TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

TEHNIK OPERASI DAN INDIKASI LAPAROTOMY

Disusun Oleh:

Kelompok 1

Kelas A

I Gede Abijana Satya Dhika 1209005116

Tri Indra E. Sihombing 1309005086
Daniel Hot Asih Sianipar 1409005003
Megawati Saputri 1409005009
I Made Agus Prabawa 1409005010

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA

TAHUN 2017

i
 RINGKASAN
Laparotomi merupakan penyayatan pada dinding abdomen atau peritoneal
atau dapat diartikan sebagai pembedahan dinding abdomen melalui insisi ventral
abdomen atau flank (dinding perut samping). Laparotomi dapat dibagi menjadi
beberapa jenis, antara lain : Laparotomi flank, medianus, dan paramedianus.
Masing-masing jenis Laparotomi ini dapat digunakan sesuai dengan fungsi, organ
target yang akan dicapai, serta jenis hewan yang akan dioperasi. Untuk hewan
besar, umumnya menggunakan laparotomi flank karena tehnik ini dapat
meminimalisir terjadinya resiko prolapses ataupun hernia, sedangkan hewan kecil
dapat menggunakan laparotomi medianus ataupun paramedianus.

Kata kunci : Laparotomi, Hewan besar, Hewan kecil

SUMMARY
Laparotomy is an incision in then abdomen or peritoneal and can be
interpreted as the venteal abdominal surgery through an incision in the abdomen
or flank. Laparotomy is divided into several type, among others : flank
laparotomy, median, and paramedianus. Each type of laparotomy can be used in
accordance with the function, organ target to be achieved, as well as the type of
animal to be operated. For large animal , generally using flank laparotomy
because this technique can minimize the risk of prolapse of a hernia, while small
animal can use a median laparotomy or paramedianus.
Keyword : Laparotomy, Large animal, Small Animal

ii
 KATA PENGANTAR

Puji syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa atas segala
limpahan rahmat dan hidayah-Nya sehingga tugas paper yang berjudul “Teknik
Operasi dan Indikasi Laparotomy” ini, dapat terselesaikan tepat waktu.

Paper ini dibuat dalam rangka menyelesaikan tugas yang akan dijadikan
landasan dalam penilaian pada proses pembelajaran mata kuliah bedah khusus
veteriner Fakultas Kedokteran Hewan Universitas Udayana.

Ucapan terimakasih penulis sampaikan kepada dosen pengajar dan semua

pihak yang membantu dan memberi dukungan pada penulis. Penulis menyadari
tulisan ini masih terdapat kekurangan. Oleh karena itu, saran dan kritik dari
pembaca yang bersifat membangun sangat penulis harapkan. Besar harapn penulis
tulisan ini dapat bermanfaat bagi pembaca khususnya bagi dunia kedokteran
hewan.

Denpasar, September 2017

Penulis

iii
 DAFTAR ISI

Halaman

HALAMAN JUDUL .................................................................................................... i

RINGKASAN... ........................................................................................................... ii

KATA PENGANTAR ................................................................................................ iii

DAFTAR ISI ............................................................................................................... iv

DAFTAR GAMBAR .................................................................................................. vi

DAFTAR LAMPIRAN .............................................................................................. vii

BAB I PENDAHULUAN

1.1 Latar Belakang .......................................................................................... 1

1.2 Rumusan Masalah ..................................................................................... 1

BAB II TUJUAN DAN MANFAAT TULISAN

2.1 Tujuan Tulisan.......................................................................................... 2

2.2 Manfaat Tulisan........................................................................................ 2

BAB III TINJAUAN PUSTAKA

3.1 Pengertian Laparotomi ............................................................................ 3

3.2 Anatomi Organ Abdomen ........................................................................ 4

3.3 Indikasi Laparotomi ................................................................................. 5

BAB IV PEMBAHASAN

4.1 Lokasi Operasi ....................................................................................... 6

4.2 Persiapan Operasi ................................................................................... 7

4.3 Tehnik dan prosedur operasi .................................................................... 9

iv
 4.4 Perawatan Pasca Operasi Laparotomi.................................................... 16

BAB V SIMPULAN DAN SARAN

5.1 Simpulan ................................................................................................ 18

5.2 Saran ...................................................................................................... 18

DAFTAR PUSTAKA...... .......................................................................................... 19

v
 DAFTAR GAMBAR

Gambar 1. Macam-macam tempat insisi laparotomi ................................................... 7

Gambar 2. Median/Midline Incision dan penutupannya ............................................ 10

Gambar 3. Paramedian Incision dan penutupannya ................................................... 11

Gambar 4. Tranverse Incision .................................................................................... 12

Gambar 5. Penjaritan ada Transverse Incision........................................................... 12

Gambar 6. Flank Incision ........................................................................................... 13

Gambar 7. Penjahitan flank incision .......................................................................... 13

Gambar 8. Muscle Separation Technique .................................................................. 14

Gambar 9. Penjaritan Muscle Separation Technique ................................................. 15

Gambar 10. Penjaritan Muscle Separation Technique ............................................... 15

vi
 DAFTAR LAMPIRAN

Jurnal 1. Surgical Treatment of Displaced Abomasum in Cattle Using Ljubljana

Method
Jurnal 2. Postoperative Analgesic Effects of Carprofen Following Osteotomy and
Laparotomy in Dogs
Jurnal 3. Efficiency Assessment of Iranian Honey on Healing of Linea Alba
Following Exploratory Laparotomy in Animal Model
Jurnal 4. Wound strength after midline laparotomy: a comparison of four
closure techniques in rats

vii
 BAB I

PENDAHULUAN

1.1 Latar Belakang

Secara anatomis tubuh hewan tersusun atas berbagai macam saluran
seperti saluran pencernaan (lambung,pancreas,usus,hati,dan empedu), saluran
limfatik (limpa), .saluran urogenital (ginjal,ureter,vesica urinaria, dan uretra)
serta saluran reproduksi (ovarium, tuba fallopi, dan uterus). Untuk melihat
kondisi patofisionya dapat digunakan pembedahan dengan teknik laparotomy.
Saat ini dunia medis veteriner telah banyak mengalami perkembangan
yang pesat. Hal ini ditandai dengan peningkatan kasus pada hewan kecil (pet
animal) yang sampai ke meja operasi. Tindakan bedah tersebut umumnya
dilakukan didaerah abdomen.
Dalam ilmu bedah, perlu digolongkan lagi tekhnik bedah agar dapat
mudah diaplikasikan dalam bidang medis terutama pada bidang terapi dan
penyembuhan pasien. Ilmu bedah yang mempelajari tetang teknik bedah
abdomen disebut dengan Laparotomi yang bertujuan untuk menemukan dan
mengetahui keadaan organvisceral yang ada di dalam ruang abdominal secara
langsung serta untuk menegakkan diagnosa. Seiring dengan berkembangnya
operasi Laparotomi pada beberapa hewan inilah yang melatar belakangi
pembuatan paper dengan mempelajari teknik bedah ini sebagai wawasan.

