ATIONS

OMPLIC ABDOMINAL SURGERY

Celiotomy
Karen Tobias, DVM, MS, Diplomate ACVS, University of Tennessee

E
xploratory celiotomy is commonly
done for diagnosis and treatment
of a variety of medical conditions are higher with surgery duration greater than Perform platelet counts, measurement of
in dogs and cats. Specific indications 90 minutes. Overall mortality rates range from buccal mucosa bleeding time, and coagula-
may include intraabdominal foreign 17% to 27%; euthanasia, done because of the tion profiles in patients with sepsis, liver
bodies, masses, abscesses, or granulo- extent of the underlying disease or poor prog- disease, significant hypoproteinemia, or
mas; uncontrolled abdominal hemor- nosis, is the most common cause of death.1,2 suspected bleeding tendencies. Low
platelet counts confirm thrombocytopenia,
rhage; gastrointestinal or urinary tract
Complications can occur both during and after whereas prolonged buccal mucosal bleed-
obstruction; radiographic evidence of
the procedure. Intraoperative complications ing time in an animal with a normal
pneumoperitoneum; persistent vomit- may include hemorrhage, inadequate ventila- platelet count is an indicator of platelet
ing, diarrhea, or abdominal pain with tion or perfusion, and inadvertent damage to dysfunction or von Willebrands disease.3
no detectable cause; findings on cyto- tissues. Postoperative complications are asso- Activated clotting time measures deficien-
logic evaluation of abdominal fluid con- ciated with the abdominal incision (i.e., pain, cies of all clotting factors except factor VII
sistent with peritonitis or leakage of swelling, seroma formation, infection, dehis- and can be used as a screening test for
cence, or suture reaction), surgical manipula- disorders of secondary hemostasis. If acti-
urine or bile; estrus in spayed female
tion (i.e., diarrhea, ileus, adhesions, seeding of vated clotting time is abnormal, prothrom-
dogs; or cryptorchidism. Exploratory
tumor cells, pancreatitis, hemorrhage); surgical bin time and activated partial thrombo-
celiotomy can also be used to obtain error (i.e., iatrogenic foreign bodies, peritoni- plastin time should be measured.3
biopsies, cytologic evaluation, and cul- tis, pneumothorax, sinus tracts from nonab-
tures for diagnosis of the underlying sorbable braided ligatures or nylon cable ties); Perform crossmatches in animals that may
or primary disease. Some complications, such require transfusions.
disease or as a prognostic indicator, as
in the case of nonresectable neoplasia. as hypothermia, pain, and swelling, are so
common that clinicians may not consider Corrective Measures
them to be complications. If possible, correct electrolyte, acidbase, and
Types glucose abnormalities before anesthesia.
Complications are observed in 26% to 30% of
Prevention Animals with coagulopathies usually require
dogs and cats surviving the procedure.1,2 Most
Blood Analysis perioperative transfusions of fresh frozen plas-
complications result from the underlying dis-
Because severely ill patients are more likely to ma or fresh whole blood, and animals with
ease process; however, they can also be relat-
have complications, preoperative diagnostics PCV 25% or less are often given packed red
ed to the incision (7.5%), anesthesia (5% to
and stabilization are critical. cells. Vitamin K therapy (2.2 mg/kg SC fol-
22%), or the procedure itself (17% to 28%).1,2
Perform a CBC and analysis of serum bio- lowed by 1.1 mg/kg SC Q 12 H) can be initiat-
In one study, complications were highest in
chemistries and electrolytes. ed in animals with prolonged clotting times
patients with gastrointestinal foreign bodies,
secondary to cholestasis or other malabsorp-
hepatic lipidosis, ureteral abnormalities, intes- Evaluate urine for evidence of renal insuffi- tive syndromes; this therapy should correct
tinal intussusception, pancreatitis, hepatic ciency (i.e., decreased urine specific gravity the coagulopathy within 1 to 2 days.3 In
neoplasia, and lymphoreticular neoplasia.1 in the presence of azotemia), infection,
Wound-related complications and infections hemorrhage, or protein loss. c o n t i n u e s

