Exploratory laparotomy, right flank

Right laparotomy site is corresponding position to that of left paralumbar fossa (incision 2 in Figure 3.6). Ensure that ventral commissure of incision is in upper half of flank, otherwise spontaneous prolapse of greater omentum and some small intestinal (jejunal) coils is almost inevitable. Take special care in peritoneal incision as descending duodenum is immediately below!

Visible features

Note greater omentum below incision, with descending duodunum passing caudally in the omentum.

Palpable features

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pass left hand and arm ventrally to palpate abomasum, note some mobil-ity is possible and abomasum may be grasped and pulled upwards towards incision

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appreciate cranially visceral surface of liver (note any rounded edges, abscesses or surface irregularity) with dependent gall bladder (normal size up to 10 × 6 × 4 cm), and insert hand between liver and diaphragm to palpate cranial hepatic surface, e.g. discrete abscessation

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pass hand along lateral body wall with palm outwards and ventrally locate reticulum (note any adhesions, or foreign bodies) beyond abomasum and greater omentum

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check contact area of reticulum with diaphragm (possible adhesions)

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note mesoduodenum is dorsal to duodenum, and deep to this area is the perirenal fat (right kidney)

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palpate, caudal to right kidney, the right surface of left kidney, both structures being slightly to right of midline due to pressure from rumen.

Right kidney is dorsal to cranial part of descending duodenum, to right of mesoduodenum. Left kidney lies adjacent to middle part of descending duodenum entirely within the supraomental recess

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pass hand caudal to caudal edge of greater omentum which runs approx-imately midway between last rib and tuber coxae

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palpate structures in this space, which include numerous coils of jejunum and ileum, as well as spiral colon, caecum, which is very vari-able in size, and dorsally ascending colon and descending colon (see Figure 3.3)

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some intestine which may be exteriorised for examination includes much of jejunum (except cranially), apex and body of caecum, and more ventral loops of ascending spiral colon

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note, suspended from midline (palpable but cannot be exteriorised), descending colon and part of ascending colon, passing into pelvic cavity together with bladder, uterus and ovaries

Closure of flank laparotomy incision

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close the incision in three layers (see Figure 3.9a)

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appose peritoneum and transverse fascia with continuous suture of 4 metric PDS on 3/8 circle round-bodied needle

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commence suture at ventral commissure and tie off dorsally

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close external and internal oblique abdominal muscles separately or together with similar single layer

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appose skin with Ford interlocking suture of monofilament nylon or Supramid^®inserted with cutting-edged semi-curved needle. A relatively fine needle about 5 cm long requires less effort to insert through 5–7 mm thickness of skin than a larger needle

visceral surface

Figure 3.8 Flow diagram of right flank exploratory laparotomy. Entire accessible abdominal cavity should be checked in any case of suspected abdominal disease.

In a case of LDA the abomasum is not found on right side (step 1), but against left abdominal wall. Nevertheless steps 2 and 3 should be followed to rule out co-existing traumatic reticulitis or liver abscessation. In suspect cases of small or large intestinal disease or displacement, step 4 should be followed, but exploration of remainder of abdominal cavity should be carried out at a later stage.

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close ventral 5 cm with interrupted sutures which may be removed later for drainage of any wound infection

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note that in all three layers sutures should be just tight enough to appose the wound edges. In the muscle layers suture should be spaced about one every 2 cm, while in the skin slightly more are advised

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single layer closure (see Figure 3.9b) is faster but less cosmetically pleas-ing, and any wound infection is liable to be more severe

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avoid leaving any dead space Discussion

The above technique achieves optimal apposition of peritoneum, muscula-ture and skin, and the cosmetic result is pleasing. Any buried deep sumuscula-tures should be of absorbable material in view of probable human consumption of the carcass.

Intra-abdominal and systemic antibiotherapy

Routine intra-abdominal medication is unnecessary. Peritonitis is controlled by systemic medication if the animal is not salvaged at once. Drainage of purulent exudate is unlikely to help control of an active process.

Intra-abdominal medication should be considered only if infection has been introduced into the peritoneal cavity. Suitable drugs include antibiotic aqueous solutions or oleaginous suspensions as carriers. Intramammary cerate preparations should not be inserted into the abdominal cavity or body wall. The most effective prophylactic medication is systemic injection of ceftiofur, penicillin, oxytetracycline hydrochloride or a single injection of long-acting oxytetracycline (see Section 1.12, p. 44).

1 2

3

4

B A

Figure 3.9 Transverse section through flank (diagrammatic) showing two methods of closing laparotomy wounds. (A) Recommended three layer closure; (B) single layer figure-of-eight closure.

1. peritoneum; 2. transverse fascia/muscle, 3. internal and external oblique muscles;

4. skin.

Complications of exploratory laparotomy

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intra-operative collapse: occasionally a weak subject undergoing a

‘last-ditch’ exploratory laparotomy collapses during intra-abdominal exploration causing gross peritoneal contamination. Such cattle, usually thin cows, are unsuitable subjects for surgery, and should be excluded on pre-operative clinical examination (see Section 1.4, pp. 10 –11)

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wound dehiscence: results from non-sterile, excessively fine material, material traumatised by forceps before or during insertion, massive wound swelling causing tearing out of sutures, and development of a subcutaneous or subperitoneal abscess, or emphysema

Treatment of wound dehiscence: in such cases any remaining (non-functional) suture material should be removed and the wound cleansed, débrided and resutured if no infection is present, leaving a 3–10 cm opening in the ventral commissure for drainage purposes.

Cases with copious purulent discharge involving a still relatively intact wound should be opened slightly, both dorsally and ventrally, to permit vigorous irrigation with dilute chlorhexidine gluconate solution (10 ml of 5% solution made up to 1 litre with clean tap water). The incision is then left to heal by secondary intention.

In the presence of considerable necrotic tissue, preliminary irrigation with dilute H₂0₂(3%) may be useful. (N.B. this solution may spread infection between tissue layers.) See Section 1.13.

3.4 Rumenotomy

In document Bovine Surgery and Lameness (Second Edition) (Page 95-98)