pulmonary function and
venous return to the heart.
Prolonged and/or marked distension of the
caecum and colon may cause interference with
mucosal perfusion leading to devitalization and
possibly fatal rupture.
Strangulating obstruction
Small intestine
These include incarcerations, intussusceptions
and volvulus and represent a common cause of
acute abdominal crisis.
Fluid retention with reflux into the stomach is
present like in SO but because vascular
compromise on the intestine is present from the
onset, the pathophysiology changes associated
with strangulation obstruction are more acute
and severe.
The vascular compromise may be venous, or
venous and arterial but venous occlusion starts
first with consequent venous congestion.
Within minutes, the involved segment of bowel
and its mesentery become deep red as the veins
and venules are filled with blood.
Immediate concurrent arterial occlusion the
intestine becomes cyanotic.
Within a few hours degeneration of vascular
epithelium becomes so extensive that blood pours
out of the distended vessel into the lumen.
The mucosal villi are sensitive to hypoxia.
The epithelial cells slough in sheets starting at the
tip of the villus towards the crypt.
Within 4-5 hrs the mucosal epithelium is
completely necrotic.
As soon as the mucosal barrier is damaged gram
+ve bacteria and endotoxins permeate the lamina
propria and submucosa.
These readily gain entry into circulation and
eventually leak through the serosa into peritoneal
cavity from which they are readily absorbed.
Endotoxins in the general circulation results in
damage to endothelial cells and platelets.
The resulting endotoxic shock is dose-related and
is more severe the greater the length of bowel
involved.
The clinical picture is acute with severe continuous
pain which show temporary or no response to
analgesics.
– HR increases progressively and pulse quality
deteriorates.
– MM become congested and the CRT increases.
– The PCV and TP also rise progressively and the RR
in creases in response to developing metabolic
acidosis.
– PF is initially serosanguinous with mild increase in
protein and leucocytes.
– As this increase the fluid becomes flocculent and
turbid.
– Toxic neutrophils indicate leakage of toxins and
bacteria.
The clinical course is rapid and most horses with
an untreated strangulating obstruction will die
within 24-30 hrs of the onset from irreversible
septic shock and marked vascular collapse.
For surgical correction to be successful it must
be done within hrs of the obstruction occurring.
 80% or more of cases may recover if operated
upon within 8 hrs.

Large Intestine
Strangulating obstruction of the LI include
intussusception of the caecum, torsion and
volvulus of the large colon and incarceration of
the small colon.
Pathophysiology is similar to that for SI with a
few variations.
The rate of systemic deterioration can vary
markedly between caecocaecal intussusception
in which it is slow and 360º torsion of the large
colon which is the most rapidly fatal of all
intestinal obstructions in the horse.
Submucosal space of the large colon is so small
that venous occlusion can result in the horse
losing half its circulating blood into the wall of the
gut within 4 hrs of a 360º torsion occurring.
Hypovolaemia is rapidly profound and the MM
become pale and cyanotic.
The degeneration of a large surface area of
bowel wall allows massive leakage of toxins and
bacteria into the peritoneal cavity and the effects
of endotoxemia are added to those of
Hypovolaemia.
Because of the short clinical course prior to
death, rupture is normally not seen.
*****
Surgical Disorders of the Small Intestine
Gastroduodenal Obstruction
Congenital Pyloric Stenosis
Congenital pyloric stenosis may occur but is rare.
Clinical signs may include abdominal pain,
depression, grinding of the teeth, and frothing
at the mouth.
The onset of signs may be correlated with a
dietary change to solid feed.
Significant clinical findings include a dilated
stomach, a thickened pylorus, and an empty
intestinal tract beyond the obstruction.
Pyloroplasty or pyloromyotomy procedures may
be used to increase the diameter of the pyloric
canal.
Acquired Gastroduodenal Obstruction

