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Abdominocentesis,
Diagnostic Peritoneal Lavage
anddEExploratory
l L
Laparotomy
(celiotomy), in Small Animals
Abdominocentesis
• Yields useful information in cases of abdominal injury,
peritonitis or ascites
p
• Physical and radiographic examinations should proceed
abdominocentesis
• Cytologic, microbiologic and biochemical examination
of aspirated fluid may help to establish the diagnosis
• Diagnostic peritoneal lavage (using a dialysis catheter) is
the most reliable and accurate method for earlyy
detection of the intraabdominal injuries
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Indications
• Intraabdominal injuries following blunt trauma
andd penetration
i off the
h abdominal
bd i l cavity i
• Shock without apparent cause
• Sever thoracic trauma
• Determining the cause of pain
• Sign of disease involving peritoneal cavity
• Suspicion of postoperative GI dehiscence
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Diagnosis
• Microscopic examination of the aspirate’s
sediment: detection of injury to the viscus
• Cytologic examination: abdominal neoplasia
• Chemical analysis: biliary tract injuries (bilirubin
test), pancreatitis (amylase activity), urinary tract
injuries (creatinine and Urea concentration),
perforation
f i off smallll intestine
i i (Alkaline
(Alk li
phosphatase), significant liver trauma (Glutamic-
pyruvic transaminase)
Catheter placement
• Preparation of the skin 2 cm caudal to the umblicus,
local anethesia containing epinephrine
• A 3 mm incision is made through the skin
• The bladder should be emptied
• Left lateral recumbency
• Insertion of catheter with the aid of a metal stylet
• If organ enlargement or adhesion is suspected: dorsal
recumbency and insertion of catheter with direct
visualization
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Timing
• Surgery should be timed to maximize the
potential for diagnostic and therapeutic success
while minimizing patient insult.
• Diagnostic peritoneal lavage is useful in
abdominal trauma cases
• There are no absolute rules to guide the surgeon
• It should be performed when the patient is not
responding sufficiently to therapy
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Technical consideration
• Preparation:
Patient preparation should maximize surgical
options
An incompletely prepared ventral abdomen is
no excuse for in complete surgical evaluation
Surgical Approaches
• Ventral midline
– Th
The incision
i i i should
h ld extend
t d from
f the
th xiphoid
i h id process to
t
immediately cranial to the pelvis
• Paracostal extension of a midline incision
• Paracostal
– incision begins at the xiphoid process, continues parallel and
three to four cm caudal to one costal arch,
arch and extends to a
point level with the end of the last rib
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Views of the abdomen of the dog showing the common sites for
incision
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Equipment Needed
• A standard soft tissue surgical pack
• Noncrushing intestinal forceps
• Electrocautery device
• Vascular tourniquet
• Intestinal forceps
Surgical technique
• Exploratory laparotomy techniques are
essentially the same regardless of the clinical
signs of the patient
• After entry into the peritoneal cavity,
microbiologic samples of peritoneal fluid are
collected
• Isolation and control of serious hemorrhage and
active ggastrointestinal leakage
g should be the first
step
• A thorough, systematic exploration of the
abdomen, size, shape, location, consistency,
surface contour
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Ventral view of dog after removal of ventral abdominal wall and the
greater omentum
Ventral view of dog after the removal of the ventral body wall, stomach and
intestines
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Biopsy techniques
• During exploratory laparotomy, gross evaluation
andd interpretation
i i alone
l often
f do d not provide
id a
definitive diagnosis
• Frequently: Liver, intestines, lymph nodes,
kidneys, prostate gland
• Less commonly: stomach,
stomach spleen,
spleen urinary
bladder, grater omentum
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Liver
• Finger of instrument fragmentation technique
• Wedge resection technique: two rows of full-
thickness horizontal mattress suture
• Use of cutaneous punch: hemostasis is achieved
by inserting a topical hemostatic agent or
omentum
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Small intestine
• Obtain full-thickness intestinal wall sample
• Incision
I i i transverse to the h mesentery
• The biopsy incision should not exceed 20% of
the intestinal circumference
• The incision is closed in a single layer using
appositional suture pattern with synthetic
absorbable or monofilament nonabsorbable
suture material
• Protection by greater omentum
Lymph nodes
• Fine-needle aspiration technique: cytological
evaluation
l i
• Excisional biopsies: morphologic interpretation
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Other tissues
• An elliptical section of gastric wall from one side
off the
h gastrotomy woundd edged
• Partial splenectomy
• Partial pancreatectomy
• Urinary bladder biopsies after cystotomy
• Excising a section of omentum
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Therapeutic intervention
• Hemorrhage control
• Correction of the source or sources of
contamination and pain
• Removal of mass lesions or intestinal
obstructions
• Elimination
Eli i ti off abnormalities
b liti
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Wound closure
• Sutures are placed approximately 3 to 10 mm from the
wound edge
• The sutures should only incorporate the linea alba and
external sheath of the rectus abdominis muscle
• Closure of a paramedian approach( 5 mm lateral to the
linea alba) is accomplished by suturing the external
sheath only
• Closure of the internal sheath of the rectus abdominis
is unnecessary
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