1.2 Rumusan Masalah

1.2.1 Apa yang dimaksud dengan Laparotomi?
1.2.2 Apa indikasi dilakukannya Laparotomi?
1.2.3 Bagaimana persiapan operasi Laparotomi?
1.2.4 Bagaimana tehnik dan prosedur operasi Laparotomi?
1.2.5 Bagaimana penanganan pasca operasi Laparotomi?

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 BAB II
TUJUAN DAN MANFAAT
2.1 Tujuan Penulisan
2.1.1 Untuk mengetahui definisi dari Laparotomi
2.1.2 Untuk mengetahui apa indikasi dilakukannya Laparotomi
2.1.3 Untuk mengetahui persiapan sebelum operasi Laparotomi
2.1.4 Untuk mengetahui tehnik dan prosedur operasi Laparotomi
2.1.5 Untuk mengetahui penanganan pasca bedah Laparotomi

2.2 Manfaat penulisan

Manfaat dari tulisan ini agar mahasiswa kedokteran hewan dapat menambah
pengetahuan dan bisa mengetahui secara lebih mendalam mengenai teknik
operasi dan indikasi laparotomy.

2
 BAB III
TINJAUAN PUSTAKA

2.1 Pengertian Laparotomi

Laparotomi berasal dari dua kata terpisah, yaitu laparo dan tomi. Laparo
sendiri berati perut atau abdomen sedangkan tomi berarti penyayatan. Sehingga
laparotomi dapat didefenisikan sebagai penyayatan pada dinding abdomen atau
peritoneal. Istilah lain untuk laparotomi adalah celiotomi (Theresa,2007). Bedah
laparatomi merupakan tindakan operasi pada daerah abdomen, bedah laparatomi
merupakan teknik sayatan yang dilakukan pada daerah abdomen yang dapat
dilakukan pada bedah digestif dan kandungan.

Laparotomi terdiri dari tiga jenis yaitu laparotomi flank, medianus dan
paramedianus. Masing-masing jenis laparotomi ini dapat digunakan sesuai dengan
fungsi, organ target yang akan dicapai, dan jenis hewan yang akan dioperasi.

Umumnya pada hewan kecil laparotomi yang dilakukan adalah laparotomi

medianus dengan daerah orientasi pada bagian abdominal ventral tepatnya di linea
alba. Banyak kasus bedah yang ditangani dengan melakukan tindakan laparotomi,
baik medianus, paramedianus anterior maupun posterior, serta laparotomi
flank. Masing- masing posisi memiliki kelebihan dan kekurangannya
tersendiri. Pemilihan posisi penyayatan laparotomy ini didasarkan kepada
organ target yang dituju. Hal ini untuk menegakkan diagnosa berbagai
kasus yang terletak di rongga abdomen. Tujuan laparotomi adalah untuk
menemukan dan mengetahui keadaan organ visceral yang ada di dalam ruang
abdominal secara langsung serta untuk menegakkan diagnose
(Gunanti,2011).

Untuk hewan besar, umumnya menggunakan laparotomi flank karena

tehnik ini dapat meminimalisir terjadinya resiko prolapses ataupun hernia,
sedangkan hewan kecil dapat menggunakan laparotomi medianus ataupun
paramedianus.
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Beberapa Hal yang Perlu Diperhatikan :

a) Kerusakan jaringan karena insisi harus seminimal mungkin (satu kali

irisan panjang akan lebih baik dari pada sebuah irisan pendek
yang dilakukan dengan beberapa kali sayatan).

b) Ligasi/pengikatan pembuluh darah pada daerah insisi dapat menyebabkan

penundaan kesembuhan luka. Sebaiknya pembuluh darah hanya
dijepit/diklem dengan arteri klem (forceps hemostatic) atau perdarahan
yang terjadi dihentikan dengan penekanan tampon selama 1-2 menit.
c) Skalpel harus benar-benar tajam, sedapat mungkin mata pisaunya/blade
harus baru.

d) Peritoneum pada hewan kecil adalah tipis dan bila dijahit secara
terpisah/tersendiri akan mudah robek. Sebaikanya peritoneum dijahit
bersama-sama dengan semua jaringan linea alba.

2.2 Anatomi Organ Abdomen

Pada bedah laparotomy ini dilakukan eksplorasi organ-organ ruang
abdomen. Organ yang akan ditemui adalah omentum, usus, vesical urinaria,
lambung, ginjal hati dan saluran reproduksi (seperti tuba fallopi,uterus, dan
ovarium) organ-organ yang ditemukan didalam rongga abdomen pada saat
operasi antara lain usus halus,usus besar, ginjal kiri, ginjal kanan, vesica
urinaria dan lambung. Usus merupakan organ yang paling mudah ditemukan
karena pada posisi yang dilakukan tepat di ventromedial abdomen. Usus
memiliki konsistensi yang lunak, licin, dan lumennya kosong ketika dipalpasi.
Vesica urinaria dapat diketahui dengan palpasi bagian hypogastrium. Vesica
urinaria berisi urin memiliki konsistensi lunak dan padat. Ginjal kanan dan kiri
dapat teraba ketika dilakukannya palpasi. Bentuk dari kedua ginjal seperti
kacang dengan konsistensi yang lunak dan padat. Organ lainnya tidak
terpalpasi pada saat eksplorasi abdomen (Sjamsuhidajat,2005).

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2.3 Indikasi Laparotomy

Laparotomi dilakukan untuk pembedahan didalam rongga abdomen

seperti:

- Seksio cesarean
- Ovariohysterectomy
- Hysterectomy
- Enterotomi
- Enterectomy
- Cystotomi
- Gastrotomy
- Splenektomy
- Nephrotomy
- Nephrectomy
- Untuk tujuan diagnosa.
- Penanganan neoplasma

5
 BAB IV

PEMBAHASAN

Laparotomi (celiotomy) adalah pembedahan membuka dinding abdomen

melalui insisi ventral abdomen atau flank (dinding perut samping). Insisi pada
ventral abdomen dapat dilakukan melalui linea alba, pada median kiri dan kanan
atau insisi transversal pada dinding abdomen. Insisi pada garis median tepat
dilakukan pada garis tengah abdomen dan linea alba, sehingga tidak terjadi
perdarahan karena tidak ada pembuluh darah atau saraf yang terinsisi. Insisi para
median merupakan irisan longitudinal disamping garis median kira-kira 1 cm.
Insisi para median berisiko terjadinya perdarahan. Insisi transversal dinding
abdomen dilakukan dengan memotong serabut-serabut otot abdomen, disini
akanterjadi perdarahan karena terpotongnya serabut-serabut otot dan pembuluh
darah. Adapun tindakan bedah digestif yang sering dilakukan dengan teknik
sayatan arah laparatomi yaitu: herniotorni, gasterektomi, kolesistoduodenostomi,
hepateroktomi, splenorafi/splenotomi, apendektomi, kolostomi, hemoroidektomi
dan fistulotomi atau fistulektomi. Tindakan bedah kandungan yang sering
dilakukan dengan teknik sayatan arah laparatomi adalah berbagai jenis operasi
uterus, operasi pada tuba fallopi dan operasi ovarium (Prawirohardjo), yaitu:
histerektomi baik itu histerektomi total, histerektomi sub total, histerektomi
radikal, eksenterasi pelvic dan salingo-coforektomi bilateral. Tujuan laparotomi
adalah untuk menemukan dan mengetahui keadaan organvisceral yang ada di
dalam ruang abdominal secara langsung serta untuk menegakkan diagnosa.

