The caudal abdomen. Small animal surgery

THE VETERINARY PUBLISHING COMPANY SMALL ANIMALS

The caudal abdomen Small animal surgery

Aimed at veterinary surgeons, students, teachers and other professionals in the veterinary sector

TECHNICAL DETAILS Authors: José Rodríguez Gómez,

This work explains, step by step, by means of high quality photographs, the approaches and resolution of the main surgical procedures in the caudal abdomen.

Format: 23 x 29.7 cm Number of pages: 440 Number of images: 1,000 Binding: hardcover ISBN: 978-84-92569-69-4 RRP: 99 e

It describes real clinical cases and the most appropriate surgical interventions for each of them. It is an essential work for both practicing professionals as well as surgery students.

María José Martínez Sañudo and Jaime Graus Morales.

Centro Empresarial El Trovador, planta 8, oficina I - Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza - España Tel.: 976 461 480 • Fax: 976 423 000 • pedidos@grupoasis.com • Grupo Asís Biomedia, S.L.

The veTerinary publishing company

The caudal abdomen. small animal surgery Table oF conTenTs hernias

ureters

Inguinal hernias

Hydroureter. Iatrogenic stenosis

Case 1 / Extra-abdominal pregnancy.

Ovariohysterectomy

Case 1 / Iatrogenic periureteral fibrosis

Case 2 / Repairing the inguinal hernia using a polypropylene mesh Traumatic hernias Closed traumatic hernia Open traumatic hernia. Evisceration

prostate Prostatic hypertrophy Prostatic and paraprostatic cysts Prostatitis. Prostatic abscesses Prostatic tumours

bladder Bladder uroliths

Case 2 / Periureteral fibrosis. Ureteral resection and end-to-end anastomosis Ectopic ureters Intramural ectopic ureter. Ureterocystostomy Case 1 / Intramural ectopic ureter Extramural ectopic ureter.

Neo-ureterocystostomy Case 1 / Extramural ectopic ureter Nephrectomy

uterus Caesarean section Case 1 / Caesarean section in a Bulldog bitch.

Hysterotomy

A single urolith in a female dog

Case 2 / Caesarean section in a case of foetal death. Hysterotomy

Multiple uroliths in a male dog with urethral obstruction

Case 3 / Caesarean section in a case of foetal death. Ovariohysterectomy

Mixed struvite / oxalate urolithiasis

Pyometra / Cystic endometrial hyperplasia

Cystine calculi in a cat

Case 1 / Pyometra

Bladder tumours

Case 2 / Pyometra / peritonitis

Papillomatosis. Partial cystectomy

Uterine neoplasia

Leiomyosarcoma. Radical cystectomy

Case 1 / Leiomyoma

Bladder reconstruction Ruptured bladder due to a car accident Ruptured bladder due to a high-rise fall (cat) Ruptured bladder due to urethral catheterisation and hydropropulsion Ruptured bladder. Iatrogenic cause

large intestine General principles Colotomy Ileocolostomy Case 1 / Coprostasis. Obstipation

Resection and reconstruction.

Gastrocystoplasty

Centro Empresarial El Trovador, planta 8, oficina I - Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza - España Tel.: 976 461 480 • Fax: 976 423 000 • pedidos@grupoasis.com • Grupo Asís Biomedia, S.L.

The veTerinary publishing company

Stenosis, neoplasias of the colon and rectum Case 1 / Rectal traction / eversion technique Case 2 / Transanal resection of the rectum Case 3 / Colectomy Case 4 / Rectal stenosis. Stent placement

small intestine General principles Enterotomy Enterectomy Enterectomy. Stapling Foreign bodies Non-linear foreign bodies Case 1 / Intestinal obstruction due to a peach stone Case 2 / Intestinal obstruction due to a stone Linear foreign bodies

general techniques Radiographic examination of the abdomen Abdominal ultrasonography Introduction to diagnostic ultrasonography Ultrasonography of the urinary tract Ultrasonography of the reproductive tract Ultrasonography of the digestive tract Ultrasound-guided fine-needle biopsies Diagnostic cytology Abdominal paracentesis, peritoneal lavage and dialysis Percutaneous bladder catheterisation Urohydropropulsion Laparotomy Ovariohysterectomy Ovariohysterectomy in the dog Ovariohysterectomy in the cat Ovariohysterectomy in the ferret