In the adult horse, the pylorus and oral

duodenum are relatively inaccessible and an
uncommon cause for acute abdominal crisis.
Obstructions of this area must be bypassed.
Gastrojejunostomy or duodenojejunostomy
provides an alternative route for gastric or
duodenal drainage.
Clinical signs
Gastroduodenal obstructions are more common
in the foal and signs:
– weakness,
– depression,
– anorexia,
– odontoprisis (teeth grinding),
– sialism,
– frothing at the mouth,
– protrusion of the tongue,
– radiographic evidence of gastric.distention, and
– regurgitation of milk often accompanied by
abdominal pain, particularly after nursing.
– If the obstruction is present for several days,
megaesophagus may develop.
– Aspiration pneumonia may be present on
survey radiographs taken of the caudal thorax
and cranial portion of the abdomen.
– Laboratory evaluation may support mild
dehydration, with hypochloremia,
hypokalemia, and metabolic alkalosis.
– If obstruction is in the region of the
hepatopancreatic ampulla, total bilirubin,
alkaline phosphatase, and gamma-glutamyl
transferase also may be elevated.
DIAGNOSIS
A tentative diagnosis is based on the history,
presenting signs, and results of PE and
peritoneal fluid analysis.
Confirmation is by barium (10 mL/kg) contrast
radiography.
If the foal has an obstruction at the cardia, there
is a dilation of the esophagus and retention of
barium.
At 60 minutes, a small stream of barium may be
seen entering the stomach.
This supports an obstruction at the cardia that
may be incomplete.
When the obstruction is at the level of or beyond
the pylorus, stomach motility is present, but at 1
hour no barium passes from the stomach.
Because a standing right lateral
radiograph is the only projection
attainable, it is not possible to differentiate
obstruction of the pylorus from the
duodenum.
It is more important to make a diagnosis of
an upper gastrointestinal obstruction
versus a specific anatomic location.
Treatment
Preoperative Management
Before surgery, food is withheld and access to
the dam for nursing prevented.
A nasogastric tube should be passed as needed
to relieve any gastric distention.
Based on serum electrolyte, hemogram, and
total protein results, solutions of dextrose, amino
acids, and crystalloids should be administered
preoperatively and continued into the
postoperative period.
A 10% dextrose solution is usually administered
initially as an energy source and can be
increased to 25% dextrose over a few days to
supply optimal caloric needs.
If peritoneal soiling is anticipated during
surgery and to treat aspiration pneumonia,
if present, the foals should be
administered:
– sodium ampicillin (22 mg/kg) four times daily
intravenously and
– amikacin sulfate (6.6 mg/kg) three times daily
intravenously both for treatment and surgical
prophylaxis prior to the induction of general
anesthesia
Surgical Management
One of five surgical procedures is used,
depending on the site of the obstruction:
(1) gastro-duodenostomy, to correct pyloric
stenosis
(2) partial gastrectomy and side-to-side
gastroduodenostomy, to bypass abscessation at
the pyloric antrum
(3) duodeno-jejunostomy and jejuno-
jejunostomy, when the duodenal obstruction is
found beyond the hepaticopancreatic ampulla
(4) gastro-jejunostomy and jejuno-jejunostomy,
to bypass extensive duodenal disease and
stricture beginning immediately beyond the
pylorus and extending to the caudal flexure and
 (5) choledocho-jejunostomy, duodeno-
jejunostomy, and jejuno-jejunostomy, to relieve
an obstruction involving the common bile duct
and duodenum at the level of the hepatopan-
creatic ampulla.

GASTRODUODENOSTOMY
On exposure of the pylorus after entering the
abdomen, generally no evidence of a pyloric
stricture is present.
The stomach is larger than normal because of
over distention with ingesta.
Because the stomach is enlarged, it is possible
to appose the pyloric antrum and the proximal
duodenum with stay sutures of 2-0 surgical
chromic gut.
A side-to-side gastroduodenostomy is performed
using 2-0 surgical gut or staples.
A handsutured three-tier method of anastomosis
is preferred.
The anastomosis should begin with a posterior
simple continuous suture of 2-0 chromic surgical
gut to align the seromuscular layers of the
stomach and duodenum.
The suture line should be extended slightly
beyond the planned anastomotic opening; the
suture end in this row should be left uncut for
incorporation into the corresponding anterior row
of sutures.
The second row of sutures is placed after
incisions/are made to but not through the
mucosa of the stomach and duodenum.
Again, a simple continuous suture of 2-0 chromic
surgical gut is placed, leaving the end uncut.
The mucosa of the duodenum and stomach is
then incised, and a third simple posterior row of
sutures is placed to approximate the cut edges.
After completion of this pattern, the anterior row
of sutures is a continuation of the third posterior
row; the second anterior row is a continuation of
the second posterior row; and the third anterior
row is a continuation of the first posterior row.
This completes the three-tier
gastroduodenostomy.
 Continuous suction and isolation of the surgical
site with saline-moistened laparotomy sponges
should be used to minimize peritoneal soiling.
Before closing the celiotomy incision, the site of
anastomosis should be irrigated with a balanced
electrolyte solution containing antimicrobial
agents.