BP = blood pressure; CBC = complete blood count; CRI = constant-rate infusion; ECG = electrocardiograph; PCV = packed cell volume

co m p l i c at i o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N AV C c l i n i c i a ns b r i e f. . . . . j u l y. 2 0 0 5 . . . . . 1 3
 COM
PLICA
TION
patients with pressure abnormalities or
expected fluid loss, place a jugular catheter to
measure central venous pressure. Use het-
astarch (5 to 40 ml/kg/day IV) for oncotic sup-
mals without infection, severe contamination,
or tissue necrosis, discontinue antibiotics with-
in 6 hours after the procedure.
S Once a contaminated organ or structure
has been closed or removed, change
gloves and instruments. Continuous suc-
tion drains can be placed in local areas of
port in animals with hypoproteinemia; het- Preoperative Preparation infection, or in multiple sites throughout
astarch can be combined with crystalloids in Preoperative preparation should be thorough the abdomen if peritonitis is present.
patients with IV fluid-volume deficits.4 but efficient, since duration of anesthesia cor- Before closure, flush the abdominal cavity
relates with infection rates. If possible, clip the with warm sterile saline and suction it dry
Pain patient immediately before surgery to prevent to remove contaminants.
Many animals that undergo exploratory bacterial colonization of microscopic nicks
celiotomy are already in pain, and postsurgical from clippers. In the surgical suite, place the Postsurgical Measures
discomfort is to be expected. Preemptive anal- animal on or under a forced-air warming sys- After surgery, measure PCV, total protein, and
gesia reduces intraoperative anesthetic tem to reduce heat loss, and perform a final blood glucose to provide a baseline for future
requirements and potentially decreases the preparation of the surgical site. comparison. Administer analgesics on a sched-
duration and severity of postoperative pain.5 uled basis for the first 12 to 24 hours and
Options include systemic opioids, nonsteroidal Surgical Procedure then on an as-needed basis. Many animals
antiinflammatory drugs, fentanyl patches, If possible, make the incision directly on require continued fluid administration and
local or regional blocks, and CRI of lidocaine the linea alba, particularly if the patient monitoring of vital signs.
or ketamine. A combination of therapies is has a bleeding tendency. Incisions can be
often given. In addition to analgesic effects, extended cranially to the xyphoid; howev-
lidocaine may have other positive benefits, er, pneumothorax may occur if it is extend-
Specific Complications:
such as improving gastrointestinal motility, ed too far or if the cranial portion of the Prevention and Treatment
decreasing neutrophil chemotaxis and platelet incision tears from excessive retraction. Hernia
aggregation, and protecting cells through Incisional hernias are most likely to occur from
To reduce bacterial translocation and
weak inhibition of calcium channels. A CRI of poor surgical techniquethat is, suture bites
hypothermia, moisten the laparotomy pads
lidocaine (10 to 25 g/kg/minute in cats or 25 that are too small or that do not contain the
placed along the incision only on the sur-
to 50 g/kg/minute in dogs) can be delivered external rectus sheath. In dogs, the subcuta-
faces that contact the intraabdominal tis-
by syringe pump or diluted in crystalloid flu- neous fat adheres to the linea, obscuring visu-
sues, especially if cloth drapes are used.
ids. Use lidocaine CRI with caution in cats alization of the site at the time of abdominal
since they are susceptible to dose-related Perform a thorough, systematic exploration incision and closure. This fat can be cleared
neurotoxicity or decreased cardiac function. before undertaking definitive therapy. immediately after subcutaneous incision with
Surgical technique should be guided by a pushcut motion (Figure 1) using
Anesthetic Monitoring & Antibiotics Halsteads basic principles: maintenance of Metzenbaum scissors. Dissecting the subcuta-
Monitor ECG, blood pressure, SPO2, and end- asepsis, gentle handling of tissue, accurate neous fat away from the linea makes the
tidal CO2 once the animal is anesthetized. hemostasis, closure of dead space, accurate white external rectus sheath visible (Figure 2)
Mechanically ventilate patients with condi- tissue apposition, and avoidance of tension or so that it can be incorporated within each
tions that may cause respiratory compromise, vascular compromise. suture bite (Figure 3). If the fat has not been
such as diaphragmatic hernia, ascites, or gas- Do the cleanest procedures firstfor exam- excised from the linea, it can be elevated at
tric distention. Animals with hypotension (sys- ple, perform liver biopsy before enterotomy. the time of closure.
tolic BP < 90 mm Hg, mean BP < 60 mm Hg)
Isolate organs with moistened laparotomy
that do not respond to IV fluids or reduction Closure of the peritoneum and internal rectus
pads to contain spillage and reduce gener-
in anesthetic delivery may require positive fascia is not necessary in dogs and cats, since