Anestesi yang digunakan adalah anestesi umum atau anestesi regional

(anestesi epidural, para vertebral). Pada hewan besar dapat dilakukan dengan
anestesi local infiltrasi.

4.1 Lokasi Operasi

Pada hewan besar, operasi dapat dilakukan pada flank kanan atau kiri
dengan posisi hewan berdiri. Sedangkan pada hewan kecil, dapat dilakukan
pada ventral midline dengan posisi hewan dorsal recumbency. Dalam banyak

6
 hal operasi dilakukan diantara tulang rusuk terakhir denga bagian externa dari
pada sudut ilium

Gambar 1. Macam-macam tempat insisi laparotomi

4.2 Persiapan Operasi

a) Persiapan dan Preparasi Hewan
Persiapan-persiapan yang dilakukan pada hewan meliputi pemeriksaan
signalemen, anamnese, status present serta pemeriksaan lain yang
dianggap perlu. Data fisiologis hewan yang harus diambil sebelum operasi
yaitu suhu tubuh, frekuensi jantung, frekuensi nafas, limfonodulus, dan
selaput lendir. Tahapan selanjutnya adalah restraint hewan kemudian
pembiusan yang dimulai dari tahap pembiusan, pre medikasi, induksi, dan
maintenance. Preparasi hewan dimulai dengan daerah operasi dicukur
minimal 10 cm disekitar sayatan. Setelahitu, sayatan dan daerah di sekitar
sayatan dibersihkan dengan alkohol 70%.Selanjutnya dikeringkan dengan
tampon kemudian diolesi dengan iodine tincture 3%. Setelah itu hewan
siap dibawa ke meja operasi. Ketika berada di atas meja operasi, posisi
hewan disesuaikan dengan keadaan. Keempat kaki diikat keujung-ujung
meja menggunakan sumbu kompor dengan simpul Tomfool. Kemudian
7
 hewan ditutup dengan duk, disesuaikan, dan difiksir dengan towel clamp.
Setelah itu, operasi siap dilakukan.
b) Metode Anastesi
Sebelum hewan dioperasi dilakukan pemeriksaan fisik telebih dahulu
untuk mengetahui keadaan normal hewan. Sepuluh menit sebelum
dioperasi, hewan diberikan premedikasi atropin dengan dosis
mg/kgBB,diverikan dengan rute sub cutan.
o Premedikasi
Atropin sulfat Jumlah pemberian=(berat badan ×dosis aplikasi) /
(kandungan sediaan). Setelah itu hewan diberikan anastethikum
atropin dan xylazine dengan rute intra muscular.
o Anastetikum
Xylazine HCl Jumlah pemberian=(berat badan ×dosis aplikasi) /
(kandungan sediaan) Ketamin Jumlah pemberian = (berat badan×dosis
aplikasi ) / (kandungan sediaan)

Operasi dilakukan setelah hewan teranasthesi. Bagian abdomen

hewan dicukur kemudian didesinfeksi menggunakan alkohol 70% dan
povidone iodine. Penyayatan dilakukan pada daerah medianus abdomen
tepat di linea alba. Setelah itu dilakukan penyayatan pada kulit
menggunakan blade, diikuti penyayatan linea alba, aponeurosem. Obliquus
abdominis internus et externus, dan peritoneum. Sayatan diperluas
menggunakan gunting.

c) Persiapan Operator dan Asisten

Langkah-langkah yang harus dilakukan oleh operator dan asisten
adalah menggunakan tutup kepala dan masker, mencuci kedua tangan
dengan sabun dan menyikatnya dengan sikat pada air yang mengalir.
Pencucian dimulai dari ujung jari yang paling steril kemudian dibilas
dengan arah dari ujung jari kelengan yang dilakukan sebanyak 10-15x.
Setelah selesai mencuci tangan dan membilasnya, keran ditutup
dengan siku untuk mencegah kontaminasi. Kemudian tangan dikeringkan
dengan handuk dan glove dipakai. Setelah semua langkah dilalui, operasi
siap dilakukan.
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4.3 Tehnik dan Prosedur Operasi
1. Insisi Abdominal
Insisi pada laparotomi sebisa mungkin harus menimbulkan sedikit
perlukaan pada dinding abdomen, namun cukup lebar sehingga dapat
memungkinkan akses yang mudah ke area yang diinginkan. Insisi harus
cukup besar, sehingga dapat dilalui tangan atau jari, dan ada beberapa
kasus dapat lebih besar serta insisi harus ditempatkan sedmikian rupa
sehingga dapat diperbesar jika diperlukan.
Sebelum memulai insisi, sangat penting untuk memastikan posisi
median pasien telah tepat karena setelah pasien ditutupi drape,
perpindahan posisi pasien mungkin tidak teramati sehingga dapat
mengakibatkan kesalahan lokasi insisi. Setelah kulit diinsisi, perlukaan
kemudian ditarik dengan retractor dan dapat diperluas menggunakan
gunting.
Insisi pada midline tidak memerlukan penarikan pada peritoneum yang
telah dibuka melewati linea alba. Sedangkan jika akses peritoneum melalui
paramedian, pararectus, atau tranversal, insisi dilakukan dengan cara
memegang dan mengangkat musculus rectus abdominis hingga
peritoneum menggunakan forceps, kemudian membuat insisi kecil yang
dapat diperbesar menggunakan gunting.
2. Lokasi Insisi
Pada pasien dengan posisi recumbency dorsal, duodenum berada pada
regio hypochondriac kanan, kantung empedu pada regio xiphoid, serta
lambung dan limpa ada pada regio hypochondriac kiri. Ginjal dan ovarium
berada pada regio abdominal lateral, kira-kira sejajar dengan umbilicus.
Kantung kemi, prostat, dan urethra berada pada midline region prepubic.
a) Longitudinal Incision
 Median Incision
Median incision merupakan insisi yang menggunakan garis median
ventral sebagai acuannya, melewati secara langsung umbilicus.
Median incision dapa dilakukan dari cranial atau caudal menuju
atau langsung melewati umbilicus dan dapat diperpanjang

9
 sepanjang yang diperlukan. pada beberapa kasus, insisi dapat
diperpanjang dari kartilago xiphoid hingga pubis. Insisi ini harus
dilakukan tepat melalui linea alba, hal ini dapat menghindari
terpotongnya musculus, pembuluh darah mayor, dan nervi.