PARTIAL GASTRECTOMY AND

GASTRODUODENOSTOMY.
This procedure is used for an obstruction
caused by an abscess involving the antrum, the
pylorus, or both.
FIG. Three-tier technique. (A), First posterior row of sutures approximating uncut
serosa (1). (B), Second posterior row of sutures approximating incised seromuscular
layers (2a). (C), Third posterior row of sutures approximating incised mucosal layers
(3a). (D), First anterior row of sutures approximating remaining incised free edge ofl
mucosa (3b). (E), Second anterior row of sutures approximating incised seromuscular
edges (2b).
Excision of the pyloric antrum, pylorus,
and duodenum can be completed using
the Autosuture staples.
It is important to maintain the vascular
supply to the affected portion.
The TA-90 stapling instrument can be
used for resection purposes.
Following removal of the involved antrum
and pylorus, the stomach can be
anastomosed to the duodenum using the
three-tier technique.
DUODENOJEJUNOSTOMY AND
JEJUNOJEJUNOSTOMY.
A duodenojejunal anastomosis is performed by
creating a 5-cm stoma between the cranial part
of the normal duodenum above the ampulla at a
segment of jejunum distal to the duodenocolic
fold using the threetier technique of
anastomosis.

HEPATICOJEJUNOSTOMY,
DUODENOJEJUNOSTOMY, AND
JEJUNOJEJUNOSTOMY.
This is the procedure of choice for an obstruction
of the duodenum beyond the ampulla and an
obstruction of the common hepatic duct.
This procedure is performed using the three-tier
technique followed by a jejunojejunostomy.
GASTROJEJUNOSTOMY AND
JEJUNOJEJUNOSTOMY.
This procedure is used as a means of bypassing
extensive duodenal disease and stricture
begining immediately beyond the pylorus and
extending to the caudal flexure.
The hand-sutured three-tier technique is
recommended.

Postoperative Management
Nasotracheal intubation is recommended to
ensure a patent airway.
Supplemental oxygen and xylazine, if needed for
sedation, may also be used.
Foals should be placed on a heating pad or
covered with blankets to maintain normothermia.
As soon as practical, foals should be allowed to nurse for
short periods.
If no regurgitation or abdominal discomfort occurs, the
frequency of feeding is soon returned to normal.
IV fluid administration is discontinued, depending on
acid-base and electrolyte abnormalities.
Antimicrobial therapy is continued for an average of 5 to
7 days.
Follow-up contrast radiographs are recommended 24
hours after surgery to confirm successful bypass of the
obstruction.
A standing right lateral survey radiograph is taken to
locate any previously administered barium.
When obstruction has been successfully bypassed, there
is rapid movement of barium into and out of the stomach,
although the stomach still is larger than normal and
contains gas and fluid.
Complications
Esophagitis, gastric abscessation, and ulceration
present before surgery are often active,
extensive, and contribute to obstruction.
Cholangitis and cholangiohepatitis may be
present on admission, based on clinical
evidence at surgery and the finding of barium-
stained bile ducts 24 hours after surgery.
Pneumonia, present on admission in some foals,
may be due to aspiration of food material during
chronic obstruction.
Treatment of the complications are symptomatic
and include the use of broad-spectrum
antimicrobial agents (ampicillin and amikacin) in
conjunction with H2 antagonists cimetidine.
Diseases of the Jejunum and Ileum
Epiploic Foramen Entrapment

