Abdominal surgery
3.2 Exploratory laparotomy (celiotomy), left flank Indications
Specific indications are suspected left displaced abomasum (LDA) (see Sec-tion 3.6), rumenotomy, traumatic reticulitis (see SecSec-tion 3.4), or caesarean
section (see Section 4.1). LDA is evident on opening into peritoneal cavity.
Traumatic reticulitis may be suspected on exploration of area between cranial aspect of ruminoreticulum and the diaphragm-body wall area. In positive cases specific surgical correction is performed.
Indication is often not clearcut. Some cattle show persistent abdominal pain apparently localised to ruminal area. Left flank exploratory laparotomy
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Figure 3.4 Cross-section of thorax through body of seventh thoracic vertebra, looking cranially.
1. body of seventh thoracic vertebra; 2. spinous process of sixth thoracic vertebra;
3. seventh rib; 4. sternum; 5. thoracic duct and aorta; 6. left lung; 7. right lung;
8. caudal vena cava; 9. liver; 10. reticulum; 11. apex of heart; 12. accessory lobe of right lung; 13. central tendon and sternal part of diaphragm. (From Pavaux, 1983.)
is rarely as useful or as practical as right flank approach and is not recom-mended if a small or large intestinal surgical disorder is suspected.
Laparoscopic surgery is being developed in cattle for abdominal exploration and treatment of LDA but is currently mostly confined to referral clinics.
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Figure 3.5 Cross-section of trunk through body of ninth thoracic vertebra, looking cranially.
1. body of ninth thoracic vertebra and head of ninth rib; 2. eighth rib; 3. seventh rib;
4. xiphoid process of sternum; 5. sternal part; 6. thoracic aorta (thoracic duct, to right, and left azygos vein to left, coursing along it dorsolaterally); 7. left lung (caudal lobe);
8. right lung (caudal lobe); 9. liver; 10. caudal vena cava; 11. omasum; 12. atrium (cranial sac) of rumen; 13. reticulum. (From Pavaux, 1983.)
Technique
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paravertebral analgesia (T13, L1 and L2, see Section 1.8, pp. 22–26) or local infiltration (see Section 1.8, pp. 26 –27)•
clip, scrub and surgically prepare a wide area of left flank including at least 30 cm around proposed incision site (see Figure 3.6)•
drape with sterile cloths or rubber drape with appropriate window•
make paracostal incision 15 cm long about 5 cm behind last rib, starting 10 cm below lumbar transverse processes•
incise skin in single movement and continue scalpel incision through sub-cutaneous fat and fascia to expose abdominal wall musculatureT13 L1
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Figure 3.6 Position of various left flank incisions (see also Figure 1.7, p. 25).
1. paracostal (18 –25 cm), cranial in sublumbar fossa: rumenotomy (essential to be as far cranial as possible in large-framed cow and short surgeon);
2. left flank abomasopexy (Utrecht technique) or exploratory laparotomy (25 cm);
3. low flank incision in recumbent cow or heifer for caesarean section, where it is anticipated that it will be difficult to bring uterine wall to flank (35 cm);
4. standard caudal left flank (35 – 40 cm) and
5. oblique flank incision (35 – 40 cm) for caesarean section in standing animal.
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insert blade of straight scissors at angle of 45° to surface and into external oblique abdominal muscle, which is separated by blunt dissection•
make 7 cm long scalpel incision through internal oblique muscle to expose underlying transverse fascia•
make small incision with scissors through this fascia to reveal parietal peritoneum beneath a variable amount of loose fat•
pick up parietal peritoneum with rat-tooth forceps and make small vertical incision with scissors•
extend incision through internal oblique, transverse fascia and peritoneum with scissors to correspond to length and direction of skin incision. Air rushes audibly into abdominal cavity at this point creating pneumoperitoneum, and contact surface of ruminal wall (unless adhesed) drops away as abdominal wall moves laterally. (Occasionally some pneumoperitoneum is present before surgery, e.g. in traumatic reticulitis.)Left side of abdominal cavity and part of right side may now be explored (see Figure 3.7).
LEFT RUMINAL WALL left kidney
uterus & ovaries
Figure 3.7 Flow diagram of left flank exploratory examination. As in right flank approach (see Figure 3.8) entire accessible part of abdominal cavity should be rapidly checked in any abdominal disease. Start from left ruminal wall with palpation of parietal peritoneum (1), then caudal abdomen (2) and the right side structures (3), before concentrating on left flank and left cranial and ventral regions (4).
Visible features
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check volume and colour of peritoneal fluid; normal colour is pale yellow.A slight pink tinge may be due to contamination of some blood from incision site. Presence of any floccules, usually purulent, is abnormal and indicates an infective focus in the visceral or parietal peritoneum. Possibly also an associated objectionable odour.
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run fingers over surface of both parietal and ruminal (visceral) peri-toneum adjacent to incision: surface should be smooth. Irregularities may be in form of discrete adhesions or generalised lesion (‘sandpaper-like’) consistent with chronic peritonitis.Palpable features
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introduce the right hand and arm to make systematic examination of the abdominal cavity (see Figure 3.7)•
pass right hand ventrally to check for possible LDA, and also cranially for adhesions between reticulum and diaphragm or liver, or (rarely) between rumen and abdominal wall, suggestive of traumatic reticulitis•
presence of abdominal adhesions may be of recent origin and significant, or may be longstanding and purely an incidental finding. Recent adhesions (less than one week) tend to be broken down easily, though this may cause localised pain. Older adhesions tend to be difficult or impossible to break down and pain is absent•
assess texture of peritoneal surface in different areas at early stage of exploration before repeated movement causes iatrogenic roughening•
structures palpated on left side (see Figure 3.1) should include: rumen, reticulum, spleen, left border of liver, diaphragm, apical beat of heart, left kidney through perirenal fat, path of ureters (normally non-palpable unless thickened), bladder including bladder neck, uterus, left and right ovaries, and descending colon•
pass right hand and arm to right abdominal wall by directing it caudal to the attachment of the ruminal wall to the abdominal roof, and ventral to left kidney and descending colon, thereby avoiding possible iatrogenic spread of infection from left side of abdomen•
structures now accessible include: left kidney, spiral colon, duodenum, jejunum and ileum, and caecum (see Figures 3.1–3.3).Discussion
Structures too distant for palpation by veterinarian of average stature in adult Holstein Friesian cow include: abomasum, much of the visceral surface of liver and gall bladder, and parts of the omasum, some of the small intestine ( jejunal loops) and large intestine (colonic coils).