SURGERY

Surgeryofthesmall
intestineindogsandcats
Part 2: surgical techniques
This article, the second on surgery of the small intestine in dogs and cats, will focus on
the surgical techniques and closure modalities of the intestinal wound. Small intestine
pathological conditions that require surgical intervention include intestinal obstruction and
perforation, ischaemia, intussusception and mesenteric volvulus.
10.12968/coan.2013.18.4.158

Daniela Murgia, DVM,DipECVS,MRCVS

AnimalHealthTrust,LanwadesPark,NewmarketCB87UU,Suffolk,UK

Key words: Enterotomy|Enterectomy|Intestinalbiopsy|Intestinalanastomosis|Enteroplication

T
he usual approach for small intestinal surgery is a
ventral midline laparotomy from xiphoid to pubis.
The edges of the wound should be protected with
saline-soaked laparotomy pads.
In order to avoid compromising intestinal blood supply and
to reduce leakage and bacterial contamination of the perito-
neal cavity with intestinal content, meticulous and gentle sur-
gical technique is very important.
Surgical exploration of the intestine should be careful and
should begin with palpation of the pylorus and stomach to
exclude the presence of any gastric foreign body. The entire
length of the intestine should be explored because multiple
lesions may be present. The affected intestinal segment is ex-
teriorised and isolated from the rest of the abdominal organs
with saline-soaked swabs.
Intestinal content is milked orally and aborally and kept
apart from the surgical site by occluding the intestinal lumen
with Doyen forceps or with the assistant’s finger.
Enterotomyandintestinalbiopsy
Enterotomy is mostly used for foreign body removal and in-
testinal biopsy. A longitudinal incision in the antimesenteric
border of the affected intestine segment is made. The incision
should be made distal to the foreign body in order to reduce
the risk of wound breakdown, which would occur if the intes-
tine undergoes pressure necrosis or distension from the pres-
ence of the foreign body (Figures 1 and 2).
The enterotomy is usually closed longitudinally in a sin-

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Figure 1: Jejunal enterotomy. Assistant’s fingers are occluding the intestinal lumen Figure 2: Intestinal mucosal eversion after enterotomy and foreign
to avoid leakage of intestinal content on the operatory field. body removal.

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Figure 3: Intestinal single-layer modified Gambee approximating suture. Figure 4: Intestinal loop after enterotomy and closure with double layer
inverting suture pattern.
gle-layer with simple interrupted suture pattern. A modified
Gambee pattern is generally recommended. This approximat- were not adequate for differentiating between inflammatory
ing suture provides adequate submucosal apposition inverting bowel disease (IBD) and lymphosarcoma in the small intes-
the mucosa by avoiding full-thickness bites of the mucosal tine of cats. Because the most common sites of alimentary
layer (Figure 3). tract lymphosarcoma in cats are the jejunum and ileum, full-
In selected cases, such as much-distended intestinal loops thickness biopsy specimens of those sites should be obtained
or where there is a high risk of intestinal suture line dehiscence via laparotomy or laparoscopy for accurate diagnosis. Laparos-
with intestinal content leakage, a two-layer inverting closure copy may be a minimally invasive alternative to endoscopy and
may be recommended (Figure 4). However, submucosal apposi- laparotomy for obtaining diagnostic biopsy specimens.
tion is poor in two-layer closure, and avascular necrosis of the
inverted tissue can develop. Furthermore, intraluminal protru-
sion of tissue makes the patient more prone to obstruction.
For intestinal full-thickness biopsy, either a rectangular or
a wedge sample is taken, although wedge biopsies are not rec-
ommended. Biopsying the intestine with a wedge incision risks
collecting little or no mucosa, and the pathologist is therefore
not able to give a meaningful interpretation (Mansell and Wil-
lard, 2003). In the author’s experience, excision of a longitudi-
nal rectangular wall portion (0.5–1 cm x 0.3–0.5 cm) from the
intestinal antimesenteric border provides a good sample for
interpretation (Figures 5a and 5b). The antimesenteric rectan-
gular defect is then closed longitudinally like an enterotomy. If
the closure of the defect causes a luminal stenosis, the defect
is closed transversely in a single-layer, appositional, simple Figure 5a: Intestinal biopsy. Two longitudinal full-thickness parallel incisions are
interrupted pattern. Usually, unless a biopsy removes greater carried out over the antimensenteric border of an intestinal loop.
than 20% of the intestinal circumference, there seems to be
only a minimal risk of causing stricture. The wedge defect is
closed with a transverse suture.
When an obvious intestinal lesion cannot be detected,
multiple samples, from the duodenum, jejunum and ileum,
should be taken.
There are still arguments over advantages and disadvan-
tages of performing endoscopic or surgical intestinal biopsies.
Advantages of endoscopic biopsy are: it is fast and minimally
invasive so that the patient can go home the same day; visuali-
sation of lesions that cannot be seen from the serosal surface
of the intestine; collection of a large number of tissue sam-
© 2013 MA Healthcare Ltd

