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SURGERY

Surgeryofthesmall
intestineindogsandcats
Part 1: surgical principles and surgical conditions: Patients with small intestinal
abnormalities are at risk for dehydration, acidbase and electrolyte imbalances, and should
be stabilised before surgery. During surgery, the bowel should be handled gently using
atraumatic instrumentation and suitable suture material. 10.12968/coan.2013.18.3.114

Daniela Murgia, DVM,DipECVS,MRCVS


AnimalHealthTrust,LanwadesPark,NewmarketCB87UU,Suffolk,UK

Key words: Smallintestineviability|Obstruction|Foreignbody|Intussusception

as the descending duodenum along the right side of the abdomen.


In dogs, the common bile duct opens at the major duodenal papilla
adjacent to the pancreatic duct. Two centimetres distally to the
major duodenal papilla, the accessory pancreatic duct (the main
excretion conduit for pancreatic secretions) enters the duodenum
at the minor duodenal papilla.
In cats, the common bile duct and the pancreatic duct en-
ter the duodenum together at the major duodenal papilla. Only
around 20% of cats have an accessory pancreatic duct entering
the duodenum at the minor duodenal papilla. The descending
duodenum turns at the level of the pelvic inlet moving from right
to left, forming the duodenal flexure and continues cranially as
the ascending duodenum. The duodenocolic ligament attaches
the ascending duodenum to the descending mesocolon. At the
level of the duodeno-jejunal flexure the intestine forms numerous
coils that constitute most of the intestinal length: the jejunum.
The terminal part of the small intestine, the ileum, is very short
Figure 1: Ileum with antimesenteric vessel and can be identified by the presence of the antimesenteric vessel

I
(Figure 1). The ileum opens in the ascending colon through the
ndications for small intestine surgery commonly in- ileo-colic orifice.
clude intestinal obstructions (foreign body and masses), The mesentery (the meso-jejuno-ileum) attaches the jejunum
intestinal perforations, ischaemia, intussusceptions, malpo- and ileum to the cranial sublumbar region by a short peritoneal
sitioning (volvulus) and the need for diagnostic or supportive attachment called the root of the mesentery. This includes the
procedures like biopsy and placement of feeding tubes. cranial mesenteric artery, intestinal lymphatic vessels and the me-
Amongst the surgical procedures, the surgeon often per- senteric nerve plexus.
forms enterotomies (incision of the intestinal wall), enterecto- Branches of the celiac artery and cranial mesenteric artery
mies (removal of an intestinal segment), intestinal anastomosis supply the small intestine. From the root of the mesentery, the
(re-establishment of continuity between two intestinal loops) and cranial mesenteric artery branches in vessels that course in the
intestinal plication (surgical fixation of one intestinal segment mesentery and anastomose with each other, forming a series
to another). of arcades from which short vasa recta extend directly into the
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intestinal wall.
Surgicalanatomy The wall of the small intestine is composed of four lay-
The small intestine is composed of duodenum, jejunum and il- ers: tunica mucosa, tunica submucosa, tunica muscularis and
eum. The duodenum is the less mobile small intestine segment. It tunica serosa. Villi of the mucosa increase the absorbing surface
begins at the pylorus at the right of midline and continues caudally and are separated by crypts. At this level the epithelial cells cover-

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Figure 2: Peyers patches

ing the villi are produced, pass up onto the villi and are shred from
the apex, with total replacement of the epithelium occurring every
2 to 6 days.
In dogs, it is often possible to identify small lymphoid islands
throughout the small intestine: the Peyers patches (Figure 2).
Blood and lymphatic vessels are located in the submucosal
layer. Blood vessels are also present in the subserosal plexus. The
intestinal tunica muscularis consists of a thin outer longitudinal
layer and a thicker inner circular layer. The Auer myoenteric plexus
is located between the circular and longitudinal layer, whereas the Figure 3a: Thoracic-abdominal staplers in three different lengths:
Meissner submucosal plexus is located within the tunica submu- 30 mm, 55 mm and 90 mm
cosa. The peritoneum represents the intestinal tunica serosa.

Surgicalgeneralprinciples
Instrumentation
Surgical instrumentation recommended to facilitate intestinal sur-
gery includes self-retaining abdominal retractors (e.g. Balfour or
Gosset) and Doyen non-crushing forceps. Crushing forceps can be
used to clamp the ends of the resected intestinal segment. Intesti-
nal tissue is fragile and should be handled gently with atraumatic
forceps (e.g. DeBakey or Adson). To promote asepsis and reduce
the contamination risk, instruments used during enterotomy or en-
terectomy have to be discarded after the procedure is completed.
Gloves change and postprocedural lavage after intestinal surgery is
always recommended. Moreover, it is advisable to use new instru-
ments before abdominal closure.

