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PAPER ILMU BEDAH KHUSUS VETERINER (BEDAH ABDOMINAL) TEKNIK OPERASI DAN INDIKASI LAPAROTOMY



Disusun Oleh : Kelompok 5 Amelia Avianti Saritjang



1109005067



I Putu Agus Antara Putra



1309005040



I Wayan Eka Darmawan



1309005050



Khoirul Nikmah



1309005075



Febio Tomasini Marciano Meus



1309005087



Mersy Rambu Maramba Ndiha



1309005127



I Putu Agus Indra Gunawan



1309005143



LABORATORIUM BEDAH VETERINER FAKULTAS KEDOKTERAN HEWAN UNIVERSITAS UDAYANA 2016



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RINGKASAN Laparotomy merupakan penyayatan pada dinding abdomen atau peritoneal atau dapat diartikan sebagai pembedahan dinding abdomen melalui insisi ventral abdomen atau flank (dinding perut samping). Laparotomy dapat dibagi menjadi bebrapa jenis, antara lain : Laparotomy flank, medianus dan paramedianus. Masing-masing jenis Laparotomy ini dapat digunakan sesuai dengan fungsi, organ target yang akan dicapai, serta jenis hewan yang akan dioperasi. Untuk hewan besar, umumnya menggunakan laparotomy flank karena teknik ini dapat meminimalisir terjadinya resiko prolapsus ataupun hernia, sedangkan hewan kecil dapat menggunakan laparotomy medianus ataupun paramedianus. Laparotomy flank dapat dibagi menjadi 2 yaitu: laparotomy flank kiri dan kanan. Laparotomy flank kiri merupakan indikasi untuk operasi rumenotomi, abomasopexy, caesaria, splenectomi, reticulitis traumatika , torsio uteri, dan lain-lain. Sedangkan laparotomy flank kanan digunakan indikasi untuk operasi daerah intestinum, caecum, colon omentopexy sisi kanan dan abomasopexy. Untuk sapi yang temperamennya tenang operasi dilakukan dengan posisi berdiri dengan anestesi regional. Pada hewan kecil, laparotomi yang umumnya dilakukan adalah laparotomi medianus dengan daerah orientasi pada bagian abdominal ventral tepatnya di linea alba. Kata kunci : Laparotomy, Hewan Besar, Hewan Kecil SUMMARY Laparotomy is an incision in the abdomen or peritoneal and can be interpreted as the ventral abdominal surgery through an incision in the abdomen or flank. Laparotomy is divided into several types, among others: flank laparotomy, median and paramedianus. Each type of laparotomy can be used in accordance with the function, organ targets to be achieved, as well as the type of animal to be operated. For large animals, generally using flank laparotomy because this technique can minimize the risk of prolapse or a hernia, while small animals can use a median laparotomy or paramedianus. Flank laparotomy can be divided into two: the left and right flank laparotomy. Left flank laparotomy is an indication for surgery rumenotomi, abomasopexy, Caesaria, splenectomi, reticulitis traumatic, uterine torsion, and others. used right flank laparotomy indications for surgery area intestine, cecum, colon omentopexy right side and abomasopexy. For cattle temperament quiet operation is performed in a standing position with regional anesthesia. In small animals, laparotomy is generally done with the area median laparotomy orientation on the part precisely in the ventral abdominal linea alba. Key word :Laparotomy, Large Animals, Small Animals.



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KATA PENGANTAR



Puji syukur penulis ucapkan kepada Tuhan Yang Maha Esa, atas limpahan rahmatNya lah



penulis dapat menyelesaikan paper ini secara maksimal dengan judul “Bedah



Abdominal : Teknik Operasi dan Indikasi Laparotomy “. Paper ini dibuat guna memenuhi tugas untuk mata kuliah Ilmu Bedah Khusus yang penulis ikuti di Fakultas Kedokteran Hewan, Universitas Udayana. Tidak lupa, penulis ucapkan terima kasih kepada dosen pengampu mata kuliah Ilmu Bedah Khusus untuk segala bimbingan dan dukungannya. Selain itu, penulis juga mengucapkan terima kasih kepada segala pihak yang turut serta membantu dalam pembuatan paper ini sehingga paper ini dapat selesai tepat pada waktunya. Karena paper ini belum sepenuhnya sempurna, maka penulis membutuhkan kritik dan saran yang bersifat membangun. Denpasar, 5 Oktober 2016



Penulis



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DAFTAR ISI



RINGKASAN ........................................................................................................................ i KATA PENGANTAR .......................................................................................................... ii DAFTAR ISI........................................................................................................................ iii DAFTAR GAMBAR ........................................................................................................... iv DAFTAR LAMPIRAN ..........................................................................................................v BAB I PENDAHULUAN 1.1 Latar Belakang........................................................................................................1 1.2 Rumusan Masalah ..................................................................................................1 BAB II TUJUAN DAN MANFAAT 2.1 Tujuan Penulisan ....................................................................................................2 2.2Manfaat Penulisan ..................................................................................................2 BAB III TINJAUAN PUSTAKA 3.1Pengertian Laparotomy ...........................................................................................3 3.2Tujuan dan Manfaat Laparotomy ............................................................................3 BAB IV PEMBAHASAN 4.1Persiapan pre-operasi Laparotomy ..........................................................................5 4.2Teknik dan Indikasi Laparotomy pada Hewan Besar..............................................5 4.3Teknik dan Indikasi Laparotomy pada Hewan Kecil ..............................................7 4.4Perawatan Pasca Laparotomy ................................................................................13 BAB V KESIMPULAN 5.1Simpulan ................................................................................................................14 5.2Saran ......................................................................................................................14 DAFTAR PUSTAKA ..........................................................................................................15 LAMPIRAN



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DAFTAR GAMBAR



Gambar 1 ................................................................................................................................6 Gambar 2 ................................................................................................................................7 Gambar 3 ................................................................................................................................7 Gambar 4 ................................................................................................................................8 Gambar 5 ................................................................................................................................9 Gambar 6 ................................................................................................................................9 Gambar 7 ................................................................................................................................9 Gambar 8 ..............................................................................................................................10 Gambar 9 ..............................................................................................................................10 Gambar 10 ............................................................................................................................10 Gambar 11 ............................................................................................................................11 Gambar 12 ............................................................................................................................11 Gambar 13 ............................................................................................................................11 Gambar 14 ............................................................................................................................12 Gambar 15 ............................................................................................................................12 Gambar 16 ............................................................................................................................12



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DAFTAR LAMPIRAN Lampiran 1. Exploratory Laparotomy in the Dog & Cat Lampiran 2. Comparative Evaluation of Midventral and Flank Laparotomy Approaches in Goat Lampiran 3. Two-step protocol for surgical treatment of complicated or bilateral perineal hernia in dogs: Laparotomy followed by herniorrhaphy



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BAB I PENDAHULUAN



1.1 Latar Belakang Laparatomi merupakan suatu tindakan operasi yang lokasinya berada pada daerah abdomen. Menurut Jong dan Sjamsuhidayat (2004) bedah laparatomi merupakan teknik sayatan yang dilakukan pada daerah abdomen yang dapat dilakukan pada bedah digestif dan kandungan. Laparatomi terdiri atas laparatomi flank, laparatomi medianus dan laparatomi paramedianus. Laparatomi flank terbagi menjadi flank kanan dan flank kiri. Laparatomi flank kiri untuk melihat organ abomasum, rumen, dan uterus. Sedangkan laparatomi flank kanan untuk melihat organ abomasum, omentum, intestine, caecum, kolon, dan uterus kanan. Sehingga laparotomy jenis ini lebih umum dilakukan pada hewan besar, sedangkan kedua jenis laparotomy yang lain (laparotomy medianus dan paramedianus) sering dilakukan pada hewan kecil. Dari ketiga laparotomy tersebut, memiliki keuntungan masing-masing. Laparotomi dengan menggunakan metode medianus, keuntungannya adalah mudah dalam menemukan daerah yang akan disayat dengan melihat linea alba dan umbilicalis. Selain itu daerah tersebut jarang terjadi pendarahan. Tetapi dengan melakukan laparatomi medianus ini, kemungkinan akan terjadinya hernia cukup tinggi. Hal tersebutlah yang melatar-belakangi penulis untuk membuat paper ini, sehingga mahasiswa mampu menentukan metode yang digunakan dalam tindakan operasi laparotomy sesuai yang dianjurkan dan meminimalisir terjadinya kesalahan dalam kerja. 1.2 Rumusan Masalah Adapun rumusan masalah dari paper ini, sebagai berikut : 1. Apa saja yang dipersiapkan pada pre-operasi laparotomy? 2. .Bagaimana teknik dan indikasi laparotomy pada hewan besar? 3. Bagaimana teknik dan indikasi laparotomy pada hewan kecil? 4. Bagaimana cara perawatan pasca laparotomy?



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BAB II TUJUAN DAN MANFAAT



2.1 Tujuan Penulisan Adapun tujuan dari penulisan ini, antara lain : 1. Untuk mengetahui yang dipersiapankan pada pre-operasi laparotomy, 2. Untuk mengetahui teknik dan indikasi laparotomy pada hewan besar, 3. Untuk mengetahui teknik dan indikasi laparotomy pada hewan kecil, 4. Untuk mengetahui cara perawatan pasca laparotomy. 2.2 Manfaat Penulisan Manfaat yang dalam penulisan paper ini didapat secara luas. Diantaranya manfaat yang didapat untuk penulis sendiri adalah, menambah wawasan tentang bedah. Terutama bedah abdominal berupa teknik operasi dan indikasi laparotomy pada hewan kecil dan besar. Selain itu, manfaat lain juga didapat untuk teman sejawat atau mahasiswa yaitu, memberikan informasi baru tentang perkembangan ilmu bedah yang mungkin belum didapatkan pada bangku perkuliahan.



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BAB III TINJAUAN PUSTAKA



3.1 Pengertian Laparotomy Laparotomy(celiotomy) berasal dari dua kata terpisah, yaitu ‘laparo’ yang berarti rongga perut/abdomen dan ‘tomi’ yang berarti penyayatan. Laparotomy didefinisikan sebagai penyayatan pada dinding abdomen atau peritoneal atau dapat diartikan sebagai pembedahan dinding abdomen melalui insisi ventral abdomen atau flank (dinding perut samping). Laparotomy terdiri dari beberapa jenis, antara lain : Laparotomy flank, medianus dan paramedius. Masing-masing jenis Laparotomy ini dapat digunakan sesuai dengan fungsi, organ target yang akan dicapai, serta jenis hewan yang akan dioperasi. Pada umumnya, Laparotomy yang dilakukan terhadap hewan kecil menggunakan Laparotomy medianus dengan daerah orientasi pada bagian abdominal ventral tepatnya di linea alba. Organ-organ pada saluran pencernaan, saluran limfatik, saluran urogenital dan saluran reproduksi merupakan organ tubuh yang berada dirung abdomen. Semua organ tersebut dapat ditemukan dengan tekni operasi Laparotomy. Pada hewan besar, umumnya menggunakan laparotomy flank. Laparotomy flank merupakan pembedahan dinding abdomen samping. Terdapat dua macam Laparotomy flank, yaitu Laparotomy flank kanan yang sering dilakukan untuk melihat organ rumen dan operasi Caesar dan Laparotomy flank kiri digunakan untuk melihat organ hati, kolon dan abomasum yang bergerak ke kanan. 3.2 Tujuan dan Manfaat Laparotomy Laparotomy memiliki tujuan untuk pengobatan ataupun untuk meneguhkan suatu diagnosa. Untuk hewan besar seperti sapi atau kuda posisi hewan seringkali dalam keadaan berdiri tetapi untuk anjing atau kucing selalu dalam keadaan rebah dorsal. Letak irisan pada hewan besar didaerah flank sedangkan anjing atau kucing 3



didaerah ventral abdomen. Tahapan yang harus diperhatikan untuk kelancaran operasi atau kesuksesan operasi sebagai berikut : 1. Anestesi sebelum dilakukan harus betul sempurna , sehingga tidak ada rasa sakit dan muskulus juga dalam keadaan relaksasi sempurna, bila ada rasa sakit maka isi abdomen akan dihentakan dan berhamburan keluar. 2. Praktek antiseptika yang optimal, kalau tidak akan memperlama kesembuham bahkan bisa berakiobat fatal. 3. Insisi yang dilakukan tidak boleh kurang tetapi tidak berlebihan, yang penting dapat mengekspose organ yang dimaksud, bila terlalu kecil akan menyebabkan trauma atau bisa sobek. 4. Jangan memperlakukan organ secara kasar karena akan menyebabkan edema atau nekrosa jaringan. 5. Mengatasi perdarahan dengan baik, tampon,ligasi jangan membiasakan dengan kauterisasi/panas api.Hemostasis yang jelek akan mempengaruhi pandangan dokter pada obyek dan banyak kehilangan darah > 1/3 koma. 6. Kembangkan sikap dan trampil dalam operasi dan berorientasi pada hubungan anatomi dan fisiologi struktur organ yang dioperasi. 7. Kerjasama yang harmonis dari team bedah.



