Summary of pig lab Contents: Clipping Scrub.

Prepare table Position animal Draping patient Opening abdomen Exploration Gastronomy: Opening stomach; closing stomach. Enterotomy: Opening small intestine; Closing small intestine Enterectomy: Transecting Small intestine; Resecting small intestine Closing abdomen Clipping: Caudal thorax to inguinal area, at least 5 cm lateral to mammalry glands. Vacuum. Scrub: Scrub first, alcohol 2nd (perpendicular method), disinfectant finally, then spray. Work proximal to distal from incision area. Prepare table: Assistant opens autoclaved packages on table, from gown to drapes to instrument pack, leaving the last tab for the surgeon to open aseptically. Assistant also opens mayo cover on mayo tray. Scrubbed surgeon should be waiting in aseptic field, hands up in front. Suregoen uses gloved hands inside mayo cover to apply to the mayo stand, turning so aseptic inside is out. Instruments and drapes should be put on tray and arranged. Position animal: Forelimbs: Loop ropes around above and below carpus, pass rope under shoulders, loop around opposite carpus, tightening flattened forelimb (flexed shoulders) against torso. Hindlimbs: loop rope above and below carpus, extend and abduct hindlimb caudally. Draping patient: As we have been shown in pracs. Roll straight drapes over hand to prevent gloves touching the client, and thus position drapes. Never drag drapes towards the incised area. Bend forward at waist to avoid dragging gown on septic patient skin. Apply straight drapes in a rectangle, then apply towel clamps at each corner, including both joining towel s and skin. Apply fenestrated window drape over all drapes, leaving incision area bare. Apply by putting fold over incised area, and laying down one then other side. Towel clamp if needed, (ie steep chest etc). Adjust table height if required. Opening abdomen:

First Incision: Apply scalpel blade (#10) with needle holder. Tense skin with non-dominant hand, hold scalpel in fingertip grip in dominant hand, make one straight careful incision down midline through skin to subcut fat. Swab to halt hemorrhage. Subcut incision: deepen incision along midline with scalpel, either hold with fingertip or pencil grip for more control. Linea alba: Aim for linea alba, elevate external rectal sheath with forceps, pierce with reversed scalpel blade, extend cut slightly with mayos (concave towards self). Use finger to remove adhesions/separate viscera from incision area. Extend incision through linea alba (inc. External rectal sheath, surrounding muscle, internal rectal sheath. Peritoneum: Pigs have a separate peritoneum padded with fat. Lift with forceps, create cut with Mayos, and extend cut as per linea alba above. Exploration: Take time to visualize. Locate: Omentum, smaller than dog/cat but same positioning, use to find spleen Spleen (can only be partially externalized in pigs), return to left side, Spiral colon, unique in omnivorous pigs. Should be in center of incision. Small intestine, cranial to spiral colon, usually mostly empty. Stomach, should be below omentum, visible at cranial end of incision. Push omentum aside, elevate stomach carefully into view. Gastronomy: Opening stomach: Stay suture stomach: take single bite of full-thickness stomach wall (2.0 suture) at either end of incision area. Leave long tails (>6cm) to apply tension to with mosquito forceps to hold stomach in position for incision. Elevate stomach and pack around with sterile swabs, protecting abdomen from stomach contents.. Aim incision on stomach mid-body along long axis, where blood vessels smaller. Incise muscular stomach wall with belly and tip of scalpel (pencil grip). Muscular layer should separate readily from underlying intact mucosa. Incise mucosa by lifting with forceps and incising with belly-up scalpel (pencil grip). Stomach should deflate with gas release. If stomach has contents remove quickly to avoid contamination (Swabs, pipette, syringe?) Closing stomach: Close mucosal layer first, use simple continuous pattern, with synthetic 3.0 monofilament absorbable suaged needle sutures. Angle needle through tissue to minimize the amount of suture exposed to the lumen, with bites emerging just distal to the mucosa surface, (ie emerging IN cut, not full thickness). Use >3 throws to finish the pattern, cut tails short to ~2mm. Use moistened gauze to prevent gastric content wound contamination, and apply gentle traction to suture thread to slightly raise incision as stiching. Minimal haemorraghe should occur if incision correctly positioned; swab, apply pressure.