NS
inotropic support (i.e., IV dopamine CRI 4 to

O
alized contamination.
If no primary lesion is found or the primary
the external rectus sheath provides the great-

I
6 g/kg/minute).6 est strength to the wound. Simple continuous

CAT
Give broad-spectrum antibiotics intravenously

I
disease cannot be resolved, sample organs
and fluids for cytologic evaluation, biopsy,
closure is faster and causes less tissue reaction
than and is as strong as interrupted closure.

L
at induction if contamination is expected, or culture.

MP
although administration can be delayed until
intraoperative cultures are obtained. In ani-
Consider feeding tubes for patients that
are malnourished, anorexic, or vomiting.
On rare occasions, incisional hernias occur
because the animals rectus abdominus fascia

CO
BP = blood pressure; CBC = complete blood count; CRI = constant-rate infusion; ECG = electrocardiograph; PCV = packed cell volume

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 3

In this dog, the subcutaneous fat attachments were

not transected during the abdominal approach. The
subcutaneous fat is being retracted with thumb
forceps to expose the edge of the rectus sheath,
which has been incorporated in the tissue bite on
the needle.
1
The fat attachments to the linea are transected with a pushcut motion to reduce dissection and expose the
Swelling of the Incision and Cellulitus
external rectus sheath. Incisional swelling is relatively common after
celiotomy in cats; suggested causes include
surgical trauma, seroma formation, suture
reaction, use of subcutaneous closure, and
infection.7 Aseptic technique and surgical
duration less than 1 hour decrease the risk for
postoperative wound infections. In most ani-
mals, incisional infection involves only the
superficial layers. Administration of a sys-
temic, broad-spectrum antibiotic, such as
amoxicillin-clavulanic acid, plus local wound
care (i.e., hot-packing) and prevention of self-
trauma (i.e., use of an Elizabethan collar), usu-
ally resolve the problem.

If infection persists, remove any skin and sub-

cutaneous sutures and collect a biopsy of
deep wound tissues for histologic and cytolog-
2 ic evaluation and culture. Manage the wound
open, with daily bandage changes and topical
The right external rectus sheath is exposed. The remaining fat attachments above the left external rectus cleansing, or perform debridement and close
sheath should also be transected. the wound after drain placement.

is weak. In these cases, the rectus fascia actu- at each end of the incision. Polypropylene, Sterile suture reactions are rare but can occur;
ally tears longitudinally along the sites of polydiaxanone, and polyglyconate have memo- the author has noted such reactions most
suture penetration. Affected animals may ry and tend to half-hitch when tied. When often when polydioxanone is used in the
require wider and thicker tissue bites within tying knots, particularly to the loop end of the linea. Suture sinuses have also been reported
each suture or support with synthetic materi- suture (at the completion of closure), place the in dogs that have undergone closure of the
als (i.e., porcine small intestinal submucosa short end of the suture under greater tension linea with monofilament, nonabsorbable
sheets) to prevent reherniation. Interrupted and make sure each throw of the knot drops suture material.8 Large, thick knots may cause
suture patterns are favored in hernia repair. straight down over the incision line to square irritation to overlying tissues, and continued
the throw. The suture ends of a square throw presence of foreign matter delays clearance of
Suture failure of abdominal wall closures is lie flat against the abdominal wall, whereas secondary infection. Animals presented with
uncommon; however, the security of simple the short end of a half-hitched throw stands severe thickening and fistulas from suture
continuous patterns relies only on 2 to 3 knots straight up after the throw is completed. c o n t i n u e s