The epiploic foramen is a narrow opening 4 to 10 cm

long, between the base of the caudate process of
the liver and the right lobe of the pancreas.
The foramen is bounded dorsally by the caudate
process of the liver and caudal vena cava and
ventrally by the right lobe of the pancreas and portal
vein.
The foramen is limited cranially by the
hepatoduodenal ligament and caudally by the
junction of the pancreas and mesoduodenum.
Normally, the foramen is a potential opening
separating the omental bursa from the abdominal
cavity.
The entrapment has been most commonly
described in older horses.
It is hypothesized that the epiploic foramen
becomes larger with age because of atrophy of
the right lobe of the liver.
Two forms of small intestinal incarceration
through the epiploic foramen have been
described: right to left (normograde), and left to
right (retrograde).
The right to-left herniation involves small
intestine passing from the peritoneal cavity
through the epiploic foramen and into the
omental bursa.
In the left-to-right herniation, the omental bursa
is involved in the hernia and is usually torn (Fig.
35-3). Incarceration from right to left was
reported to be more common.
FIGURE 35-3. Epiploic foramen incarceration. (A), Right-to-Ieft herniation and
(B) left-to-right herniation of small intestine through epiploic foramen.
DIAGNOSIS AND TREATMENT
Preoperative diagnoses are difficult.
Clinical signs are inconsistent, which may delay
surgical intervention.
The condition is diagnosed during exploratory
celiotomy and is found by locating the ileocecal fold
and following the ileum cranially until the
incarceration is encountered.
Any portion of the jejunum or ileum may be
entrapped in the foramen, but aboral jejunum and
ileum appear to be more commonly involved.
The length of incarcerated intestine varies from a
few centimeters to several meters.
Reduction of the hernia is generally achieved by
gentle traction of the bowel.
If excessive edema of the intestine occurs, it may
be necessary to decompress the herniated intestine
or, in rare instances, to resect the affected bowel
before reduction.
Resection of the affected portion of intestine is
often necessary with subsequent jejunojejunostomy
or jejunocecostomy.
The prognosis is guarded but varies depending on
the length of intestine involved and the promptness
of surgical intervention.
Twelve of 14 horses died in the two published
reports on epiploic foramen entrapment in horses.
 INTUSSUSCEPTION
DEFINITION AND ETIOLOGY
Formed when one segment of intestine and its
mesentery invaginate into the lumen of the adjacent
bowel immediately aboral to it.
The invaginated segment is called the intussusceptum,
and the enveloping segment is called the intussuscipiens
(Fig. 35-4).

FIGURE 35-4. Small

intestinal intussusception
SI intussusception in horses, as with other species, is most
commonly seen in young individuals and may involve the
jejunum, the ileum, or the ileocecal junction.
Numerous mechanisms have been proposed to explain the
occurrence of intussusception.
The two most frequently suspected causes are segmental
motility differences and local changes in the bowel wall.
Its been hypothesized that a hyperstatic segment of bowel
adjacent to a relative atonic segment could induce
intussusception.
Peristalsis affecting parameters such as enteritis, heavy
ascarid burden, mesenteric arteritis, and sudden dietary
changes have been implicated as predisposing factors.
The tapeworm Anoplocephala perfoliata may cause local
changes in the bowel wall, inducing ileocecal intussusception.
Small intestinal intussusception occurred after enterotomy of
the small intestine.
CLINICAL SIGNS AND DIAGNOSIS
Clinical signs depend on the position and length of the
involved segment and the degree of vascular and
luminal compromise.
Horses with jejunal intussusception usually show signs
of complete obstruction.
Gastrointestinal sounds are either absent or reduced.
Rectal examination may reveal distended loops of small
intestine, or occasionally, the intussusception may be
palpated as a firm, painful, sausage-like structure.
In horses and foals too small for rectal palpation,
transabdominal ultrasonography has been a useful
diagnostic tool.
Sonographically, the crosssectional view of the
intussusception wall appears as concentric rings or has
a bull's-eye appearance.
Peritoneal fluid analysis generally does not reflect the
severity of vascular compromise or necrosis of the
intussusceptum because the affected bowel is
sequestered in the intussuscipiens.
Ileocecal intussusception may result in complete
obstruction and severe abdominal pain early in the
course of the disease, although chronic, low-grade
pain of several days' to weeks' duration with passage
of scant feces may be present.
Rectal palpation of a firm tubular structure at the
base of the cecum and distended small intestine is
suggestive of an ileocecal intussusception.
Ileocecal intussusception is the least commonly
reported form of small intestinal intussusception.
It is characterized by an acute onset of moderate to
severe abdominal pain that subsides in 8 to 12 hours
and thereafter is mild and intermittent.
Appetite and feces are reduced, and the horses
lose weight.
Muscular hypertrophy of the small intestinal wall
oral to the lesion develops and can lead to complete
obstruction.
Intussusception is easily recognized during
exploratory celiotomy.
Jejunal intussusception appears like a corkscrew
configuration because of tension on the mesentery
of the intussusceptum.
The average length of jejunal intussusception has
been reported to be 50 to 70 cm but can be
considerably longer if the mesentery is torn.
Ileal and ileocecal intussusceptions are identified by
locating the ileocecal band and following it
proximally.
TREATMENT
In acute cases, manual reduction of the intussusception
may be possible, which facilitates surgical resection.
In longer standing cases, manual reduction may be
precluded by serosal adhesions and excessive swelling of
the intussusceptum.
Although manual reduction alone can be usefull, surgical
resection is recommended.
In the jejunum, both the intussusceptum and
intussuscipiens should be resected.
The serosal surface of the intussuscipiens may appear
viable, but the mucosal surface can undergo progressive
deterioration.
An end-to-end or side-to-side jejunojejunostomy is
performed.
Complete ileal resection is technically difficult to perform
because of the inaccessibility of the ileocecal junction and
the potential of peritoneal contamination.
 The preferred method of treating
nonreducible and reducible ileal and
ileocecal intussusceptions is side-to-side
jejunocecostomy or ileocecostomy.
This technique reduces the chances of
peritoneal contamination.