Case 1 / Obstruction due to an elastic net

Nephrectomy

Case 2 / Linear obstruction with multiple intestinal perforations

Cystotomy

Case 3 / Linear obstruction due to a sock

Force-feeding. Gastrostomy tube

Intestinal intussusception Case 1 / Intussusception secondary to parasitic enteritis

Omentalisation

general complications Postoperative complications of laparotomy

Case 2 / Intussusception secondary to an idiopathic digestive disorder

Incisional hernia / Wound breakdown

Intestinal volvulus. Mesenteric torsion

Short Bowel Syndrome (SBS)

Intestinal neoplasia

Ischaemic / reperfusion syndrome

Adhesions. Peritonitis. Abscesses

Case 1 / Acinar adenocarcinoma Case 2 / Leiomyosarcoma Abnormal bowel position Case 1 / Peritoneal-pericardial hernia Case 2 / Perforated umbilical hernia Case 3 / Intestinal strangulation

Centro Empresarial El Trovador, planta 8, oficina I - Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza - España Tel.: 976 461 480 • Fax: 976 423 000 • pedidos@grupoasis.com • Grupo Asís Biomedia, S.L.

Prostate

Diagram of the male genital tract

Arteries of the pelvic region in the male dog Right internal iliac a.

Right external iliac a.

Cat

Median sacral a.

Prostate

Prostatic hypertrophy

Bulbourethral gland

Cranial gluteal a.

Testis

Urethra

Glans

Vas deferens

Bladder

Lateral caudal a.

Aorta

Caudal gluteal a.

Caudal mesenteric a.

Internal pudendal a.

Prostate

Dog

Umbilical a.

Urethra

Ureter

Middle rectal a.

A. of penis

Bladder Anus

Vas deferens

Left colic a.

Prostatic and paraprostatic cysts

Bulbus glandis Urethral a.

Ventral perineal a.

Prostatic a.

Ureteral branch Urethra

Caudal vesical a.

Testis

Prostate

Rectum Cranial vesical a.

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39

Cranial rectal a.

Dorsal a. of penis

Urogenital system of the male dog

Bladder

Perineal region of the male dog

Bladder Ureter

Retrococcygeus m.

Round ligament of the bladder

Coccygeus m.

Vas deferens

Prostate

Ampulla of vas deferens

Levator ani m.

Urethra

External anal sphincter m.

Ilium Ischial tuberosity

Ischiourethralis m.

Ischiocavernosus m.

Prostatic tumours

Prostate

Pubis Internal obturator m.

Retractor penis m.

Prostatitis and prostatic abscesses

Internal obturator m.

Ischiourethral m.

Bulb of penis Retractor penis m.

Retractor penis m.

Bulb of penis covered by the bulbospongiosus m.

Bulbospongiosus m.

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Prostate

Diagram of the male genital tract

Arteries of the pelvic region in the male dog Right internal iliac a.

Right external iliac a.

Cat

Median sacral a.

Prostate

Prostatic hypertrophy

Bulbourethral gland

Cranial gluteal a.

Testis

Urethra

Glans

Vas deferens

Bladder

Lateral caudal a.

Aorta

Caudal gluteal a.

Caudal mesenteric a.

Internal pudendal a.

Prostate

Dog

Umbilical a.

Urethra

Ureter

Middle rectal a.

A. of penis

Bladder Anus

Vas deferens

Left colic a.

Prostatic and paraprostatic cysts

Bulbus glandis Urethral a.

Ventral perineal a.

Prostatic a.

Ureteral branch Urethra

Caudal vesical a.

Testis

Prostate

Rectum Cranial vesical a.

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39

Cranial rectal a.

Dorsal a. of penis

Urogenital system of the male dog

Bladder

Perineal region of the male dog

Bladder Ureter

Retrococcygeus m.

Round ligament of the bladder

Coccygeus m.

Vas deferens

Prostate

Ampulla of vas deferens

Levator ani m.