ples; and it is usually diagnostic. Disadvantages include the

fact that the endoscope cannot reach distal duodenal or jeju-
nal lesions, and some lesions are so dense that obtaining diag-
nostic tissue samples is difficult (Mansell and Willard, 2003). Figure 5b: Intestinal biopsy. A rectangular portion of intestinal wall has been
Evans et al (2006) reported that endoscopy biopsy specimens excised from the antimesenteric border of an intestinal loop.

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Figure 6: Linear foreign body looped around the tongue of a cat after
being freed.
Figure 7: Duodenal loops with multiple enterotomies after removal of a linear
intestinal foreign body in a dog.
Figure 8: Multiple intestinal wall perforations at the mesenteric side and intesti-
nal wall necrosis caused by the presence of a linear foreign body in a dog.
160
Figure 9: Single enterotomy catheter technique performed in a cat
with intestinal linear foreign body.
Surgical biopsy allows samples to be taken from any
lesion, no matter where it is or how challenging it is; it allows
obtaining large amounts of submucosa and can be therapeutic
for focal diseases like neoplasia or perforations. Disadvantages
include the risk of wound dehiscence, prolonged patient
recovery from the surgery and higher costs.
Howtodealwithintestinallinear
foreignbodies
A linear foreign body, most of the time, anchors itself around
the base of the tongue in cats or at the pylorus in dogs. Before
proceeding with intestinal surgery to remove the linear foreign
body, it is recommended to free it from around the tongue or
to perform a gastrotomy if the anchoring side lies within the
stomach (Figure 6).
In dogs, a jejunal or, less frequently, a duodenal enteroto-
my on the antimesenteric side is performed; the foreign body
localised at the mesenteric site of the intestine is grasped
and gently pulled after the anchored portion has been freed.
Traction is applied until the more distal point of fixation is
reached. At this level another enterotomy is performed. At
each enterotomy, the foreign body should be removed as
much as possible. Removal of the entire linear foreign body
may require multiple enterotomies spaced along the intestine
(Figure 7). It is important not to pull too vigorously because
it may cause perforation of an already compromised intestine.
Multiple perforations may not be visible until the intestinal
plication relaxes; even then, they may be hidden by the overly-
ing mesenteric fat. In some cases, long segments of intestine
have multiple perforations and need resection or have areas of
questionable viability (Figure. 8). In these animals, a second
exploratory laparotomy should be planned 24 hours later for
reassessment of the intestinal viability and consequent appro-
© 2013 MA Healthcare Ltd
priate treatment. Performing intestinal resection in a second
later procedure allows demarcation of necrotic tissue and re-
duces the risk of leaving necrotic intestine behind. During the
second exploration, the previously performed suture lines are
reassessed as well in order to decide if resection and anasto-
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 SURGERY