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BAB IV PEMBAHASAN



4.1 Persiapan Pre-Operasi Laparotomy 1. Persiapan alat, bahan, dan obat Sterilisasi alat dengan menggunakan autoclave selama 15 menit. Selain itu, juga dipersiapkan alat bedah minor, towl klaim, pinset anatomis dan syrorgis. 2. Obat-obatan Mempersiapkan obat-obatan yang digunakan, seperti desinfektan (alcohol, iodine), preanastesi (atropine sulfat), sedative (cloropromazine, xylazine), anastesi ( ketamine, lidokain), anti radang (vitamin K), cairan infus (NaCL fisiologis, laktat einger) dan antibiotic (ampicillin, tetramycin) 3. Persiapan hewan Memeriksa fisik hewan sebelum dilakukan operasi laparotomy. Hal ini bertujuan jika terjadi hal yang tidak stabil maka dapat distabilkan terlebih dahulu. Selain itu, hewan juga dipuasakan selama 12 jam agar hewan tidak munrtah saat teranastesi. 4. Persiapan ruang operasi Ruang operasi harus dibersihkan dengan desinfektan, meja operasi didesinfeksi dengan menggunakan alcohol 70%. Penerangan ruang operasi sangat penting untuk menunjang operasi.



4.2 Teknik dan Indikasi Laparotomy pada Hewan Besar Laparatomi dilakukan dorso-lateral rongga perut atau di daerah fossa paralumbal yaitu di flank kiri atau kanan. Sesuai dengan tempat irisan dibedakan anterior dan posterior laparatomi. Pada hewan besar tidak dilakukan paramedian atau median laparatomi karena adanya resiko akibat tekanan isi rongga abdomen dan berat badan yang menyebabkan prolapsus ataupun hernia. Laparotomy dapat dibagi menjadi 2, yaitu :



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a. Laparatomi pada flank kiri Indikasi : untuk operasi rumenotomi, abomasopexy, caesaria, splenectomi, reticulitis traumatika , torsio uteri, dan lain-lain. b. Laparatomi pada flank kanan Indikasi : untuk operasi daerah intestinum, caecum, colon omentopexy sisi kanan dan abomasopexy. Untuk sapi yang temperamennya tenang operasi dilakukan dengan posisi berdiri dengan anestesi regional. Teknik Operasi Adapun teknik operasi laparotomi pada hewan besar (sapi) yaitu : 1. Lakukan anestesi regional(paravertebral ataupun epidural anestesi). 2. Rambut yang cukup panjang dicukur dan didesinfeksi pada daerah yang akan dioperasi. 3. Buat sayatan vertikal di tengah dari fossa paralumbal dan di bagian ventral prosesus transversus vertebrae lumbalis. 4. Sayatan kulit di tekan secara halus, kemudian pisahkan kulit dengan subkutan dari m.obliqus abdominis eksternus, lapisan ini juga disayat vertikal sampai m. obliqus abdominis internus. 5. Sayatan dilanjutkan sampai m. abdominis transversus dan akan terlihat peritoneum. Tindakan selanjutnya tergantung dari jenis operasinya. 6. Penutupan dilakukan lapis demi lapis dengan urutan pertama yaitu peritoneum dengan pola jahitan menerus atau kombinasi menerus dengan jahitan matras atau kombinasi dengan sederhana tunggal dengan catgut chromic ataupun benang katun.



Gambar 1. Saluran pencernaan sapi



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Gambar 2. Incisi pada daerah flank dexter



Gambar 3. Penutupan dinding perut (Peritoneum-Muskulus-Kulit) 4.3 Teknik dan Indikasi Laparotomy pada Hewan Kecil Pada hewan kecil, laparotomi yang umumnya dilakukan adalah laparotomi medianus dengan daerah orientasi pada bagian abdominal ventral tepatnya di linea alba. Macam Laparotomy: 1. Laparotomy Anterior (Dorsal/Cranial). Daerah insisinya antara umbilicus dan cartilago xiphoideus. 2. Laparotomy Posterior (Ventral/Caudal). Daerah insisinya antara umbilicus dan tepi pelvis (lihat gambar 4).



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Gambar 4. Skema Laparotomi Anterior (A), Laparotomi Posterior (B), skema potongan melintang muskulus abdomen anjing Tempat Incisi 1. Incisi Garis Tengah Cranial (Cranial Midline/ Linea Mediana Cranial), mulai dari umbilicus sampai cartilago xiphoideus. Indikasi : Mencapai diaphragma, hepar, gaster dan pylorus. 2. Incisi Garis Tengah Caudal (Caudal Midline/ Linea Mediana Caudal) pada hewan jantan. Indikasi : Mencapai vesica urinaria, kelenjar prostat, colon dan abdomen bagian caudal. 3. Incisi Garis Tengah Caudal pada hewan betina, yang dimulai dari umbilicus sampai tepi pelvis. Indikasi : Mencapai ovarium, uterus, usus, vesica urinaria dan abdomen bagian caudal. 4. Incisi paramedian, di bagian lateral linea mediana melalui m. rectus abdominis. Indikasi : mencapai ren, lien dan discus intervertebralis lumbalis.



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Gambar 5. Macam-macam tempat incisi laparotomi



Gambar 6. Skema incisi Laparotomi pada anjing jantan dan betina Teknik Operasi dan Indikasi Operasi Langsung pada linea alba Tekniknya: 1. Tandai bagian yang akan diinsisi, yakni processus xiphoideus pada bagian cranial dan pubis pada bagian kaudal. Berikan jarak 5-10 cm dari garis tengah tubuh sisi ventral kesisi lateral.



Gambar 7. Operasi step 1 9



2. Suntikan anestesi bupivakain IM (2 mg/kgBB) mulai dari garis tengah tubuh sisi ventral bagian cranial sampai kaudal.



Gambar 8. Operasi Step 2 3. Lakukan insisi dengan teknik four corner draping. Pada hewan jantan (anjing,kucing), pegang bagian preputium dengan forcep dan arahkan kebagian lateral dari garis tengah tubuh untuk mencegah kontaminasi urin. Untuk mengatasi permasalahan insisi, dapat dilakukan insisi pada bagian parapreputial, sehingga memisakan otot prepusium. Pembuluh darah yang ada dapat diligasi dengan elektrocautery diikuti dengan insisi untuk memperlihatkan linea alba pada bagian tersebut.



Gambar 9. Operasi Step 3 4. Setelah insisi pada kulit, jepit pembuluh darah bagian subkutan dengan electrocautery. Insisi otot rektus secara lateral untuk memperlihatkan linea alba. Hindari menginsisi terlalu lebar untuk mencegah terbentuknya dead space dan bentukan subsekuen serosa.



Gambar 10. Operasi Step 4



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5. Buat tusukan kecil dengan scapel pada linea alba dan masukan satu jari untuk memastikan tidak ada jaringan yang menempel pada bagian tersebut. Tusukan tersebut membuatu darah akan masuk kedalam rongga perut dan menjauhkan organ abdomen kearah dorsal.



Gambar 11. Operasi Step 5 6. Masukan pinset kedalam linea alba pada posisi yang telah dilubangi dan buat insisi pada bagian atasnya dimulai dari posisi cranial kearah kaudal. Dengan posisi ujung pinset mengarah kekranial.



Gambar 12. Operasi Step 6 7. Alternative lain untuk membuka rongga abdomen adalah dengan teknik menjepit linea alba dengan pinset sehingga terangkat dan lakukan tusukan dengan posisi bagian tajam scapel mengarah keatas.



Gambar 13. Operasi Step 7a 11



Gambar 14. Operasi Step 7b 8. Teknik membuka rongga abdomen dapat pula dilakukan dengan gunting mayo. 9. Setelah rongga abdomen terbuka, lindungi bagian yang dipotong dengan kain khusus dan gunakan balfour retractor untuk membuka dan mempertahankan bukaan abdomen.



Gambar 15. Operasi Step 9 10.Lakukan pemeriksaan pada organ abdomen secara sistematis.



Gambar 16. Operasi Step 10 11.Setelah pemeriksaan, cuci organ abdomen dengan cairan hangat (saline) dan hisap saline dengan alat penghisap setelah selesai dicuci.



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12. Tutup bagian abdomen dengan 3 lapisan jahitan. 



Bagian dalam ditutup dengan jahitan pola simple continue suture atau simple interrupted suture. Bahan yang digunakan adalah polydioxanone atau polygliconate. Pada waktu menutup linea alba, jahitan harus dilakukan bersamaan dengan pembungkus otot rectus abdominis.







Pada bagian subkutan, jahitan dilakukan dengan pola simple continue suture dan bahan yang dipakai adalah material absorbable monofilament. Ikatan yang dilakukan harus kuat dan tidak ada dead space. Karena itu, perlu menjaga agar pada saat penjahitan dilakukan sedekat mungkin (serapat mungkin).







Pada bagian kulit dilakukan jahitan dengan pola simple continue suture atau ford interlocking atau intradermal pattern with buried knots atau dengan staples.



4.4 Perawatan Pasca Laparotomy Perawatan pasca oprasi laparotomy pada hewan baik hean kecil maupun besar dapat dilakukan dengan pemberian antibiotik topikal dan general, pemberian pakan dan air yang cukup, perlindungan pada luka operasi, pemberian infus dan vitamin jika diperlukan, serta pembukaan jahitan pada hari ke 10-14 pasca operasi.



