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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

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.

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

ii

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

iii

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

iv

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

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?

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.

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.

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 :

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

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).

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.

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

10

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.

12

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.

13

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.

14

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 McIlwraiths 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.

15

LAMPIRAN

16

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; babaji32002@gmail.com


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 1824 hours and 1014 days ater surgery between the two approaches; signiicant diference of dehiscence
between the two groups was also recorded at 1014 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 [511]. 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 kg1 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 mL1 ,
Kepro Holland) at 0.025 mg kg1 intramuscular and atropine
sulphate 0.6 mg mL1 (Laborate Pharmaceuticals India) at
0.05 mg kg1 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 kg1 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 kg1 (Vetrimoxin) was
administered once ater surgery.
2.1.1. Surgical Wound Assessment. he clinical appearance of
the skin was assessed and scored twice: 1824 hours and 1014
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, 1824 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. Students

Journal of Veterinary Medicine

Table 2: Postsurgical wound assessment score of lank and midventral approaches at 1824 hours and 10 days (mean SD).
Parameters

Discharge
Swelling
Erythema
Dehiscence

Groups
FA
MVA
FA
MVA
FA
MVA
FA
MVA

1824 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
1014 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 1824 hours ater
surgery, there was serous discharge in all groups; the mean
discharge scores were (0.800.45 and 0.800.84) for lank and
midventral approaches, respectively. here was no signiicant
diference between the two groups when compared. At 1014
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 1824 hours ater surgery
compared to 1014 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 1824 hrs and at 1014 days ater surgery.
he lank approach at 1824 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 1014
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 1824 hours ater surgery
in all the groups; however, at 1014 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 (1.000.70); 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 1824 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 1824hour interval (Table 5).
he packed cells volume of the two approaches showed
slight variations with the midventral approach having the

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 /)


Granulocytes (103 /)
Lymphocytes (103 /)
Monocytes (103 /)
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

1824 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 /)
Platelets critical value (%)
Mean platelets volume ()
Platelets dimension width ()

Mean scores
1824 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

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 1824 and at 1014 days ater surgery

Journal of Veterinary Medicine

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 ()
MVA
FA
Mean corpuscular haemoglobin (pg)
MVA
FA
Mean corpuscular haemoglobin con. (g/L)
MVA
FA
RBC distribution width (%)
MVA
RBC (106 /)

ab

Mean scores
Before surgery 1824 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 1824 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
1014 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 1824 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.

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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. Drner (1) and G. Dupr (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 Tierrztliche


Monatsschrift* (2008), 95: p. 269-276

Introduction
Diagnosis of perineal hernias (PH) is based on the patients 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; Veterinrplatz 1, A-1210 Vienna.
E-mail: Judith.Doerner@vetmeduni.ac.at
(2) Univ. Prof. Dr. Gilles Dupr, Clinic of Surgery and Ophthalmology, Vienna University of Veterinary Medicine; Veterinrplatz 1, A-1210 Vienna.
* Presented by VK (Austria)

186

EJCAP - Vol. 20 - Issue 2 October 2010

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).

187

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

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 patients 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 patients cardiovascular
system by administration of a shock treatment infusion (60 ml/
kg lactated Ringers 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 dogs
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

188

EJCAP - Vol. 20 - Issue 2 October 2010

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 patients 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 Ringers 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

189

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

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

190

EJCAP - Vol. 20 - Issue 2 October 2010

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

17

Healing by local
treatment

local abscess at
the ColP site

10

n=2 Re-intervention
(laparotomy)

Perineal suture
dehiscence

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 grsslinger, 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, Dupr 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

191

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

Chambers Jn, Rawlings CA Applications of semitendinosus muscle lap


in two dogs. J Am Vet Med Assoc 1991; 199: 84-86
Dupr 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
Dupr 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
Dupr gP, QUAU, 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.): Strombecks 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, grsslinger 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

192

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PEER REVIEWED

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

Eleni Basdani, DVM, PhD


Bessys 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.

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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.

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

STEP 2

STEP 3

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

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

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

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 510 mm from the incision edge and spaced 510 mm apart, depending
on the size of the animal (A).6,7 Suture size
depends on the animals weight (animals <5 kg:
3/0; 520 kg: 2/0; 2040 kg: 0; and >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

14B
20

ROSTRAL

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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September 2015

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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