Figure 10a (Left): Traction on the intussusceptum and pressure on the intussuscipiens for manual reduction of an invagination in a dog; Figure 10b
(Right): Manual resolution of the invagination.

mosis is necessary. Plication of the duodenum usually is not necessary, whereas

In cats, a single enterotomy catheter technique has been complete plication of the jejunum and ileum is recommended
described. A single incision is made at the antimensenteric because invagination tends to recur proximal to areas of lim-
margin of the intestine and the linear foreign body tied to a ited enteroplication.
thin piece of rubber or silicone tube (e.g. giving set piece). Enteroplication is performed by placing sutures, which
The catheter with the attached foreign body is re-inserted into penetrate the submucosal layer, midway between the me-
the intestine, the enterotomy closed and the catheter milked senteric and antimesenteric borders of two adjacent intesti-
distally through the intestine out to the anal orifice (Figure 9). nal loops. Complications related to enteroplication generally
This manoeuvre could result in intestinal lesion if the wall of occur one or more months after surgery and include intesti-
bowel is compromised. Application of this technique is not nal perforation and consequently peritonitis, obstruction and
recommended in dogs because in these patients, linear for- strangulation. Enteroplication should therefore be used to
eign bodies tend to be bigger, and wider in diameter. prevent recurrence when no predisposing cause for the in-
vagination is found (Applewhite et al, 2002).
Treatmentofintestinalintussusception
The treatment of intestinal intussusception may require surgi-
cal resection, although sometimes manual reduction is suc-
cessful (Figures 10a and 10b). Gentle traction on the intussus-
ceptum and pressure on the intussuscipiens aid the reduction;
when the lesion cannot be reduced, resection and intestinal
anastomosis are necessary. Multiple invaginations and recur-
rence can occur after reduction/resection, particularly in the
presence of enteritis or hyperperistalsis. In these cases, enter-
oplication may be required (Figure 11). General anaesthesia
and analgesia may contribute to spontaneous reduction of the
invagination but the likelihood of recurrence appears to be
high, so exploration and enteroplication may be warranted.
Recurrences usually happen within 3 days, although have
been reported up to 3 weeks post-operatively. Patients with
invagination should be tested and treated for endoparasites,
and a sample of the intestine should undergo histopathology
© 2013 MA Healthcare Ltd

in order to diagnose any underlying predisposing condition.

Since the excised intestinal segment is usually necrotic, sam-
pling of the intestine in a region cranial or caudal to the in-
tussusception is warranted. Enteroplication decreases recur-
rence rate but can be associated with severe complications. Figure 11: Enteroplication in a cat.