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BAB V SIMPULAN DAN SARAN



5.1 Simpulan Laparotomy merupakan penyayatan pada dinding abdomen atau peritoneal atau dapat diartikan sebagai pembedahan dinding abdomen melalui insisi ventral abdomen atau flank (dinding perut samping). Laparotomy terdiri dari beberapa jenis, antara lain : Laparotomy flank, medianus dan paramedius. Pada hewan besar, jenis laparotomy yang digunakan yaitu laparotomy flank sedangkan pada hewan kecil menggunakan laparotomy medianus ataupun paramedius. Laparotomy memiliki tujuan untuk pengobatan ataupun untuk meneguhkan suatu diagnosa. Untuk hewan besar seperti sapi atau kuda posisi hewan seringkali dalam keadaan berdiri tetapi untuk anjing atau kucing selalu dalam keadaan rebah dorsal. Letak irisan pada hewan besar didaerah flank sedangkan anjing atau kucing didaerah ventral abdomen. Adapun beberapa hal yang harus dilakukan dalam laparotomy, antara lain: persiapan pre-operasi, operasi laparotomy, dan perawatan pasca operasi laparotomy. 5.2 Saran Untuk kepentingan pendiagnosaan ataupun pengobatan pada sapi ataupun anjing yang berhubungan dengan abdominal, maka laparotomy dapat diberikan akan tetapi laparotomy harus sesuai dengan prosedur yang telah ditetapkan agar tidak terjadi kesalahan ataupun meminimalisir terjadinya infeksi sekunder akibat operasi yang dilakukan.



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DAFTAR PUSTAKA Abubakar, A.A, et.al. 2014. Comparative Evaluation of Midventral and Flank Laparotomy Approaches in Goat. Hindawi Publishing Corporation, Journal of Veterinary Medicine : Vol.2014, p.1-6 Dorner J, Dupre G. 2010. Two Step Protocol for Surgical treatment of Complicated or Bilateral Perineal Hernia in Dogs: Laparotomy Followed by Herniorraphy. The European Journal of Companion Animal Practice, Oktober Vol.20 p.186-192 Hickman, J et.al 1995. An Atlas of Veterinary Surgery Third Edition. Blackwell Science. Great Britain. Papazoglou, L. G; Basdani, E. 2015. Exploratory Laparotomy in the Dog & Cat. Ed. Oktober 2015, p. 15-21 Anonim. 2015. Abdominal Exploratory laparotomy. http://www.michigananimalhospital.com/abdominal-exploratory (diakses tanggal: 1 Oktober 2016) Hendricson, D. A. et.al. 2013. Turner and McIlwraith’s Techniques in Large Animal Surgery 4th Edition. Wiley Blackwell Publishing: United Kingdom. Sudarminto. Teknik Bedah Dasar, Restrain dan Casting. Yogyakarta : Universitas Gadjah Mada.file:///C:/Users/kersa%20jaya/Downloads/Teknik%20Bedah%20Dasar,%20Restr ain%20&%20Casting%20(5).pdf (diakses : Senin, 03 Oktober 2016) Bailey, J dan Saphiro Mj. 2006. Abdominal compartement syndrome. Crit care 4: 23-9. Davidson W, Davidson C (Ed). 2008. Practice of anesthesia 6th edition. Little brown. Boston.



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LAMPIRAN



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Hindawi Publishing Corporation Journal of Veterinary Medicine Volume 2014, Article ID 920191, 6 pages http://dx.doi.org/10.1155/2014/920191



Research Article Comparative Evaluation of Midventral and Flank Laparotomy Approaches in Goat A. A. Abubakar,1 R. A. Andeshi,1 A. S. Yakubu,1 F. M. Lawal,1 and U. Adamu2 1 2



Department of Veterinary Surgery and Radiology, Usmanu Danfodiyo University, Sokoto 2346, Nigeria Department of heriogenology and Animal Production, Usmanu Danfodiyo University, Sokoto 2346, Nigeria



Correspondence should be addressed to A. A. Abubakar; [email protected] Received 29 May 2014; Revised 21 July 2014; Accepted 21 July 2014; Published 24 August 2014 Academic Editor: Vito Laudadio Copyright © 2014 A. A. Abubakar et al. his is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. he aim of the study was to compare two laparotomy approaches (lank and midventral). Ten (� = 10) apparently healthy goats of diferent breeds and sex, average age of 12 ± 2.1 months, and average weight of 13.4 ± 2 kg were used for the investigation. he goats were randomly divided into lank and midventral groups, each group comprising ive goats (� = 5). Standard aseptic laparotomy was performed under lumbosacral epidural anaesthesia with mild sedation. Postsurgical wound score showed signiicant diference (� < 0.05) in erythema at 18–24 hours and 10–14 days ater surgery between the two approaches; signiicant diference of dehiscence between the two groups was also recorded at 10–14 days ater surgery. Total white blood cells (WBC) and lymphocytes counts were signiicantly diferent (� < 0.05) at the irst and second week ater surgery. here was signiicant diference of platelets critical value and platelets dimension width at the irst and second week ater surgery. Signiicant diference of packed cells volume between the two approaches was also recorded one week ater surgery. It was concluded that midventral laparotomy approach can be conveniently and safely performed under aseptic precautions without fear of intra- and postoperative clinical problems.



1. Introduction Laparotomy in goat is an invasive surgical procedure into the abdominal cavity that allows visual examination of abdominal organs and documentation and correction of certain pathologic abnormalities observed [1, 2]. Generally, it constitutes the single largest group of surgical operations carried out in ruminants [3, 4]. Laparotomy is indicated for exploration of abdominal and pelvic cavities and other surgical procedures involving abdominal and pelvic organs; other speciic indications are caesarean section, embryo transfer to produce transgenic goats, ovariectomy, rumenotomy, abomasotomy, ventral abdominal herniorrhaphy, intestinal resection, anastomosis, and cystotomy [5–11]. Two approaches (lank and midventral) have been recognized and are currently in use in both small and large animals surgery; however in ruminants lank approach is the most widely and frequently practiced [1, 2]; due to the fact that surgical site can be visualized and observed from a distance and access healing, it was also reported to have reduced potential risk



for evisceration if wound dehiscence is to occur, and the overlapping arrangement of the oblique muscles in the lank helps maintain the integrity of the abdominal wall if wound complication occurs [7]. he lank laparotomy approach is the most widely used among small ruminants surgeons for accessing abdominal and pelvic organs. However, the approach is associated with some challenges: animals tend to rub the surgical site during healing against available solid objects leading to loosening of sutures and subsequently formation of wound dehiscence, prolonged lateral recumbency in goats under anaesthesia is associated with decrease in rumen stasis thereby predisposing the animal to bloat and toxemic lactic acidosis, and the accessibility to the distant organs (far proximal or distal to the point of incision) is also limited [12]. We hypothesized that midventral laparotomy approach could be an alternative to lank laparotomy approach without much intra- and postsurgical complications. To test this hypothesis we compare the surgical wound assessment, intra- and postsurgical assessment, haematological proile, and subjective healing



2 interval of the two laparotomy approaches. he aim of the study was to compare and evaluate lank and midventral laparotomy approaches in goats.



Journal of Veterinary Medicine Table 1: Criteria used to score intraoperative and postsurgical complications. Outcome



2. Material and Methods Ten (� = 10) apparently healthy goats free of any dermatological lesions with average age of 12 ± 2.1 months (mean ± SD), male and female of diferent breeds, and average weight of 13.4 ± 2 kilograms (mean ± SD) were used for the investigation. he goats were kept at the Usmanu Danfodiyo University Veterinary Teaching Hospital facilities and were conditioned for two weeks during which they were evaluated and stabilized for surgery. During evaluation serial blood sampling was done for comprehensive haematology to ascertain that the goats are it for surgery and fecal sample was also collected to ascertain the intestinal worms burden. he goats were maintained on daily ration comprising wheat bran, bean husks, ground nut hay, and water ad libitum. he goats were randomly grouped into lank (FA) and midventral (MVA) approaches. Five (� = 5) goats were allocated to each group. 2.1. Surgical Procedure. Feed and water were withdrawn from animals at least 12 hours prior to the surgery. he let lank region of each goat in the FA group was prepared for routine aseptic surgery by clipping the hairs around the proposed surgical site; the site was scrubbed with Purit solution containing chlorhexidine gluconate B. P. 0.3% W/V (Saro Lifecare Limited, Lagos, Nigeria) and rinsed with methylated spirit (Binji Pharmaceutical Company, Sokoto, Nigeria). Regional anesthesia was achieved with plain lignocaine hydrochloride and lignocaine injection B. P. 2% (Sahib Singh Agencies, Mumbai, India) at 4 mg kg−1 through lumbosacral epidural anaesthesia as described by [13]. he epidural space was identiied by loss of resistance to injection of 1 mL of air ater piercing the ligamentum lavum. Mild sedation was achieved using xylazine 20 (xylazine HCl 20 mg mL−1 , Kepro Holland) at 0.025 mg kg−1 intramuscular and atropine sulphate 0.6 mg mL−1 (Laborate Pharmaceuticals India) at 0.05 mg kg−1 intramuscular as vagolytic agent. Goats in FA group were placed on right lateral recumbency exposing the let lank. Laparotomy was done according to standard procedure described by [1, 3, 14]. he laparotomy was routinely closed from within outward; muscle layers were closed using Becton chromic catgut of the size of 1/0 and atraumatic 1/2 circle taper point needle (Anhui Kangning Industrial Groups, China) using interrupted horizontal mattress suture pattern with simple interrupted reinforcement. he subcutaneous layer was closed using Becton chromic catgut of the size of 2/0 and atraumatic 1/2 circle taper point needle using simple continuous suture pattern. he skin was closed using Ford interlocking pattern with Agary nylon of the size of 0 and atraumatic 3/8 curved, cutting needle (Agary PharmaceuticalsLtd, Xinghuai, China). In MVA group, the cranial midventral area was prepared for aseptic procedure as described in FA group. Regional anesthesia was also achieved as described in FA group.



Haemorrhage Seroma Wound istula Incisional hernia



0 None None None None



Scores 1 Mild Mild Mild Mild



2 Severe Severe Severe Severe



Each animal was placed on dorsal recumbency exposing the midventral region. Laparotomy was done through linea alba in all female goats with little paramedian incision at the level of prepuce in all the males according to standard procedure described by [1, 3, 4]. he incision was closed routinely in three layers from within outward (linea alba, subcutaneous layer, and skin) with the same suture materials as described in FA group. he linea alba was closed using interrupted horizontal mattress pattern with simple interrupted reinforcement. 5% acetaminophen injection 10 mg kg−1 intramuscular (Cadence Pharmaceutical Inc., Ireland) was administered for 3 days ater surgery to take care of postoperative pain. Long acting 15% amoxicillin injection 20 mg kg−1 (Vetrimoxin) was administered once ater surgery. 2.1.1. Surgical Wound Assessment. he clinical appearance of the skin was assessed and scored twice: 18–24 hours and 10–14 days ater surgery as described by [15] using 4-point scoring scale, based on the following criteria: discharge, swelling, erythema, and dehiscence. 2.1.2. Haematology. Blood samples were collected from each animal in the two groups through the jugular vein ater thorough disinfection of the area with methylated spirit; the sample was collected using 5 mL syringe and needle into EDTA bottles. he samples were collected before surgery as baseline, 18–24 hours ater surgery, and subsequently on weekly interval till complete healing when sutures were removed. he samples were analyzed using digital automated haemoanalyser (Full Automated Blood Cell Counter PCE-210, Erma Inc., Tokyo, Japan) according to procedure described [16]. 2.1.3. Intra- and Postoperative Complications. Intra- and postsurgical complications were assessed using 3-point scoring system designed by ourselves; parameters considered were intraoperative haemorrhages, postsurgical seroma, incisional hernia, and wound istula (Table 1). 2.2. Subjective Healing Interval. Subjective healing interval was determined by visual observation and taking notes of days of apparent surgical site healing according to [17]. 2.3. Statistical Analysis. Data generated from the four parameters (surgical wound scoring, haematology, surgical complications, and healing interval) were tabulated and mean and standard deviation were computed in each case. Student’s



Journal of Veterinary Medicine



3



Table 2: Postsurgical wound assessment score of lank and midventral approaches at 18–24 hours and 10 days (mean ± SD). Parameters



Discharge Swelling Erythema Dehiscence



Groups FA MVA FA MVA FA MVA FA MVA



18–24 hrs ater surgery 0.80 ± 0.45 0.80 ± 0.84 1.80 ± 0.45 2.00 ± 0.00 1.40 ± 0.55a 0.80 ± 0.45b 0.00 ± 0.00 0.00 ± 0.00



Scores 10–14 days ater surgery 0.00 ± 0.00 0.00 ± 0.00 0.50 ± 0.56 0.80 ± 0.45 0.25 ± 0.50a 0.00 ± 0.00b 0.25 ± 0.50a 0.00 ± 0.00b



ab



Pair of means bearing diferent superscript are signiicantly diferent (� < 0.05).