Urethra

External anal sphincter m.

Ilium Ischial tuberosity

Ischiourethralis m.

Ischiocavernosus m.

Prostatic tumours

Prostate

Pubis Internal obturator m.

Retractor penis m.

Prostatitis and prostatic abscesses

Internal obturator m.

Ischiourethral m.

Bulb of penis Retractor penis m.

Bulbospongiosus m.

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Retractor penis m.

Bulb of penis covered by the bulbospongiosus m.

The caudal abdomen Mixed struvite / oxalate urolith

Bladder / Bladder uroliths Jaime Graus. Mª José Martínez

“Cali”, a 9-year-old female Pug is presented with a clinical history of recurrent cystitis (fig. 1).

The patient presents with haematuria and polyuria. Due to the nervous disposition of the animal and the pain elicited by palpation of the bladder region, examination of the abdomen does not provide any conclusive information. Complementary diagnostic methods include radiography and ultrasonography, which reveal a single disc-shaped urolith (figs. 2, 3 y 4). Cystotomy is advised in order to extract the urolith (figs. 5-14).

Fig. 1. “Cali” during the initial consultation at the hospital.

Fig. 6. A stay suture is placed in the apex of the bladder, allowing easy and atraumatic manipulation of the bladder. The least vascularised area of the ventral side of the bladder is identified.

Fig. 7. After adequate isolation of the bladder, a first incision of the bladder wall is made with a scalpel blade. This is extended with scissors as needed to allow removal of the urolith.

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65

Fig. 2. Lateral abdominal radiograph revealing a single disc-shaped urolith.

Fig. 3. A further radiograph confirms the discoid form of the urolith. The difference in radiodensity between its core and periphery suggests a mixed composition.

Fig. 8. The stone is removed with forceps.

Fig. 4. This ultrasound image shows the measurements of the urolith and the characteristic shadow behind it.

Fig. 5. A caudal midline laparotomy is performed, sufficiently large to permit externalisation of the bladder. The image shows congestion of the bladder.

Fig. 9. Finally, the bladder is closed in the usual manner.

The first layer is closed using a Schmieden suture.

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The caudal abdomen Mixed struvite / oxalate urolith

Bladder / Bladder uroliths Jaime Graus. Mª José Martínez

“Cali”, a 9-year-old female Pug is presented with a clinical history of recurrent cystitis (fig. 1).

The patient presents with haematuria and polyuria. Due to the nervous disposition of the animal and the pain elicited by palpation of the bladder region, examination of the abdomen does not provide any conclusive information. Complementary diagnostic methods include radiography and ultrasonography, which reveal a single disc-shaped urolith (figs. 2, 3 y 4). Cystotomy is advised in order to extract the urolith (figs. 5-14).

Fig. 1. “Cali” during the initial consultation at the hospital.

Fig. 6. A stay suture is placed in the apex of the bladder, allowing easy and atraumatic manipulation of the bladder. The least vascularised area of the ventral side of the bladder is identified.

Fig. 7. After adequate isolation of the bladder, a first incision of the bladder wall is made with a scalpel blade. This is extended with scissors as needed to allow removal of the urolith.

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65

Fig. 2. Lateral abdominal radiograph revealing a single disc-shaped urolith.

Fig. 3. A further radiograph confirms the discoid form of the urolith. The difference in radiodensity between its core and periphery suggests a mixed composition.

Fig. 8. The stone is removed with forceps.

Fig. 4. This ultrasound image shows the measurements of the urolith and the characteristic shadow behind it.

Fig. 5. A caudal midline laparotomy is performed, sufficiently large to permit externalisation of the bladder. The image shows congestion of the bladder.

Fig. 9. Finally, the bladder is closed in the usual manner.

The first layer is closed using a Schmieden suture.

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The caudal abdomen

Bladder / Bladder reconstruction

Ruptured bladder due to a high-rise fall (cat)

Jaime Graus. Mª José Martínez

Technical difficulty

A 2-year-old, male domestic shorthair cat was presented after having fallen from the fourth floor of a building a few hours earlier. General examination leds to a provisional diagnosis of a ruptured bladder, which is confirmed by cystography (fig. 1).