Suturematerialandsuturepatternforentericclosure
Although most absorbable suture materials can be used, mono-
filament synthetic suture like poliglecaprone-25 (MonocrylTM, Figure 3b: Gastrointestinal anastomosis stapler
Ethicon, Cincinnati, Ohio, USA) is preferred. It combines the
advantages of low tissue drag, easy handling and appropriate su- testinal closure, either continuous or interrupted patterns can be
ture duration. Long-lasting monofilament, absorbable, suture-like used with equal efficacy.
polydioxanone (PDS) or polygliconate (Maxon) or nonabsorbable Mechanical staplers, like GIA (gastrointestinal anastomosis
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suture like nylon or polypropylene should be selected for patients stapler) and TA (thoracic-abdominal stapler) (Figures 3a and 3b)
with low albumin levels. Monofilaments are less susceptible than are excellent choices for enteric anastomosis as they provide rapid
multifilaments to bacterial adhesion and allow easier clearance of procedural lead time; their use, however, is frequently limited
bacteria by the immune system. Cutting-tipped atraumatic nee- by cost and lack of familiarity. In cats and toy breeds, the size of
dles are recommended for intestinal surgery. For hand-sewn in- the GIA devices may be too large for the diameter of the bowel;

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submucosal apposition. Accurate submucosal apposition is im-


portant because it results in primary intestinal healing with rapid
mucosal reepithelialisation and with direct bridging of the defect.
Furthermore, an approximating pattern does not compromise the
lumen diameter. Inverting suture patterns may result in initial nar-
rowing of the intestinal lumen, whereas everting patterns are more
likely to cause adhesion formation (Ellison, 2011). Sutures should
not be tied too tight to reduce the risk of tissue ischaemia at the
suture line.
Autostapling lays an overlapping double/triple row of staples
(Figures 4 and 5), and when GIA and TA are used in combination,
create a functional end-to-end anastomosis. The GIA portion of
the anastomosis is inverted, and even though the portion of the
intestine sutured with a TA results everted, this does not seem to
Figure 4: TA staplers lay an overlapping double or triple row of staples cause significant clinical concerns in dogs and cats. An omental
patch over this area is always recommended to reduce the risk of
leakage. Circular stapling places a double, staggered, circular row
of staples and creates a stoma within the staples. The resulting
anastomosis is inverted.
The functional end-to-end intestinal anastomosis is preferred
to the EEA because it is easy and does not compromise the anas-
tomotic lumen. Moreover, the luminal disparity is not an issue in
this kind of anastomosis because the length of the GIA limbs ulti-
mately determines the size of the stoma.

Intestinalviability
An important aspect in small intestinal surgery is the assessment
of intestinal viability (Figure 6). Intraoperative criteria for estab-
lishing intestinal viability include intestinal wall colour, arterial
pulsations, presence of peristalsis and bleeding by incision. These
criteria are subjective. Decision-making in intestinal resection can
therefore be challenging because the amount of intestine that may
recover from an ischaemic insult can be either overestimated or
Figure 5: GIA staplers deploy staggered rows of staples and then incise tissue underestimated. Questionable areas of bowel should be pinched
between staples to determine whether muscle contraction and peristalsis are
present. This should be carried out gently with the fingers to avoid
therefore, the use of endoscopic stapler devices is recommended. any lesion to the bowel in case it was ischaemic or necrotic.
Circular stapling devices are designed to perform mainly end-to-
end anastomosis (EEA stapler) but require pre-placement of a
purse-string suture around the intestinal open stumps to secure
the bowel to the stapler, and an incision of the intestinal wall of
one of the two stumps for insertion. Use of EEA staplers has size
limitations in dogs and cats. Furthermore, they should not be used
when combined intestinal tissue thickness is less than 1 mm or
greater than 2.5 mm.
Skin staplers have been successfully used for closure of enter-
otomies or intestinal anastomosis. Despite their success, caution
is required when using a stapling device for applications it is not
designed for.
The connective submucosal tissue represents the supporting
intestinal skeleton and binds the mucosal and muscular layer
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together. The submucosal tunica is the holding layer of intes-


tine and therefore the layer that provides mechanical strength
and that must be engaged when suturing intestine to pro-
vide a secure closure. Single-layer intestinal closure and ap- Figure 6: Assessment of intestinal viability. Necrotic duodenal, jeju-
proximating suture patterns are preferred as this allows better nal and ilial intestinal loops following a mesenteric volvulus