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 ONS
reactions may require en bloc resection of
affected tissue and closure with a less reactive
cause, prokinetic agents, such as cisapride,
metaclopramide CRI (1 to 2 mg/kg/day), lido-
ATI 70%.11 Dehiscence of the small intestine is
more common in dogs that undergo surgery
material. caine CRI (25 g/kg minute), or erythromycin,
can be used to stimulate intestinal motility.
PLIC for traumatic lesions or foreign body obstruc-
tion. Clinical signs usually occur 3 to 5 days
Incisional swelling secondary to seeding of
tumor cells was reported in six dogs 2 to 30
weeks after abdominal surgery.9 Histologically
Enteral nutrition should be encouraged; dogs
and cats that are not vomiting can be fed
after surgery on the same day, even if gastric
COM after the procedure, when integrity of the
enteric closure is primarily dependent on the
suture. Early clinical signs can be nonspecific
aggressive, exfoliative carcinomas, such as or intestinal procedures have been performed. (i.e., vomiting, diarrhea, anorexia, or abdomi-
transitional cell carcinoma of the urinary tract, Animals that do not respond to therapy nal pain), but can progress to signs of shock.
are more likely to seed the primary incision should be reevaluated for obstructive gas-
site. Since occurrence of tumor seeding corre- trointestinal disease or other metabolic prob- Diagnosis
lates with the number of contaminating cells, lems. Dogs with septic peritonitis have increased
reduction of contamination (i.e., use of laparo- band neutrophils on CBC.12 Other blood value
tomy pads to isolate the organs undergoing Peritonitis changes are nonspecific but help guide treat-
biopsy and changing gloves and instruments) Types ment of the patient. Plain abdominal radi-
is critical for prevention. Postoperative peritonitis most commonly ographs and ultrasonography are difficult to
occurs from leakage at gastrointestinal sur- interpret after gastrointestinal surgery
Ileus gery sites.11,12 It may also result from reaction because of air and fluid introduced during
Ileus is a common complication of abdominal to foreign bodies, such as retained surgical celiotomy.
surgery. It may also be caused by focal or gen- sponges or contaminated nonabsorbable
eralized peritonitis, prolonged intestinal dis- suture or implants. Mild inflammation of the Abdominal fluid analysis is the most useful
tention, enteritis, drugs (i.e., opioid agonists), intestines is expected if visceral surfaces test for diagnosing generalized peritonitis.
electrolyte or fluid imbalances, or intestinal become dry during celiotomy. Fluid can be obtained by blind or ultrasonog-
obstruction or ischemia.1012 Animals are usu- raphy-guided abdominocentesis or by diag-
ally affected within the first 24 hours after Prevention nostic peritoneal lavage. Abdominal fluid cell
surgery and may have gaseous or fluid Prevention of peritonitis focuses on appropri- counts are increased in dogs that have under-
abdominal distention, pain, or vomiting. ate surgical techniqueisolating viscera, gone uncomplicated intestinal surgery; howev-
keeping them moist, performing wide resec- er, the presence of degenerate or toxic neu-
Adynamic (functional) ileus must be differenti- tions of diseased tissue, maintaining blood trophils, bacteria, or plant matter is indicative
ated from obstructive ileus, which may require supply, avoiding tension, using drains if need- of peritonitis.12
further surgical intervention. Intestinal wall ed, and counting sponges and laparotomy
thickness, lumen diameter, and peristalsis can pads before opening and closing the Dogs and cats with septic peritonitis have a
be detected on ultrasonography; however, the abdomen. During intestinal resection and blood-to-peritoneal glucose concentration
presence of residual intraabdominal air after anastomosis, everted mucosa conceals the difference greater than 20 mg/dl. In addition,
surgery may interfere with this imaging tech- submucosa, resulting in suture bites that miss in dogs with septic peritoneal effusion, the
nique. Plain or contrast radiography is often this critical holding layer, particularly along blood-to-peritoneal fluid lactate concen
used to diagnose functional ileus. the mesenteric surface. Resection of the evert- tration difference is less than 2.0 mmol/L.14
ed mucosa, or use of a modified Gambee pat- Abdominal fluid should be submitted for
Animals with adynamic ileus should be rehy- tern, improves visualization during suturing. culture and sensitivity and Gram stain to help
drated and administered appropriate anal- Intestinal anastomoses can be done with sim- guide antibiotic selection, since administration
gesics. Any primary cause (such as peritonititis ple continuous patterns without increasing of inappropriate antibiotics is associated with
or electrolyte deficiencies) should be treated. risk for dehiscence. Omentalization of gas- a poorer prognosis.
Dogs with decreased serum magnesium (<1.2 trointestinal surgery sites or drained abscesses
mg/dl) can have severe ileus and vomiting improves local blood supply and thus speeds Timing
that resolves with IV magnesium supplemen- healing. Onset of clinical signs in animals with
tation (30 mg/kg IV over 2 to 24 hours). retained surgical sponges can be delayed if
Patients with intestinal edema may respond to Dehiscence there is no bacterial contamination. In these
hetastarch administration. Dehiscence occurs in 7% to 16% of patients animals, the presence of a mass may be the
undergoing small intestinal surgery and is only abnormality (Figure 4), and diagnosis
For animals with no apparent underlying associated with a mortality rate of over can be delayed for months to years after sur-

