SMALL INTESTINE

Surgical Anatomy:
Total intestine approximately five times the body length.
Small intestine: duodenum, jejunum, ileum (80%)
Four layers (serosa, muscularis, submucosa, mucosa)
Two main procedures
1. Enterotomy
2. Intestinal Resection and Anastomosis
Main Surgical Problems:
Foreign bodies, Ischemic, necrotic, neoplastic or fungal
infected segments, irreducible intussusceptions, volvulus (twisting
along long axis) and torsion (twisting at root of mesentry). Volvulus &
torsion often used interchangeably.
1. Enterotomy:
Surgical Tech:
1.Exteriorize, isolate & towel pack the desired intestinal segment.
2.Gently milk intestinal contents sideways and occlude the lumen of the isolated
segment at both ends.
3.Full thickness incision at the antimesenteric border in healthy appearing tissue.
4.Sutures (inverting, everting, S.I appositional, S.I crushing); 2mm from the edge
& 2-3mm apart.
5.Non-absorbable sutures if albumen is 2gm/dl or less.
6.Check for any leakage.
7.Place additional sutures in case of leakage between the sutures.
8.Place omentum over the suture line before closing the abdomen.
9.Replace contaminated gloves & instruments before closing abdomen.
Enterotomy
Enterotomy with
tissue reorientation
2. Intestinal Resection & Anastomosis
Indications:
Ischemic, necrotic, neoplastic or fungal infected segments & irreducible
intussusceptions.
Surgical Tech:
1.Exteriorize, isolate & towel pack the desired intestinal segment.
2.Double ligate and transect the arcadial mesenteric vessels that supply the segment.
3.Double ligate the terminal arcade vessels & vasa recta vessels within the mesenteric fat at
the points of proposed transection.
4.Gently milk intestinal contents sideways and occlude the lumen of the isolated segment at
both ends.
5.Transect the intestine with an oblique incision (45 to 60 degree angle).
Closure: First suture at mesenteric border. Second suture at antimesenteric border. Then
complete the suturing. Close the mesenteric defect.
Check for any leakage before closing the laparotomy incision.
Intestinal Foreign Body
Jejunal adenocarcinoma in a cat
Resection & end to end anastomosis
Foreign Bodies
Discrete: Bones, balls, toys, rocks, corncobs, cloth, metal
objects (fish hooks, needles, peach pits, acorns, Pecans. Obstruction
may be partial or complete. The higher the obstruction, the overt the
clinical signs.
Linear objects: String, thread, fabric, Pantyhose, plastic, cassette tapes
and ribbon. Part of the object usually lodges at the base of the tongue
or pylorus and the remainder advances into the intestine. Due to
peristaltic waves, the intestine gathers around the foreign body
(bunching of intestine) and the foreign body may cut through the
mesenteric border.
Diagnosis: Radiography, u/s and endoscopy (pyloric region).
Treatment: Enterotomy or resection and anastomosis and single-
enterotomy catheter technique.
Radiopaque intestinal foreign body
String (linear F.B) wrapped around
the base of tongue in a cat
 Bunching of small intestine
(typical sign of linear foreign body)
Bunched intestines (linear foreign body)
Intussusception:
Telescoping or invagination of one intestinal segment (intussusceptum)
into the lumen of an adjacent segment (intussuscipien).
Signalment: More common in dogs. History of recent surgery. Scant,
bloody diarrhea, vomiting, abdominal pain.
Diagnosis:
P.E: An elongated, thickened, palpable mass in the caudal abdomen.
Plain & contrast rads.
U/Sonography:
Transverse scans (concentric hyperechoic & hypoechoic rings).
longitudinal scans (alternate parallel hyperechoic & hypoechoic lines.
Treatment: Laparotomy to perform manual reduction or resection and
anastomosis.
Schematic diagram of intussusception
SURGICAL TECHNIQUE
Explore the abdomen, collect specimens, and isolate the involved
intestine with laparotomy pads (Fig. 18.124). Reduce intussusceptions
manually if possible by gently applying traction on the neck of the
intussusceptum while milking its apex (leading edge) out of the
intussuscipiens (see Fig. 18.121B). Avoid excessive traction because
this may tear the compromised intestine. Push on the intussuscipiens
more than pull on the intussusceptum. Manual reduction is suc
cessful only if fibrin has not formed firm serosal adhesions.
Evaluate the reduced intestine for viability and perforation. Carefully
palpate the leading edge of the intussusceptum to detect mass lesions.
Perform a resection and anastomosis if a mass is detected, manual
reduction is impossible, tissue is devitalized, or mesenteric vessels
have been avulsed from a portion of the involved intestine. Submit
biopsies of the involved intestine to help identify the cause of the
intussusception.
Jejunal intussusception in a cat
Intestinal Volvulus & Torsion
Volvulus: Twisting of intestine at its mesenteric axis
Torsion: Twisting of intestine along its long axis.
History: Vigorous activity, trauma, rolling down from stairs, recent GIT
surgery.
Clinical Signs: Acute pain, shock (tachycardia, pale to injected mm, increased
CRT, weak pulse, nausea,retching, vomiting, recumbency or all
of these.
Diagnosis: Shock wd acute abdomen, entire intestinal tract distended
wd gas, intestinal fluid, free abdominal fluid (Rads & u/s).
Definitive dx at surg or necropsy.
Treatment: Quick exploratory laparotomy and decision on the basis of
Findings.
• SURGICAL TECHNIQUE:
• Quickly explore the abdomen to confirm the diagnosis and
determine
• the direction of twisting. The intestine will appear dilated,
• edematous, and discolored, with the serosal surfaces ranging
• from red to black. Decompress the intestine if necessary to allow
• derotation and reposition the intestines. Allow the intestine to
• reperfuse and stabilize while the abdomen is more thoroughly
• explored. Evaluate intestinal viability and resect devitalized tissue.
• Thoroughly lavage the abdomen with warm physiologic saline or
• a balanced electrolyte solution. Perform open peritoneal drainage
• (see p. 534) if intestinal necrosis and peritonitis are identified.
• Some have recommended concurrent right-sided gastropexy,
• gastrocolopexy, and colopexy of the descending colon when the
• colonic torsion is discovered.
Strangulating
Intestinal obstruction
Rectal prolapse in dogs
protrusion or eversion of
the rectal mucosa from
the anus
Exciting causes
 Causes
• severe enteritis
• endoparasitism
• disorders of the rectum (eg, foreign bodies, lacerations,
diverticula, or sacculation)
• neoplasia of the rectum or distal colon
• urolithiasis
• urethral obstruction
• cystitis
• dystocia
• colitis
• prostatic disease
Complete or Incomplete Prolapse
 Physical Examination Findings
• Protrusion of anorectal
mucosa