See radiography of the bladder.

page 322

It is decided to perform a laparotomy to repair the ruptured bladder.

After preparing the patient in the usual manner, an incision is made with scissors through the midline, from the umbilicus to the pubis.

The bladder and surrounding tissues are located and the damage is assessed (figs. 2-4).

See laparotomy.

page 376

Fig. 3. The blood clot is removed, exposing the bladder wall.

Fig. 4. Using urethral catheterisation, the rupture of the bladder is located (arrow).

After removal of the blood clots, the bladder lesion is assessed. In this case, it is rather large (figs. 5-7).

One of the most common complications of the high-rise syndrome in cats is a ruptured bladder, and its integrity should always be checked in these patients.

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Fig. 1. Lateral radiograph of the abdomen showing leakage of the contrast medium from the bladder into the abdominal cavity.

Fig. 5. After removal of the last clots from the lesion, the borders of the bladder wound are clearly visible, as shown here.

Fig. 2. The bladder is completely empty and is surrounded by a large blood clot, preventing assessment of the lesion.

Fig. 6. The bladder rupture was larger than initially thought. Prior to suturing, all remaining necrotic tissue, clots and adhesions should be carefully removed.

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The caudal abdomen

Bladder / Bladder reconstruction

Ruptured bladder due to a high-rise fall (cat)

Jaime Graus. Mª José Martínez

Technical difficulty

A 2-year-old, male domestic shorthair cat was presented after having fallen from the fourth floor of a building a few hours earlier. General examination leds to a provisional diagnosis of a ruptured bladder, which is confirmed by cystography (fig. 1).

See radiography of the bladder.

page 322

It is decided to perform a laparotomy to repair the ruptured bladder.

After preparing the patient in the usual manner, an incision is made with scissors through the midline, from the umbilicus to the pubis.

The bladder and surrounding tissues are located and the damage is assessed (figs. 2-4).

See laparotomy.

page 376

Fig. 3. The blood clot is removed, exposing the bladder wall.

Fig. 4. Using urethral catheterisation, the rupture of the bladder is located (arrow).

After removal of the blood clots, the bladder lesion is assessed. In this case, it is rather large (figs. 5-7).

One of the most common complications of the high-rise syndrome in cats is a ruptured bladder, and its integrity should always be checked in these patients.

92

93

Fig. 1. Lateral radiograph of the abdomen showing leakage of the contrast medium from the bladder into the abdominal cavity.

Fig. 5. After removal of the last clots from the lesion, the borders of the bladder wound are clearly visible, as shown here.

Fig. 2. The bladder is completely empty and is surrounded by a large blood clot, preventing assessment of the lesion.

Fig. 6. The bladder rupture was larger than initially thought. Prior to suturing, all remaining necrotic tissue, clots and adhesions should be carefully removed.

Start

The caudal abdomen

Ureters / Hydroureter

Technique for ureteral end-to-end anastomosis

The distal part of the right ureter was closely adherant to the bladder and the fibrous tissue surrounding the ureter was so thick that identification of the ureter was not possible (fig. 4). It was therefore decided to cut the ureter proximally and distally to the fibrosis (fig. 5).

Dissection of the proximal ureter from the peritoneal wall allowed moving it in a distal direction thus preventing tension on the ureteral anastomosis.

The ureter was reconstructed with five simple sutures using 6/0 monofilament synthetic absorbable material (figs. 6 and 7).

2 ■■ Two

Ureteral sutures should be made with very fine material, while avoiding the placement of too many sutures.

When passing through one end of the ureteral anastomosis, care should be taken not to include the opposite wall in the suture.

traction sutures are placed on the cranial side of the anastomosis, about 120° apart (1 and 2)

3

■■ Between these two, a third suture is

1

placed (3).

2 p ■■ One

120

of the two traction sutures is tied (1) as well as the third suture (3).

3

d

■■ The

1 Fig. 4. The fibrous tissue surrounding the right ureter was very dense and strongly adherant to the bladder (grey arrow). The ureter could only be correctly dissected in the proximal (p) and distal (d) parts.

second traction suture (2) is not tied to allow better visibility of the anastomosis ends from the other side.

