CHAPTER
Colic: Diagnosis, Surgical Decision,
Preoperative Management, and
Surgical Approaches to the Abdomen
John F. Marshall and Anthony T. Blikslager
The veterinarian presented with an equine colic faces a diagnostic
challenge and a potential emergency. Through the combination
of history, physical examination, and diagnostic procedures, the
veterinarian must determine and communicate to the owner the
source of the abdominal pain, the correct treatment strategy, the
prognosis for recovery, and the estimated costs. Although a great
deal of valuable information can be gained from an accurate
signalment, medical history, and physical examination, a range
of further diagnostic procedures are necessary to aid in this
process. It is therefore essential to understand the indications
for and the significance and limitations of these techniques. This
information may then be interpreted, and a decision to continue
medical treatment or perform an exploratory celiotomy can be
made.
DIAGNOSIS
History and Signalment
The signalment of the colic patient is important when determining
the specific information that should be obtained during history
taking, and which physical examination and diagnostic procedures
are indicated. The signalment itself can often lead to an early
differential diagnosis that may be investigated further during
the subsequent history and physical examination. The information
obtained from the owner should include both the medical history
and management practices. Details of the medical history related
to the current and previous episodes of colic, other illnesses or
surgery, and current and previous medications administered are
valuable. Knowledge of all analgesics and sedatives administered
before presentation is crucial when interpreting signs of pain
and physical examination findings, as they may alter clinical
signs. A description of the current management of the horse and
any changes to diet, exercise, stabling, anthelmintic regimen, or
medications is important in identifying potential risk factors for
certain conditions. These include the association between the
feeding of coastal Bermuda hay and the risk of ileal impaction,1
the association between the behavior of crib biting and epiploic
foramen entrapment,2 and the association between phenylbu-
tazone and impaction of the ascending colon or right dorsal
colitis.3
Physical Examination
Physical examination of the colic patient should be conducted
in a thorough, logical order and should not be limited to the
abdomen. The measurement and recording of body temperature
and the heart and respiratory rates on initial examination allows
the response to medication and therapy to be quantified. The
heart rate is an indicator of the physiologic response to pain,
dehydration, and endotoxemia, and is useful in determining
prognosis in both large and small intestinal disease.4,5 Conditions
associated with pyrexia include anterior enteritis, colitis, septic
33
peritonitis, and pleuropneumonia, and do not generally require
immediate surgical intervention. Therefore complete auscultation
of the thorax to rule out conditions of the respiratory tract should
be performed. Examination of the oral mucous membranes,
including measurement of capillary refill time, aids in the
determination of hydration status and the diagnosis of endo-
toxemia. In the endotoxemic horse, the capillary refill time is
prolonged and the mucous membranes develop a brick red or
purple color. A dark “toxic line” may be apparent along the gum
line of the horse.
Auscultation of abdominal borborygmi allows the subjective
assessment of large intestinal motility; small intestinal movement
is not specifically audible. Cecal motility may be auscultated
over the right flank, whereas the pelvic flexure and ascending
colon are auscultated over the left flank. Audible movements of
the cecum and ventral colon include propulsive, retropulsive,
and mixing contractions.6 Propulsive contractions of the cecum
and colon occur approximately every 3 to 4 minutes but are
decreased in frequency by conditions including anorexia and
sedation (e.g., α2-adrenergic receptor agonists).7 Ileus of the large
or small intestine will result in the absence of intestinal borbo-
rygmi and is therefore a significant physical examination finding.
