VSUR 143

SMALL ANIMAL SURGERY

SURGEON: Marzo, Trisha Joy J. DATE: March 14,2023

ASSISTANT SURGEON: Sobrevilla, Lyka M. PRE-OPERATIVE GRADE:
NURSE: Cariaso, Vladys Claire OPERATIVE GRADE:
ANESTHESIOLOGIST: Canero, Etheline P. POST-OPERATIVE GRADE:

SURGICAL EXERCISE NO. 5

ENTEROTOMY

I. INTRODUCTION

Enterotomy is a surgical procedure where the lumen of a segment of the intestine is incised.

II. SIGNALMENT

Patient’s Name: Jake

Species: Felis catus
Age: 1 year old
Sex: Male
Weight: 2 kgs
Color Markings: White, Gray-black

III. INDICATIONS
Enterotomy allows full thickness biopsy samples to be collected from all areas of the intestine and
from other abdominal structures. It is usually used to remove foreign bodies and luminal examination.

IV. ANATOMY

Abdominal Muscles

The muscles of the abdominal wall fall into two groups, the ventrolateral and the sublumbar. The
sublumbar are more properly considered part of the girdle division of hind limb musculature. The muscles of
the ventrolateral group comprise the flank and the abdominal wall muscles which are of more immediate
relevance for abdominal surgery.

The intrinsic musculature of the flank and abdominal wall comprises three broad, fleshy sheets that
lie one on top of the other, with contrasting orientation of muscle fibers. Ventrally each is continued by
means of an aponeurotic tendon that has a main insertion along the linea alba. A fourth muscle, the rectus
abdominis, lies along the ventral abdominal wall to either side of the linea alba, where it is ensheathed by
these aponeurotic tendons.

The external abdominal oblique (EAO) muscle has its origin over the lateral surface of the ribs and
the lumbar fascia from where the bulk of the fibers run caudoventrally, radiating outwards slightly. The
aponeurosis of the EAO divides into two crura, with the larger medial crus terminating on the linea alba
after passing around the rectus abdominis. The smaller lateral crus attaches to fascia over the iliopsoas, and
the pubic brim lateral to the insertion of the rectus abdominis.

The internal abdominal oblique (IAO) muscle arises predominantly from the tuber coxa, with smaller
points of origin from the lateral crus of the EAO, thoracolumbar fascia and the transverse processes of the
lumbar vertebrae.. the fibers of the IAO run largely caudoventrally, and central fascicles insert via an
aponeurotic tendon to the linea alba after passing round the rectus abdominis. Towards the middle insertion
there is usually some interchange of fibers between the aponeurosis of the IAO and EAO. The IAO has a
free caudal margin, which is important with regard to the formation of the inguinal canal. In the dog, the
cremaster muscle from a caudal slip of muscle from the IAO, but in the cat the levator scroti muscle replaces
the cremaster, which is absent. The levator scroti muscle is formed from the fibers of the caudoventral
border of the external anal sphincter and the pars caudalis of the external anal sphincter.

The transversus abdominis (TAB) from the inner surfaces of the last ribs and the transverse process
of the lumbar vertebrae. The fibers run transversely intrenal to the rectus interal to the rectus abdominis to
their aponeurotic insertion at the midline.

The rectus abdominis (RA) is a broad band of muscle on either side of the linea alba that has a
segmental appearance caused by irregular transverse septae. It takes its origin from the ventral surfaces of
the rib cartilages and inserts at the pelvic brim via the strong prepubic tendon in dogs. It has been speculated
that in cats the strong attachments of the crura of the superficial inguinal ring on the illiopubic eminance,
plus the EAO muscle aponeurosis to the medial tigh may serve the same function as the prepubic tendon
does in the dog.

