Surgical Techniques for Treating Left Displaced Abomasum

Left Side Abomasopexy

Advantages
■ Good visualization of the abomasum
■ Good access to the rumen and reticulum
■ Secure fi xation
■ Can be done on a standing cow

Disadvantages
■ If at the time of surgery the abomasum is in the normal position (not displaced to the
left), access to the abomasum is extremely limited.
■ Requires assistance
■ Requires a long reach
Restraint
■ Standing restraint
Presurgical Procedures
■ Administer sedation or analgesia as needed
■ Surgically prepare the left paralumbar fossa
● Prepare an area 15 × 25 cm (6 × 10 inches) posterior to the xiphoid and just right
of the midline. Note the location of the subcutaneous abdominal vein.
● The abomasal sutures will exit from this area.

Anesthesia
■ Proximal lumbar paravertebral nerve block (preferred)
■ Optional anesthesia:
● Distal lumbar paravertebral nerve block
● Local infi ltration or inverted “L” technique
Surgical Technique
■ Use a regional, fenestrated, moisture-repellent sterile drape. Stabilize the drape to
the left paralumbar area with towel clamps.
■ Make a modifi ed muscle-spreading abdominal incision.
■ Explore the peritoneal cavity thoroughly before the abomasopexy.
■ Prepare the suture material.
● Use heavy, No. 3 synthetic nonabsorbable material 180 to 200 cm (6 to 7 feet) long.
● Thread a straight 4-inch trocar point needle on each end of the suture material.
● Locate and mark the center of the suture material.
■ Place sutures in the abomasum.
● Grasp one of the two needles while maintaining the second needle outside the
body.
● While you cradle and protect the needle, carry the needle and suture material
intra-abdominally to the dorsocranial aspect of the displaced abomasum. (This
area of the displaced abomasum should constitute the ventral, cranial, and fundic
portion of the abomasum when it is in its normal position.)
● Place running sutures in the abomasum for a distance of approximately 8 cm
(3 inches).
◆ Sutures bites should be at least 2 cm (1 inch) long.
◆ The suture pattern may be simple continuous, Ford interlocking, or zig-zag
(preferred).
◆ Pull about half the suture material through the abomasal wall to the previously
marked center of the material.
◆ The completed line of sutures will be about 8 cm (3 inches) long in the
abomasal wall, and a long strand of suture material will be at each end of the
suture line.

■ Placement of sutures through the ventral abdominal wall

● Each end of the abomasal suture material will exit the ventral abdominal wall.
● These ends are tied outside the abdominal wall to secure the abomasum to the
ventral abdominal wall.
● While you protect the needle point in the palm of your hand, insert your arm
along the lateral body wall between the peritoneum and the displaced abomasum
until you palpate the xiphoid area.
● Force the point of the anterior needle ventrally through the body wall (the
area previously prepared). A surgical assistant should guide you to the proper
location.
● A surgical assistant should grasp the needle outside the body wall and exert slight
to moderate traction.
● Repeat the process with the second (caudal) needle and suture, placed about 8 cm
(3 inches) caudal to the fi rst.
■ Remove the gas from the distended displaced abomasum with a large-gauge
(12 to 14 gauge) needle attached to tubing leading out of the abdominal cavity with
or without suction.
■ As the assistant places tension on the sutures, the surgeon pushes the abomasum into
its normal position by using a kneading-like motion.
■ Palpate carefully to ensure that no other structures (e.g., small intestine) are
entrapped by the sutures under the abomasum.
■ Tie the suture strands with a surgeon’s knot. Leave the cut ends at least 8 cm (3 inches)
long.
● You can place your hand between the abomasum and ventral abdominal wall and
between the abomasal sutures to ensure that the suture material has the correct
tension. Sutures tied too tightly will cut through the skin; sutures tied too loosely will
allow displacement of the abomasum to recur.
■ Perform a routine three-layer closure of the abdominal incision.
Postoperative Care
■ Give systemic medications as needed
● Fluidsand electrolytes
● Dextrose, for ketosis
● Antibiotics
■ Remove ventral abdominal sutures in 5 to 7 days.
■ Remove paralumbar skin sutures in 14 to 21 days.
Omentopexy and Pyloro-omentopexy
Advantages
■ Can be performed on a standing cow
■ LDA, RDA, and RTA can be corrected from the right-side approach.
■ Assistant not necessary
■ Pyloro-omentopexy can serve as prophylaxis in a normal animal.
Disadvantages
■ Fat cows occasionally have displacement again after omentopexy.
■ A long reach is required to correct LDA.
■ Blind technique: The abomasum is not visualized.
Restraint
■ Standing restraint
Presurgical Procedures
■ Administer sedation or analgesia as needed
■ Prepare the right paralumbar incision site.