Intestinal borborygmi can also be increased in certain conditions,
including the early stages of distention and inflammation. There
is experimental evidence that sand in the large colon can be
accurately auscultated, which may contribute to a tentative
diagnosis of sand impaction. These sounds have been described
as “similar to the sound produced if a paper bag were partially
filled with sand and slowly rotated.”8 In investigations in which
sand was administered to horses via nasogastric tube, these sounds
could be heard in all horses after repeated administration of
sand, verifying the accuracy of the technique. Importantly, the
sounds were heard most prominently when auscultating the
ventral abdomen just caudal to the xiphoid process.8
A critical aspect of the examination of any horse presented for
colic is the assessment of the degree and persistence of signs of
pain.9 It is often easiest to observe a horse in a box stall where it
may display signs of pain that are not apparent during handling
or restraint in stocks. Obvious signs of pain include pawing at
bedding, looking at the flank, kicking at the abdomen, repeated
lying down and standing, and rolling. Abdominal pain may also
manifest itself by more subtle behavior including a dull appear-
ance, lowered head position, and reluctance to move.10 Foals may
display additional signs including bruxism, ptyalism, abdominal
distention, and straining. The severity of pain is often related
to the degree of intestinal injury, which is in turn related to the
need for surgical intervention. A large colon volvulus resulting in
large colon distention and ischemic injury will cause severe pain
that is refractory to treatment with analgesics and sedatives. In
contrast, a nonstrangulating obstruction typically results in lower
grade pain that responds positively to analgesia. Observation of
the response to treatment with nonsteroidal antiinflammatory
521
522 SECTION V Alimentary System
drugs (NSAIDs), spasmolytics (hyoscine butylbromide, Buscopan),
or sedatives is important when characterizing the type of pain.9
Mild pain typically responds to treatment for a period of 8 to
12 hours. In contrast, moderate pain will respond to analgesia
for a limited period and requires repeated administration. Severe
pain is manifested by violent behavior and may not respond
to analgesia, which is frequently an indicator of the need for
immediate abdominal surgery.
During the physical examination, when indicated, it may be
prudent to place an intravenous jugular catheter and begin fluid
therapy while further diagnostic procedures are performed.
Palpation of the Abdomen per rectum
Palpation of the abdomen per rectum should be performed using
a suitable combination of physical and chemical (sedative)
restraint to allow palpation of the descending (small) colon,
cecum, spleen, caudal pole of the left kidney, nephrosplenic
(lienorenal) ligament, left dorsal and ventral colon, pelvic flexure,
and reproductive tract. If sedation does not provide adequate
relaxation to allow a safe examination, the instillation of lidocaine
into the rectum or administration of hyoscine butylbromide can
reduce straining, improve the quality of the abdominal palpation,
and reduce the risk of rectal tearing.11,12 Careful palpation should
be performed to prevent rectal tears and allow diagnosis of any
existing tear. The position and size of each palpable organ may
be assessed as well as the content, which include ingesta, fluid,
or gas. Entrapment of the large colon in the nephrosplenic space
may be palpable in the upper left abdominal quadrant. The
small intestine is not normally palpable per rectum and is therefore
an abnormal finding on rectal examination. The small colon is
normally distinguished by the presence of fecal balls and a broad
antimesenteric band. A small colon presenting as a long, tubular
structure without obvious fecal balls suggests an impaction. In
the pregnant mare, the broad ligaments should be palpated to
diagnose a possible uterine torsion. If a tight broad ligament is
palpated, the direction of the torsion should be determined to
allow correction.
Nasogastric Intubation
The passage of a nasogastric tube should be performed during
all colic examinations to allow decompression of the stomach
if necessary and prevent gastric rupture. Water is flushed through
the tube to begin a siphoning action, and should be measured
to allow the net volume of fluid recovered to be determined.
The color and smell of the fluid should be assessed. It is normal
to recover up to 2 L of green, nonodorous fluid. Excessive fluid
indicates either gastric outflow obstruction or decreased small
intestinal motility, resulting in an accumulation of fluid in the
stomach. In the adult horse, nasogastric reflux is frequently
associated with small intestinal disease. Anterior enteritis cases
often yield a large volume of malodorous orange or yellow fluid.
Large amounts of feed in the gastric fluid may indicate gastric
impaction. Gastric outflow obstruction may also be caused by
gastroduodenal ulceration in the foal, or rarely neoplasia in the
adult horse. The cause of gastric outflow obstruction may be
further investigated by endoscopy and ultrasonography (see later).
Following decompression of the stomach, the nasogastric tube
may be left in place during transportation to a surgical referral
facility and during surgery. The latter prevents fluid aspiration
and allows intraoperative decompression.