PROGNOSIS
The prognosis for horses with small intestinal
intussusception varies depending on the length
of intestine involved and the time elapsed before
surgical intervention.
Ileoileal intussusception carry a better prognosis
than jejunal or ileocecal intussusception.
Volvulus
This involves a greater than 180-degree rotation of
a segment of jejunum or ileum about the long axis
of the mesentery.
Rotations of less than 180 degrees may occur
physiologically without producing disturbances.
Volvulus may be segmental or involve the majority
of the small intestine at the root of the mesentery.
Segmental volvulus may occur as a primary
displacement or secondary to pre-existing lesions,
such as entrapment in the epiploic foramen,
gastrosplenic ligament, or mesodiverticular band.
Presence of adhesions, Meckel's diverticulum, and
regional infarction has also resulted in volvulus of
the involved segment (Fig. 35-5).
FIGURE 35-5. Jejunal adhesion providing a fixed point for a segmental volvulus of
the small intestine.
It is assumed that the preexisting lesions provide
a fixed axis for bowel rotation.
Primary lesions may be related to abnormal
intestinal motility and are most commonly
encountered in horses less than 3 years of age.
Once a portion of intestine rotates, peristalsis of
the intestine oral to the lesion causes further
mesenteric twisting, drawing bowel both orally
and aborally into the volvulus.
The terminal ileum is fixed in position and may
be predisposed to involvement in small intestinal
volvulus.
Blood becomes sequestered, resulting in an
edematous blue-black intestinal wall with gas
and fluid accumulation in the lumen.
CLINICAL SIGNS
Horses usually exhibit signs of acute, severe
abdominal pain.
Heart rate and packed cell volume are generally
markedly elevated, and, depending on the
length of intestine involved, hypovolemia and
acidosis develop rapidly.
Peritoneal fluid samples are generally
sanguinous with an increased nucleated cell
count and total protein level.
On rectal examination, multiple thickened,
distended loops of small intestine are palpable.
Although prompt surgical intervention is
indicated, the horse's metabolic status should be
stabilized before anesthesia.
TREATMENT
At laparotomy, the involved intestine is easily identified and the
direction of the volvulus can be ascertained by tracing the
mesentery toward the mesenteric root.
The involved segment is subsequently untwisted en masse.
Occasionally, after untwisting of the bowel, massive endotoxin
release occurs, causing cardiovascular collapse.
The anesthesiologist should be forewarned so that appropriate
precautions can be initiated to prevent or treat ensuing
hypotension.
If the volvulus is secondary to a preexisting lesion and involves
less than 50% of the small intestine, resection of the involved
segment is indicated.
Evacuation of the contents of the distended intestine oral to the
lesion is beneficial to decrease the postoperative morbidity, and
a jejunojejunostomy or jejunocecostomy is performed.
If the volvulus involves more than 50% of the small intestine,
euthanasia is indicated.
The prognosis for horses with small intestinal volvulus is
generally poor owing to the extensive amount of intestine
usually involved and the rapid systemic deterioration.
Ileal Impaction
Impaction of the ileum can be a primary condition or occur
secondary to pathology of the ileum.
However, in the majority of cases, no underlying pathology is
identified and the condition is of primary origin.
Occur most commonly in mares and Arabian horses.
Ileal impaction causes simple mechanical obstruction with
biphasic signs of abdominal pain.
Initial pain has been attributed to increased mural pressure
and hypermotility oral to the site of the impaction.
As small intestinal distention progresses, pain becomes more
severe and constant because of intestinal and gastric
distention oral to the impaction.
Small intestinal distention is generally a consistent rectal
examination finding,
Varying amounts of gastric reflux are generally present, and
results of abdominocentesis vary depending on the duration
of the condition.
DIAGNOSIS
The clinical and laboratory data small intestinal
distention, progressive circulatory failure, and
increased capillary permeability within the
abdominal cavity.
Clinical assessment appears to be the most
valuable in differentiating ileal impaction from
duodenitis-jejunitis.
Horses with duodenitis-jejunitis show signs of more
depression and less pain than horses with ileal
impaction, particularly after gastric decompression.
On rectal examination, the degree of small intestinal
distention with duodenitisjejunitis is subjectively less
than with ileal impaction.
TREATMENT
At surgery, the impacted ileum is easily identified by
tracing the ileocecal fold proximally.
The impaction is broken down by manual massage.
It is often beneficial to massage some of the digesta
orally to mix it with the fluid in the bowel.
Saline infusion is sometimes necessary to soften
digesta.
Enterotomy is contraindicated in all but rare instances.
Once the impaction is broken down, gas and fluid
distention in the jejunum can be massaged into the
cecum, which may help decrease postoperative ileus.
Jejunocecostomy may be done in certain cases,
because it was thought that ileal impactions were
associated with ileal dysfunction.
 The bypass was performed to prevent reimpaction.
However, better results are obtained when extraluminal
massage of the digest is performed without bypass
surgery.
Jejunocecostomy is no longer recommended unless
ileal ischemia or muscular hypertrophy of the ileum is
suspected.