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Figure 12: Placement of the non-crushing intestinal forceps before enterectomy
in a cat.
Figure 13: Intestinal end-to-end anastomosis with simple interrupted suture
pattern.
Intestinalresectionandanastomosis
Intestinal resection and anastomosis is recommended if re-
moval of an intestinal segment is required.
Irreducible intussusceptions, intestinal neoplasia, intes-
tinal necrosis or ischaemia are managed by resection and
anastomosis. This can be performed using an end-to-end, an
end-to-side or a side-to-side technique. As the latter two are
technically more demanding, the use of an end-to-end anasto-
mosis is recommended.
If the involved segment of bowel is movable, it should be
gently pulled out from the abdominal cavity. The arcadial me-
senteric vessels from the cranial mesenteric artery that supply
this segment are ligated with double ligatures or staples, and
transected. The terminal arcade vessels and vasa recta within
the mesenteric fat are ligated at points of intestinal transec-
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Figure 14: Completed end-to-end anastomosis followed by the
closure of the mesenteric defect.
tion as well. The mesentery is incised near the ligated vessels,
leaving as much mesentery as possible for later closure. After
milking the intestinal content from the surgical site, forceps
are placed to occlude the lumen (Figure 12). Forceps placed
across each end of the diseased segment, which will be ex-
cised, can be crushing ones. Forceps applied on the healthy
intestinal segments must be atraumatic. The intestine is then
transected alongside the crushing forceps leaving at least
1.5 cm of healthy intestinal wall to allow easy suture place-
ment. The incision is perpendicular to the long axis at each
end if the luminal diameters are the same. In case of luminal
disparity, a perpendicular incision across the intestine with
the larger luminal diameter, and an oblique one across the
segment with the narrower diameter are recommended. The
oblique incision is made so that the antimesenteric side is left
shorter than the mesenteric one. Further corrections for size
where there is luminal disparity include: spacing each suture
farther apart on the larger lumen side; reducing the diameter
of the larger segment with sutures; or incising the smaller seg-
ment longitudinally on the antimesenteric margin in order to
create a larger spatulated opening.
The healthy intestinal ends are then cleaned of debris with
© 2013 MA Healthcare Ltd
moistened swabs and the everting mucosa is trimmed. Intesti-
nal edges are apposed and sutured with a single-layer, simple
interrupted or simple continuous, approximating, 3-0 or 4-0
monofilament suture such as polygecaprone 25 or polygly-
conate (Figure 13). In peritonitis cases, where the on-going
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inflammation may accelerate the absorption of the suture ma-
terial, the use of polydioxanone (3-0 or 4-0) is recommended.
In fact, absorption of polydioxanone sutures takes 180 days,
providing wound support for a longer period if compared with
polygecaprone or polyglyconate sutures. The mesenteric defect
is closed with a simple interrupted suture pattern (Figure 14).
Functionalend-to-endanastomosis
Anastomosis can also be accomplished with staples. A func-
tional end-to-end anastomosis is usually preferred because
this does not compromise the anastomotic lumen, and luminal
disparity is not an issue.
For this type of intestinal anastomosis, GIA and TA sta-
plers are used. The antimesenteric surfaces of the two intes-
tinal segments to be anastomosed are apposed side by side
and one limb of the GIA stapler is inserted into each lumen
through the open, cut end. The stapler is than locked and
fired. Four rows of staples are placed and a blade cuts between
the two central rows to create the stoma. The GIA stapler is
removed and a TA stapler is placed across the open intestinal
edges, locked and fired. Excessive intestinal tissue is trimmed
and anchoring sutures are placed at the base of the GIA staple
line to prevent tension and separation of the anastomosis.
Stapling permits reduction of surgical time compared with
simple interrupted anastomosis, and permits anastomosis of
two intestinal segments with large differences in lumen diam-
eter. In cats and toy breeds, an endoscopic GIA stapler can be
used because the size of the regular GIA device is too large to
be inserted into the intestinal lumen.
Skin staplers have been used in dogs for rapid end-to-end
anastomoses. Three full-thickness stay sutures are placed at
120° intervals around the intestine. Tension is then applied
between two stay sutures, and anastomosis is performed with