Clinical Pathology
The use of clinical pathology has become a crucial part of the
assessment and treatment of the colic patient. The measurement
of the blood packed cell volume (PCV) and total protein (TP)
can be performed using a centrifuge and refractometer to quickly
assess the patient’s hydration status. A high PCV has been shown
to be associated with a poor prognosis in horses with both small
and large intestinal disease, likely associated with the level of
dehydration and endotoxemia.4,13,14 In contrast, a low TP has
been associated with a poor prognosis in horses undergoing
surgery for the treatment of small intestinal disease, potentially
reflecting protein loss into the abdominal cavity.5,13 The introduc-
tion of point-of-care analyzers has created widespread availability
of blood electrolyte and acid-base balance information. When
using a point-of-care analyzer it is important to store and prepare
the cartridges for use according to the manufacturer’s instructions
to ensure accuracy.15 Although the majority of changes seen on
hematology are nonspecific, it is useful in diagnosing inflam-
mation, endotoxemia, or sepsis. These changes may be evident
as leukopenia, neutropenia with appearance of immature and
toxic neutrophils, lymphopenia, and thrombocytopenia.
The blood electrolyte profile of horses losing fluids through
gastric reflux or diarrhea often reveals abnormalities, including
low Na+, K+, Ca2+, and HCO3− levels that may be addressed
during fluid therapy. Because lactate is a product of anaerobic
glycolysis, its measurement may reflect ischemic injury and
may aid in determining the prognosis.16 For instance, among
horses with large colon volvulus, a serum lactate concentration
greater than 6 mmol/L was associated with a poor prognosis
for survival.17 Measurement of the anion gap allows the indirect
measurement of blood lactate and is of value when determining
prognosis.18 A study of horses with large colon displacement
revealed an increased serum γ-glutamyltransferase (GGT) in 49%
of right dorsal displacement cases but in only 2% of horses
with a left dorsal displacement.19 This increase in GGT in horses
with right dorsal displacement of the large colon is the result
of obstruction of the bile duct. Additional information on
acid-base derangements and their management can be found
in Chapter 3.
There has been recent interest in the ability of acute-phase
proteins such as serum amyloid A (SAA), haptoglobin, and
fibrinogen to enhance the clinician’s ability to distinguish between
different categories of colic. For example, in a recent study, horses
with high blood SAA (>5 µg/mL) were more likely to be managed
surgically than horses with lower levels.20 In another study, horses
with inflammatory causes of colic or strangulating obstruction
had significantly higher SAA levels than horses with simple
obstructions, but levels were highly dependent on duration of
colic.21 The same group used a multivariable model including
clinical parameters at admission to differentiate between inflam-
matory causes of medical colic, such as colitis, and surgical cases
of colic. Of the acute phase proteins evaluated (SAA, haptoglobin,
and fibrinogen), only SAA improved the model for detection of
horses requiring surgery. Horses with inflammatory causes of
medical colic had a higher level of SAA than horses with surgical
colic.22 The finding that inflammatory causes of colic had the
highest SAA levels was also found in an earlier study by another
group,23 suggesting some consistency in this result. Nonetheless,
SAA values should be carefully interpreted in the context of a
full medical examination based on the high degree of overlap
between categories of colic patients.
 CHAPTER 33 Colic 523

gastric volume can be estimated and stomach decompression

Abdominocentesis confirmed by measurement of the gastric wall height at the 12th
Peritoneal fluid can be examined as both a diagnostic and intercostal space.27
prognostic aid. Peritoneal fluid can be collected by clipping and The small intestine can be identified in the cranial ventral
aseptically preparing the most dependent part of the abdomen, abdomen and can be examined for wall thickness, diameter, and
on or slightly to the right of midline to avoid the spleen, and motility. The normal wall thickness of the small intestine is less
inserting an 18-gauge needle. Alternatively, following local than 3 mm, and an increase may indicate enteritis or strangulating
anesthesia, a small incision can be made using a No. 15 scalpel obstruction (Figure 33-1). Obstruction results in distention of
blade and inserting a teat cannula. Care must be taken during small intestinal loops, which can be identified and measured
the collection of fluid to avoid enterocentesis, particularly in ultrasonographically (Figure 33-2). The motility of these loops
horses with distended viscera, or to avoid amniocentesis in the should be assessed, because ileus may be diagnosed as hypomotile
pregnant mare. Where fluid is not easily obtained, abdominal small intestine on ultrasonographic examination.
ultrasonography can be performed to identify an area of fluid
accumulation for collection. The abdominal fluid should be
collected in a plain tube for the measurement of protein concentra-
tion and in an ethylenediaminetetraacetic acid (EDTA) tube for
a cell count and hematology.
Immediately following collection, the gross appearance of
the fluid should be visually assessed. Normal peritoneal fluid
has a clear, colorless to light yellow appearance. When a strangulat-
ing lesion is present, there is movement of protein followed by
red blood cells and finally leukocytes into the peritoneal cavity.