Gambar 2. Median/Midline Incision dan penutupannya

 Paramedian Incision
Sama seperti median incision, paramedian incision
menggunakan umbilicus sebagai penanda. Insisi
paramedian dibuat parallel 0,5 – 1 cm lateral midline tubuh.
Lamina externa dan lapisan rektus diinsisi searah dengan
arah serat rektus. Sedangkan musculus tidak diinsisi,
melainkan ditarik kea rah lateral untuk dapat
memperlihatkan lamina interna dan peritoneum.

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 Gambar 3. Paramedian Incision dan penutupannya

 Pararectus Incision
Insisi ini dilakukan pada lateral rektus otot. Hanya pada
lamina externa saja dilakukan insisi, sedangkan otot ditarik
kearah medial sehingga memperlihatkan lamina interna
yang kemudian diinsisi bersama peritoneum untuk dapat
membuka cavum abdominal
 Transverse Incision
Insisi ini dibuat secara melintang, biasanya pada rektus.
Insisi dapat unilateral ataupun bilateral, dan dapat
dilakukan pada berbagai tingkat di abdomen. Terjadi lebih
banyak perdarahan pada insisi ini dibandingkan pada insisi
longitudinal, dan jaritan menjadi lebih tegang
dibandingkan dengan pada jaritan untuk menutup insisi
longitudinal. Namun, ada bukti bahwa jika dijarit dengan
benar maka hasilnya akan lebih kuat dibandingkan dengan
jaritan pada insisi longitudinal.

11
 Gambar 4. Tranverse Incision

Gambar 5. Penjaritan ada Transverse Incision

b) Flank Incsion
Insisi ini terkadang dilakukan pada nephrectomy, ovariectomy,
dan C-section. Kelebihan insisi melalui flank adalah rendahnya
resiko terjadinya hernia pasca operasi. Namun, resiko terjadinya
12
hernia tetap saja ada seperti pada insisi ventral. Pada insisi flank,
terjadi lebih banyak perdarahan, pembentukan bekas luka yang
lebih besar dan adanya pembatasan insisi.
Insisi pada flank dapat dilakukan pada kedua sisi di regio
lumbar dan midway antara costae terakhir dan sejajar tuber coxae.
Setelah dilakukan insisi pada kulit, maka dilakukan sayatan
melintang pada musculus oblique externa dan interna serta
musculus tranversus.

Gambar 6. Flank Incision

Gambar 7. Penjahitan flank incision

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 Muscle Separation Technique
Teknik ini merupakan teknik modifikasi dari insisi flank
standar dan memiliki keuntungan berupa lebih sedikit trauma,
lebih sedikit perdarahan, dan lebih sedikit gangguan pada
fungsi otot pasca operasi. Namun, kelemahan teknik ini adalah
harus membuat insisi yang besar untuk melakukan operasi.
Setelah kulit diinsisi, baik arah dorso-ventral, oblique,
maupun cranio-caudal, lapisan pembungkus otot kemudian
diinsisi sesuai dengan arah serat otot dan kemudian serat otot
ditarik menggunakan forceps. Ketika forceps dilepas, maka
otot akan kembali ke posisi semula dan menimbulkan lebih
sedikit pembentukan scar.

Gambar 8. Muscle Separation Technique

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 Gambar 9. Penjaritan Muscle Separation Technique

Gambar 10. Penjaritan Muscle Separation Technique

3. Menutup Insisi
a) Peritoneum
Pada anjing peritoneum melekat erat pada lapisan dalam dari
selaput rektus internal dan pada penjaritan dilakukan
15
 bersamaan atau menjadi satu. Peritoneum memiliki daya
pegang terhadap jaritan yang lemah karena merupakan selaput
yang tipis, upaya penutupan sesuai standar dilakukan dengan
melibatkan lamina interna dari selaput rektus.
b) Musculus dan Fascia
Musculus memiliki daya pegang terhadap jaritan yang lemah
dan penyatuan otot biasanya dilakukan dengan cara
menyisipkan jaritan ke fascia. Pada kasus - kasus abdomen,
disisipkan pada lamina interna dan externa dari selaput rektus.
Dengan sedikit jaritan yang menembus otot, akan membantu
aposisi otot.
c) Kulit
Kulit memiliki daya pegang terhadap jaritan yang kuat, dan
sangat membantu dalam penutupan luka operasi. Penutupan
luka yang besar pada abdomen kemungknan sulit untuk
dilakukan, namun dapat diantisipasi dengan penutupan
sementara dengan menggunakan kasa steril dengan Vaseline
steril. Kasa yang digunakan, tebal 4 sampai 6 lapis, kemudian
dijarit sampai ke tepi jaritan dan dijarit longgar untuk dapat
dibuat sebagai drainase. Kasa digunakan untuk melindungi
rongga abdomen dari infeksi luar. Kasa dapat dikeluarkan 2
hingga 3 minggu dan dapat dilanjutkan dengan implant plastic
atau logam.

4.4 Perawatan Pasca operasi Laparotomy

Penanganan pasca operasi laparotomy adalah dengan pemberian antibiotic
topical dan general, pemberian pakan dan air yang cukup, perlindungan luka
operasi,pemberian infus jika perlu, pemberian vitamin jika perlu, dan pada
hari ke tujuh jahitan dibuka jika luka sudah mengering.
Prosedur bedah laparotomi umumnya didukung perawatan postoperatif .
Pengecekan tersebut anatara lain efek anastesi dan meyakinkan bahwa
persembuhan luka berjalan dengan baik (Hedlund 2002). Komplikasi sering

16
kali menyertai operasi seperti reaksi alergi jahitan, seroma, hematoma, self
trauma dan ketidaknyamanan pasien.
Terapi cairan harus dilanjutkan pada kebanyakan hewan pasca operasiabdo
men. Elektrolit, asam-basa, dan protein serum harus diperhatikan dan
dikoreksi pasca operasi untuk memastikan bahwa pasien dengan memiliki
asupan kalori yang memadai pasca operasi (Theresa 2007). Perawatan seperti
pemberian antibiotic, terapi cairan, perawatan balutan,anti imflamasi akan
membantu persembuhan luka setelah operasi. Penanganan post operatif sangat
penting karena dapat mempengaruhi persembuhan hewan (pasien). Beberapa
hal yang perlu diperhatikan terhadap pasien bedah post operatif untuk
perawatan pasien bedah, dianataranya hewan dibawa keruang pemulihan yang
tenang, hewan tetap dimonitor dengan diukur suhu, frekuensinafas, frekuensi
denyut jantung, serta diameter pupil. Diperhatikan membran
mukosa,limphonodus, dan selaput lendir, serta pasien diberikan obat untuk
mengatasi rasanyeri selama 1 sampai 3 hari setelah operasi (Hedlund 2002).
Diberikan infus bilaterjadi muntah dan diare hebat, disfungsi ginjal dan
penyakit hati denganmemperhatikan laju infus dan jenis infus yang diberikan.
Apabila pasien hypothermia, diberi penghangat menggunakan air hangat,
diberikan suplemenoksigen, kateter apabila diperlukan (Mc Curnin 2002).

