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Describe the attachments of the duodenum.
- suspended by mesoduodenum
- ascending duodenum is fixed to mesocolon via duodeno-colic ligament
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The pancreas is located...
within the mesoduodenum
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What is the blood supply of the duodenum?
- duodenal branches of the celiac artery
- cranial mesenteric artery gives rise to jejunal a., ileocolic a., right and middle colic a.
- caudal mesenteric artery gives rise to left colic a., and cranial rectal a.
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What ducts empty into the duodenum?
- major duodenal papilla- common bile duct, pancreatic duct
- minor duodenal papilla- accessory pancreatic duct (larger one in dogs)
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How do you identify the illeum?
- short segment b/w jejunum and cecum/ colon
- identified by antimesenteric artery
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What are the histologic layers of the intestines?
- mucosa- absorption barrier
- submucosa- HOLDING LAYER
- muscularis- motility
- serosa- quick seal after injury or incision
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Describe peri-operative antibiotics with intestinal surgery.
- broad-spectrum b/c intestines are contaminated
- cephalosporin common choice- cefazolin IV
- start the drug before surgery and continue post-operatively if infection/ peritonitis is present
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What are antibiotic considerations for colonic surgery?
- must reduce bacterial numbers
- neomycin
- erythromycin
- cefmetazole
- cefoxitin
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Describe nutritional management around intestinal surgery.
- critical for wound healing and patient survival
- malnourished animals have delayed wound healing and increased chance of dehiscence
- consider esophagostomy, gastrostomy, jejunostomy tube if anorexic
- +/- liquid diets
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What aspect of technique is of paramount importance with intestinal surgery?
- maintenance of blood supply
- GENTLE TISSUE HANDLING
- do not use forceps to grab tissues- manipulate with fingers
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How do you assess tissue viability? (4)
- color**- most surgeons use serosal color as primary indicator
- temperature
- peristalsis
- bleeding when cut
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What sutures are used to close the intestines?
- taper-cut needle
- 4-0 polypropylene or PDS
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What is the holding layer of the intestines?
submucosa
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Dehiscence is more likely after ________ surgery.
large intestinal
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What patient factors may delay healing or promote dehiscence and how do you manage this as the surgeon?
- hypoproteinemia, emaciation, chemotherapy
- use non-absorbable, monofilament sutures (prolene)
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How fast do the intestines heal?
80% of original strength in 10-14 days
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Intestinal dehiscence usually occurs within...
3-5 days post-op
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What are potential complications of intestinal surgery? (3)
- dehiscence and peritonitis
- stricture (uncommon, more common if you invert tissues at closure)
- short-bowel syndrome if large resection (>80% in SA)--> chronic diarrhea and weight loss
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What are indications for intestinal surgery? (5)
- GI obstruction (FB, mass)
- trauma (perforation, ischemia)
- malpositioning
- infection
- diagnostic/ supportive (biopsy, culture, feeding tube)
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What are indications for intestinal biopsy? (4)
malabsorption, hypoproteinemia due to GI loss, chronic diarrhea of unknown etiology, suspected intestinal neoplasia
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Where are stay suture places when performing intestinal surgery?
antimesenteric surface
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What are indications for enterotomy? (3)
biopsies, FBs, luminal examinations
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Where do you incise with regard to an intestinal FB?
incise distal to FB in healthy tissue, milk FB down to incision, suture closed healthy tissue
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What pattern is used to close the intestines?
simple continuous appositional (maybe simple interrupted, but probably not)
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What are indications for intestinal R&A? (7)
- removal of ischemic, necrotic intestines
- neoplasia or fungus
- trauma
- intussusception
- mesenteric volvulus
- strangulation in hernia
- idiopathic megacolon in cats
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With R&A, how can you manage suturing two areas of different diameter together?
transverse incision on thicker part and oblique incision on thinner part to increase lumen of smaller intestine
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What are methods of closing R&A? (4)
- approximating: simple interrupted, full thickness, sutures tied only tight enough to approximate tissues
- crushing: simple interrupted, full thickness, sutures tied tight to cut through mucosa and muscularis (not used much...don't use it)
- simple continuous: best method, minimal trauma
- stapling: device used on antimesenteric surface
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What are signs of intestinal dehiscence? (5)
- depression
- high fever
- excessive abdominal pain
- vomiting
- ileus
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What is the next step if peritonitis is suspected?
- abdominal tap
- CBC/Chem
- culture and sensitivity peritoneal fluid
- antibiotics and fluid therapy
- +/- aggressive treatment
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Is there a higher chance of contamination with small or large intestinal surgery?
large
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