Dick White Referrals, SIX MILE BOTTOM, Newmarket, UK CB8 0UH

BASICS OF INTESTINAL SURGERY:

ANATOMY, PATHOPHYSIOLOGY, INSTRUMENTATION & SUTURING

D. White

ANATOMY
The small intestine extends from the pylorus to the caecum. The most fixed portion
of the small bowel is the distal duodenum, due mostly to the duodenocolic
ligamentous attachment to the descending colon. This anatomical landmark must be
recognized to allow proper exploration of the small intestine. The jejunum is the
major portion of the small lntestine with the ileum being only 6-20 centimeters in
length in most small animals.
The major blood supply to the small intestine is from the cranial mesenteric artery. A
portion of the proximal duodenum is supplied by the celiac artery and shares a
source of blood (pancreaticoduodenal) with the right lobe of the pancreas.
The wall of the small intestine comprises the mucosa, submucosa, muscularis and
the serosa. The submucosal layer provides blood vessels, lymphatics and nerves.
Importantly, it is also the "holding" layer which must be included in any suturing
technique that is used to re-appose tissue of the small intestine.

INSTRUMENTATION
Bowel surgery does not require major investment in instrumentation!
However some basic tools are essential and these include:
• Atraumatic (deBakey) thumb forceps
• Doyen bowel clamps
• Fine (Mayo) needle holders
 • Diathermy
• Suction
• Laparotomy towels
• Fine (4/0) monofilament suture material
An extremely useful (but very expensive!) instrument that has recently become
available is the Ligasure (Valleylab Inc®) system that permits rapid vascular
coagulation of mesenteric vessels.

CHEMOPROPHYLAXIS

INTESTINAL VIABILITY
An assessment of bowel viability can be very difficult; bowel that appears normal
during surgery may later become non-viable and cause failure of an anastomosis.
The standard clinical criteria used for bowel viability assessment include:
• colour
• peristaltic motility
• arterial pulsations
When the amount of bowel to be resected is in question, then more should be
removed. Evaluation of appearance and motility the blue-black colour and flaccid
texture allows the surgeon a fair amount of accuracy when predicting bowel viability.
Examples of this type of venous occlusion include intussusceptions, intestinal
volvulus or strangulated hernias. Some techniques have been investigated to
increase the accuracy of determining bowel viability with a view to eliminating
unnecessary intestinal resection or the return of compromised bowel to the
peritoneal cavity. These include:
• Doppler ultrasound
• Thermistor thermometry
• Intravenous fluorescein
However, investigations show that clinical examination is at least as effective as
other techniques for assessing bowel viability.
PRINCIPLES OF INTESTINAL ANASTOMOSIS
Suture materials: today, most surgeons prefer to use a synthetic monofilament
suture material that reduces frictional damage during suturing and limits the
inflammatory reaction at the repair site.
Suture needles: classically, round bodied needles have been used to prevent
tearing of the intestinal wall that occurs with cutting needles. In practice, this leads to
poor penetration of the bowel wall and hence most surgeons prefer a taper-cut
needle that avoids both problems.
Suture patterns: The type of suture pattern used for bowel incisions (enterotomy,
end-to-end anastomosis) in the dog and cat is probably best limited to a simple
approximating type of suture pattern - the simple interrupted appositional (SIA) type.
The SIA is a non-crushing technique that causes less tissue ischemia at an
anastomotic site for the first week. This method is technically simple and
recommended for general use in all anastomoses in small animals. The crushing
technique, although causing more ischaemia than the SIA, allows quicker
regeneration of mucosa over the incision and less scar formation. Bursting pressure
studies and histopathological evaluation of the crushing method and SIA techniques
were similar. An alternate method would be the use of a continuous pattern. The
continuous approximating suture pattern will cause less mucosal eversion and
postoperative peritoneal adhesions than the interrupted patterns. It also produces
precise apposition of the submucosal layer between sutures. Regardless of the
suture pattern chosen for use in the intestine of the small animal, meticulous care is
of paramount importance when placing sutures through this delicate tissue.
Disruption of the vascular supply is probably the most common biological factor
responsible for failure. Failures are almost always due to faulty surgical technique.

CORRECTION OF LUMINAL DISPARITY

Luminal disparity will sometimes accompany resection of bowel. Correction of
almost all disparities can be accomplished by suture spacing techniques alone.
Other techniques including: cutting the smaller diameter loop of bowel at an angle,
'fish mouthing', partial closure of the larger bowel opening or end-to-side or end-to-
end are rarely if ever really necessary.

SEROSAL & OMENTAL PATCHING

The omentum is capable of sealing off infection, perforations and revascularizing
compromised gut. The surgeon should take advantage of these characteristics in
gastrointestinal surgery by using omentum to wrap an anastomotic site or an
enterotomy incision. This helps protect against suture line failure by decreasing the
possibility of leakage or infection and by bringing in an additional source of blood
vessels.
The serosal surface of a loop of bowel can likewise be used to patch leaking areas
of bowel or to reinforce suture lines involving stomach or bowel. It has been
successfully employed in veterinary medicine in some animals where omental
patching or wrapping had failed.

PATHOPHYSIOLOGY
OBSTRUCTION OF THE SMALL INTESTINE
Bowel obstruction in the dog or cat is the most common indication for surgical
intervention involving the gastrointestinal tract.
The obstruction is classified as:
• simple (mechanical or functional)
• strangulated.
Simple obstructions can be:
• high (proximal) and involve the pylorus, duodenum and the proximal jejunum.
A high obstruction is usually considered to be associated with higher mortality
rates.
• low (distal) small bowel obstruction involves the lower one-half of jejunum and
ileum.
The severity of the obstruction is further modified by whether it is a partial or
complete obstruction. Causes of small bowel obstruction can be due to foreign
bodies, intussusceptions, tumours (lymphoma, annular adenocarcinoma), strictures,
abscesses or rarely adhesions.