Close seromuscular layer with Lembert pattern(interrupted/continuous) or Cushing pattern (~continuous). Began pattern prior to cut commissure with an intro knot as per simple interrupted, end just after with a transverse bite and loop knot. Lembert: Take bite in and out perpendicular of one side of incision, emerging several mm from incision edge. Cross incision perpendicular, take a bite proximal to distal perpendicular to incision edge. Run stich diagonally over incision, pull taut, repeat for next stich. Cushing: Basically a continuous parallel mattress stich. Begin with simple interrupted knot, bite parallel (~1cm from) to incision, run stich perpendicular over incision, take bite parallel on opposite side, pull taut, run stich over incision and repeat. Ensure all is nice neat right angles. Thread should be just taught enough to create even edge inversion. To aid inversion, push muscular layer down with needle holders. Trim tail <5mm, check inversion, lavage with saline to ensure all is clean. Remove stay sutures, swabs, and replace stomach. Enterotomy Select section of small intestine, assistant should milk chime and gently apply traction and occlude intestine above and below incision area to prevent intestinal content contact with incision. Opening small intestine: incision to be made along antimesenteric border of bowel to avoid blood supply, (and distal to obstruction in healthy tissue). Use pencil-grip 10 scalpel tip to incise full width of intestine wall ~3 cm long, parallel with direction of intestine. Muscular layer will invert. Closing small intestine: Single layer Connell inversion pattern, (continuous parallel mattress, ~5mm bites) through full with of intestine wall, inc muscle, submucosia and fascia layer (same as cushings but full depth.) Ensure tissue inversion by pushing edge into lumen as loops are tensioned for full serosal contact. Do not grasp tissue with any forceps, use suture to raise/traction intestine, or apply adson forceps to inside of lumen and stretch outwards for access. Connell will unfortunately decrease lumen diameter, hence appositional stiches often preferred in small animal surgery. Finish with loop knot. Enterectomy Choose incision sites incision close to arched large mesenteric vessels on either side of the previous gastronomy incision to maximize blood supply for healing.

Transecting Small intestine: Vessels supplying part of bowel to be resected should be clamped and ligated.

Place Carmalt forceps at acut angle to maximse lumen, angling more acutely on smaller side if part of the intestine has been stretched. The surgical assistant should gently occlude bowel as above, and rotate anastomoses as surgeon sutures. Transect bowel with scalpel against viable side of clamp, discard bowel and Carmalt forceps. Bowel anastomoses to be stiched with simple interrupted appositional pattern. Mucosal eversion is generally less severe than in enterotomy dogs, which may require trimming. Resecting small intestine: First stich should be placed at mesenteric border, second should be at anitmesenteric border, positioning bowel for resection and dividing in half. Stiches should then be placed ~ 3mm apart, requiring ~10-12 sutures total to complete. Ensure suture bites roll mucosa inwards, by entering tissue 3-4 from cut edge, angling to exit at or close to cut edge, ensuring tough sub mucosa is included, crossing the incision internally, then entering tissue at cut edge, and exiting 3-4mm from edge, and tensioning and tying knot (double throw, then >3 single throws). Tension will then ensure correct mucosal inversion and apposition of matching layers. Fine rat-tooth forceps can be used to gently roll tissue inwards for positioning stiches, but great care must be taken to not damage tissue or tear edge. Inspect resection for maintained lumen diameter, minimal mucosa visibility, and leaks by injecting saline into lumen. Apply more sutures if required. Close Mesenteric tear with simple continuous suture, avoiding remaining blood vessels. Closing abdomen Peritoneum is weak and will not hold sutures, identify this and do not include in sutures. Find Linea alba, or if missed, external rectal sheath for closing sutures. Close fascia with simple interrupted sutures, first surgeon knot ant >3 single throws. Sutures should be ~1cm apart, leaving tails of ~3-5mm. Use Adsons forceps to retract subcutaneous tissue only for visualization. Sweep finger under sutures prior closing fully to check for even depth, no accidental piercings/inclusions. Close sub-cut layer to apposition skin and remove dead space. Use continuous pattern on tissue adjacent to skin edge. Bury first knot by starting first bite deep-superficial, and placing upside-down suture to tie square knot. Run thread deep under knot to commissure to continue stich in a continuous mattress pattern in sub-cut tissue only. Finish pattern using a knot. Leaving last few stiches loose for visibility, run parallel bites superficial to and from commissure, then take two bites anchored in deep tissue. Carefully tighten all bar last loop, to tie square knot deep in tissue. Cut tails 1-2 mm long, and bite through skin to exit wound, and cut tail flush to skin. Close skin with simple interrupted sutures, leaving tails ~5mm, and suture width 7-10mm, 710 mm apart.