a regular-dimension skin stapler. The technique is repeated
between each of the stay sutures. These anastomoses are
equivalent in bursting strength, lumen diameter and quality of
healing to the traditional simple interrupted hand-sewn tech-
nique but can be performed in significantly less time (Bradley
et al, 2000).
Suture or staple lines at the site of enterotomies and anas-
tomoses are checked for leaks; the bowel is clamped proximal
and distal to the suture line with fingers, and sterile saline is
injected into the lumen with a syringe and a needle to distend
the loop. Additional sutures are placed to correct any defect.
A leaf of omentum is laid over the intestinal wound and the
intestines returned into the abdomen (Figure 15). Omentum
has an extensive vascular and lymphatic supply and exhibits
angiogenic and adhesive properties that assist the healing of
the intestinal suture by vascularizing the region.
In some cases, serosal patching may be necessary to rein-
force intestinal repairs and to prevent leakage. A mobile intes-
© 2013 MA Healthcare Ltd
tinal loop, usually jejunum, is placed with the antimensenteric
surface over the questionable suture line and held in posi-
tion with simple interrupted 3-0 or 4-0 monofilament sutures.
Each suture should include the submucosal layer of both in-
testinal segments. In very long suture lines, multiple segments
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SURGERY
Figure 15: Omentalisation of the intestinal suture line.
of jejunum may be necessary for adequate serosal patch.
As access to proximal duodenum is difficult because of the
anatomic position, defects in this region can be reinforced us-
ing a gallbladder serosal patch (Hosseini et al, 2009).
Postoperativemanagement
Animals undergoing small intestinal surgery should be closely
monitored for vomiting during recovery. Fluids, acid-base ab-
normalities and electrolyte needs should be reassessed seri-
ally after surgery in order to determine if further potassium
supplementation or variation in the intravenous solution rate/
type is needed.
Pain checks are performed regularly every 2 hours and ad-
equate postoperative analgesia is imperative. This includes
administration of opioids such as methadone (0.2–0.3 mg/kg
intramuscularly every 3 to 6 hours). If administration of metha-
done is required more frequently than every 3 hours, then ad-
junctive analgesia is required. In the author’s opinion, the use
of anti-inflammatory drugs (NSAIDs) in patients that undergo
gastro-intestinal (GI) surgery is not recommended. In facts, the
most serious adverse effects associated with all NSAIDs occur
in the GI tract, such as ulceration and bleeding.
In some cases, administration of lidocaine infusion (25–
50 µgr/kg/minute) may be recommended in dogs. Lidocaine
has analgesic and anti-inflammatory properties (inhibits leu-
kocyte migration and lysosomial enzyme release). Further-
more, lidocaine stimulates smooth muscle and therefore it has
prokinetic effects on intestinal peristalsis. This is important
because lidocaine could be administered to reduce the risk of
intestinal paralytic ileus. Lidocaine can be potentially toxic in
cats; therefore, lidocaine infusion administration is not rec-
ommended in feline patients. It can also lead to cardiovas-
cular and central nervous system toxicity in cats; symptoms
include bradycardia, hypotension, cardiovascular depression
up to cardiac arrest and excitement, convulsion, and coma.
Weighing patients every 8 hours daily in the first 48 to 72
postoperative hours can provide important information be-
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cause an increase in the postoperative body weight may be a
sign of volume overload or presence of free abdominal effu-
sion, which is indicative of potential on-going septic peritoni-
tis. Early feeding has been shown to have a positive influence
on the healing rate of intestinal wounds as it increases GI
blood flow and prevents ulcerations. These patients should
be fed as soon as the bowel recovers its peristaltic activity,
which can be assessed by abdominal auscultation. Initially,
patients should be fed a low-fat diet, e.g. boiled rice, potatoes
and pasta with chicken or cottage cheese, and should be re-
introduced gradually to their normal diet 48 to 72 hours post-
operatively. Early ambulation and feeding should be encour-
aged to minimize ileus. Clinical signs like depression, fever,
vomiting, ileus and response to abdominal palpation should be
monitored for evidence of peritonitis due to intestinal leakage.
The need for antibiotic prophylaxis in small intestinal sur-
gery is still debated, although bacteria present in the bowel
represent a possible source of peri-operative infection. Anti-