This results in the peritoneal fluid becoming turbid and red to
brown (serosanguinous). The presence of ingesta in the peritoneal
fluid suggests a ruptured viscus and a hopeless prognosis. In this
situation, care must be taken to ensure that the sample was not
obtained by enterocentesis. The normal total protein concentration
of abdominal fluid is less than 2 g/dL, and this will increase
with intestinal disease. The appearance of red blood cells in the
abdominocentesis sample may be the result of an intestinal
strangulation or an iatrogenic source. For example, a small amount
of blood contamination may occur if a vessel in the abdominal
wall is punctured. If the peritoneal fluid is normal, a small pellet Figure 33-1. Ultrasonographic examination of the ventral abdomen of
of red blood cells will collect on centrifugation, leaving fluid a horse using a 3.5-MHz curvilinear probe. A cross section of the jejunum
with a normal appearance.24 It is also possible to insert the can be identified, and measurement reveals a thickened wall (1.01 cm)
needle into the spleen, resulting in the collection of a sample characteristic of enteritis. (Courtesy MK Sheats, North Carolina State
University, Raleigh.)
with a PCV similar to that of peripheral blood.
Clinical biochemistry may be performed on peritoneal fluid
to determine other factors, including fibrinogen, lactate, phos-
phate, glucose, and pH. A high peritoneal lactate has been shown
to be a more sensitive indicator of a strangulating obstruction
of the intestine than plasma lactate.16 In those horses with
suspected septic peritonitis, the serum and peritoneal fluid glucose
levels can be compared. A difference of greater than 50 mg/dL
between the serum and peritoneal fluid glucose level, a low
peritoneal fluid glucose level (<30 mg/dL), and pH of less than
7.3 are indicators of septic peritonitis.25

Ultrasonography
Ultrasonography has become an important part of the diagnosis,
treatment, and management of the colic patient.26 Abdominal
ultrasonography is generally performed using a percutaneous
approach following preparation of the skin by clipping and appli-
cation of alcohol or coupling gel. A low-frequency (2.5–5 MHz)
linear, curvilinear, or sector transducer will produce a diagnostic
quality image while providing sufficient penetration to identify
deeper structures. It is possible to identify the stomach, small Figure 33-2. Ultrasonographic examination of the ventral abdomen of
intestine, cecum, and large colon, and determine their size, a horse using a 3.5-MHz curvilinear probe. Several cross-sectional loops
position, wall thickness, and motility.26 of distended jejunum can be identified with a normal intestinal wall
The stomach may normally be imaged cranially on the left of thickness. These findings are characteristic of a functional or obstructive
the abdomen between the 11th and 13th intercostal spaces. The ileus. (Courtesy MK Sheets, North Carolina State University, Raleigh.)
524 SECTION V Alimentary System
Ultrasonography has been demonstrated to be useful for the
diagnosis of large colon displacement and volvulus in the horse.28,29
The colon can be identified on the ventral abdominal midline,
and the appearance and thickness of the wall and motility are
assessed. Normally, the sacculated ventral colon with a wall
thickness of less than 5 mm is identified. If a large colon volvulus
of 180 or 540 degrees is present, the nonsacculated dorsal colon
can be identified on the ventral abdomen.29 Measurement of
the colonic wall thickness has been shown to be useful in the
diagnosis of large colon volvulus (Figure 33-3). A colonic wall
thickness measurement of thicker than 9 mm had a sensitivity
of 67% and a specificity of 100% in diagnosing large colon
volvulus.28 A retrospective study of horses undergoing exploratory
celiotomy demonstrated that identification of mesenteric blood
vessels coursing horizontally along the right body wall at the
level of the costochondral junction between the 12th and 17th
intercostal spaces is a sensitive and specific method of predicting
the presence of right dorsal displacement or 180-degree large
colon volvulus.30
Figure 33-3. Ultrasonographic examination of the ventral abdomen
2 cm caudal to the xiphoid of a horse using a 3.5-MHz curvilinear probe.
A longitudinal image of the ventral colon reveals significant thickening
of the colonic wall (1.97 cm) diagnostic of a large colon volvulus. (Courtesy
MK Sheets North Carolina State University, Raleigh.)