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Figure 7: Intraluminal intestinal complete foreign body


obstruction. Proximal to the obstruction, the intestinal loop ap-
pears distended and congested. The intestinal wall shows some
degree of ischaemia at the level of the foreign body. Figure 8: Intestinal foreign body necrosis and perforation with severe
Distal to the obstruction, the intestine appears normal septic peritonitis

In experimental models, clinical factors such as vascular pulsa-


tion, intestinal colour or the presence of intestinal contractions did
not correlate with the severity of the intestinal damage or with the
survival of the animal (Freeman et al, 1988). Surgeons can there-
fore be misled by intramural haemorrhage or oedema, for example,
and overestimate the extent of the intestinal segment to remove.
Subjective assessment of intestinal vitality is still a well recom-
mended and helpful decision-making modality and, fortunately,
overzealous intestinal resection is rarely detrimental.

Smallintestinesurgicalconditions
Clinical signs of small intestine disease are non-specific and in-
clude vomiting, anorexia, abdominal pain (acute abdomen), de-
pression and shock.

Intestinalobstruction
Intestinal obstruction can be simple or strangulating and, depend- Figure 9: Linear foreign body anchored around the base of the tongue in a
ing on the degree of obstruction, it can be partial or complete. young cat
Furthermore, the obstruction can be intraluminal (when a foreign
body occludes the bowel lumen), intraparietal (in case of neoplas- oedema (Figure 7). Distension causes an increase of the myoelec-
tic changes of the intestinal wall or benign stricture) or extralumi- tric activity of the intestine proximal to the obstruction and a si-
nal (in case of pathologic processes in the peritoneal cavity involv- multaneous decrease distally. When the obstruction is prolonged,
ing the gut secondarily) (Papazoglou et al, 2003). periods of absent motor activity interrupt the intense myoelectric
activity as a protective mechanism. This happens because unin-
Intestinalforeignbodies hibited hyperperistalsis may result in muscular exhaustion, ischae-
Intestinal foreign bodies may cause obstruction, which can be par- mia and intestinal wall rupture.
tial or complete depending on the relative size of the foreign body. As a result of stasis, the intraluminal toxins and pathogenic bac-
Complete intestinal obstructions are characterised by a gradual terial population increase and due to impairment of the enteric
increase of intraluminal pressure and luminal distension proximal mucosal barrier they enter into the systemic circulation or into
to the foreign body due to accumulation of gas and fluids. Gas the peritoneal cavity, resulting in endotoxic shock or peritonitis
accumulates from swallowed air, organic gas from bacterial fer- (Figure 8).
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mentation and carbon dioxide formed from intestinal bicarbonate Clinical signs associated with small intestinal obstruction
neutralisation. Furthermore, fluids accumulate from retention of vary with the location, duration and severity of the obstruction.
ingested liquids and gastrointestinal secretions such as saliva, bile, Vomiting, anorexia and depression are common. Vomiting may
gastric, pancreatic and small intestinal secretions. Luminal disten- be frequent and projectile with proximal and complete obstruc-
sion causes capillary bed congestion and leads to intestinal wall tions, or more sporadic and less profuse with distal or partial ob-

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tussusceptions) whereas indirect or retrograde intussusceptions