The rectus sheath in the term used for the anatomic arrabgement of the aponeurosis from the IAO,
EAO and TAB around the RA. The EAO aponeurosis always lies external to the RA, but the IAO
aponeurosis may lie either internal or external, depending on the portion of the abdominal wall studied. In
the cranial third of the abdomen, fibers pass both internal and external to the RA, but from the umbilicus
caudally all fibers pass external. All fascial structures lying external to the RA are termed the external sheath
or external leaf, while those lying internal to the RA are termed the internal shealth or leaf. The internal
rectus sheath is lined by a thin layer of transversalis fascia and peritoneum.

The linea alba is the ventral midline fibrous zone where the right and left abdominal walls meet. In
cats, the linea alba is a broad white band typically 3-4 mm wide, whereas in the dog the linea alba is a
shallow trough rarely more than 2 mm wide.

The inguinal canal is located adjacent to the groin, between the fleshy part of the IAO on one side
and the lateral crus of the EAO on the other. Other than where the external pudendal vessels, the
genitofemoral nerve, and the spermatic cord (male) or vaginal process (female) pass through the canal, it
contains only fatty tissue. In male dogs the peritoneum evaginates through the inguinal canal, to form the
vaginal tunic around the spermatic cord and testis while in the bitch it envelops the round ligament of the
uterus and is called the vaginal process .

The deep inguinal ring is a slit-like entrance to the abdomen along the free caudal edge of the IAO,
while the superficial inguina lring is contained between the two crura of the EAO aponeurosis.

Small Intestine
 The small intestine extends from the pylorus of the stomach to the ileocolic orifice leading into the
large intestine. It is the longest portion of the alimentary canal. The small intestine consists of three main
parts, relatively fixed and short proximal loop, or duodenum, the freely movable, long, middle and distal
portions, the jejunum, and the very short terminal part, the ileum.

The duodenum is the first and most fixed part of the small intestine. It begins in the dorsal half of the
right hypochondriac region opposite the 9th intercostal space. It runs mainly caudally to a transverse level
through the tuber coxae, makes a U-shaped turn, and runs obliquely craniosinistrally to be continued by the
jejunum to the left root of the mesentery.both the pancreatic and the bile ducts open into the duodenum. The
acid chyme that enters it from the stomach is mixed with the alkaline secretions from the liver, pancreas, and
small intestinal glands. Because of the high nutritive content of the material ingested, most freeiliving
intestinal parasites are found in the duodenum.

The jejunum and ileum compose the remainder and the majority of the small intestine with the
jejunum being the longest portion. The jejunum begins at the left of or caudal to the root of the mesentery at
the duodenojejunal flexure, and the ileum ends by opening into the initial portion of the ascending colon as
the ileal papilla with an ileal orifice and an associated circular sphincter muscle. In contrast to the relatively
fixed duodenum, the jejunoileum is the most mobile and free part of the entire alimentary canal. It is
suspended by the long mesentery from the cranial part of the sublumbar region and is therefore also known
as the mesenteric portion of the small intestine.

Mesentery of the Small Intestine

The mesentery is also known as the great or proper mesentery, or the mesojejunoileum, to
differentiate it from the various other portions that are derived from the primitive dorsal mesentery. The
mesentery is in the form of a large fan hanging from the cranial part of the sublumbar region. The root of the
mesentery is the thickest portion because it includes the cranial mesenteric artery, intestinal lymphatics, and
the extensive mesenteric plexus of nerves that surround the artery. The free, or intestinal boarder of the
mesentery is the longest part.

Wall of the Small Intestine

The intestinal wall consists of an outer serosa formed by visceral peritoneum, the tunica muscularis
with its outer longitudinal, and inner circular layers. The submucosa, which is rich in collagen, also serves as
the principal holding layers for sutures. The intestinal mucosa is lined by simple columns of epithelial cells
mixed with variable population of mucous providing goblet cells. The cat’s microvascular anatomy is
similar to that of the dog’s, with the vasa recta perforating the outer longitudinal and inner circular
muscularis layers and supplying a rich submucosal vascular plexus. One distinguishing factor is cats is the
presence of prominent lymphatic nodules in the mucosa, mostly along the antimesenteric aspect of the small
intestine.