17
 BAB V

SIMPULAN DAN SARAN

5.1 Simpulan
Laparotomi adalah penyayatan pada dinding abdomen atau peritoneal.
Istilah lain untuk laparotomi adalah celiotomi. Bedah laparatomi merupakan
tindakan operasi pada daerah abdomen, bedah laparatomi merupakan teknik
sayatan yang dilakukan pada daerah abdomen yang dapat dilakukan pada
bedah digestif dan kandungan.
Laparotomi terdiri dari tiga jenis yaitu laparotomi flank, medianus dan
paramedianus. Masing-masing jenis laparotomi ini dapat digunakan sesuai
dengan fungsi, organ target yang akan dicapai, dan jenis hewan yang akan
dioperasi.
Sebelum dilakukan laparotomi, dilakukan beberapa persiapan diantaranya
persiapan operator, alat dan bahan instrumen bedah, pasien, serta tempat untuk
laparotomi. Persiapan ini dilakukan bertujuan untuk mempermudah jalannya
proses laparotomi. Selain itu dilakukan sterilisasi alat yang bertujuan agar
tidak terjadi infeksi mikroba pada pasien dan untuk membantu proses
penyembuhan pada pasien.
Setelah dilakukan laparotomi pada pasien (hewan) dilakukan perawatan
pasca operasi pada pasien untuk mempercepat proses penyembuhan luka
jahitan pada pasien dan juga untuk mengembalikan kondisi pasien ke kondisi
awal.

5.2 Saran
Sebaiknya dipahami terlebih dahulu anatomi topografi dari hewan yang akan
dibedah serta dipahami teori-teori pembedahan laparotomi agar operasi dapat
berjalan dengan lancar.

18
 DAFTAR PUSTAKA

Archibald, J. 1974. Canine Surgery : Second Archibald Edition. Santa Barbara.

America Veterinary Publications.

B. T. Abass And O. J. Ali. 2008. Comparison Of Laparoscopic And Conventional

Surgery Of Intestinal Anastomosis In Dogs. Iraqi Journal Of Veterinary
Sciences, Vol. 22, No. 1 (13-19).
Errol, Muharrem. Celal, Izci. 2011. Postoperative Analgesic Effects of Carprofen
Following Osteotomy and Laparotomy in Dogs. Department of Surgery,
Faculty of Veterinary Medicine, University of Selcuk.
Jennifer L. Lansdowne, DVM, MSc, DACVS-SA, DECVS-SA,Dkk. 2012.
Minimally Invansive Abdominal adn Thoracic Surgery:
Techniques,Dkk.2012. Compedium: Countinuing Education For
Veterinarians. Vetlearn.com
Joze Staric,etc. 2010. Surgical Treatment of Displaced Abomasum in Cattle Using
Ljubljana Method. Acta vet. Brno, 79: 469–473.
Ma’ruf, Adrin. Teknik Operasi Laparotomy (Celiotomy) pada Hewan.
https://mydokterhewan.blogspot.com/2016/05/teknik-operasi-laparotomy-
celiotomy.html (diakses 22 September 2017)
N. Cutten. Immediate and Long Term Effects of PostMating Laparotomy on the
Lambing Performance of merino ewes.

Shokouhi, Farnood S J. et al. 2007. Efficiency Assessment of Iranian Honey on

Healing of Linea Alba Following Exploratory Laparotomy in Animal
Model

19
 ACTA VET. BRNO 2010, 79: 469–473; doi:10.2754/avb201079030469

Surgical Treatment of Displaced Abomasum in Cattle Using Ljubljana Method

Jože Starič1, Halil Selcuk Biricik2, Gurbuz Aksoy3, Tomaž Zadnik1
1
Clinic for Ruminants, Veterinary Faculty, University of Ljubljana, Slovenia
2
Department of Surgery, 3Department of Internal Medicine, Faculty of Veterinary Medicine,
Harran University, Turkey

Received April 5, 2009

Accepted May 13, 2010

Abstract
Displacement of the abomasum (DA) is an increasingly common disease in dairy cattle in
intensive production. This study presents surgical treatment of DA using Ljubljana method in
years 2005 and 2006. Slovenian Black and White dairy cows (n = 30) with left DA in 19 cows,
right DA in four cows, anterior DA in two cows and abomasal volvulus in five cows were used.
The surgical treatment was successful in 28 cows, 2 had to be euthanized due to complications
associated with left DA and abomasal volvulus. One month after the surgery all 28 cows were
productive. Omentopexy using Ljubljana method can be used as a clinical procedure as well as
procedure performed in ambulatory practice.
Displacement, surgery, percutaneous, abdomen, omentopexy

In the last decade, displacement of the abomasum (DA) has been one of the most common
surgical interventions in dairy cattle. It occurs due to gas accumulation in the abomasum,
which pulls the organ from its physiological position on the abdominal floor either between
the left abdominal wall and rumen or between the right abdominal wall and intestines.
Distended abomasum can also change its normal position in the cranial direction. In such
case, displaced abomasum is trapped between the reticulum and diaphragm. This type of
displacement is called anterior DA (Zadnik et al. 2001; Zadnik 2003a). The incidence
of left abomasal displacement on lactation varies between 0.5 and 2.2%; in certain
circumstances it may be even 5% or more (Steiner 2006). Left DA is much more common
(85–96% of DA) than right DA, accounting for 4–15% of cases (Constable et al. 1992).
In a study conducted in Slovenia, anterior abomasal displacement accounted for 12.4% of
cases (Zadnik 2003a).
Majority of cases develop within the first month after calving and other cases develop
during last months of pregnancy or in other physiological periods. Beside known
predisposing factors such as negative energy balance, hypocalcaemia, retained foetal
membranes, uterine infections, dystocia, cow breed, and others, physiologically more
transverse and cranial position of the abomasum during the last 3 months of gestation
(Wittek et al. 2005) and increasing depth of abdomen (Wittek et al. 2007) increase the
risk of displacement in dairy cattle.
In rare cases, abomasum spontaneously returns to its physiological position on the
abdominal floor. In majority of cases, treatment of the affected animal is necessary.
Decision upon the type of treatment is dependent on various factors including availability
of equipment, clinical status of the animal, costs of procedure, clinician’s skills and
preferences, value of the animal, owner’s wishes, etc. Abomasal displacements can be
corrected by surgical or nonsurgical techniques. Nonsurgical techniques include rolling the
cow to flip the abomasum back in place, or securing the abomasum to the body wall with
a percutaneous blind tack or a toggle pin fixation. Rolling is not an effective long-term
treatment because most cows will have a recurrence. Left DA can be corrected surgically
using right flank omentopexy, right paramedian abomasopexy, left flank abomasopexy,
Address for correspondence:
Jože Starič, DVM, MSc Phone: 00386 1 4779 217
University of Ljubljana, Veterinary Faculty e-mail: joze.staric@vf.uni-lj.si
Gerbičeva 60, 1000 Ljubljana, Slovenia http://www.vfu.cz/acta-vet/actavet.htm
470