Figure 33-5. Ultrasonographic examination of the 17th intercostal space on the left side using a 5-MHz
curvilinear probe. In the normal horse the spleen (S), kidney (K), and large colon can be visualized (left).
Displacement of the colon prevents visualization of the right kidney, indicative of a nephrosplenic entrapment
(right).
In addition to the diagnosis of large colon volvulus, ultraso-
nography can be used to monitor postoperative recovery of the
colon.31 In horses in which right dorsal colitis is suspected, a
diagnosis can be confirmed using ultrasonography performed
between the 10th and 14th right intercostal spaces.32 Ultrasono-
graphic changes associated with right dorsal colitis include a
thickened colon wall and a hypoechoic layer of submucosal
edema and inflammatory infiltrate (Figure 33-4).32 Left dorsal
displacement of the large colon can be diagnosed ultrasonographi-
cally through identification of the large colon lateral or dorsal
to the spleen at the level of the 17th intercostal space.33 The
displaced colon prevents visualization of the right kidney (Figure
33-5). If nonsurgical management is performed, ultrasonography
can be used to confirm correction of the displacement.33 Although
radiography remains the gold standard for diagnosing sand
impaction of the colon, ultrasonography can identify sand, which
produces a hyperechoic signal and acoustic shadowing of deeper
structures.34 The presence of a sand impaction can also reduce
colonic motility.
Right dorsal colon
Figure 33-4. Ultrasonographic examination of the 11th intercostal space
on the right side of a horse using a 5-MHz curvilinear probe. The wall
of the right dorsal colon is thickened (1.46 cm) and a hypoechoic layer
of edema, cellular infiltrate, and granulation tissue is visible. These changes
are consistent with right dorsal colitis. (Courtesy MK Sheets, North Carolina
State University, Raleigh.)

Figure 33-6. Lateral radiograph of the ventral abdomen of a horse.
Accumulation of sand is apparent in the ventral colon (arrows).
Radiography
In the examination of the adult horse presented for colic,
radiography is useful when the presence of radiopaque material
is suspected. Therefore abdominal radiographs are particularly
useful for the diagnosis of sand accumulation and enterolithiasis
(Figure 33-6).35,36 When performing abdominal radiography,
adequate exposure is critical to maximize diagnostic quality and
reduce the incidence of false-negative examinations. Radiography
has high sensitivity and specificity for the diagnosis of large
colon enterolithiasis,36 but lower sensitivity for the diagnosis of
small colon enterolithiasis. The presence of gas in the colon
negatively affects the ability of radiography to detect enteroliths
(see Chapter 38).
The improved image quality of abdominal radiography in
the foal and small horse allows examination of the stomach and
small and large intestines. Radiography can be performed using
both plain images and contrast techniques to allow diagnosis
of obstruction, intussusception, and radiopaque foreign bodies.
Contrast radiography can be performed using 30% wt/vol barium
sulfate suspension administered orally or rectally.37 This technique
is useful for identifying delayed gastric outflow and obstruction
of the small, transverse, and large colons.
Ancillary Diagnostic Aids
Endoscopy
Examination of the esophagus, stomach, and duodenum can be
performed in the adult horse using a 3-m flexible endoscope.
During a colic examination, endoscopy can be used to confirm
gastric decompression and diagnose gastric ulcer disease, gastric
impaction, and gastric squamous cell carcinoma. Endoscopic
examination of the rectum allows the minimally invasive investiga-
tion of rectal tears.
Laparoscopy
The use of laparoscopy has been described for investigation of
both the acute and chronic colic patient.38 Laparoscopy is an
option in those patients with controlled abdominal pain. Its
use is limited in the horse by the inability to completely visualize
the abdominal contents and by the difficulties associated with
manipulating the large viscera of the horse. The sensitivity and
specificity of laparoscopy as a diagnostic technique are greater
CHAPTER 33 Colic 525
in horses with acute colic than chronic colic.38 When performing
laparoscopy in the acute colic patient, care must be taken to
prevent penetration of gas-distended abdominal viscera. Although
laparoscopy is generally a diagnostic technique in the acute equine
colic patient, its use has been described for correcting left dorsal
displacement of the large colon.39
Laparoscopy is suitable for diagnosis of a range of abdominal
conditions, including mesenteric tears, uterine rupture, intestinal
adhesions, small intestinal strangulating lesions, large colon
displacement, and visceral rupture.38
DECISION FOR SURGERY
Following the examination and diagnostic procedures, there are
three general options available for the management of the colic
patient. In patients with a poor prognosis, the owner may elect
to have the horse euthanized. In all other cases, the veterinarian
must decide whether an immediate exploratory celiotomy is
required or if medical management and further observation
should be instituted. The decision to perform an exploratory
celiotomy is largely based upon the ability to control pain and
the abnormalities identified by physical examination and diag-
nostic procedures. Prompt surgical intervention is critical in
maximizing the probability of a successful outcome, whereas a
delayed exploratory celiotomy may result in visceral rupture or
deterioration in the patient’s condition. Therefore surgery is often
performed before a definitive diagnosis of the cause of the colic
has been reached.