�-test was used to compare statistical signiicant diference between the lank and midventral variables of each parameter at 95% conident interval using GraphPad Instat Statistical sotware package 2010. � value was considered signiicant when � value is less than 0.05.



3. Results 3.1. Postsurgical Wound Assessment. At 18–24 hours ater surgery, there was serous discharge in all groups; the mean discharge scores were (0.80±0.45 and 0.80±0.84) for lank and midventral approaches, respectively. here was no signiicant diference between the two groups when compared. At 10–14 days ater surgery, there was no discharge observed (Table 2). Midventral group had higher swelling score (2.00 ± 00) in comparison with lank approach (1.8 ± 0.45) and the overall swelling score was higher at 18–24 hours ater surgery compared to 10–14 days ater surgery (0.50 ± 0.56 and 0.80 ± 0.45) in lank and midventral, respectively (Table 2). here was no signiicant diference between lank and midventral approach both at 18–24 hrs and at 10–14 days ater surgery. he lank approach at 18–24 hours had higher erythema score (1.40 ± 0.55) when compared with midventral group (0.80 ± 0.45) and there was signiicant diference (� < 0.05) of erythema between the two approaches (Table 2). At 10–14 days ater surgery, lank approach had higher erythema score (0.25 ± 0.50) while midventral approach had no erythema record and there was signiicant diference (� < 0.05) between the two approaches. Dehiscence was not recorded at 18–24 hours ater surgery in all the groups; however, at 10–14 days ater surgery dehiscence was observed in lank approach with signiicant diference (� < 0.05) between the two groups (Table 2). 3.2. Intra- and Postsurgical Complications. Intraoperative haemorrhage score was higher in lank approach (1.4 ± 0.55) when compared with midventral approach (1.00±0.70); there was no signiicant diference (� > 0.05) between the two groups (Table 3). here were no postoperative complications of incisional hernia, seroma, and wound istula recorded.



Table 3: Intra- and postsurgical complications scores of lank and midventral approaches (mean ± SD). Parameters Intraoperative complication Haemorrhage



Groups



Scores



FA MVA



1.40 ± 0.55 1.00 ± 0.70



FA MVA FA MVA FA MVA



0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00



Postoperative complications Incisional hernia Seroma Wound istula



here is no signiicant diference (� > 0.05).



3.3. Haematological Proiles. here were variations of total white blood cells (WBC) count of the two approaches before surgery, at 18–24 hours, and at the irst and second week ater surgery; the midventral group had higher WBC value at all the intervals with signiicant diferences (� < 0.05) at irst and second week ater surgery (Table 4). here were slight variations of total granulocytes between the two groups with the midventral group having the higher values at all the intervals, but there is no signiicant diference between the two groups (Table 4). he lymphocytes values of the two groups also varied and the midventral approache had the highest value. here were signiicant diferences (� < 0.05) recorded between the two approaches at irst and second week interval: 21.33 ± 8.22 lank approach against 28.32 ± 11.98 midventral approach and 15.20 ± 3.52 lank approach against 25.48 ± 6.00 midventral approach (Table 4). here were also slight variations of monocytes values between the lank and midventral approaches at diferent timing interval; the midventral had higher values when compared with lank approach but there were no signiicant diferences between the two approaches at any given time interval (Table 4). he values of the platelets varied slightly between the two approaches, with the midventral approach having a higher value when compared with lank approach, and there was no signiicant diference between the two approaches at all the timing intervals (Table 5). he platelets critical values varied between the two approaches with the midventral having the higher values; there was signiicant diference (� < 0.05) at second week interval between the lank and midventral approach (0.15 ± 0.04 against 0.25 ± 0.08), respectively (Table 5). he mean platelets volumes also showed slight variations between the two groups, but there was no signiicant diference between the groups at any of the timing intervals; the midventral approach had higher values when compared with the lank approach (Table 5). he platelets dimension width values were slightly higher in midventral approach compared to lank approach and a signiicant diference (� < 0.05) was recorded between the two approaches at 18–24hour interval (Table 5). he packed cells volume of the two approaches showed slight variations with the midventral approach having the



4



Journal of Veterinary Medicine



Table 4: Total leucocytes and diferential leucocytes counts before and ater surgery of the lank and midventral approaches (mean ± SD). Parameters



Groups



Total WBC (×103 /�ℓ) Granulocytes (×103 /�ℓ) Lymphocytes (×103 /�ℓ) Monocytes (×103 /�ℓ) ab



FA MVA FA MVA FA MVA FA MVA



Before surgery 25.48 ± 4.19 33.86 ± 9.96 11.10 ± 3.69 11.38 ± 4.41 11.74 ± 3.27 33.86 ± 3.40 2.60 ± 0.89 4.14 ± 1.02



18–24 hrs ater surgery 37.70 ± 3.90 50.52 ± 16.32 13.24 ± 3.45 20.90 ± 10.51 19.16 ± 2.61 24.06 ± 7.37 4.08 ± 1.21 5.60 ± 1.54



Mean scores One week ater surgery 34.93 ± 3.12a 51.08 ± 5.07b 10.23 ± 5.72 18.62 ± 5.07 21.33 ± 8.22a 28.32 ± 11.98b 3.35 ± 0.66 4.12 ± 0.44



Two weeks ater surgery 32.98 ± 5.28a 45.62 ± 6.85b 13.85 ± 5.33 15.06 ± 3.52 15.20 ± 5.05a 25.48 ± 6.00b 3.88 ± 0.66 5.06 ± 3.52



Pair of means bearing diferent superscript are signiicantly diferent (� < 0.05).



Table 5: Platelet characteristics before and ater surgery of the two approaches (mean ± SD). Parameters



Groups 3



Platelets (×10 /�ℓ) Platelets critical value (%) Mean platelets volume (�ℓ) Platelets dimension width (�ℓ)



Mean scores 18–24 hrs ater surgery One week ater surgery 375.60 ± 99.58 369.95 ± 144.66 416.60 ± 94.88 376.20 ± 90.78 0.21 ± 0.06 0.21 ± 0.08 0.24 ± 0.05 0.22 ± 0.03 5.68 ± 0.22 5.60 ± 0.09 5.74 ± 0.08 5.72 ± 0.22 684.80 ± 0.29a 684.30 ± 0.05 684.2 ± 0.18 684.22 ± 0.20b



Two weeks ater surgery 269.75 ± 128.18 444.40 ± 149.93 0.15 ± 0.04a 0.25 ± 0.08b 5.55 ± 0.24 5.68 ± 0.13 684.30 ± 0.47 684.12 ± 0.18



Pair of means bearing diferent superscript are signiicantly diferent (� < 0.05).



higher PCV values when compared with the lank approach. here was signiicant diference (� < 0.05) recorded at one week interval between the two approaches (Table 6). here were no signiicant diferences (� > 0.05) between the two approaches in all other erythrocytic indices (red blood cells count, haemoglobin, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, and red blood cells distribution width). However, the values of midventral approach are higher at diferent timing intervals in all other erythrocytic indices (Table 6). 3.4. Subjective Healing Interval. he mean subjective healing intervals were 13.0 ± 1.14 and 12.4 ± 0.5 for lank and midventral approach. Midventral approach had lower mean healing intervals in days compared to the lank approach. here was no signiicant diference (� = 0.643) between the two groups when compared (Figure 1).



35 Subjective healing interval (days)



ab



FA MVA FA MVA FA MVA FA MVA



Before surgery 287.20 ± 123.58 351.40 ± 75.20 0.16 ± 0.07 0.20 ± 0.04 5.60 ± 0.14 5.72 ± 0.09 683.90 ± 0.37 684.26 ± 0.13



30



12 14



13



25



11



12 20 17 15 13



12



13 10



10 5 0 1



2



3



4



5



Number of animals per group MVA FA



4. Discussions



Figure 1: Subjective healing interval (days) of the animals lank (FA) and midventral (MVA) approaches.



Laparotomy is commonly indicated either for exploratory purposes when clinical diagnosis is uncertain or for therapeutic surgical intervention when speciic diagnosis has been made [2]. Flank approach is the most commonly practiced technique among large animal surgeons with the animal under local anaesthesia [18]. Ventral paramedian or midventral laparotomy approach is an alternative practice by few large animal surgeons that necessitates the animal



placement in dorsal recumbency. he two main indications in bovine are ventral abomasopexy and cesarean section, in which it ofers advantages in the delivery of oversized or emphysematous fetuses and in complicated deliveries, including uterine tears [12, 19]. Surgical wound assessment showed signiicant diference of erythema both at 18–24 and at 10–14 days ater surgery



Journal of Veterinary Medicine



5



Table 6: Erythrocytic indices before and ater surgery of the two approaches (mean ± SD). Parameters



Groups



FA MVA FA PCV (%) MVA FA Haemoglobin (g/d) MVA FA Mean corpuscular volume (�ℓ) MVA FA Mean corpuscular haemoglobin (pg) MVA FA Mean corpuscular haemoglobin con. (g/L) MVA FA RBC distribution width (%) MVA RBC (×106 /�ℓ)



ab



Mean scores Before surgery 18–24 hrs ater surgery One week ater surgery Two weeks ater surgery 12.32 ± 1.35 12.79 ± 1.23 12.23 ± 1.32 12.10 ± 2.07 13.13 ± 0.51 13.69 ± 0.52 13.36 ± 0.85 13.03 ± 1.05 21.92 ± 2.56 24.66 ± 5.24 16.15 ± 2.85a 22.75 ± 5.98 25.22 ± 1.19 25.90 ± 1.15 25.72 ± 4.37b 23.84 ± 3.07 8.12 ± 1.36 8.98 ± 2.25 8.63 ± 1.51 8.68 ± 2.19 9.16 ± 0.43 9.84 ± 0.59 9.86 ± 1.28 9.30 ± 1.36 17.72 ± 2.56 19.08 ± 2.37 17.58 ± 0.88 18.58 ± 1.98 19.10 ± 2.09 18.06 ± 0.57 14.10 ± 2.09 18.20 ± 1.13 6.50 ± 0.42 6.88 ± 0.95 6.78 ± 0.50 7.00 ± 1.13 6.92 ± 0.04 7.13 ± 0.26 7.37 ± 0.61 7.04 ± 0.48 36.80 ± 2.16 36.26 ± 3.50 38.5 ± 1.94 37.36 ± 2.18 36.32 ± 1.91 37.96 ± 1.90 38.58 ± 3.12 38.94 ± 1.82 30.18 ± 4.71 32.00 ± 4.37 30.98 ± 4.86 29.80 ± 6.19 32.18 ± 1.26 34.48 ± 1.96 33.40 ± 2.23 32.92 ± 2.72