121

■■ The

ends of the traction sutures should be left long.

Fig. 5. As it was impossible to dissect the ureter from the fibrous area, it was decided to cut it and perform an anastomosis. The blue arrows indicate the proximal and distal ends of the severed ureter.

2 1

3

1 2

■■ Next,

Fig. 6. This image shows the first three sutures placed in the cranial side of the anastomosis. The suture on the left will be tied last, to allow correct visualisation of the posterior side of the anastomosis during suturing.

Fig. 7. Final appearance of the ureteral end-to-end anastomosis. This was followed by omentalisation to avoid adhesions and facilitate healing.

the ureter is rotated. To do so, the long ends of the first tension suture are passed underneath the ureter, while the ends of the second suture are passed over it. Pulling on the ends will turn the ureter and permit visualisation of the posterior side of the anastomosis.

Previous

3

4

5 ■■ The

second traction suture is left untied to allow good visualisation of the ureters.

■■ Two

further sutures are placed (4 and 5), taking care not to include any of the earlier sutures which would reduce the intraluminal space of the anastomosis.

Next

■■ After

tying off the sutures on the posterior side, the ureter is returned to its anatomical position and the second traction suture is tied (2), which concludes the anastomosis.

The caudal abdomen

Ureters / Hydroureter

Technique for ureteral end-to-end anastomosis

The distal part of the right ureter was closely adherant to the bladder and the fibrous tissue surrounding the ureter was so thick that identification of the ureter was not possible (fig. 4). It was therefore decided to cut the ureter proximally and distally to the fibrosis (fig. 5).

Dissection of the proximal ureter from the peritoneal wall allowed moving it in a distal direction thus preventing tension on the ureteral anastomosis.

The ureter was reconstructed with five simple sutures using 6/0 monofilament synthetic absorbable material (figs. 6 and 7).

2 ■■ Two

Ureteral sutures should be made with very fine material, while avoiding the placement of too many sutures.

When passing through one end of the ureteral anastomosis, care should be taken not to include the opposite wall in the suture.

traction sutures are placed on the cranial side of the anastomosis, about 120° apart (1 and 2)

3

■■ Between these two, a third suture is

1

placed (3).

2 p ■■ One

120

of the two traction sutures is tied (1) as well as the third suture (3).

3

d

■■ The

1 Fig. 4. The fibrous tissue surrounding the right ureter was very dense and strongly adherant to the bladder (grey arrow). The ureter could only be correctly dissected in the proximal (p) and distal (d) parts.

second traction suture (2) is not tied to allow better visibility of the anastomosis ends from the other side.

121

■■ The

ends of the traction sutures should be left long.

Fig. 5. As it was impossible to dissect the ureter from the fibrous area, it was decided to cut it and perform an anastomosis. The blue arrows indicate the proximal and distal ends of the severed ureter.

2 1

3

1 2

■■ Next,

Fig. 6. This image shows the first three sutures placed in the cranial side of the anastomosis. The suture on the left will be tied last, to allow correct visualisation of the posterior side of the anastomosis during suturing.

Fig. 7. Final appearance of the ureteral end-to-end anastomosis. This was followed by omentalisation to avoid adhesions and facilitate healing.

Start

3

4

the ureter is rotated. To do so, the long ends of the first tension suture are passed underneath the ureter, while the ends of the second suture are passed over it. Pulling on the ends will turn the ureter and permit visualisation of the posterior side of the anastomosis.

5 ■■ The

second traction suture is left untied to allow good visualisation of the ureters.

■■ Two

further sutures are placed (4 and 5), taking care not to include any of the earlier sutures which would reduce the intraluminal space of the anastomosis.

■■ After

tying off the sutures on the posterior side, the ureter is returned to its anatomical position and the second traction suture is tied (2), which concludes the anastomosis.