An exploratory celiotomy is frequently necessary in horses
with uncontrollable abdominal pain, even if other diagnostic
procedures find no abnormalities. The presence of distended,
hypomotile small intestine on rectal and ultrasonographic
examination is commonly associated with the need for surgical
intervention. Serosanguinous peritoneal fluid with an increased
total protein and white blood cell count is an indicator of sig-
nificant pathology and requires surgical exploration. The continued
production of gastric reflux or deterioration in physical parameters
including hydration status may suggest an exploratory celiotomy
is necessary for both diagnostic and therapeutic purposes.
Preoperative Management
The preoperative management of the colic patient requires
preparation to undergo anesthesia and administration of pro-
phylactic antimicrobial and antiinflammatory agents. Although
an exploratory celiotomy is frequently an emergency surgery, it
is important to attempt fluid therapy to address hydration status
and acid-base and electrolyte abnormalities before anesthesia
(see Chapter 3). Antimicrobial prophylaxis in the colic patient
is administered to reduce the risk of incisional infection, septic
peritonitis, and adhesion formation. The prevalence of incisional
surgical site infection (SSI) has been estimated to be between
3% and 20%, while the prevalence of septic peritonitis is
approximately 3%.40,41 It has been shown that the prevalence of
both incisional SSI and septic peritonitis is significantly higher
in patients undergoing repeat celiotomy at 57% and 9.5%
respectively.42 The species and antimicrobial sensitivity of the
most common bacterial isolates from potential SSIs should be
considered when selecting appropriate prophylactic antimicrobials.
The most frequently reported isolates from incisional infections
are Escherichia coli, a gram-negative facultative anaerobe, and the
gram-positive Streptococcus and Staphylococcus spp.43 Gram-negative
526 SECTION V Alimentary System
bacteria including E. coli are typically sensitive to gentamicin,
a bactericidal aminoglycoside, and it is therefore considered to
be a suitable first-choice antimicrobial.44 Aminoglycosides
are concentration-dependent antimicrobials and therefore the
effectiveness of gentamicin is dependent on the peak concentration
achieved. A dose of 6.6 mg/kg IV is typically recommended to
achieve a peak plasma concentration greater than 25 µg/mL,
more than 8 to 10 times the minimum inhibitory concentration
(MIC) of E. coli.45
Gram-positive bacteria including the Streptococcus and Staphy-
lococcus spp. are generally sensitive to penicillin, a bactericidal
β-lactam, with an MIC of at or below 0.5 µg/mL. The effectiveness
of penicillin depends on achieving and maintaining a tissue
concentration greater than the MIC for a prolonged period of
time.44 Pharmacokinetic studies demonstrate that a penicillin
dose of 22,000 IU/kg administered by either the intravenous or
intramuscular route will result in a serum concentration above
MIC for both Streptococcus and Staphylococcus spp.46 Intravenous
administration results in higher peak serum concentrations, but
because of the short half-life (30–40 min) repeated intraoperative
administration after 4 hours may be warranted to ensure the
serum concentration remains above the MIC.46 Intramuscular
administration of penicillin results in a significantly lower peak
serum concentration but greater half-life (20 hours),46 eliminating
the need for repeated intraoperative administration. Intravenous
administration of antimicrobials is usually recommended in
human surgical prophylaxis guidelines, but the availability of
IV penicillin formulations and cost can be limiting factors in
equine practice. The actions of penicillin and gentamicin are
synergistic, and they are therefore frequently administered together
for both prophylaxis and treatment.44 In an effort to prevent the
development of antimicrobial resistance, enrofloxacin and the
third- and fourth-generation cephalosporins such as ceftiofur
and cefquinome should not be administered for the purposes
of surgical prophylaxis.47
Although there is limited information on the effect of timing
of antimicrobial administration on the effectiveness of prophylaxis
in the horse, evidence from human surgery suggests that admin-
istration should occur within 60 minutes of clean-contaminated
surgery.47 All colic surgery is potentially clean-contaminated;
therefore preoperative administration of antimicrobials is recom-
mended. Early (>120 min) or late (<30 min) administration
prior to surgery reduces the effectiveness of prophylaxis in humans.