Blood Supply
 The cranial mesenteric artery is the largest visceral branch of the aorta. This unpaired artery arises
from the ventral surface of the abdominal aorta. It passes ventrocaudally through the mesentery and acts as
an axis around to which the whole small and large intestine rotates during development. As it extends into
the intestinal mass, it is loosely bounded by the duodenum on the right and caudally. The first two branches
of the cranial mesenteric artery arise from the opposite sides of the artery. One of these, a common trunk for
colic and ileocolic arteries, runs cranially in the transverse mesocolon, and the other, the caudal
pancreaticoduodenal artery, from a caudal origin runs to the right and cranially. The remaining part of the
artery gradually diminishes in size as some 14 jejunal arteries arise from it. Ileal arteries terminate the
cranial mesenteric artery.

The jejunal arteries are 12-15 in number. Some of these are larger than the others, and branch after
they have traveled only a few millimeters. They arise from the caudal or convex side of the cranial
mesenteric artery. The proximal 8-10 vessels are covered on each side by two large jejunal lymph nodes.
Usually the first 5-7 arteries arise closely together. The cranial mesentric artery then gives rise to the
branches that go to the distal party of the jejunum and finally to the two ileal arteries. The ileal arteries
branch on approaching the intestine and join to form primary and secondary arcades, which lie directly
adjacent to the intestinal wall.

V. PRE-OPERATIVE PREPARATION

Fasting
The patient is deprived of food and water for atleast 20 hours prior to surgery to reduce the tendency
of regurgitation, vomiting and aspiration of ingesta. Fasting the animal also means that there will be little
chyme in the intestines during the surgery, reducing the risk of infection.

Patient Preparation
Prior to surgery, the patient must be exercised to encourage voiding. It should be bathed, a day or
two before surgery and badly matted/soiled fur must be removed, especially in the operative site which must
be cleaned thoroughly.

Skin Preparation
To prepare the skin for surgery, clip the fur of the abdomen at a minimum distance of 2-4 mm
around the surgical site using a hair clipper in the direction they normally grow. After this, standard aseptic
technique should be used to prep the skin for surgery. Use Chlorhexidine solution to disinfect the site where
the IV cannula will be inserted and the same solution is used to clean the operative site.
Surgical Positioning
The patient is placed in a dorsal recumbency.

IV Fluid/Hydration
A 24 G (yellow) cannula is inserted on the cephalic vein of the patient and D5LRS fluid is used.
D5LRS is better than plain LRS for this surgical procedure because of the presence of glucose molecules in
D5LRS. The patient’s body will still be able to produce energy despite being fasted for quite a long time,
and being unable to eat hours after the surgical procedure.

Anesthesia
The pre-anesthetic ( Atropine Sulfate), injected subcutaneously, then after 10-15 minutes, the
anesthetic (Zoletil 50) will be administered intramuscularly.

Patient Monitoring
The heart rate(120-140 bpm), temperature(38.1-39.2 ºC) and respiratory rate (15-30bpm) of the
patient are monitored throughout the surgery.

Antibiotic treatment during surgery is therefore recommended as a preventative precaution. A broad

spectrum antibiotic should be infused intravenously within an hour after making the initial incision and then
every 90 minutes until the procedure is complete.