Pair of means bearing diferent superscript are signiicantly diferent (� < 0.05).



with lank approach having the highest erythema score and this could be due to surgical trauma elucidated by the traumatic surgical instruments on the sot tissue in the course of surgery; this is because the lank region has three layers of abdominal muscles that have to be passed through before getting access into the abdominal cavity in comparison with midventral approach through linea alba aponeurosis (ligament) which is passed through before gaining access to abdominal cavity; the ligament poorly responds to pressure of traumatic surgical instruments which brought about the less erythematous response. he high erythema score recorded in lank approach could also be a result of abdominal muscles tissue response to absorbable suture materials used for apposing the muscles mass which is more bulky than that of midventral approach. he overall scoring showed higher erythema earlier before surgery at 18–24 hours and this inding is consistent with the studies conducted by [15, 17] where signiicant diferences among the variables were observed. Dehiscence was also observed in the lank approach at 10–14 days ater surgery with signiicant diference when compared with midventral approach; this could be a result of scratching the surgical site (lank) with available objects in the pen as a result of tissue irritation in the course of healing process. It could also be due to self-mutation with horn of hind limbs in response to tissue irritation. Dehiscence score was by far less in midventral approach due to lesser chances of scratching and self-mutilation around the region. Our inding was contrary to that of [15], which recorded no dehiscence in a similar study using canine species, and that of [17], which recorded mild dehiscence both at 18–24 hours and at 10– 14 day ater surgery but without signiicant diference in a similar study using caprine species. he intraoperative hemorrhage score recorded was higher in the lank approach compared with the midventral approach, though without signiicant diference; this could be a result of high vascular channels available in the abdominal



muscle mass when compared to poor vasculatures associated with tendons and ligament in the linea alba. his could serve as one of the advantages of midventral approach particularly when dealing with nonelective laparotomy in which the patient hematocrit reading is below normal range. he packed cell volume (PCV) of the lank approach decreased signiicantly one week ater surgery when compared with midventral approach; this could be due to high intraoperative hemorrhage recorded. his inding was in line with the inding of [20, 21], both in a study involving laparotomy with goat; they noted that remarkable hematocrit decreased ater surgery with signiicant diference. [8] also reported signiicant decrease in PCV in postoperative abdominal surgery in bovine. Higher values of total white blood cells count and lymphocytes count were recorded in midventral approach at the second week ater surgery with signiicant diference when compared with the lank approach and this could be attributed to high persistent chronic inlammatory response in the course of tissue repair or it could be due to surgical stress because midventral approach is more stressful in relation to surgical positioning than lateral recumbency. Our inding is also in line with those of [20, 21] who also recoded elevated values leukocytes count. But [8] noticed an average total leukocytes value within normal physiologic range ater abdominal surgery in dairy cows. Percentage platelets critical value recorded was higher in midventral approach; this could be due to lesser whole blood loss observed intraoperatively as decrease in whole total blood volume leads to gross interference of the diferent components of the blood cells including platelets. his may also serve as an advantage in midventral approach because the higher the platelets critical values, the quicker the chances of blood clotting response. here were slight variations of means subjective healing interval of the two approaches but without signiicant diference (� = 0.643), with the lank approach having higher means number of days (13± 1.14) to complete surgical



6 wound healing when compared with 12.4 ± 0.5 mean days for midventral approach. he slight variation of days of healing interval might be due to surgical site interference with the object coming contact with the surgical wound as reported by [22, 23], as the chance of surgical site contact with surrounding object is higher in lank laparotomy site compared to midventral site. he variation could also be a result of other local factors that afect wound healing like oxygenation, foreign body contact with the surgical wound, and venous insuiciency as reported by [23].



5. Conclusion It was concluded that the midventral laparotomy approach can be safely and conveniently performed without fear of clinical complications in goats. When correctly performed, it will ofer less intraoperative hemorrhage and postoperative tissue reactions. We recommend the use of midventral laparotomy approach for routine abdominal surgery in goats as an alternative to lank approach. Further study on pregnant goats to see whether midventral abdominal incisional closure can withstand pressure of gravid uterus also needs to be conducted.



Conflict of Interests he authors declare that there is no conlict of interests regarding the publication of this paper.



Acknowledgments he authors appreciate the efort of Mallam Bello Kaura of haematology laboratory, college of health sciences, for processing the blood samples. hey also appreciate the efort of technical staf too numerous to mention in large animal surgery of Veterinary Teaching Hospital, Usmanu Danfodiyo University, Sokoto.



References [1] N. K. Ames, Noordsy's Food Animal Surgery, Wiley-Blackwell, 5th edition, 2007. [2] D. A. Hendrickson, Techniques in Large Animal Surgery, Blackwell Publishing, Ames, Iowa USA, 3rd edition, 2007. [3] D. E. Freeman, Abdominal Surgery: Summary Procedure and Principles, International Veterinary Information Service, New York, NY, USA, 2003. [4] S. R. R. Haskell, “Surgery of the sheep and goat digestive system,” in Farm Animal Surgery, S. L. Fublin and N. G. Ducharme, Eds., pp. 521–526, Saunders an Imprint of Elservier, 2004. [5] S. N. Dehghani and A. M. Ghadrdani, “Bovine rumenotomy: comparison of four surgical techniques,” he Canadian Veterinary Journal, vol. 36, no. 11, pp. 693–697, 1995. [6] M. hibier and B. Gu´erin, “Embryo transfer in small ruminants: the method of choice for health control in germplasm exchanges,” Livestock Production Science, vol. 62, no. 3, pp. 253– 270, 2000.



Journal of Veterinary Medicine [7] D. C. van Metre, J. W. Tyler, and S. M. Stehman, “Diagnosis of enteric disease in small ruminants.,” he Veterinary Clinics of North America: Food Animal Practice, vol. 16, no. 1, pp. 87–115, 2000. [8] K. Nuss, B. Lejeune, C. Lischer, and U. Braun, “Ileal impaction in 22 cows,” Veterinary Journal, vol. 171, no. 3, pp. 456–461, 2006. [9] F. A. Al-Sobayil and A. F. Ahmed, “Surgical treatment for diferent forms of hernias in sheep and goats,” Journal of Veterinary Science, vol. 8, no. 2, pp. 185–191, 2007. [10] T. S. Sang, K. J. Sung, S. Y. Hong et al., “Laparoscopy versus laparotomy for embryo transfer to produce transgenic goats (Capra hircus),” Journal of Veterinary Science, vol. 9, no. 1, pp. 103–107, 2008. [11] P. P. M. Teixeira, L. C. Padilha, T. F. Motheo et al., “Ovariectomy by laparotomy, a video-assisted approach or a complete laparoscopic technique in Santa Ines sheep,” Small Ruminant Research, vol. 99, no. 2-3, pp. 199–202, 2011. [12] L. G. Schultz, J. W. Tyler, H. D. Moll, and G. M. Constantinescu, “Surgical approaches for cesarean section in cattle,” Canadian Veterinary Journal, vol. 49, no. 6, pp. 565–568, 2008. [13] A. B. Sadegh, Z. Shaiei, and S. D. Nazhvani, “Comparison of epidural anesthesia with lidocaine-distilled water and lidocaine-magnesium sulfate mixture in goat,” Veterinarski Arhiv, vol. 79, no. 1, pp. 11–17, 2009. [14] R. P. S. Tuagi and S. Jit, “Ruminant surgery,” in Textbook of the Surgical Disease of Cattle, Bufaloes, Camels, Sheep and Goats, pp. 195–223, C.S.B Publishers and Distributors, New Delhi, India, 1993. [15] A. Sylvestre, J. Wilson, and J. Hare, “A comparison of 2 diferent suture patterns for skin closure of canine ovariohysterectomy,” Canadian Veterinary Journal, vol. 43, no. 9, pp. 699–702, 2002. [16] D. J. Weiss, “Application of low cytometric techniques to veterinary clinical hematology,” Veterinary Clinical Pathology, vol. 31, no. 2, pp. 72–82, 2002. [17] A. A. Abubakar, J. B. Adeyanju, R. O. C. Kene et al., “Evaluation of three suture techniques based on surgical wound assessment in Caprine,” Scientiic Journal of Veterinary Advances, vol. 1, no. 4, pp. 101–104, 2012. [18] P. Mulon and A. Desrochers, “Surgical abdomen of the calf,” Veterinary Clinics of North America—Food Animal Practice, vol. 21, no. 1, pp. 101–132, 2005. [19] Z. B. Ismail, A. Al-Majali, and K. Al-Qudah, “Clinical and surgical indings and outcome following rumenotomy in adult dairy cattle afected with recurrent rumen tympany associated with non-metallic foreign bodies,” he American Journal of Animal and Veterinary Sciences, vol. 2, no. 3, pp. 66–71, 2007. [20] A. Mohammed, I. O. Igbokwe, and H. Abdul, “Observations on the proximal duodenal obstruction in Borno White goats,” Small Ruminant Research, vol. 12, no. 2, pp. 185–192, 1993. [21] L. O. Aka, R. I. Obiadike, C. A. Eze, and C. O. Igbokwe, “Physiological evidence of good tolerance of concurrent rumen istlation and duodenal cannulation in West African Dwarf Sheep,” Animal Research International, vol. 6, no. 2, pp. 1019–1027, 2009. [22] J. L. Burns, J. S. Mancoll, and L. G. Phillips, “Impairments to wound healing,” Clinics in Plastic Surgery, vol. 30, no. 1, pp. 47– 56, 2003. [23] S. Guo and L. A. DiPietro, “Factors afecting wound healing,” Journal of Dental Research, vol. 89, no. 3, pp. 219–229, 2010.



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gASteRointeStinAl SYSteeM REPRINT PAPER (A)



Two-step protocol for surgical treatment of complicated or bilateral perineal hernia in dogs: Laparotomy followed by herniorrhaphy J. Dörner (1) and G. Dupré (2) SUMMARY Incidence of recurrences after surgical repair of perineal hernias in dogs is a well-known and frequently observed problem. Depending on the method used, recurrence rates can be as high as 45% [Bellenger, 1980; Burrows and Harvey, 1973]. Particularly in cases of complicated perineal hernias with concomitant diseases of the rectum and/ or prostate or urinary bladder retrolexion, morbidity is considerably increased. These concurrent conditions are also responsible for higher recurrence rates after perineal hernia surgery. On the basis of a case report originally presented by [Brissot et al. 2004], this paper describes a two-step protocol for surgical repair of complicated, bilateral or recurrent perineal hernia. Before performing the perineal herniorrhaphy, laparotomy is carried out as the initial step of repair, including colopexy, vasopexy and – in dogs with urinary bladder retrolexion – also cystopexy. During laparotomy, alterations of the affected organs (urinary bladder, rectum, prostate gland) cannot only be evaluated macroscopically but can immediately be treated surgically. A few days later, herniorraphy is performed using an internal obturator muscle lap for closure of the hernia or other modiied methods like supericial gluteal muscle transposition or fascia lata graft. This article focuses on the advantages and disadvantages of this two-step protocol and gives a description of speciic indications for this procedure. Key words: Perineal hernia, dog, herniorraphy, laparotomy, colopexy



recurrent hernia. Any additional complication contributes to the severity of PH and should be carefully evaluated during the initial examination. Rectal alterations associated with PH are classiied as deviation (abnormal rectal orientation), sacculation (symmetric or asymmetric sudden increase in rectal diameter) and diverticulum (protrusion of rectal mucosa associated with tearing of the muscular wall of the rectum) [Mann and Boothe, 1985; Krahwinkel, 1975; Hosgood et al., 1995]. Brissot et al. established a grading scheme for rectal lesions