biotic prophylaxis is warranted in case of intestinal obstruc-
tion because of likely bacterial overgrowth, with extensive
intestinal resections, when devitalised tissue is present, and
in compromised patients. Prophylactic antibiotics should be
administered peri-operatively in order to have effective con-
centration in the tissue at start of surgery, and those concen-
trations must be maintained for the duration of the procedure.
As a general rule, the antibiotic is administered intravenously
within 1 hour before surgical incision and repeated every 2
hours during surgery. An additional dose or two may be war-
ranted to suppress the late growth of contaminating organisms
that were not killed by the first doses administered intra-oper-
atively. Antibiotics should be continued for a maximum of 24
hours postoperatively. The choice of antibiotic depends on the
likely pathogens. The proximal small intestine contains mainly
Gram-positive organisms like Staphylococcus, Streptococcus,
Lactobacillus and Clostridium. In the middle and distal small
intestine, the total number of bacteria increases and there are
larger quantities of E.Coli and Enterococcus. The feline small
intestine contains primarily aerobes like Pasteurella, Entero-
KEY POINTS
zzSurgical exploration of the intestine should be careful and
the entire length of the intestine should be explored
zzEnterotomy wounds are usually closed in a single-layer with
simple interrupted suture pattern (modified Gambee)
zzSamples from each section of small intestine should be
taken when intestinal biopsy is required and no obvious
intestinal lesion is detected
zzCareful intestinal exploration is mandatory in case of
intestinal linear foreign body as multiple perforations on
the mesenteric border may be hidden by the mesenteric fat
zzEnteroplication is required only in selected patients
zzFluids rate, acid–base abnormalities and electrolyte needs
should always be reassessed after intestinal surgery.
164
coccus, Streptococcus and Staphylococcus, and anaerobes like
Bacteroides, Fusobacterium and Clostridium.
First generation cephalosporins (cefazolin 22 mg/kg IV) are
still recommended for small intestinal antimicrobial prophy-
laxes, although clavulanate-potentiated amoxicillin (Augmen-
tin 20 mg/kg IV) retains more than 90% efficacy against the
commonly aerobic pathogens. Furthermore, metronidazole is
secreted into the gastrointestinal tract and is effective against
most anaerobes. It is recommended to include metronidazole
(10 mg/kg IV) in the chemoprophylaxis plan for surgery of the
small intestine. CA
References
Applewhite AA, Corenell KK, Selcer BA (2002) Diagnosis and treatment of
intussusceptions in dogs. Available from: http://bit.ly/18qXSaa (accessed
28 May 2013).
Coolman BR, Ehrhart N, Pijanowski G et al (2000) Comparison of skin
staples with sutures for anastomosis of the small intestine in dogs. Vet Surg
29(4): 293–302
Evans SE, Bonczynski JJ, Broussard JD et al (2006) Comparison of endoscopic
and full-thickness biopsy specimens for diagnosis of inflammatory bowel
disease and alimentary tract lymphoma in cats. J Am Vet Med Assoc 229(9):
1447–50
Hosseini SV, Abbasi HR, Rezvani H et al (2009) Comparison between
gallbladder serosal and mucosal patch in duodenal injuries repair in
dogs.J Invest Surg 22(2): 148–53
Mansell J, Willard MD (2003) Biopsy of the gastrointestinal tract. Vet Clin
North Am Small Anim Pract 33(5): 1099–116
Continuing Professional Development
In order to test your understanding of this article, answer these
multiple choice questions, or if you are a subscriber, go online at
www.ukvet.co.uk, and find many more multiple choice questions
to test your understanding.
Adjunctive tests
1. Enteroplication is a procedure indicated in patients
affected by:
a. Intestinal linear foreign body
b. Chronic enteritis
c. Recurrent intestinal invagination
d. Intestinal obstruction
2. Which is the best technique to sample an intestinal
biopsy?
a. Two longitunal parallel incisions on the mesenteric border
in order to sample a rectangular tissue shape
b. Two longitudinal parallel incisions on the antimesenteric
border in order to sample a rectangular tissue sample
c. A wedge biopsy on the mesenteric border
d. A wedge biopsy on the antimesenteric border
3. Which of the following statements regarding the
enterectomy is correct?
a. Forceps placed across each end of the diseased segment
have to be atraumatic
b. Forceps placed across each end of the diseased segment
© 2013 MA Healthcare Ltd
should be atraumatic
c. Forceps placed across each end of the diseased segment
can be traumatic
d. Forceps placed on the healthy segment can be traumatic
For answers please see page 182
Companion animal|June 2013, Volume 18 No 4