Anesthesia
■ A proximal lumbar paravertebral nerve block with 2% lidocaine is preferred.
■ A distal lumbar paravertebral nerve block may be an option.
■ Local infi ltration or inverted “L” technique may be effective.
Surgical Technique
■ Drape the region with a fenestrated moisture-repellent drape anchored in position
with towel clamps.
■ Make a vertical skin incision in the right paralumbar fossa (slightly ventral to lumbar
transverse processes L3 and L4) of adequate length 15 to 20 cm (6 to 8 inches) for
easy arm insertion.
● A slightly lower incision is made for pyloro-omentopexy to achieve adequate
exposure of the pylorus.
■ Use a modifi ed muscle-spreading technique on the abdominal wall to expose the
peritoneal cavity.
■ Exploration of the peritoneal cavity before abomasal manipulation is strongly
recommended.
■ With a 2- to 3-inch, 14-gauge needle with attached tubing, defl ate the abomasum.
Insert the needle into the dorsal aspect of the abomasum. Removing excess gas is
often needed to facilitate movement of the abomasum under the rumen and into its
normal position.
■ Place your left hand on the dorsal aspect of the displaced abomasum. With a
combined sweeping motion of the abomasum and a lifting of the rumen, bring the
abomasum under the rumen and into its normal position.
■ Identify the greater omentum and retract it dorsally and caudally through the
abdominal incision until you see and identify the pylorus. Grasp the pylorus with
two vulsellum forceps.
■ While holding the pylorus with the forceps, start at the ventral commissure of the
incision and begin closing the fi rst layer of the abdominal wall with No. 3 gut in a
simple continuous pattern.
■ Incorporate at least three bites of the pylorus and the omentum into the fi rst layer of
the abdominal wall.
● For security, the suture bites into the omentum should be large but should not
penetrate the lumen of the pylorus or the duodenum.
■ Close the second layer of the abdominal wall with No. 3 gut in a simple continuous
pattern, and close the skin with heavy nonabsorbable synthetic sutures in a Ford
interlocking pattern.

Basic Omentopexy Suturing via the Dirkson Method

(Figure 11-6 and Figure 11-7)

■ With No. 3 medium chromic gut, place two mattress sutures, one caudal and one
cranial to the abdominal incision. They should include the internal oblique muscles,
transverse muscles, peritoneum, and both layers of the greater omentum (previously
identifi ed).
■ Suture the peritoneum and transverse and internal oblique muscles in a continuous
pattern that incorporates a large bite of the greater omentum in each suture.
■ The second layer and skin are routinely sutured.
Postoperative Care
■ Give systemic medications as needed
● Fluidsand electrolytes
● Dextrose, for ketosis
● Antibiotics as deemed necessary
■ Remove paralumbar sutures in 14 to 21 days

Ventral Abomasopexy
Advantages
■ Good visualization of the abomasum
■ Very secure fi xation
■ Spontaneous uterine drainage with the animal in dorsal recumbency
Disadvantages
■ With a down cow: possible injury, bloat, regurgitation, or aspiration pneumonia
■ Incisional complications, especially in cows housed in fi lthy conditions
■ Assistant required
Restraint
■ Dorsal recumbency with legs extended
■ Marked sedation or analgesia will facilitate casting into dorsal recumbency.
Presurgical Procedures
■ Deprive the patient of water for a minimum of 12 hours before surgery.
Deprivation decreases the potential for regurgitation during dorsal recumbency
restraint.
■ Restriction of feed intake is usually unnecessary because the subject is commonly
anorectic.
■ Identify and mark the subcutaneous abdominal veins so that they can be avoided
during surgery.
■ Administer (marked) IV sedation and analgesia.
Surgical Site Preparation
■ Prepare the ventral right paramedian area just caudal to the xiphoid for
surgery.
■ The prepared area should be 35 to 45 cm (15 to 18 inches) square.
Anesthesia
■ Administer a local line infusion anesthesia with 2% lidocaine along the proposed
incision line.