This paper originally appeared in: Wiener Tierärztliche Monatsschrift* (2008), 95: p. 269-276



Introduction Diagnosis of perineal hernias (PH) is based on the patient´s history and physical and rectal examinations. Hernias are characterized as unilateral or bilateral, simple or complicated (with additional pathologies of urinary bladder and/or prostate or rectum) or



(1) Clinic of Surgery and Ophthalmology, Vienna University of Veterinary Medicine; Veterinärplatz 1, A-1210 Vienna. E-mail: [email protected] (2) Univ. Prof. Dr. Gilles Dupré, Clinic of Surgery and Ophthalmology, Vienna University of Veterinary Medicine; Veterinärplatz 1, A-1210 Vienna. * Presented by VÖK (Austria)



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Fig. 1: Right-sided perineal bulging; male Dachshund (8.5 years)



Fig. 2: Perineal cystocentesis



where 0 = no lesion, 1 = deviation without rectal dilation, 2 = mild rectal dilation, 3 = severe unilateral, or mild to severe bilateral dilation. Mild rectal dilation is deined as asymmetric dilation with accumulation of impacted faeces but without any visible perineal deformation. Manual evacuation of the rectum is usually possible without any problems. in contrast, asymmetric rectal dilation with massive faecal impaction and obvious perineal swelling is qualiied as severe dilation. Retrolexion of the urinary bladder is clinically assessed by palpation of a more or less luctuant perineal swelling (depending on bladder illing). the bladder is no longer palpable in the caudal abdomen. Ultrasonography of the abdomen is recommended. the perineal region can also be examined by this technique, and an ultrasound-guided puncture of the swelling may be advisable in selected cases; aspiration of urine conirms the tentative diagnosis of bladder retrolexion. According to Brissot et al. [2004], PH is deined as complicated if the following criteria are met: recurrent PH, unilateral PH with severe rectal dilation, PH with concurrent prostate disease requiring surgical intervention (e.g. prostate omentalization) or PH in combination with urinary bladder retrolexion. the traditional approach to treatment of perineal hernias is by closure of the defect using the pelvic diaphragm. Several techniques have been described like the transposition of the supericial gluteal muscle [Spreulll and Frankland, 1980; Weaver and omamegbe, 1981], the internal obturator muscle lap [Weaver and omamegbe, 1981; Hardie et al., 1983; Sjollema and van Sluijs, 1989; orsher,1986; Hosgood et al., 1995] or a combination of both [Raffan, 1993]. Also remote laps like the semitendinosus muscle lap have been used [Chambers and Rawlings, 1991]. in cases where the obturator muscle is not apt



for transposition, i.e. in small dogs, in recurrent PH or in dogs with severe atrophy of the obturator muscle, a fascia lata graft or a polypropylene hernia mesh can be used to close the defect [Vnuk et al., 2006; Bongartz et al. 2005]. the high incidence of perineal hernias with concomitant lesions of the rectum, prostate or bladder [Dupre et al. 1993, 1996 and 2000] has led to the development in 1993 of a two-step approach for surgical repair of complicated or bilateral PH. As a irst step, laparotomy is performed followed by the second step, the perineal herniorraphy using an internal obturator muscle lap [Dupre et al., 1993]. With this protocol, the mentioned authors carried out a long-term outcome study. During four years, a total of 41 dogs with complicated or bilateral perineal hernias were treated according to this protocol, and outcome was followed for more than six months. Satisfactory results were obtained in complicated PH using laparotomy in combination with colopexy (ColP), cystopexy (CYSP) or vas deferens pexy (DeFP) as additional treatment [Bilbrey et al., 1990; Huber et al., 1997; Dupre et al., 1993; Maute et al., 2001]. on the basis of one case report, this paper describes the protocol recommended by Brissot et al. [2004] discussing advantages and disadvantages of the technique.



Case report An 8.5 year old male intact Smooth Dachshund was presented to the Clinic of Surgery and ophthalmology at the Vienna University of Veterinary Medicine with a history of long-standing defecation problems and tenesmus. in addition, the dog showed acute anuria, which had started the day before. A right-sided soft and luctuant perineal swelling of about the size of a ist was observed (Fig. 1).



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Two-step protocol for surgical treatment of complicated or bilateral perineal hernia in dogs - J. Dörner and G. Dupré



A clinical and rectal examination was performed. the patient displayed cardiovascular instability, dry and reddened mucosae, a weak pulse and a cardiac frequency of 200 beats/min. inner body temperature was 38.9 °C and the patient´s abdomen was painful on palpation. the urinary bladder could not be palpated in the abdomen. Rectal examination to assess the grade of rectal alterations revealed severe dilation and deviation of the rectum to the right, with massive faecal impaction and obvious perineal bulging. Based on abdominal, perineal and rectal palpation indings, a unilateral perineal hernia was diagnosed. the luctuant swelling in the perineal region was punctured yielding urine. As this was a clear sign of bladder entrapment in the hernia, immediate therapy was indicated and it was tried to introduce a urinary catheter into the urethra. this was not possible due to bladder retrolexion so the bladder had to be emptied by perineal cystocentesis (Fig. 2). once the bladder had been reduced in size, it could be advanced cranioventrally into the abdomen by applying moderate pressure. With the bladder in normal position, it was possible to place the urinary catheter. A closed system (a catheter directly connected to a scaled urine bag) was used to collect and measure the produced urine. the catheter was sewed to the tip of the prepuce and remained in place until surgery was performed. After stabilization of the patient´s cardiovascular system by administration of a shock treatment infusion (60 ml/ kg lactated Ringer´s solution [Ringerlactat Fresenius®] during 30 minutes) and analgesics (0.1 mg/kg methadone [Heptadon®]), ultrasonography of the abdomen was performed. Sonographic examination revealed a hyperechoic, dense and enlarged prostate (5.4 x 4 cm) with inhomogeneous parenchyma as well as several irregularly shaped intraprostatic cysts of up to 0.8 cm. the urinary bladder was small with an irregularly thickened wall. Mesenteric and sublumbar lymph nodes were not enlarged. Both testicles showed homogeneous texture of intermediate echogenicity. Perineal tissue was characterized by signiicant liquid accumulation around the rectum and by severe oedema. Wall thickness of the ampulla recti was increased measuring up to 3 mm. According to perineal hernia (PH) classiication as mentioned in the introduction, the dog suffered from a complicated PH, as in



addition to severe dilation of the rectum (grade 3) there were also retrolexion of the bladder and sonographically evident prostate alterations. For this reason, laparotomy was recommended as the initial step of the staged surgery protocol. After premedication with 0.2 mg/kg butorphanol (Butomidor®) and 0.1 mg/kg diazepam (Valium®), anaesthesia was induced with 1.5 mg/kg etomidate (etodmidat-lipuro®). the dog was then intubated and anaesthesia was maintained with isolurane in oxygen. in addition, the patient received a perioperative constant rate infusion of butorphanol (0.2 mg/kg/h). Before starting the procedure, the caudal part of the dog´s rectum was manually evacuated and the patient was positioned in dorsal recumbency. Before opening the peritoneal cavity, the dog was castrated. For surgical repair or at least improvement of the rectal dilation, an incisional musculo-muscular colopexy was performed by digitally retracting the caudal part of the colon into the abdominal cavity and making a longitudinal seromuscular incision of 3-5 cm in the antimesenterial side of the distal descending colon. At the same level, on the left abdominal wall (approx. 3 cm lateral to the linea alba) another incision of the same length was made in the peritoneum and through the underlying muscular layer (Fig. 3). then, the incisional edges of colon and abdominal wall were apposed and pexied by two rows of simple continuous sutures (Fig. 4). each suture included the submucosa of the colon but extreme care was taken in order not to perforate the mucosa completely, as this would have meant severe bacterial contamination of the entire surgical ield. to prevent recurrence of bladder retrolexion, the urinary bladder was also ixed to the abdominal wall performing an incisional musculo-muscular cystopexy (Fig. 5). For that purpose, two incisions were made: the irst one of about 2-3 cm in the ventral pole of the bladder (taking care not to damage the mucosa) and another one into the abdominal wall, at the same level as the irst incision and some centimetres from the midline. then, the bladder was ixed to the abdominal wall by placing several simple interrupted sutures. A vasopexy should contribute to maintain bladder and prostate in a cranial position. Both the right and the left ductus deferens were secured to the abdominal wall (Fig. 6). Approximately 1-2



Fig. 3: Incision in the left abdominal wall to prepare colopexy



Fig. 4: Two rows of simple continuous sutures were used for colopexy



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Fig. 5: Cystopexy



Fig. 6: Vas deferens pexy



cm above the colopexy site on the left side, an incision was made into the peritoneum and the underlying muscular layer, and the deferent duct was ixed by two simple interrupted sutures placed at a certain distance to each other. the same procedure was performed on the right side to secure the right deferent duct. For all pexies, 3-0 or 4-0 monoilament synthetic absorbable suture was used. As the patient´s prostate was enlarged and several intra- and paraprostatic cysts had been detected, two biopsies were taken from the prostatic parenchyma for pathohistological examination and microbial cultures. Considering the reduced size of the intraprostatic cysts, it was decided to refrain from performing an omentalization of the prostate. After lavage of the abdominal cavity using warm Ringer´s solution, the abdomen was closed in three layers. Postoperatively, the patient was given buprenorphine (temgesic®; 0.3 mg/kg every 8 hours) and carprofen (Rimadyl®; 4.4 mg/kg every 24 hours). After two days of hospitalization, the dog was discharged from the clinic for home care during the next four days. the owner was instructed to administer 2 ml lactulose (laevolac®) orally twice a day in order to facilitate defecation. Four days after the irst intervention, the dog was again hospitalized to prepare the second step of the staged surgery protocol and perform herniorrhaphy. Premedication and anaesthesia were the same as for the irst surgery. in addition, epidural anaesthesia was performed administering 1 mg/kg bupivacaine (Carbostesin®) and 0.2 mg/ kg methadone (Heptadon®). the dog was placed in sternal position with the pelvis slightly elevated. the entire tail was clipped and ixed over the back in cranial direction without applying excessive tension. the rectum was digitally evacuated removing a small quantity of faeces, and the anal sacs were manually expressed. A purse-string suture was placed around the anus to achieve its temporary closure. the lumbosacral area, the perineum and the caudolateral part of the right thigh were also clipped and aseptically prepared for surgery (Fig. 7). Herniorraphy was performed by ioMF (internal obturator muscle lap) [Hardie et al. 1983] using 0 monoilament synthetic absorbable sutures. the fascia was incised at the origin of the internal obturator muscle and an incision was made into the



periosteum along the caudal border of the ischium. the internal obturator muscle was then dissected in cranial direction up to the obturator foramen and elevated from the ischium. then, the muscle was transposed dorsomedially to allow apposition between the coccygeus, levator ani and external anal sphincter muscle, and simple interrupted sutures were placed to ix the lap. As the internal obturator muscle was very weak in this dog – a phenomenon frequently observed in dogs of small breeds – an additional fascia lata graft was used. For this purpose, a part of the fascia lata (Fig. 8) was taken from the ipsilateral thigh, directly placed into the perineal defect and secured to the adjacent muscles using simple interrupted sutures. Routine closure of all surgical wounds was done using 3-0 monoilament synthetic sutures (Fig. 9). immediately after surgery, rectal examination was performed to evaluate the irmness of the pelvic diaphragm. Fig. 7: Positioning of the patient for herniorrhaphy and harvesting of the fascia lata graft