Since antimicrobials are frequently administered prior to the
induction of anaesthesia, effort should be made to limit the
time for surgical preparation to 1 hour and account for this time
when considering repeat dosing of drugs with a short half-life.
If antimicrobials are administered under general anesthesia, the
potential adverse effects such a decrease in blood pressure should
be anticipated and managed as necessary.
If the colic patient has not already received an NSAID, flunixin
meglumine (0.25–1.1 mg/kg IV) should be administered pre-
operatively to treat surgical pain and endotoxemia.
Before surgery, a nasogastric tube should be placed to allow
stomach decompression during surgery as necessary. The horse’s
mouth should be rinsed to prevent aspiration of feed material
during intubation. Any bedding or other material in the horse’s
hair coat should be removed with a dry brush to reduce con-
tamination of the operating room. Following induction of
anaesthisia the horse is positioned and secured in dorsal
recumbency. An indwelling urinary catheter should be placed
and in male horses the penis should then be secured within the
prepuce by suturing it closed. The hair coat is clipped from the
level of the xiphoid to the inquinal region and extended out to
the rib cage before the skin is aseptically prepared for surgery.
Surgical Approaches to the Abdomen
The most frequently utilized surgical approach to the abdomen
of the horse with acute colic is the ventral midline celiotomy, or
laparotomy. An incision is made through the skin and subcutane-
ous tissues starting at the level of the umbilicus and extending
cranially for approximately 30 to 40 cm. Hemorrhage is controlled
using hemostatic forceps or electrocautery to allow visualization
of the linea alba. At the level of the umbilicus, the linea alba is
approximately 10 mm thick and easily defined.48 A small, 2- to
3-cm-long incision is made through the linea alba at or very
close to the umbilicus, taking care not to incise any distended
viscera. The small incision in the linea alba is extended cranially
using an instrument such as thumb forceps or the surgeon’s
fingers to shield the viscera. As the incision extends cranially the
linea alba becomes thinner and care should be taken to continue
the incision in the dense, white, fibrous tissue on midline. The
incision should be extended approximately 30 to 40 cm to allow
complete exploration of the abdomen by palpation and exteri-
oristation of viscera without restriction or excessive tension
increasing the risk of iatrogenic damage to the viscera. The
falciform ligament may be identified and the peritoneum is
bluntly perforated by the surgeon’s fingers to gain access to the
peritoneal cavity. A ventral midline celiotomy allows the surgeon
to exteriorize approximately 75% of the gastrointestinal tract,
with the exception of the stomach, duodenum, distal ileum,
dorsal body and base of the cecum, distal right dorsal colon,
transverse colon, and terminal descending colon (Figure 33-7).49
In cases where a significantly distentended fluid or food-filled
viscera is encountered or access to the stomach is required, the
incision can be extended cranially as necessary.
Closure of the linea alba in the adult horse is performed with
large absorbable suture material in a simple continuous pattern
placing bites between 1.2 and 1.5 cm from the wound margin.48,50
Common choices of suture material include polyglactin 910 (USP
size No. 6, metric size No. 8) and polydioxanone (USP size No.