one-step standing or dorsally recumbent cow laparoscopic abomasopexy or two-step

laparoscopic abomasopexy. Right DA and abomasal volvulus are corrected surgically using
right paralumbar fossa omentopexy or right paramedian abomasopexy. Current scientific
findings favour laparoscopy-assisted correction of uncomplicated left DA over other surgical
procedures due to lesser invasiveness, quicker completion of surgery, less complications,
quicker return to productivity and minor or no need of antibacterial treatment (Rohn et al.
2004; Seeger et al. 2006; Steiner 2006; Roy et al. 2008).
At the Clinic for Ruminants, Veterinary Faculty of Ljubljana we generally advise surgical
correction in the right paralumbar fossa based on more than 30-year-long experience with
DA. Right paralumbar fossa laparotomy gives excellent opportunity for evaluation of
almost the whole abdomen with organs, very good orientation and possibility of favourable
omentopexy position. Based on obtained information about clinical status, surgical and
clinicopathological findings, we are able to institute post-surgical medical treatment,
focused also on other pathological findings obtained at surgery and to give a firm prognosis
about recovery of the affected cow (Zadnik et al. 2001; Zadnik 2003b).
The study describes Ljubljana method of surgical correction of all types of displacements
of the abomasum or abomasal volvulus.
Materials and Methods
Animals
A total of 30 Slovenian Black and White dairy cows were included in this study. All the cows were within
4 weeks after calving, except one cow that was 140 days in milk. Cows were affected with left displacement
of abomasum (19), right DA (4), anterior DA (2) and abomasal volvulus (5).Cows were surgically treated by
Ljubljana method at the Clinic for Ruminants, Veterinary Faculty of Ljubljana in the years 2005 and 2006.
Diagnosis
The diagnosis was based on findings obtained by signalment and history of the disease and clinical examination.
The diagnosis was confirmed surgically. Clinic-pathological profile was examined to better assess the health
status of affected cows and further assist them with specific treatments (supplementation of fluids, minerals,
glucose, etc.) to facilitate faster return to full production.
Anaesthesia
Local anaesthesia with 2% procaine (procaine powder with sterile distilled water) was prepared. Proximal
paralumbar block (last thoracic T 13 and first two lumbar L 1 and L 2 spinal nerves) and inverted L block a few
cm cranial from surgical incision was performed. Twelve ml of 2% procaine were injected at each location of
dorsal and ventral branch of spinal nerves. Additional 60 ml was infiltrated subcutaneously in inverted L block.
Sedation was not used.
Ljubljana method – percutaneous omentopexy using Bühner tape (silk ribbon)
Standing laparotomy was performed in right paralumbar fossa. Vertical or slightly oblique cranio-caudal
surgical incision started little less than a hand-width beneath transverse processes of lumbar vertebrae and
continued until the most caudal part of the costal arch where it ended about 4 to 5 cm caudal from it. M. obliqus
abdominis externus and internus were incised, although internus could be also separated bluntly in the direction
of muscle fibres. For entering the abdomen, rat-tooth tissue forceps were used to tent fascia and peritoneum, and
blunt Mayo scissors for cutting a hole big enough for passing a finger that helped as a guide for extending the
incision with scissors dorsally and ventrally. When the abdomen was entered, the suction of air into abdominal
cavity could be heard. For haemostasis Pean haemostats and 4 × 4 s were used. The surgical incision should
be long enough to permit passing a hand up to a shoulder. During the abdomen exploration, the quantity and
quality of abdominal fluid was evaluated followed by examination of the kidneys, caecum, uterus, small and
large intestines, rumen, and displaced abomasum. Then the abomasum was deflated at its most dorsal part at an
acute angle with a 2 mm diameter needle attached to sterile rubber tubing until there was no palpable gas left in it.
Palpation of the cranial part of the abdomen was followed by evaluation of liver fattiness, gall bladder, omasum
and reticulum. Thick omentum close to pylorus was then grabbed and the abomasum pulled to the right side in
case of left DA. In right DA or abomasal volvulus, the abomasum was deflated after excluding the possibility
of volvulus, perforating ulcer or establishing the direction of volvulus followed by retorsion and before any
exploration of the abdomen. Identification of pylorus was the next step. The landmark was thick omentum, which
was followed cranio-ventrally until pylorus was reached. Pylorus (Plate II, Fig. 1) could be identified due to its
unique characteristics: pale bluish pink colour, distinctive difference from omentum majus and its meaty structure
on palpation. For omentopexy silk ribbon (1 cm wide and 50 cm long), originally used for Bühner closure of vulva
in cows, was used and placed with Gerlach needle (Plate II, Fig. 2). Omentopexy suture was positioned about 5
 471

to 10 cm caudal from pylorus through the thick omentum with Gerlach needle. Than each loose end of a suture
was passed through the abdominal wall using Gerlach needle about 5 cm beneath the ventral end of the surgical
incision (Plate III, Fig. 3). To enable penetration of the needle through the skin, small stab incision was made
over the protruding Gerlach needle. The same was repeated with the other loose end of the omentopexy suture.
Position of the abomasum was rechecked and both ends of the suture tightened (not too tight in order to prevent
ischemia of the omentum). The suture was supported with rolled sterile 4 × 4, which was put under the knot.
Surgical incision was closed with three layers. Peritoneum, fascia and transversus muscle were sutured together
with simple continuous pattern with chromic catgut. M. obliqus internus if bluntly separated was apositioned with
about 3 simple interrupted sutures and m. obliqus externus was sutured with simple continuous pattern, both with
chromic catgut. Skin was closed with supramid (Ford interlocking suture and most ventral 2 sutures were simple
interrupted). Skin sutures and omentopexy sutures were removed about 10 days after the surgery.

Results
reduced appetite or off feed, reduced milk production, not chewing cud and reduced
faecal output of more dry or pasty faeces were recorded in all cows. Other predisposing
factors for abomasum displacement like obesity, milk fever, retained placenta etc. were
found. Concurrent diseases were often present (Table 1). Ketosis that did not respond
favourably to treatment was very common.