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Two-step protocol for surgical treatment of complicated or bilateral perineal hernia in dogs - J. Dörner and G. Dupré



Sluijs, 1989; Hosgood et al., 1995; White and Herrtage, 1986]. if no cystopexy is carried out in patients with PH and bladder retrolexion, recurrence is observed in most cases [Sjollema and Van Sluijs, 1989). However, it remains unknown whether reposition of the bladder and cystopexy are able to avoid the development of future dysuria of neurological origin. Further investigation is required to evaluate the inluence of vas deferens pexy and cystopexy on the development of neurologically induced dysuria. in any case, cystopexy does reduce the risk of increased pressure applied to force urine out and with it the pressure exerted on the pelvic diaphragm. Vasopexy stabilizes the bladder neck and the prostate and at the same time improves ixation of the colon by the coloprostatic fascia [Bilbrey et al., 1990; Dupre et al. 1993). However, recurrence of vesical retrolexion is possible if only vasopexy has been carried out, as there is a time span of several days between laparotomy and herniorrhaphy. For this reason, the authors recommend to perform a cystopexy in all cases of retrolexion of the urinary bladder. the role of prostate lesions in the pathogenesis of perineal hernias remains unclear, although they frequently occur in association with PH (10 – 51 %) [Matthieseen, 1989; Sjollema and Van Sluijs, 1989; Bilbrey et al., 1990; Hosgood et al., 1995; Dupre et al., 1996 and 2000; Maute et al., 2001; niebauer et al., 2005]. As this means a relatively high coincidence of both pathologies, it is recommended to systematically explore the prostate in all dogs with PH performing rectal and ultrasonographic examinations prior to surgery. During laparotomy, the prostate can then be examined macroscopically; at the same time, any necessary surgical intervention (e.g. prostate omentalization) can be carried out and biopsies can be obtained. Possible postoperative complications include primarily local wound infections and partial suture dehiscence. in any case, prolonged duration of surgery seems to have a negative inluence on the wound infection risk. Correlations between wound infection and duration of surgery, types of preoperative positioning and surgical skin preparation, suture material, temporary anal closure (which did not yield



Fig. 8: Fascia lata graft During eight days after herniorrhaphy, metronidazole (12.5 mg/ kg b.i.d.) was administered orally. Analgesics (carprofen 4.4 mg/ kg q24h) were given during ive days after surgery. local cleaning of the wound and feeding a low-ibre diet to reduce faecal volume were recommended. in addition, lactulose (laevolac®) or Pascomucil®, respectively, should be given to facilitate defecation. Rectal examination performed ten days after surgery did not reveal any sacculation of the rectum. Healing of the surgical wounds occurred without any complications and the dog showed no dificulties to defecate. Four months after surgery the dog was still asymptomatic.



Discussion Perineal hernias are classiied as complicated if the following criteria are met: unilateral PH with rectal lesions grade 2 or worse, unilateral PH with bladder retrolexion and/or prostatic disease, or recurrent PH. Bilateral or complicated PH can be successfully treated using laparotomy to perform incisional colo-, vaso- and cystopexy and, if necessary, surgical treatment of prostatic lesions (prostate omentalization, cyst resection), followed by herniorrhaphy. Recurrence rate is low and in most cases the inal outcome is satisfactory. in the study carried out by Brissot et al. [2004], a total of 41 dogs with complicated PH were treated using the two-step protocol, and in 90 % of the cases, PH could be permanently resolved. Rectal disorders included dilations, sigmoidal deviation or diverticulum [Mann and Boothe, 1985; Krahwinkel, 1983; Hosgood et al., 1995; Dupre et al., 1993]. in dogs with rectal dilation, colopexy reduces the rectal diameter avoiding further accumulation of faeces; in addition, reduction of the pressure on the pelvic diaphragm is achieved by cranial ixation of the rectum [Huber et al., 1997; Dupre et al., 1993, Maute et al, 2001]. Colopexy not only corrects rectal deviations, but also reduces the size of any existing sacculation. By this procedure, the linear morphology of the colorectal ampulla can be re-established. this also reduces the possibility of faecal accumulation in the rectum [Huber et al., 1997; Dupre et al., 1993, Maute et al, 2001]. Perineal hernias associated with retrolexion of the urinary bladder show higher mortality rates (30 %) and worse prognosis than cases without bladder retrolexion [SJollema and Van



Fig. 9: Postoperative status after herniorrhaphy and harvesting of the fascia lata graft



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Complication



Number



repair of bilateral or complicated perineal hernias is that pexying the organs in the initial laparotomy creates more perineal space. As colopexy resolves rectal dilation or deviation and vasopexy together with cystopexy stabilizes bladder and prostate, the perineal space is almost empty at the time of herniorrhaphy. this means a better overview and easier identiication of important anatomic structures like the muscles of the pelvic diaphragm, the pudendal nerve, the caudal rectal nerve and artery, the internal obturator muscle and its tendon as well as the rectal wall. Herniorrhaphy is considerably easier on account of this improved overview of the surgical ield, which facilitates exact reconstruction of anatomical structures and minimizes the duration of surgery. Keeping the duration of surgery short reduces the risk of perioperative infection. Better identiication of anatomic structures also contributes to a reduced risk of faecal incontinence, as this complication often occurs due to compression of the caudal rectal nerve. two to four days are considered to be the ideal lapse of time between laparotomy and herniorrhaphy, as longer periods could neutralize the positive effect of colopexy consisting in the reduction of rectal dilation. Disadvantages of performing laparotomy as a irst separate step of this surgical technique to repair bilateral and complicated perineal hernias refer to the general drawbacks associated with two interventions and to higher costs. However, these are fully offset by the beneits of this staged protocol: Additional problems (rectum, urinary bladder, prostate) can be resolved during one and the same surgery. Bladder and prostate can be directly evaluated macroscopically and immediate surgical interventions like partial cystectomy, omentalization of the prostate or biopsies, if needed, can be performed. By cranial ixation of the prolapsed organs in the abdominal cavity the pressure on the pelvic diaphragm is reduced. All this facilitates the following herniorrhaphy so that the duration of surgery is shorter. long-term results are very good and complication rates are low.



Percent Course



local sepsis



7



17



Healing by local treatment



local abscess at the ColP site



4



10



n=2 Re-intervention (laparotomy)



Perineal suture dehiscence



3



7



tenesmus



18



41



n = 14 intermittent n = 4 Permanent



Urine incontinence



15



36



n = 3 Up to 15 days postoperative n = 5 Up to 6 months postoperative n = 7 > 6 months postoperative



Healing by local treatment



Abbreviations: PH = perineal hernia ioMF = internal obturator muscle lap ColP = colopexy CYSP = Cystopexy DeFP = Vas deferens pexy PoM = omentalization of the prostate



Table 1: Postoperative complications observed in the study performed by Brissot et al. [2004] in 41 dogs signiicant advantages with regard to the postoperative infectious state of the wound) and perioperative antibiotic therapy were evaluated in several studies [Sjollema and Van Sluijs, 1989; Hosgood et al., 1995; Matthieseen, 1989; lorinson and grösslinger, 2002]. in rare cases, abscesses may develop at the colopexy site. this complication was commonly observed after laparoscopic ixation of the colon, which might be due to the fact that using this method, the depth of each suture cannot be controlled as exactly as during laparotomy [Brissot et al., 2004] (table 1). Persistent or intermittent postoperative tenesmus during defecation has been described in rare cases. involuntary urine dribbling during sleep or walking has also been observed. this urinary incontinence almost always resolved within the irst two weeks after surgery [Brissot et al., 2004]. occurrence of rectal prolapse, formerly a frequent complication (7-42 %) in the immediate postoperative phase [orsher, 1986; Sjollema and Van Sluijs, 1989; Popovitch et al., 1994; Hosgood et al., 1995] could be reduced by performing a colopexy during laparotomy. in the study carried out by Brissot et al. [2004], none of the patients developed this complication. the reasons why postoperative tenesmus occurred despite colopexy, vas deferens pexy or cystopexy may be associated with persistent rectocolitis [Hosgood et al., 1995]. Another frequent cause of persistent postoperative tenesmus is prostate hyperplasia [guilford, 1996]. in 4-8 % of the cases, postoperative urine dribbling was observed [White and Herrtage, 1986; Sjollema and Van Sluijs, 1989; Hosgood et al., 1995; Maute et al., 2001]. this might be due to vascular and nerve damage of the bladder wall during retrolexion. one of the major beneits of the two-step protocol for surgical



the two-step protocol is primarily indicated for dogs with bilateral PH but also patients with complicated PH (i.e. recurrent perineal hernias, unilateral PH with marked rectal dilation, PH with concurrent prostatic pathologies that need surgical repair, PH associated with retrolexion of the urinary bladder) are ideal candidates for this surgery. For all these cases, the two-step protocol can be considered as the method of choice.



References Bellenger CR. Perineal hernia in dogs. Aust Vet J. 1980; 56: 434-438 Bilbrey SA, Smeak, DD, Dehoff W. Fixation of the deferent ducts for retrodisplacement of the urinary bladder and prostate in canine perineal hernia. Vet Surg. 1990; 19: 24-27 Bongartz A, Caroiglio F, Balligand M, Heimann M,Hamaide A. Use of autogenous fascia lata graft for perineal herniorrhaphy in dogs. Vet Surg 2005; 34: 405-413 Brissot Hn, Dupré gP, Bouvy BM. Use of laparotomy in a Staged Approach for Resolution of Bilateral or Complicated Perineal Hernia in 41 dogs. Vet Surg 2004; 33: 412-421 Burrows CF, Harvey Ce. Perineal hernia in the dog. J Small Anim Pract 1973; 14: 315-332



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Chambers Jn, Rawlings CA Applications of semitendinosus muscle lap in two dogs. J Am Vet Med Assoc 1991; 199: 84-86 Dupré gP, Bouvy BM, Prat n. the nature and treatment of perineal hernia-related lesions. A retrospective study of 60 cases, and the deinition of the protocol for treatment. Prat Med Chir Anim Comp 1993; 28: 333-344 Dupré gP, Dupuy-Dauby, l, Bouvy, BM. (1996): the pathology and the surgical treatment of canine prostatic disease. Prat Med Chir Anim Comp 31: 503-514 Dupré gP, QUÉAU, e., Bouvy, BM. (2000): Use of laparoscopy and laparotomy in the treatment of perineal hernia. Scientiic Proceedings WSAVA (World Small Animal Veterinary Association) – FeCAVA (Federation of european Companion Animal Veterinary Association) World Congress, Amsterdam. guilford Wg. (1996): Motility disorders of the bowel. in: guilford Wg, Center, SA, Strombeck DR. (Hrsg.): Strombeck´s Small Animal gastroenterology. 3. Aul., Saunders, Philadelphia, PA, S. 532540 Hardie eM, Kolata RJ, early tD. (1983): evaluation of internal obturator muscle transposition in treatment of perineal hernia in dogs. Vet Surg 12: 69-72 Hosgood g, Hedlung SC, Pechman DR, Dean PW. (1995): Perineal herniorrhaphy: perioperative data from 100 dogs. J Am Anim Hosp Assoc 31 Huber DJ, Seim HB, goring Rl. (1997): Cystopexy and Colopexy for the management of large or recurrent perineal hernia in the dog: 9 cases (1994-1996). Vet Surg 26: 253-254 Krahwinkel DJ. (1983): Rectal diseases and their roles in perineal hernia. Vet Surg 12: 160-165 lorinson D, grösslinger K. (2002): the effect of preoperative anal closure on wound infection rate in perineal hernia surgery. Vet Surg 31: 301 (abstract) Mann FA, Boothe, HW. (1985): Rectal diverticulum in a dog with perineal hernia. Calif Vet 8-10