VI. OPERATIVE TECHNIQUE

Using a scalpel holder #3 with blade #10, make a 2 inches ventral midline abdominal incision in the
middle of the abdomen. Use retractors to retract the abdominal wall and provide adequate exposure of the
intestines. Exterorize the desired intestine from the abdomen by packing with laparotomy sponges and
sterile gauze. Gently milk chyme (intestinal contents) from the lumen of the jejunum. To minimize spillage
of chyme, occlude the lumen at both ends of the isolated segment by having an assistant use a scissor like-
grip with the index and middle fingers 4-6 cm on each side of the proposed enterotomy site. If an assistant is
not available, use noncrushing intestinal forceps (Doyen) or a Penrose drain tourniquet to occlude the
intestinal lumen. Make a full thickness stab incision into the intestinal lumen on the antimessenteric border
with a #11 scalpel blade. Lengthen the incision along the intestine’s long axis with Metzenbaum scissors of
scalpel as necessary to allow removal of foreign body without tearing the intestine. Use 4-0 polyglactin
suture to suture the layers of the intestinal wall. All layers of the intestinal wall must be sutured, 2 mm from
the edge and 2-3 mm apart, with simple interrupted suture pattern. Angle the needle so the serosa is engaged
slightly further from the edges than the mucosa to prevent mucosal evertion. Tie each suture carefully with
apposition without cutting through the serosa layer of the intestine. Sutures should be tied just tight enough
to appose all layers of the intestine. Before releasing luminal occlusion near the enterotomy leak test the
enterotomy site by tunneling a 20-22 gauge needle into the lumen of the intestine and injecting sterile saline
into the lumen. Inject just enough saline to distend the enterotomy site. If leakage occurs place one or two
more sutures and retest the enterotomy site for leakage. Lastly, wrap a small amount of omentum around the
enterotomy site. This will help seal the enterotomy site. For the first and innermost layer of closure the
abdomen, suture the peritoneum or linea alba using 3-0 polyglactin multifilament suture, simple interrupted
pattern. For the second layer, which is the subcutaneous layer, use a 3-0 polyglactin suture, simple
continous pattern. Then make an intradermal suture with a cushing pattern and an aberdeen knot for more
security of the abdomen. Lastly, affix the skin with a simple interrupted pattern, using a 3-0 silk cutting
suture.
VII. POST-OPERATIVE TECHNIQUE
For the first 24 to 48 hours, D5LR should be given intravenously. During the first few days, only
water and wet food should be offered in small amounts at frequent intervals. Use tolfenamic acid as an
analgesic and an anti-inflammatory, along with penicillin as an antibiotic. The area where the procedure was
done must be cleaned and properly dressed. To prevent the animal from licking the site, use an e-collar.
Keep a close eye on the animal to spot any issues after surgery. Depending on how quickly the wound is
healing, the skin suture can be taken out 10 to 14 days later..

VIII. COMPLICATIONS

Due to the fact that there are a lot of microorganisms and other materials found in the intestine,
wound infection is a great possibility. Wound dehiscence can also happen, and if the suture is not strong
enough peritonitis can occur. Hernias may also develop if the wound closure in the muscles are not strong
enough.

IX. IV FLUIDS/ DRUGS COMPUTATION

PRE-MED
Pre-anesthetic: Atropine sulfate
2 kg x 0.044 mg/kg
0.65 mg/ml
=.135 ml
Anesthetic: Zoletil
IM:
2 kg x 10 mg/kg
50 mg
= 0.4 ml
IV:
2 kg x 7.5mg/kg
 50 mg/kg
= .3 ml

INTRA OP MEDICINE: Tranexamic acid

2 kg x 10mg/kg
100 mg/ml
= .2 ml

POST-OP: Tolfenamic
2 kg x 4 mg/kg
40 mg/ml
= .2 ml

ANTIBIOTICS: Ampicillin
2kg x 22 mg/kg
200 mg/ml
=0.22 ml

IV Fluid : Lactated Ringer’s Solution (D5LR)

a. Maintenance Need:
2 kg x 65ml/kg/day
=130 ml/day
b. Replacement Fluid:
2 kg x 3%
=0.06 ml
c. Total:
130 + 0.06 ml
= 130.06 ml
Drip Rate
130.06 ml
24 hrs
= 5.42 ml/hr
Drops per minute
130.06 ml x 60 gtts/ml
6hrs 60 mins/hr
= 21.68 gtts/min
60 secs
= 0.36 drops/sec