Use these five steps to conduct a successful procedure and identify and investigate areas of concern.
EDITOR'S NOTE: SurgerySTAT is a collaborative column between the American College of Veterinary Surgeons (ACVS) and DVM Newsmagazine.
Abdominal exploratory surgery—a systematic evaluation of the abdominal cavity and its contents—is often done in veterinary practice for therapeutic reasons, including elective sterilization, retrieval of urinary calculi, gastrointestinal foreign body removal and treatment of neoplastic conditions and other abdominal maladies. Looking beyond the therapeutic benefits, abdominal exploratory is an invaluable diagnostic tool as well, particularly in patients with nonspecific chronic gastrointestinal signs, hepatopathy or abnormal findings on radiographic or ultrasonographic examination. Acquiring good biopsy samples is key to maximizing the information gained during an exploratory.
An exploratory can be done via open laparotomy or laparoscopy. Open laparotomy has the advantage of allowing visual and tactile inspection as well as the ability to address any problems identified. Laparoscopy is a minimally invasive alternative that allows good visual inspection of the abdomen, acquisition of excellent biopsy samples and completion of many procedures.
1. Prepare the patient and operating room. A complete sponge count (4-x-4 gauze sponges and laparotomy sponges) and instrument count (hemostats) should be done before entering any body cavity.
Figure 1: An abdominal exploratory revealing splenic neoplasia.
2. Approach the abdomen via the ventral midline through the linea alba. A full exploratory is best done with an incision from the xyphoid to pubis. Excision of the falciform ligament and associated fat allows better access to the cranial abdomen.
Figure 2: Evaluation of the small intestine during an exploratory.
3. Begin exploration as soon as the linea is incised. Note the appearance of the abdomen, the presence and character of fluid, organ positions, gut motility and the integrity of the peritoneal wall and diaphragm. Traditionally, the abdomen is explored cranially to caudally, but the order of exploration doesn't really matter as long as you use a systematic approach and do it the same way every time. Look at and feel everything (Figures 1-3). And be sure to evaluate the entire abdomen before addressing any problems you identify. Good technique and tissue handling throughout the procedure are a must.
Figure 3: A laparoscopic exploratory evaluating the kidney, intestine, liver and adrenal gland.
4. Complete your plan once the entire abdomen has been evaluated. Isolate the area of interest with moistened laparotomy sponges, particularly if entering a lumen. Use stay sutures, atraumatic retractors, clamps and forceps to minimize tissue damage. Use appropriate suture materials—ideally, in most cases, this involves monofilament, absorbable sutures on small taper needles. Biopsies are indicated for any abnormalities noted (e.g., thickened bowel, lymphadenopathy, lesions or nodules on the liver or spleen) (Figure 4). Organs commonly biopsied, indications for biopsy, general rules of thumb and basic techniques regarding biopsies are listed in Table 1. Local lavage of the surgical site or, if warranted, lavage of the entire abdomen with warm, sterile saline solution can be done at the end of the procedure. Evacuate as much fluid as possible from the abdomen, and perform sponge and instrument counts before closure.
Figure 4: A liver biopsy sample being obtained via laparoscopy.
5. Close the abdomen by using the external fascia of the rectus abdominis, not the muscle or subcutaneous fat. A local block using bupivacaine can be performed along the linea for additional analgesia. Then perform standard subcutaneous and skin closures. To ensure a good recovery, administer appropriate analgesia, heat support and supportive care.
Table 1: Guidelines for biopsy of organs during abdominal exploratory
Abdominal exploratory is a useful therapeutic and diagnostic tool when done appropriately. Even if you have a plan going into surgery, be prepared for surprises and be ready able to adapt your plan to address the findings. Never leave the abdomen without doing something—there should never truly be a negative exploratory.
Dr. Janice Buback is a surgeon with Lakeshore Veterinary Specialists in Port Washington, Glendale and Oak Creek, Wis. She and her family, including Angus and Pinot (a.k.a. "Steak and Wine"), enjoy working and playing in southeast Wisconsin.