The caudal abdomen

General techniques / Diagnostic cytology

the presence of cells in a lymph node that do not belong to the lymphoid group may be sufficient to diagnose metastasis. Usually, tumour cells can be obtained when the metastasis has progressed sufficiently to cause enlargement of the lymph node. For this reason the clinical findings should always have priority over a negative cytological result in the diagnosis of adenomegaly. Carcinoma is the most common neoplasm in the lymph nodes (figs. 26 to 38).

â– â– Metastases:

Fig. 26. Lymph node. Metastasis of a transitional cell carcinoma of the bladder as

Fig. 31. Same case as fig. 30.

Fig. 32. Mesenteric lymph node. Presence of connective tissue cells with obvious

in fig. 10. Together with the scanty lymphoid cells, a population of epithelial cells with morphological characteristics that are similar to those described in fig. 10 can be seen.

atypia corresponding to the metastasis of an intestinal leimyosarcoma.

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357

Fig. 27. Lymph node. Metastasis of a transitional cell carcinoma of the bladder in

Fig. 28. Lymph node. Metastasis of a transitional cell carcinoma as in figs. 12

Fig. 33. Mesenteric lymph node of the same case as in fig. 32. A large atypical

Fig. 34. Iliac lymph node. A group of moderately atypical epithelial cells. Their

figs. 8 and 9. The morphological malignant characteristics are clearly visible.

and 13.

mesenchymal cell is visible.

presence in the lymph node is compatible with a cytological diagnosis of metastasis.

This case concerned a dog with an adenocarcinoma of the anal glands.

Fig. 29. Subiliac lymph node. Haphazard group of epithelial cells with an obvious

Fig. 30. Sample of the subiliac lymph node. Small group of atypical epithelial cells that correspond to metastasis from a mammary carcinoma.

Fig. 35. Lymph node of the same case as in fig. 34. Cellular atypia, or the signs of

Fig. 36. Lymph node. Metastasis of a transitional cell carcinoma.

variation in nuclear size. Their presence in a sample of an enlarged lymph node from a bitch that underwent surgery for a mammary carcinoma is compatible with metastasis.

malignancy, are more clearly visible.

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The caudal abdomen

General techniques / Diagnostic cytology

the presence of cells in a lymph node that do not belong to the lymphoid group may be sufficient to diagnose metastasis. Usually, tumour cells can be obtained when the metastasis has progressed sufficiently to cause enlargement of the lymph node. For this reason the clinical findings should always have priority over a negative cytological result in the diagnosis of adenomegaly. Carcinoma is the most common neoplasm in the lymph nodes (figs. 26 to 38).

â– â– Metastases:

Fig. 26. Lymph node. Metastasis of a transitional cell carcinoma of the bladder as

Fig. 31. Same case as fig. 30.

in fig. 10. Together with the scanty lymphoid cells, a population of epithelial cells with morphological characteristics that are similar to those described in fig. 10 can be seen.

Fig. 32. Mesenteric lymph node. Presence of connective tissue cells with obvious

atypia corresponding to the metastasis of an intestinal leimyosarcoma.

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357

Fig. 27. Lymph node. Metastasis of a transitional cell carcinoma of the bladder in

Fig. 28. Lymph node. Metastasis of a transitional cell carcinoma as in figs. 12

Fig. 33. Mesenteric lymph node of the same case as in fig. 32. A large atypical

Fig. 34. Iliac lymph node. A group of moderately atypical epithelial cells. Their

figs. 8 and 9. The morphological malignant characteristics are clearly visible.

and 13.

mesenchymal cell is visible.

presence in the lymph node is compatible with a cytological diagnosis of metastasis.

This case concerned a dog with an adenocarcinoma of the anal glands.

Fig. 29. Subiliac lymph node. Haphazard group of epithelial cells with an obvious

Fig. 30. Sample of the subiliac lymph node. Small group of atypical epithelial cells that correspond to metastasis from a mammary carcinoma.

Fig. 35. Lymph node of the same case as in fig. 34. Cellular atypia, or the signs of

Fig. 36. Lymph node. Metastasis of a transitional cell carcinoma.

variation in nuclear size. Their presence in a sample of an enlarged lymph node from a bitch that underwent surgery for a mammary carcinoma is compatible with metastasis.

Start

malignancy, are more clearly visible.