Table 1. Information on concurrent diseases in treated cows using Ljubljana method at the hospital and their
follow up status after 1 month
Type of abomasal pathology
LDA ADA RDA AV
In hospital Number of cows 19 2 4 5
Average days in milk 14.1* 14.5 12 20.2
No other problems 4 0 0 3
Metritis 8 0 1 1
Mastitis 0 0 0 0
Ketosis 13 2 4 2
Euthanized after surgery 1 0 0 1
1 month follow-up No problems 13 2 4 2
Lower than expected productivity 5 0 0 2
Surgical site infections 0 0 0 0
Euthanized 0 0 0 0
*One cow had LDA 140 days in milk and was not included in this calculation
LDA - Left displacement of abomasum, RDA - Right displacement of abomasum, ADA - Anterior displacement
of abomasum, AV - Abomasal volvulus

Clinical examination usually revealed typical ping effect on simultaneous percussion

and auscultation positioned either in the right or left costal region of abdomen that
could extend to paralumbar fossa, depressed ruminal motor activity, often mild
jaundice, deep paralumbar fossa, positive succussion test over sight of abomasal
displacement (splashing sounds), sound of gas bubbles emerging through accumulated
fluid in the abomasum on auscultation, high or slightly elevated arterial pulse and
often enophtalmus (especially if diagnosed late in the course of the disease). Clinico-
pathological findings indicative of abomasal displacement included hypokalaemia,
hypochloridaemia, hyperbilirubinaemia, mild hypocalcaemia, elevated beta-hydroxy
butyrate. Higher activities of aspartame amino transferase, lactate dehydrogenase,
gamma glutamyl transferase and glutamate dehydrogenase were frequently observed.
Stress leucogram and hyperglycaemia were also present in many cases. Especially
in long-lasting and AV cases, haemoconcentration was often observed. Clinical signs
were usually more pronounced in abomasal volvulus (AV) cases, where also signs of
dehydration were usually more evident.
472

The surgical correction was successful in 28 cows, 2 had to be euthanized, one due to bad
clinical status after abomasum displacement and perforating ulcer correction and the other
due to n. vagus indigestion following AV correction. No relapses occurred within a month
after the surgery. All 28 cows were productive one month after the surgery.
Discussion
Since the first cow was treated for DA at the Clinic for Ruminants, Veterinary Faculty of
Ljubljana in 1969 (Skušek et al. 1970), the frequency of the disease has increased rapidly
(Zadnik et al. 2001). Based on recent data collected by Veterinary Administration of the
Republic of Slovenia, current incidence rate of DA is about 2% of dairy cows in lactation.
Displaced abomasum is also the most frequent diagnosis in dairy cows admitted at the
Clinic for Ruminants.
Clinical and clinic-pathological findings in studied cows with abomasal displacement
were in accordance with findings of other studies (Zadnik et al. 2001; Zadnik 2003b).
Experience with DA and AV shows that the clinical treatment using Ljubljana method
is successful. Based on our experience, percutaneous omentopexy using Ljubljana method
does not produce permanent adhesion of the omentum to the abdominal wall. When
omentopexy suture is removed about 7–14 days after the surgery, abomasum can be free
again and can move in the abdominal cavity. We assume that in the period of up to 14 days
after the surgery, the rumen improves to disable abomasal movement. Affected cows also
stabilize metabolically which is necessary for the healthy tonus and motorical function
of the abomasum. Even though abomasum may be free when the omentopexy suture is
released, re-displacements are very rare, and none was observed in cows included in this
study. We did not perform follow-up ultrasound or laparoscopic examination to exclude
formation of permanent adhesions after Ljubljana method surgical correction of DA. Our
assumption is based on few documented cases of cows (n = 15) which had DA again in
consecutive lactations. A small round adhesion of about 0.5 cm diameter and a few cm
length of the omentum to the abdominal wall was observed only once in these cows. Even
in a cow that was surgically treated for LDA in the second, third and fourth lactation, there
were no adhesions found at the surgery.
The possibility of re-displacement is a disadvantage of this method compared to methods
that produce a permanent adhesion. This is the reason why some owners of cows with
DA prefer permanent fixation. However, we are of the opinion that enabling normal
physiological movement of the abomasum during pregnancy is beneficial for cows.
Permanent omentopexy can cause stretching of the omentum in late pregnancy when the
abomasum moves physiologically more cranial and transverse than in non-pregnant cows
(Wittek et al. 2005). The situation can be more aggravated in cows with abomasopexy.
This can potentially cause discomfort and complications when these cows are in late
pregnancy. Another potential disadvantage of surgical correction of DA using Ljubljana
method compared to other surgical methods that do not produce percutaneous pexy is
the possibility of infection through percutaneous omentopexy suture. Omentopexy suture
presents a potential route of entry for bacteria into the abdominal cavity. This could be a
problem especially if cows are kept in unsanitary conditions after surgery. At the Clinic
for Ruminants in Ljubljana, cows are hospitalized for about 3 to 7 days after surgery and
receive antibiotic treatment. If omentopexy suture is soiled it needs to be cleaned and
disinfected (we usually use povidon iodide or oxytetracycline spray). Occasionally some
pus comes out of the suture site after the suture is removed, but infection usually resolves
spontaneously without complication. To reduce the possibility of abdominal contamination
and infection, the suture should be disinfected with povidon iodide and then pulled lightly
before cutting one side of it and pulling it out. In case of fluid accumulation in the abdominal
cavity, omentopexy suture draining peritoneal fluid was observed.
 473

Surgical treatment of DA using Ljubljana method is financially acceptable and useful

for all types of DA and AV. Bühner tape is not expensive, and except the Gerlach needle
there are no other special surgical instruments needed. Because only one percutaneous
omentopexy suture is placed, the surgery can be completed faster than in laparotomy
techniques where pexy is carried out by suturing. The surgery can be performed also in the
field. Many ambulatory cattle practitioners in Slovenia successfully perform it on farms.
In conclusion, we recommend omentopexy using Ljubljana method as an alternative
to laparoscopy-guided surgery and other laparotomy techniques, as a clinical procedure
as well as procedure performed in ambulatory practice. The surgery can be used in all
types of DA and AV; it is rapidly performed in standing animal; it does not need expensive
equipment; it can be performed with minimal personnel; it has low recurrence rate, and is
not expensive. It can also be used in cows in late pregnancy.
Acknowledgment
The authors thank Jožica Ježek PhD, DVM and Čedo Bursač, veterinary technician, for their help in cow treatment
and Marija Nemec MSc, DVM for performing haematology and biochemistry analyses.