7, metric size No. 9). Dissection of the subcutaneous tissues
to ease placement of sutures in the linea alba is not recom-
mended as it is associated with an increased risk of incisional
complications, most likely because of the increased deadspace.40
Clinically, dehiscence of the body wall in the perioperative period
is rare.40,41,51 To reduce the risk of incisional infection, the linea
alba should be lavaged with sterile isotonic fluids before closure
of the subcutaneous tissues.51 Absorbable suture material, typically
USP size 2/0 (metric size 3.5), in a simple continuous pattern
is typically used to close the subcutaneous tissues. The skin is
closed with either nonabsorbable monofilament suture material,
absorbable suture material, or skin staples; however, there is
some evidence that skin staples are associated with an increased
risk of incisional complications.51 Modifications of the standard
wound closure have been described; a study found that a 2-layer
closure of linea alba and combined subcutaneous and subcuticular
tissues had a decreased risk of incisional drainage when compared
with a standard 3-layer closure.52 However, a study comparing a
standard 3-layer closure to a 2-layer closure without a subcutane-
ous layer found no difference in wound complications.53 The
skin can be sutured in an interrupted or continuous pattern;
and one author prefers to use USP size 2/0 (metric size 3.5)
polypropylene in a Ford interlocking pattern (JFM). Finally, a
wound stent or incise drape is applied to protect the wound

1. Exteriorized
2. Visualized but not
exteriorized
3. Palpated but not
visualized
Figure 33-7. Anatomic drawing of the equine intestinal tract. Differential
shading indicates the portions that may be (1) exteriorized, (2) visualized
and palpated but not exteriorized, and (3) palpated only via a standard
ventral midline approach. (Redrawn from Sack WO. Guide to the Dissection
of the Horse. Ann Arbor, Michigan: Edwards Brothers; 1977.)
during recovery. To reduce the risk of incisional complications,
the wound stent should be removed after a maximum of 12
hours and an abdominal bandage applied.40,54 It is common
to reopen the original incision in horses that require a repeat
celiotomy, except where the surgeon is concerned about disrupting
healing of the original incision or there is evidence of a surgical
site infection.42
The ventral paramedian approach to the celiotomy is preferred
by some surgeons, or when it is necessary to perform a repeat
celiotomy in a horse with a surgical site infection, dehiscence
or other wound complication. It is typically performed by making
an incision 8 to 12 cm to the right of midline through the skin,
subcutaneous tissues, and rectus abdominus muscles. Hemorrhage
is significantly greater and more difficult to control than with a
ventral midline approach, and care must be taken to avoid
iatrogenic damage to the superficial and deep epigastric vessels.
Surgical access to the abdominal viscera is similar to the ventral
midline approach. Closure of the ventral paramedian incision
is performed by suturing the facia of the rectus sheath in a simple
continuous pattern using large, absorbable suture material such
as polyglactin 910 (USP size No. 6, metric size No. 8) or
polydioxanone (USP size No. 7, metric size No. 9). The subcutane-
ous tissues and skin are closed as previously described for the
ventral midline incision. The rate of incisional complications
reported following ventral paramedian celiotomy is similar to
that of ventral midline celiotomy.55
A flank laparotomy approach may occasionally be required in
the colic patient, for example to access the small colon in cases
of impaction or rectal tear. The flank region is clipped and
aseptically prepared before local anesthetic is infiltrated into the
CHAPTER 33 Colic 527
skin and muscle layers. A skin incision is then made centered
between the tuber coxae and last rib, just proximal to the palpable
dorsal edge of the internal abdominal oblique muscle. The external
abdominal oblique muscle is then sharply divided vertically,
whereas the internal abdominal oblique and transverse abdominal
muscles are bluntly divided parallel to their fiber directions,
usually with the surgeon’s hand or a pair of Mayo scissors. The
peritoneum is bluntly perforated by a short thrust with the fingers
or scissors. The incision is closed by apposing the muscle layers
with absorbable suture material in a simple continuous pattern
before closing the skin with either staples or nonabsorbable
suture material in a simple interrupted or continuous pattern.49
When performing surgery on a stallion with an inguinal hernia,
an inguinal approach is used in conjunction with a ventral midline
incision. The inguinal approach allows access to the incarcerated
intestine while the ventral midline approach allows complete
exploration and decompression of the prestenotic and poststenotic
intestine. A skin incision is made over the superficial inguinal
ring and blunt dissection of the soft tissues is performed to
expose the parietal tunic, which is sharply incised to reveal the
herniated intestine. Closure of the external inguinal ring is
performed with USB size 2 or 3 (metric size 5 or 6) absorbable
suture material in a simple-interrupted or simple-continuous
pattern with sutures placed 1.5 cm apart. Closure of the inguinal
ring is also performed following correction of eventration of the
intestines following castration. The inguinal fascial layers are
apposed in one or two layers with absorbable suture material
in a simple continuous pattern before the skin is closed using
an intradermal skin suture pattern. The parainguinal approach
may be used to gain access to very aboral lesions of the small
colon and is described in Chapter 60.
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