DISCRETE FOREIGN BODIES

Simple obstruction results in distension of the bowel proximal to the obstruction
causing fluid and gas accumulation. The content of the fluid will depend upon the
location of the obstruction.
High: If the obstruction is proximal to the pylorus, then hydrogen ion loss will likely
predominate resulting in a metabolic alkalosis. Hypokalaemia often accompanies
this acid-base disturbance. Vomiting due to obstructions below the pancreatic and
biliary ducts will result in a much greater volume of fluid loss. This fluid will have a
significant amount of bicarbonate ion present in it contributing to a metabolic acidotic
state. Fluid loss can be rapid and severe due not only to vomiting but also to the
inability of the fluid collecting proximal to the obstruction to pass distally into the
intestine where absorption can take place. The fluid loss from vomiting and
decreased absorption can result in clinical signs ranging from dehydration to
hypovolaemic shock. The latter can result in metabolic acidosis due to lactic
acidosis. The rise in intraluminal pressures associated with a high obstruction is
minimal but the intramural pressure is great.
Low: obstructions involving the distal jejunum or ileum cause less severe systemic
effects. Vomiting is an uncommon sign and when it occurs it is intermittent. Fluid and
electrolyte loss is much less initially but if allowed to become chronic, these losses
can become significant. Low bowel obstruction is not often associated with vomiting.
If vomiting does occur, it is intermittent with fluid and electrolyte loss being minimal.
If the obstruction persists for weeks, the animal will eventually become anorectic,
lose weight, and eventually die from starvation. Distension of the intestinal wall is
less severe in distal obstructions and as a result circulation of the affected portion of
gut is not impeded.
The blood supply to the segment of intestine undergoing distension may be
so severely compromised that blood is shunted away from intestinal capillaries and
into arteriovenous anastomoses. Ulceration and pressure necrosis of the bowel can
also occur from the physical presence of a large foreign body. The result is hypoxia
to the bowel, loss of viability, and increased permeability to toxins, including
endotoxins. The duodenum is more sensitive to the circulatory changes associated
with distension. Thus the need for earlier surgical intervention in a high obstruction is
apparent when distension is a significant entity.

LINEAR FOREIGN BODIES

Linear intestinal foreign bodies may be seen in both the dog and cat. Thread and
needle foreign bodies or strings are seen in the cat with greatest frequency. In one
study, the mean age of cats with thread and needle foreign body was 2.7 years. In
the vast majority of these cases, thread is most often found (90%) with a needle
involved in less than 10% of the cases. The linear foreign body usually starts as a
partial obstruction. Its continued presence in the bowel, however, can cause large
sections of the bowel to become non-functional and essentially become completely
obstructed. The pathogenesis of linear foreign body obstruction requires that the
object become fixed somewhere cranial in the digestive tract (see diagram). The
object is either looped around the base of the tongue or trapped at the pylorus.
Normal smooth muscle contraction of the small intestine continues to propel the
object aborally but due to its fixation, it will damage the mesenteric border of the
bowel through which the string passes. Continuation of peristalsis against the
pressure of the fixed linear object will eventually result in a perforation of the gut with
leakage and peritonitis quickly following. When lacerations occur, mortality increases
dramatically.

INTUSSUSCEPTION
Intussusception is an invagination of a portion of the gastrointestinal tract into a
posterior or preceding segment of intestine. Intussusception occurs more frequently
in the dog than the cat. This disease is most often seen in the young dog or cat and
the location is usually near the ileocolic valve. It is though to occur due to the
vigorous contraction of a segment of intestine into the lumen of the adjacent relaxed
segment. The invaginated portion of intestine is called the intussusceptum and the
portion into which this segment invaginates is called the intussuscipiens.
The blood supply to the intussuscepted piece of gut is compromised due to its
inclusion in the invagination. Initially, venous occlusion is present resulting in edema
of the bowel and, if prolonged, can eventually cause arterial occlusion and necrosis.
Eventually, fibrinous adhesions can form making spontaneous or surgical reduction
of the intussusception less likely.

STRANGULATION
Strangulation of the bowel is a much more severe form of obstruction. Luminal
blockage as such is not always present, but the blood supply to a segment of bowel
is severely compromised. Strangulation should always be considered in cases of
suspected bowel obstruction when the clinical signs are more severe than those
usually associated with a simple mechanical obstruction. Partial or total obstruction
of the venous drainage of a segment of bowel is most often seen in cats related to
intussusception or strangulated hernias. An intact arterial supply allows the
intramural sequestration of blood and eventually bowel wall edema. Proximal to the
strangulation, the bowel will distend and become filled with gas and fluid. The fluid in
a strangulated obstruction will have a significant amount of blood in it. If the
strangulation continues, the bowel wall will become nonviable and necrotic allowing
the transmural migration of toxins and bacteria. Fluid and blood loss combined with
the peritoneal absorption of these bacteria and toxic substances will eventually lead
to hypovolaemia and endotoxic shock and death if left untreated.
CORRESPONDING AUTHOR
Professor Dick White
BVetMed PhD DSAS DVR FRCVS, Diplomate, ACVS Diplomate, ECVS
Dick White Referrals
SIX MILE BOTTOM
Newmarket
UK CB8 0UH
E-Mail: [email protected]