• Degree of prolapse may

vary
 DIFFERENTIAL DIAGNOSIS

• Primary differential diagnosis for rectal prolapse is

intussusception
• it must be differentiated from prolapsed ileocolic
intussusception by passing a probe, blunt instrument,
or finger between the prolapsed mass and the inner
rectal wall. In rectal prolapse, the instrument cannot
be inserted because of the presence of a fornix.
 MEDICAL MANAGEMENT
• Manual reduction and
placement of a purse-string
suture around the anus

• Recommended for acute

prolapses with minimal
tissue damage and edema
• Warm saline lavage and lubrication with a water-soluble
gel should be applied to the prolapsed tissue before
reduction. Alternatively, hypertonic sugar solution (50%
dextrose or 70% mannitol) applied topically may be used
to relieve edematous mucosa. The placement of a loose,
anal purse-string suture for 5–7 days is indicated.
• Place a probe into the rectal lumen
• Place three horizontal mattress
• stay sutures (at the 12 o'clock, 5 o'clock, and 8
o'clock positions)
• Transect the traumatized tissue in stages caudal
to the stay sutures.
• After each stage of the resection, anatomically
appose the transected edges with simple
interrupted sutures
• Space the sutures approximately 2 mm apart
and 2 mm from the cut edge
• Remove the stay sutures and gently replace the
anastomotic site in the pelvic or
• anal canal.
• Place a purse-string suture around the anus if
postoperative tenesmus is expected.
• Retention enemas of Kaopectate or epidural
Anal Sacculectomy:
Indications: Chronically infected or impacted anal sacs, anal sac
fistulae.
Surgical Treatment:
1. Closed tech:
a. Insert a small probe, hemostat or balloon tip catheter into the orifice of
anal sac duct.
b. Advance the instrument or inflate the balloon with saline to identify the
lateral extent of the sac.
c. Make a curvilinear incision over the sac and separate the external and
internal anal sphincter muscle fibers from the sac’s exterior with scissors.
d. Dissect out the sac and the duct; place a ligature wd 4/0 suture material
around the duct and excise the sac and the duct.
e. Appose s/c tissue and skin with 3/0 or 4/0 material.
Closed Sacculectomy
Anal Sacculectomy (cont):
2. Open Tech:
a. Place a scissors blade or groove director into the duct
of the sac.
b. Apply medial traction on the duct while incising
through the skin, s/c tissue, ext anal sphincter, duct and
sac.
c. Continue the incision to the lateral extent of the sac.
d. Elevate the cut edge of the sac and dissect it free of its
attachments.
e. Complete the procedure as for closed sacculectomy.
Open Sacculectomy