Prognosis
The prognosis for horses with ileal impactions is
excellent, if horses receive prompt surgical intervention.
Unfortunately, the clinical signs are often not severe
enough early in the disease to necessitate prompt refer-
ral to a surgical facility.
Thorough rectal examination may be the key to early
recognition.
Pendunculated Lipoma
This is a benign spherical mass that is suspended
on a mesenteric pedicle that may reach 30 cm in
length.
Usually, several of these tumors are encountered in
the same horse.
The masses can cause simple or strangulation
obstruction of the jejunum or ileum, with
strangulation obstruction being more common.
The lipomatous mass and pedicles have the
potential to encircle a segment of small intestine
and associated mesentery and thereby cause
strangulation obstruction (Fig. 35-6).
Pedunculated lipomas are seen in horses over 8
years of age.3.
FIGURE 35-6. A pedunculated lipoma causing strangulation obstruction of the
small intestine.
Clinical signs are consistent with small
intestinal strangulation obstruction and
include persistent abdominal pain, ileus, and
hemoconcentration.
Multiple distended loops of small intestine
are palpable on rectal examination, and
varying amounts of gastric fluid are obtained.
Peritoneal fluid analysis reflects the amount
and degree of intestinal necrosis.
Occasionally, the lipomas cause a simple
obstruction with signs of a more protracted
intermittent colic and less severe metabolic
deterioration.
Treatment
At surgery, an incarcerated segment of small intes-
tine is identified, with a taut band of tissue causing
the obstruction.
The pedicle is either incised or broken down by
digital manipulation.
Resection and anastomosis of the affected portion
of bowel may be indicated.
Pedunculated lipomas should be suspected in older
horses showing signs of strangulation obstruction.
The prognosis varies depending on the length of
intestine involved and the time elapsed before
surgical intervention.
Read
Incaceration through the gastrosplenic
ligament
Mesodiverticular bands
Meckel's diverticulum
Strangulated umbilical hernia