Matthieseen Dt. (1989): Diagnosis and management of complications occurring after perineal herniorrhaphy in dogs. Compend Contin educ Pract Vet 11: 797-822 Maute AM, Koch DA, Montavon PM. (2001): Perinealhernie beim Hund – Colopexie, Vasopexie, Cystopexie und Kastration als therapie der Wahl bei 32 Hunden. Schweiz Arch tierheilkd 143: 360-367 niebauer gW, Shibly S, Seltenhammer M, Pirker A, Brandt, S. (2005): Relaxin of prostatic origin might be linked to perineal hernia formation in dogs. Ann n Y Acad. Sci. 1041: 415-422 orsher R. (1986): Clinical and surgical parameters ind dogs with perineal hernia – analysis of results of internal obturator muscle transposition. Vet Surg 15: 253-258 Popovitch CA, Holt D, Bright R. (1994): Colopexy as a treatment for rectal prolapse in dogs and cats: a retrospective study of 14 cases. Vet Surg 23: 115-118 Raffan PJ. (1993): A new surgical technique for repair of perineal hernias in the dog. J Small Anim Pract 34: 13-19 Sjollema Be, Van Sluijs FJ. (1989): Perineal hernia repair in dog by transposition of the internal obturator muscle; i: surgical technique; ii: complications and results in 100 patients. Vet Quart 11: 12-23 Spreull JSA, Frankland Al. (1980): transplanting the supericial gluteal muscle in the treatment of perineal hernia and lexure of the rectum in dogs. J Small Anim Pract 21: 265-278 Vnuk D, Maticic D, Kreszinger M, Radisic B, Kos J, lipar M, Babic, t. (2006): A modiied salvage technique in surgical repair of perineal hernia in dogs using polypropylene mesh. Vet Medicina 51: 111117 Weaver AD, omamegbe Jo. (1981): Surgical treatment of perineal hernia in the dog. J Small Anim Pract 22: 149-158 White RAS, Williams JM. (1995): intracapsular prostatic omentalization: a new technique for management of prostatic abscesses in dogs. Vet Surg 24: 390-395



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Exploratory Laparotomy in the Dog & Cat Lysimachos G. Papazoglou, DVM, PhD, MRCVS Aristotle University of hessaloniki hessaloniki, Greece



Eleni Basdani, DVM, PhD Bessy’s Klinik Zurich, Switzerland



Exploratory laparotomy is routinely performed in small animal practice and is indicated when organ dysfunction or trauma involving the abdominal cavity requires deinitive diagnosis along with surgical treatment and prognosis.1 Surgical exploration provides information through inspection, palpation, and/or hollow organ luminal mucosa observation. Samples can be obtained for microbiologic and cytologic examination or biopsy for histopathologic examination. Abdominal exploration should be performed in a timely manner to increase the likelihood of successful diagnosis and management without negatively afecting the patient. A ventral midline laparotomy of adequate length from xiphoid to the pubis is the standard approach to explore the entire abdominal cavity in a systematic manner. Every surgeon may develop his or her own technique, but a suggested method includes exploring the cranial quadrant (diaphragm; liver, gallbladder, and bili-



1. Surgical bowl, 2. bulb syringe for irrigation, 3. laparotomy pads, 4. 4 x 4” gauze sponges, 5. monopolar diathermy cable, 6. suction tube, 7. Poole suction tip, 8. Babcock tissue forceps, 9. Allis tissue forceps, 10. No 15 and 10 scalpel blades, 11. Bard Parker scalpel handle, 12. Backhaus towel clamps, 13. curved and straight Metzenbaum scissors, 14. straight Mayo scissors, 15. Balfour retractors, 16. Debakey tissue forceps, 17. Rat-tooth thumb forceps, 18. Mayo-Hegar needle holders, 19. straight and curved Rochester-Carmalt hemostatic forceps, 20. straight and curved mosquito hemostatic forceps.



ary tree; spleen and stomach; duodenum and pancreas), caudal quadrant (jejunum, ileum, and colon; urinary bladder; urethra and prostate or uterus), right paravertebral region by retracting the mesoduodenum, and left paravertebral region by retracting the mesocolon (kidneys, adrenal glands, ureters, and ovaries).2



A ventral midline laparotomy of adequate length from xiphoid to the pubis is the standard approach to explore the entire abdominal cavity in a systematic manner. October 2015



WHAT YOU WILL NEED d Necessary instrumentation



for performing an exploratory laparotomy includes a well-equipped general surgery pack. Swabs and sponges should be counted at the beginning and the end of surgery.



cliniciansbrief.com



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STEP-BY-STEP EXPLORATORY LAPAROTOMY STEP 1 Generously clip and prepare the surgical site, extending cranially to the xiphoid, caudally to the pubis, and over 5 to 10 cm from the ventral midline on either side. Express the bladder through the abdominal wall.



1



Author Insight: Midline laparotomy incision should extend from xiphoid to pubis.



STEP 2



STEP 3



2



3 ROSTRAL



Inject preincisional block (2 mg/kg bupivacaine) along the ventral midline from the beginning to the end of the proposed incision in a fan-like fashion to iniltrate subcutaneous and muscular tissues. his technique provides postoperative analgesia for at least 24 hours.3,4



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Use a 4-corner draping technique: in male dogs, grasp the prepuce with towel forceps and position laterally to the midline to avoid urine spillage into the surgical site; penis and prepuce can be covered by 1 of the lateral drapes. Make a parapreputial skin incision, dividing the preputial muscles and sealing external pudendal vessels with elecrocautery following the incision to allow relection of the prepuce and penis laterally to visualize the linea alba. In female dogs and all cats, extend the ventral midline incision from xiphoid to pubis.



STEP 4



STEP 6



4



6 ROSTRAL



After skin incision, seal subcutaneous vessels via elecrocautery and undermine subcutaneous tissues from attachment to the rectus sheath 1 cm laterally to visualize the linea alba. Avoid excessive undermining to prevent vascular compromise of the fascia and dead space creation and subsequent seroma formation.



STEP 5



Insert thumb forceps with the tips placed caudally to lift upward on the linea alba and make a cranial to caudal incision. Extend the incision cranially by directing thumb forceps with tips placed cranially.



STEP 7



7A



5 ROSTRAL



Make a stab incision to the linea alba with a scalpel and insert a inger into the incision to ensure entry to the abdominal cavity and to conirm that there are no adhesions between the abdominal wall and intra-abdominal organs. A stab incision and letting air into the abdominal cavity also allows the abdominal organs to “fall” dorsally, away from the ventral aspect of the abdominal wall, making the subsequent extension of the midline incision safer.



7B



ROSTRAL



An alternative technique to enter the abdominal cavity is to lift the linea alba with thumb forceps and make a stab incision with the cutting edge of the scalpel blade pointing upward (A). Use Mayo scissors to extend the incision (B).



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STEP 8



STEP 10



8



10A



ROSTRAL



10B



When treating dogs, excise the falciform ligament with elecrocautery or by placing a ligature at its base to improve exposure to the cranial abdomen.



STEP 9



9



ROSTRAL



After the abdomen is entered, protect wound edges with moistened laparotomy pads and place Balfour retractors.



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Use a systematic approach for abdominal exploration. Abdominal organs should be inspected by direct vision and palpation. Gently lift the right lobe of the duodenum and mesoduodenum toward the left side of the animal to allow exposure of the right kidney, adrenal gland, ovary, and ureter (A). Gently lift the colon and mesocolon toward the right side of the animal to expose abdominal organs of the left paravertebral fossa (B).



STEP 11



STEP 12



11A



12A



ROSTRAL



12B 11B



Following abdominal exploration, lavage the abdominal cavity using large volumes of warm normal saline solution, which aids in removal of contaminants and patient warming (A, B).2,5 Completely remove lavage luid by suction before closing the abdomen to avoid compromise of defense mechanisms.2



he midline laparotomy incision is closed in 3 layers. he abdominal wall is closed using the external leaf of the rectus abdominis muscle sheath in a simple continuous or simple interrupted suture pattern. Most surgeons favor a continuous polydioxanone or polyglyconate suture pattern, which provides a quick and secure closure. Sutures should be placed 5–10 mm from the incision edge and spaced 5–10 mm apart, depending on the size of the animal (A).6,7 Suture size depends on the animal’s weight (animals 45 kg: 1)(B).



Author Insight: Closure of the linea alba must include the external leaf of the rectus sheath.



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STEP 13



STEP 14



13A



14A



ROSTRAL



13B



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Place 6 throws at the beginning and 7 at the end of the continuous pattern (A).8,9 Sutures should be placed tightly enough, depending on the suture material used, to get the incision edges into apposition (B).



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For the second layer, subcutaneous closure is most commonly accomplished in a simple continuous pattern using 3/0 synthetic absorbable monoilament suture to eliminate dead space and decrease tension in the incision, allowing skin edges to be placed in close apposition (A). Bury knots in the beginning and end of the suture pattern (B). In male dogs, preputial muscle should be apposed separately with a couple of simple interrupted sutures to reposition the penis normally.



Author Insight: Sutures should not be placed too tightly as this can cause ischemic necrosis of the incision edges; however, they must be tight enough to achieve adequate apposition of the incision edges.



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STEP 15



15A



15C



ROSTRAL



15B



15D



ROSTRAL



Close skin using a simple continuous (A), Ford interlocking (B), or intradermal pattern with buried knots (C), or use staples (D).



References 1. Boothe HW, Skater MR, Hobson HP, et al. Exploratory celiotomy in 200 nontraumatized dogs and cats. Vet Surg. 1992;21(6):452-457. 2. Boothe HW. Exploratory laparotomy in small animals. Compendium Contin Educ Pract Vet. 1990;12:1057-1066. 3. Savvas I, Papazoglou LG, Kazakos G, et al. Incisional block with bupivacaine for analgesia ater celiotomy in dogs. JAAHA. 2008;44(2):60-66. 4. Campagnol D, Teixeira-Neto FJ, Monteiro ER, Restitutti F, Minto BW. Efect of intraperitoneal or incisional bupivacaine on pain and the analgesic requirement ater ovariohysterectomy in dogs. Vet Anaesth Analg. 2012;39(4):426-430. 5. Nawrocki MA, MacLaughlin R, Hendrix PK. The efects of heated and



6. 7.



8. 9.



room-temperature abdominal lavage solutions on core body temperature in dogs undergoing celiotomy. JAAHA. 2005;41(1):61-67. Rosin E. Single layer simple continuous suture pattern for closure of abdominal incisions. JAAHA. 1985;21(6):751-756. Rosin E, Richardson S. Efect of fascial closure technique on strength of healing abdominal incisions in the dog. A biomechanical study. Vet Surg. 1987;16(4):269-272. Mufy TM, Kow N, Iqbal I, Barber MD. Minimum number of throws needed for knot security. J Surg Educ. 2011;68(2):130-133. Marturello DM, McFadden MS, Bennett RA, Ragently GR, Horn G. Knot security and tensile strength of suture materials. Vet Surg. 2014;43(1):73-79.



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