11/9/2008

Abdominocentesis,
Diagnostic Peritoneal Lavage
anddEExploratory
l L
Laparotomy
(celiotomy), in Small Animals

Presented by Dr. Ali Baniadam

Abdominocentesis
• Yields useful information in cases of abdominal injury,
peritonitis or ascites
p
• Physical and radiographic examinations should proceed
abdominocentesis
• Cytologic, microbiologic and biochemical examination
of aspirated fluid may help to establish the diagnosis
• Diagnostic peritoneal lavage (using a dialysis catheter) is
the most reliable and accurate method for earlyy
detection of the intraabdominal injuries

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Indications
• Intraabdominal injuries following blunt trauma
andd penetration
i off the
h abdominal
bd i l cavity i
• Shock without apparent cause
• Sever thoracic trauma
• Determining the cause of pain
• Sign of disease involving peritoneal cavity
• Suspicion of postoperative GI dehiscence

• Moderate leukocytosis in peritoneal fluid is

normal following uncomplicated abdominal
surgery ) up to 1000 cells/µL
• Toxic or degenerative cells occur with
overwhelming peritonitis
• Presence of intracellular bacteria is an indication
for surgery
• Abdminocentesis is not indicated when there is
a good physical or radiographic evidence of the
need for exploratory laparotomy

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Estimating intraabdominal blood

volume
• Observing the lavage sample
• The amount of blood can be estimated using the
following equation
X=(LV) / (P-L)
X= the amount of blood in the abdominal cavity
L= the PCV of the returned lavage fluid
V= the volume of lavage fluid infused into the abdominal
cavity
P= the PCV of the peripheral blood before IV infusion of
fluids

• Surgical intervention is indicated when the PCV

off aspirated
i d lavage
l samples
l taken
k within
i hi 5-20
5 20
min increases to a PCV of over 5%
• If an animal in shock does not respond to
aggressive fluid therapy
• Retroperitoneal or diaphragmatic injuries may
give false-negative results

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Diagnosis
• Microscopic examination of the aspirate’s
sediment: detection of injury to the viscus
• Cytologic examination: abdominal neoplasia
• Chemical analysis: biliary tract injuries (bilirubin
test), pancreatitis (amylase activity), urinary tract
injuries (creatinine and Urea concentration),
perforation
f i off smallll intestine
i i (Alkaline
(Alk li
phosphatase), significant liver trauma (Glutamic-
pyruvic transaminase)

Catheter placement
• Preparation of the skin 2 cm caudal to the umblicus,
local anethesia containing epinephrine
• A 3 mm incision is made through the skin
• The bladder should be emptied
• Left lateral recumbency
• Insertion of catheter with the aid of a metal stylet
• If organ enlargement or adhesion is suspected: dorsal
recumbency and insertion of catheter with direct
visualization

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• Warm, balanced solution is infused by gravity

flow at 22 ml/kg
• The patient is rolled gently from side to side
• A small amount (20ml) of fluid is removed
• The skin is closed
• Strict hemostasis
• The catheter may be left in place

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Exploratory laparotomy indications

• Abnormal accumulation within the peritoneal cavity of
abdominal viscera
• Nonresponsive pain
• Major organ disruption
• Nonresponsive dystocia
• Abnormal discharge from abdominal tissue
• Inspection and palpation of organs
• Microbiologic
b testing, b
biopsy, or histopathological
analysis
• Trauma and neoplasia

Timing
• Surgery should be timed to maximize the
potential for diagnostic and therapeutic success
while minimizing patient insult.
• Diagnostic peritoneal lavage is useful in
abdominal trauma cases
• There are no absolute rules to guide the surgeon
• It should be performed when the patient is not
responding sufficiently to therapy

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Technical consideration
• Preparation:
Patient preparation should maximize surgical
options
An incompletely prepared ventral abdomen is
no excuse for in complete surgical evaluation

Surgical Approaches
• Ventral midline
– Th
The incision
i i i should
h ld extend
t d from
f the
th xiphoid
i h id process to
t
immediately cranial to the pelvis
• Paracostal extension of a midline incision
• Paracostal
– incision begins at the xiphoid process, continues parallel and
three to four cm caudal to one costal arch,
arch and extends to a
point level with the end of the last rib

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Views of the abdomen of the dog showing the common sites for
incision

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Equipment Needed
• A standard soft tissue surgical pack
• Noncrushing intestinal forceps
• Electrocautery device
• Vascular tourniquet
• Intestinal forceps