BP = blood pressure; CBC = complete blood count; CRI = constant-rate infusion; ECG = electrocardiograph; PCV = packed cell volume

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 GRANULOMA

BLADDER
5
Multifenestrated closed-suction drainage system. The
suction bulb has a one-way valve that prevents back-
flow of fluid into the drain.
COLON
While the drains are in place, the animal will
lose fluid, electrolytes, protein, and red blood
cells; therefore, intensive care and monitoring
are required. Determine the volume of fluid

4 administration by calculating maintenance

requirements plus the amount of fluid lost
Sponge foreign body. This female dog presented with hematuria and constipation more than 1 year after from the drains. Most animals require contin-
ovariohysterectomy. The sponge granuloma had eroded through the bladder and was compressing the colon. ued oncotic support while the drains are in
Resection of bladder wall, colonic serosa, and uterine body were required to remove the mass. place. Continue broad-spectrum antibiotics
until culture results return.
gery. On radiographs, the encapsulated including normal peritoneal fluid, so the dura-
sponge may appear as a localized gas lucency tion of drain retention depends on the charac- See Aids & Resources, back page, for
with a speckled or a whirl-like pattern. On
ultrasonography, the mass is hypoechoic with
ter of the fluid. Remove the drains once the
fluid becomes clearer and toxic cells are not COM references, contacts, and appendices.

an irregular hyperechoic center.13 seen on a fresh sample (usually in 2 to 3 days).

PLICA
Treatment
Dogs with peritonitis should be treated with
crystalloids, colloids, oxygen, analgesics, and
TIO
broad-spectrum antibiotics (i.e., ampicillin
with a third-generation cephalosporin or an
aminoglycoside). Give fresh frozen plasma if
clotting times are prolonged. Perform surgery
as soon as possible to correct the underlying
problem and to lavage and suction out any
contamination.

In patients with extensive contamination or

fibrin deposition, place three to five closed-
suction drains (Figures 5 and 6) before clos-
ing the abdominal cavity. These drains should
exit out separate incision sites through the
lateral body wall and be secured with purse-
string and finger-trap sutures. Postoperative
bandaging is easier in male dogs if the drains
exit cranially. 6
The drains will remove large quantities of fluid, Multiple continuous suction drains in a dog with peritonitis from gastrointestinal perforation

co m p l i c at i o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N AV C c l i n i c i a ns b r i e f. . . . . j u l y. 2 0 0 5 . . . . . 1 7