occur against the direction of intestinal peristalsis. Invaginations
can be single or multiple and can involve any area along the intes-
tinal tract. Clinical signs are those of bowel obstruction, includ-
ing vomiting, depression, anorexia and diarrhoea. Compromise of
the venous return in the presence of an intact arterial circulation
results in intramural haemorrhage, loss of blood into the intesti-
nal lumen and subsequent bloody diarrhoea. Intussusception may
progress to a point where the small intestine protrudes from the
anus. This is easily differentiated from rectal prolapse by passage
of a probe between the prolapsed segment and the rectum. The
condition can be associated with enteritis secondary to parasites,
viruses, linear foreign body and intestinal neoplasia. (Applewhite
et al, 2002). Recently, a review of histological examinations of the
intestine from dogs and cats with intussusception revealed that
most cats have underlying neoplasia and dogs are more likely to
have intestinal inflammatory disease (Levien and Baines, 2011).
Figure 10: Small intestinal invagination in a cat with mesenteric lymphadenopa- Examination of affected patients demonstrates a cylindrical
thy mass during abdominal palpation. The characteristic ultrasono-
graphic appearance of intussusception is a series of concen-
structions. The foreign body or a mass can be identified on gentle tric rings in the transverse plane (target sign) (Figure 11a) and
abdominal palpation. multiple parallel lines in the longitudinal plane (Figure 11b).
Intestinal linear foreign bodies (LFB) are more commonly re-
ported in cats than in dogs. The clinical, radiological and surgical
presentation is unique. In cats, the foreign body usually anchors
itself around the base of the tongue (Figure 9), whereas in dogs it
is entrapped in the pylorus, and when peristaltic waves continue to
move the free end of the foreign body aborally, the intestine gath-
ers and pleats around it. Vomiting, anorexia and depression are the
most common clinical signs for both species. Intestinal obstruc-
tion is usually partial and the diagnosis may be delayed because
of the non-specific nature of the clinical signs. Cats with a linear
foreign body looped around the base of the tongue can be treated
conservatively after the foreign body is freed from the tongue, pro-
vided the cat is presented soon after ingestion and it is not show-
ing signs of peritonitis. Once being freed the remnant of the LFB
should pass through the gastrointestinal tract within 1 to 3 days.
These patients need to be closely monitored.The decision to pro-
ceed with surgery is based on worsening of clinical signs and fail-
ure to pass the LFB, as repeat radiographs and serial blood work Figure 11a: Ultrasonographic appearance of intussusceptions in
may not reflect the presence of severe surgical conditions such as the transverse plane (target sign)
intestinal perforation or peritonitis. Progressive anorexia, vomiting,
depression and abdominal distension are signs that may suggest
immediate abdominal exploration. If untreated, the intestine be-
comes devitalised and may develop full-thickness perforations of
its mesenteric border, and peritonitis can develop. Occasionally,
secondary intussusception may occur.

Intestinalintussusception
Intestinal intussusception is the most common form of gastroin-
testinal invagination detected in dogs and cats. Invagination con-
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sists of a displacement of an intestinal segment into the lumen of


another tract (Figure 10). The outer receiving intestinal portion is
referred to as the intussuscipiens, whereas the displaced segment
is referred as the intussusceptum. Invaginations usually occur in Figure 11b: Ultrasonographic appearance of intussusception in the
the direction of the normal peristalsis (direct or normograde in- longitudinal plane