The caudal abdomen

General complications / Complications

Postoperative Complications complications of laparotomy

Seromas and haematomas Subcutaneous haemorrhage may leave blood clots that become organized into fibrous tissue.

Haematomas hamper healing, increase the risk of postoperative infection and contribute to suture dehiscence.

Seromas result from cell injuries in the subcutaneous tissue (fig. 2).

Amaya de Torre. José Rodríguez

Complications after a laparotomy may occur sooner or later, but their frequency should be minimised and they should be treated as efficiently as possible.

It is better to open the patient again and make sure that the haemorrhage is not internal than remain in doubt while the blood keeps seeping through the suture line.

Postoperative complications rarely occur if the surgery has been performed with care and the patient is healthy.

The surgeon’s experience is a very important factor.

Beginners have a higher incidence of complications.

Prevention ■■ Identify

Fig. 2. Seroma in a patient following ovariohysterectomy. The skin was closed with an intradermal absorbable suture.

any existing coagulation disorders before surgery.

■■ Determine

bleeding time, either by pricking a vein to obtain a blood sample, or by nicking the gums with the bevel of a needle.

Haemorrhage in the immediate postoperative period

418

The first complication that may appear after surgery is haemorrhage at the laparotomy site. And with this, the first question: where does the blood come from? From the subcutaneous vessels when blood pressure returns to normal after anaesthesia? Or from an internal ligature that may have slipped?

The surgeon should be confident that it is an external haemorrhage, because all the internal sutures and ligatures should have been perfectly placed. However, the situation should be monitored, because the haemorrhage could still be internal.

What to do?

■■ Keep

the intravenous catheter in place to administer any fluids that may be necessary: blood, lactated Ringer’s solution, etc.

■■ Determine ■■ Count

coagulation time in vitro.

A seroma or haematoma should not be mistaken for an abscess or an incisional hernia due to suture dehiscence.

the platelets.

■■ After

incising the skin, bleeding should be controlled in as many vessels of the subcutaneous tissue as possible, either by electrocoagulation (mono- or bipolar) or by haemostatic forceps with a ligature if necessary, depending on the diameter of the vessels.

■■ During

abdominal surgery, the surgeon should make absolutely certain that vessels will not bleed because of slipped ligatures (fig. 1) and that the sutures will not damage vascular structures or friable organs.

419

A

■■ Compress

the suture line to remove the accumulated blood and check if the bleeding continues.

Fig. 3. Aspiration of a seroma. Note the serohaemorrhagic appearance.

■■ If

bleeding continues, apply a compression bandage to the abdomen to inhibit the haemorrhage.

■■ Check

the patient’s haematocrit.

■■ Administer

procoagulants.

What to do?

Prevention

■■ Use

■■ Use

ultrasonography or radiography to ensure that there is no incisional hernia.

■■ If

the haemorrhage persists, the patient should be opened again to look for an internal source of the haemorrhage.

■■ The

B

contents should be aspirated, analysed and drained (fig. 3).

■■ If

the blood clot is large, it should be removed by external pressure on the skin sutures. Sometimes, it is necessary to remove one or two sutures in the centre of the suture line.

good surgical technique:

■■ Control

■■ Minimize

dissection of the subcutaneous tissue to reach the linea alba.

■■ Dissect

■■ Some seromas require repeated aspirations on consecutive days.

■■ Flush

■■ Hot compresses on the area speed up the resorption of seromas.

■■ Protect

A patient should never be left bleeding in the hospital cage.

Not even the slightest sign of haemorrhage should remain when the owner picks up his pet.

subcutaneous bleeding with mono- or bipolar electro-

cautery.

gently.

the subcutaneous tissue regularly with sterile saline.

the subcutaneous tissue with humid, sterile swabs and compresses to prevent it drying out.

■■ Apply

a compression bandage to the abdomen for 5 or 6 days and limit physical exercise.

Fig. 1. A) Correctly tied knot. B) Incorrectly tied knot. The material is more likely to break and, since it is a sliding knot, it is likely that it will slip and become untied.

Be as gentle as possible with the subcutaneous tissue. It will respond in kind.