Surgical technique
• Exploratory laparotomy techniques are
essentially the same regardless of the clinical
signs of the patient
• After entry into the peritoneal cavity,
microbiologic samples of peritoneal fluid are
collected
• Isolation and control of serious hemorrhage and
active ggastrointestinal leakage
g should be the first
step
• A thorough, systematic exploration of the
abdomen, size, shape, location, consistency,
surface contour

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Ventral view of dog after removal of ventral abdominal wall and the
greater omentum

Ventral view of dog after the removal of the ventral body wall, stomach and
intestines

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Exploration of the peritoneal cavity

• The cranial extent of the abdomen is evaluated first:
• Diaphragm (transection of triangular ligament between
the liver and diaphragm, although often unnecessary),
• Liver lobes, gall bladder, hepatic hilus
• Inspection and palpation of the stomach
• Spleen and greater omentum (exteriorization)
• After replacement of the spleen, mesentric arterial
p l ti and
palsation d peristaltic
p ri t lti activity
ti it should
h ld also
l beb
evaluated

• The duodenum and pancreas

• The use of mesoduodenum as an anatomic
retractor gently improves visulaization of the
right paraverteral region
Portal vein, caudal vena cave, celiac artery,
hepatic lymph nodes, right kidney and proximal
ureter, right ovary and uterine horn
• Duodenum is traced to the dudenocolic
g
ligament
• Jejunum, cecum, descending colon

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• The mesocolon as a rtractor enable the surgeon

to examine the left paravertebral area
• Left kidney and proximal ureter, aorta, left
adrenal gland
gland, left ovary and uterine horn
• Distal colon, urinary bladder, distal urter,
proximal urethra, prostate gland, ductus
deferens or uterine body and vagina

Biopsy techniques
• During exploratory laparotomy, gross evaluation
andd interpretation
i i alone
l often
f do d not provide
id a
definitive diagnosis
• Frequently: Liver, intestines, lymph nodes,
kidneys, prostate gland
• Less commonly: stomach,
stomach spleen,
spleen urinary
bladder, grater omentum

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Liver
• Finger of instrument fragmentation technique
• Wedge resection technique: two rows of full-
thickness horizontal mattress suture
• Use of cutaneous punch: hemostasis is achieved
by inserting a topical hemostatic agent or
omentum

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Small intestine
• Obtain full-thickness intestinal wall sample
• Incision
I i i transverse to the h mesentery
• The biopsy incision should not exceed 20% of
the intestinal circumference
• The incision is closed in a single layer using
appositional suture pattern with synthetic
absorbable or monofilament nonabsorbable
suture material
• Protection by greater omentum

Lymph nodes
• Fine-needle aspiration technique: cytological
evaluation
l i
• Excisional biopsies: morphologic interpretation

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Kidneys and prostate gland

• Needle biopsy technique
Th needle
The dl is
i inserted
i d through
h h the
h renall capsule
l
at the caudal aspect of the kidney and is directed
within the cortex toward the cranial pole.
Digital pressure to achieve hemostasis
• Wedge resection biopsies: After excision a
wedge-shaped segment the defect is closed with
mattress suture

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Other tissues
• An elliptical section of gastric wall from one side
off the
h gastrotomy woundd edged
• Partial splenectomy
• Partial pancreatectomy
• Urinary bladder biopsies after cystotomy
• Excising a section of omentum

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Therapeutic intervention
• Hemorrhage control
• Correction of the source or sources of
contamination and pain
• Removal of mass lesions or intestinal
obstructions
• Elimination
Eli i ti off abnormalities
b liti

Intraoperative peritoneal lavage

• Peritoneal lavage using one to three liters of
warm isotonic solution is beneficial because it
warm,
facilitates aspiration of such contaminations as
soft tissue fragment, bacteria, blood clots and
fat.
• Lavage also warms the patient
• It is important
p to suction the lavage
g fluid
completely before closure of the wound
• Antibiotics, antiseptics and anticoagulants
(heparin: 100 µg/kg) can be added to peritoneal
lavage

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Wound closure
• Sutures are placed approximately 3 to 10 mm from the
wound edge
• The sutures should only incorporate the linea alba and
external sheath of the rectus abdominis muscle
• Closure of a paramedian approach( 5 mm lateral to the
linea alba) is accomplished by suturing the external
sheath only
• Closure of the internal sheath of the rectus abdominis
is unnecessary

• The peritoneum heals quicker and with fewer

complictions if it has not been sutured
• The simplep continuous p pattern usingg
nonabsorbable synthetic sutures has been
demonestrated to be efficient and effective
clinically

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