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These findings correlate with the different layers of intestinal leads to gradual return to normality of the perfusion parameters.
wall of the intussusceptum and intussuscipiens present within Intravenous infusion increases systemic arterial pressure and con-
the invagination. sequently, intestinal perfusion. Fluid therapy should be continued
during surgery in order to correct any deficits that may still exist
Intestinalvolvulus and to replace intra-operative losses.
Mesenteric volvulus is a rapidly fatal condition in which the in- Abdominal radiographs, which should be taken only if
testine twists on its mesenteric root resulting in strangulation and patients are haemodynamically stable, may demonstrate for-
ischaemia. Volvulus is generally rare and mainly described in dogs. eign bodies, gas/fluid distended intestinal loops, masses, visceral
Malpositioning of intestine leads to obstruction of the veins and displacement or free peritoneal fluid. Both lateral recumbent and
lymphatic vessels initially, and of the mesenteric artery with its ventrodorsal projections should be taken. Contrast radiographic
branches secondarily resulting in vascular engorgement and oede- studies are infrequently performed because of the availability
ma of the bowel wall followed by ischaemic necrosis. Clinical signs of sonography.
are peracute to acute, with rapidly progressive abdominal disten- Ultrasonography allows detection of intestinal foreign bodies
sion, haematochezia and shock. Vomiting secondary to obstruction that are not visible radiographically (radiotransparent and linear),
and pain has also been reported in some cases. free peritoneal fluid, intestinal/intra-abdominal masses and can
The cause of intestinal volvulus is unknown but it is frequently evaluate the thickness of the intestinal wall. Furthermore it can
reported in German shepherd dogs and English Pointers. Treat- define appearance and symmetry of the different wall layers, the
ment includes rapid fluid resuscitation and immediate surgery to presence of normal intestinal peristaltic contraction, lymphad-
reduce the torsion of the mesenteric root. If recognition and treat- enopathy, and the location and extension of the disease. In the
ment are immediate, survival may be possible, although de-rotation intestinal wall, five layers are normally visible sonographically:
of the intestine and its re-oxygenation may result in a reperfusion the hyperechoic mucosal surface; the hypoechoic mucosa; the
injury. If the volvulus is only segmental, resection and anastomosis hyperechoic submucosa; the hypoechoic muscularis; and the hy-
can have a good outcome. Usually, dogs with intestinal volvulus die perechoic serosa.
as a result of circulatory, endotoxic and cardiogenic shock. Both abdominal radiography and ultrasonography are accurate
for diagnosing small-intestinal obstruction and either may be used
Pre-andperioperativemanagement depending on availability and examiner choice. However, abdomi-
Haematologic, biochemical and blood gas profiles should be always nal ultrasonography has greater accuracy, fewer equivocal results
performed on patients with small intestinal abnormalities to rule and provides greater diagnostic confidence compared with radi-
out concurrent systemic diseases. Dehydration resulting from de- ography (Sharma et al, 2011). Abdominal ultrasonography alone
pletion of intravascular fluid volume, acidbase abnormalities and could also be used to make the diagnosis of intestinal pathological
electrolyte imbalances are common sequelae of these conditions. condition (Tyrrel and Beck, 2006).
Patients with small intestinal mechanical obstruction are at risk for
hypokalaemia, hyponatraemia, hypochloraemia and hypovolemic Explorewithoutdelay!
shock. Loss of sodium, water and bicarbonate leads to metabolic In some patients, the benefit of stabilisation before surgery must
acidosis, while excessive loss of gastric hydrochloride in proximal be weighed against the risk of intestinal necrosis, perforation and
intestinal obstructions may result in metabolic alkalosis. Treatment peritonitis. It is usual to explore the abdomen without delay if
consists of intravenous infusion of crystalloids solutions to control there is suspicion of a penetrating abdominal injury, if abdominal
the hypovolaemic status, and correction of acidbase and electro- effusion with intracellular bacteria or very toxic neutrophils is
lyte abnormalities before inducing anaesthesia. The type of solution identified at cytology, if bacterial culture of free peritoneal fluid is
varies depending on serum electrolyte values, and additional potas- positive, if imaging reveals spontaneous pneumoperitoneum or ex-
sium supplementation may be needed. Potassium infusion should traluminal bubbles, and if a volvulus is detected. CA
not exceed 0.5 mmol/kg/hr. The most commonly used intravenous
solutions are crystalloids. In patients with decreased oncotic pres- References
sure or oedema, colloid solutions used in combination with isotonic Applewhite, AA, Corenell KK, Selcer BA (2002) Diagnosis and treatment of intus-
susceptions in dogs. Compend Cont Educ Pract Vet 24(2): 11027.
crystalloids may be superior for treatment of shock because they are Ellison GW (2011) Complications of gastrointestinal surgery in companion animals.
retained in the circulation and have a longer duration of effect than Vet Clin North Am Small Anim Pract 41(5): 91534
Freeman DE, Gentile DG, Richardson DW et al (1988) Comparison of clinical
crystalloids. Colloids like tetrastarch (Voluven 6%) should be con- judgment: Doppler ultrasound, and fluorescein fluorescence as methods for
sidered in these patients at doses of 5 to 20 ml/kg in dogs and 2.5 to predicting intestinal viability in the pony. Am J Vet Res 49(6): 895900
10 ml/kg in cats. A colloid dose of 20 ml/kg is considered equivalent Levien AS, Baines SJ (2011) Histological examination of the intestine from dogs and
cats with intussusception. J Small Anim Pract 52(11): 599606
to a 6090 ml/kg dose of isotonic crystalloid. Papazoglou LG, Patsikas MN, Rallis T (2003) Intestinal foreign bodies in dogs and
The dose should be scaled down according to the severity of cats. Compendium of Continuing Education for the Practicing Veterinarian 25:
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83044
shock. Rapid administration of Voluven may cause vomiting in
Sharma A, Thompson MS, Scrivani PV et al (2011) Comparison of radiography and
the cat; therefore, slow administration over at least 15 minutes ultrasonography for diagnosing small-intestinal mechanical obstruction in vomit-
is recommended. Animals receiving intravenous fluids for rapid ing dogs. Vet Radiol Ultrasound 52(3): 24855
Tyrell D, Beck C (2006) Survey of the use of radiography vs.
volume expansion should be constantly monitored to assess the ultrasonography in the investigation of gastrointestinal foreign bodies in
clinical response to treatment. Successful volume replacement small animals. Vet Radiol Ultrasound 47(4): 4048

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