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The caudal abdomen

General complications / Complications

Postoperative Complications complications of laparotomy

Seromas and haematomas Subcutaneous haemorrhage may leave blood clots that become organized into fibrous tissue.

Haematomas hamper healing, increase the risk of postoperative infection and contribute to suture dehiscence.

Seromas result from cell injuries in the subcutaneous tissue (fig. 2).

Amaya de Torre. José Rodríguez

Complications after a laparotomy may occur sooner or later, but their frequency should be minimised and they should be treated as efficiently as possible.

It is better to open the patient again and make sure that the haemorrhage is not internal than remain in doubt while the blood keeps seeping through the suture line.

Postoperative complications rarely occur if the surgery has been performed with care and the patient is healthy.

The surgeon’s experience is a very important factor.

Beginners have a higher incidence of complications.

Prevention ■■ Identify

Fig. 2. Seroma in a patient following ovariohysterectomy. The skin was closed with an intradermal absorbable suture.

any existing coagulation disorders before surgery.

■■ Determine

bleeding time, either by pricking a vein to obtain a blood sample, or by nicking the gums with the bevel of a needle.

Haemorrhage in the immediate postoperative period

418

The first complication that may appear after surgery is haemorrhage at the laparotomy site. And with this, the first question: where does the blood come from? From the subcutaneous vessels when blood pressure returns to normal after anaesthesia? Or from an internal ligature that may have slipped?

The surgeon should be confident that it is an external haemorrhage, because all the internal sutures and ligatures should have been perfectly placed. However, the situation should be monitored, because the haemorrhage could still be internal.

What to do?

■■ Keep

the intravenous catheter in place to administer any fluids that may be necessary: blood, lactated Ringer’s solution, etc.

■■ Determine ■■ Count

coagulation time in vitro.

A seroma or haematoma should not be mistaken for an abscess or an incisional hernia due to suture dehiscence.

the platelets.

■■ After

incising the skin, bleeding should be controlled in as many vessels of the subcutaneous tissue as possible, either by electrocoagulation (mono- or bipolar) or by haemostatic forceps with a ligature if necessary, depending on the diameter of the vessels.

■■ During

abdominal surgery, the surgeon should make absolutely certain that vessels will not bleed because of slipped ligatures (fig. 1) and that the sutures will not damage vascular structures or friable organs.

419

A

■■ Compress

the suture line to remove the accumulated blood and check if the bleeding continues.

Fig. 3. Aspiration of a seroma. Note the serohaemorrhagic appearance.

■■ If

bleeding continues, apply a compression bandage to the abdomen to inhibit the haemorrhage.

■■ Check

the patient’s haematocrit.

■■ Administer

procoagulants.

What to do?

Prevention

■■ Use

■■ Use

ultrasonography or radiography to ensure that there is no incisional hernia.

■■ If

the haemorrhage persists, the patient should be opened again to look for an internal source of the haemorrhage.

■■ The

contents should be aspirated, analysed and drained (fig. 3).

■■ If

the blood clot is large, it should be removed by external pressure on the skin sutures. Sometimes, it is necessary to remove one or two sutures in the centre of the suture line.

B

A patient should never be left bleeding in the hospital cage.

Not even the slightest sign of haemorrhage should remain when the owner picks up his pet.

good surgical technique:

■■ Control

subcutaneous bleeding with mono- or bipolar electro-

cautery.

■■ Minimize

dissection of the subcutaneous tissue to reach the linea alba.

■■ Dissect

■■ Some seromas require repeated aspirations on consecutive days.

■■ Flush

■■ Hot compresses on the area speed up the resorption of seromas.

■■ Protect

gently.

the subcutaneous tissue regularly with sterile saline.

the subcutaneous tissue with humid, sterile swabs and compresses to prevent it drying out.

■■ Apply

a compression bandage to the abdomen for 5 or 6 days and limit physical exercise.

Fig. 1. A) Correctly tied knot. B) Incorrectly tied knot. The material is more likely to break and, since it is a sliding knot, it is likely that it will slip and become untied.

Start

Be as gentle as possible with the subcutaneous tissue. It will respond in kind.