References
Constable PD, Miller GY, Hoffsis GF, Hull BL, Rings DM 1992: Risk factors for abomasal volvulus and left
abomasal displacement in cattle. Am J Vet Res 53: 1184-1191
Rohn M, Tenhagen B-A, Hofmann W 2004: Survival of dairy cows after surgery to correct abomasal displacement:
2. Association of clinical and laboratory parameters with survival in cows with left abomasal displacement. J
Vet Med Series A 51: 300-305
Roy JP, Harvey D, Bélanger AM, Buczinski S 2008: Comparison of 2-step laparoscopy-guided abomasopexy
versus omentopexy via right flank laparotomy for the treatment of dairy cows with left displacement of the
abomasum in on-farm settings. J Am Vet Med Assoc 232: 1700-1706
Seeger T, Kümper H, Failing K, Doll K 2006: Comparison of laparoscopic-guided abomasopexy versus
omentopexy via right flank laparotomy for the treatment of left abomasal displacement in dairy cows. Am J
Vet Res 67: 472-478
Skušek F, Gregorović V, Jazbec I 1970: Right and then left displacement of the abomasum in a cow. Vet Glasn
24: 285
Steiner A 2006: Surgical treatment of the left displacement of the abomasum an update. In: XXIV. World Buiatrics
Congress, Nice, France, pp. 165-169
Wittek T, Constable PD, Morin DE 2005: Ultrasonographic assessment of change in abomasal position during the
last three months of gestation first three months of lactation in Holstein-Friesian cows. J Am Vet Med Assoc
227: 1469-1475
Wittek T, Sen I, Constable PD 2007: Changes in abdominal dimensions during late gestation and early lactation in
Holstein-Friesian heifers and cows and their relationship to left displaced abomasum. Vet Rec 161: 155-161
Zadnik T, Mesarič M, Reichel P 2001: A review of abomasal displacement – clinical and laboratory experiences
at the Clinic for ruminants in Ljubljana. Slov Vet Res 38: 201-216
Zadnik T 2003a: Review of anterior displacement of the abomasum in cattle in Slovenia. Vet Rec 153: 24-25
Zadnik T 2003b: A comparative study of the hemato-biochemical parameters between clinically healthy cows and
cows with displacement of the abomasum. Acta Vet Beograd 53: 297-309
 Plate II
Starič J. et al.: Surgical ... pp. 469-473

Fig. 1. Appearence of pylorus during operation

Fig. 2. Bühner tape and Gerlach needle

 Plate III

Fig. 3. End of suture is passed through the abdominal wall using Gerlach needle about 5 cm
beneath the ventral end of the surgical incision
Veterinarski Arhiv 77 (5), 397-408, 2007

Wound strength after midline laparotomy: a comparison of four

closure techniques in rats

Mario Kreszinger1*, Domagoj Delimar2, Josip Kos1, Nataša Jovanov3,

Dražen Vnuk1, Dražen Matičić1, Boris Pirkić1, Marko Stejskal1,
and Darko Capak1
1
Clinic for Surgery, Orthopaedics and Ophthalmology, Faculty of Veterinary Medicine, University of Zagreb,
Zagreb, Croatia
2
Clinic for Orthopaedics, Medical Faculty, University of Zagreb, Zagreb, Croatia
3
Institute for Brain Research, Medical Faculty, University of Zagreb, Zagreb, Croatia

KRESZINGER, M., D. DELIMAR, J. KOS, N. JOVANOV, D. VNUK, D. MATIČIĆ,

B. PIRKIĆ, M. STEJSKAL, D. CAPAK: Wound strength after midline laparotomy:
a comparison of four closure techniques in rats. Vet. arhiv 77, 397-408, 2007.
ABSTRACT
The primary objective of this study was to determine which closure technique - simple interrupted suture
(SIS), simple continuous suture (SCS), interrupted double loop closure (IDLC) or continuous double loop
closure (CDLC) - results in stronger wound repair after midline laparotomy. Surgery was performed on 48
male rats. On the 5th postoperative day the rats were sacrificed and wound strength was measured by inserting a
balloon into the abdomen and filling it with air until the abdomen burst. Pressure was measured in millimetres
of mercury. Abdominal bursting pressure was 281.25 ± 26.5 mm Hg (mean ± SD) in the SIS group, 287.91 ±
29.6 mm Hg in the SCS group, 295.41 ± 31.9 mm Hg in the IDLC group and 314.58 ± 24.7 mm Hg in the CDLC
group (P<0.05). Closure of the midline abdominal incisions using SCS has almost the same wound strength as
SIS or IDLC but it is recommended because of simplicity, speed, and costs. CDLC ensures the greatest wound
strength on the basis of the intraperitoneal pressure required to burst the abdomen. The results of the comparison
of the SIS to SCS, as well as IDLC to CDLC, show that continuous suture techniques are more favourable than
the interrupted suture techniques from which they were derived.
Key words: suture technique, laparotomy, wound strength, rat

Introduction
Wound dehiscence after midline laparotomy in human beings mostly appears between
the fifth and eighth postoperative day (HÖGSTRÖM et al., 1990; SEID et al., 1995). Wound
*Contact address:
Dr. Mario Kreszinger, Clinic for Surgery, Orthopaedics and Ophthalmology, Faculty of Veterinary Medicine, University of Zagreb,
Heinzelova 55, 10000 Zagreb, Croatia, Phone: +385 1 2390 111, Fax: +385 1 2390 280, E-mail: mario.kreszinger@vef.hr

ISSN 0372-5480
Printed in Croatia 397
 M. Kreszinger et al.: Wound strength after midline laparotomy

integrity in this period depends on the mechanical profile of the suture technique (MEEKS et
al., 1995). Closure technique involves a choice of continuous versus interrupted suture, the
size of fascial bites, distance between consecutive sutures (stitch interval), the length and
size of the suture used (CARLSON and CONDON, 1995). The mechanical characteristics of
different suture techniques have a direct influence on wound strength (POOLE et al. 1984;
MEEKS et al., 1995a). Considering wound strength in interrupted versus continuous suture
techniques there are numerous studies with contradictory findings (LARSEN and ULIN,
1970; MAXWELL et al., 1996; SANDERS et al., 1977). Simple interrupted suture (SIS) is a
traditionally used technique for closure of laparotomy wounds in human and veterinary
surgery (KUMMELING and VAN SLUIJS, 1998; ROSIN, 1985). The disadvantages of SIS are
the greater amount of suture material used, and overall time involved in tying and cutting
numerous knots (McNEILL and SUGERMAN, 1986). Suture material contained in SIS is
mostly in the form of knots which makes that part of the tissue subject to foreign body
reaction and wound infection (VAN RIJSSEL et al., 1989). Interrupted double loop closure
(IDLC) and simple continuous suture (SCS) techniques are used often. Proponents of
the IDLC credit enhanced wound strength to tension on the inner loops of suture, which
keeps the incision edges in close approximation (MEEKS et al., 1995a). Wounds closed
by IDLC can tolerate higher intra-abdominal pressures than those closed by the SCS
technique (NIGGEBRUGGE et al., 1997). POOLE et al. (1984) and SEID et al. (1995) made
similar tests and draw the opposite conclusion. The advantages of a continuous suture are
speed, an equal distribution of tension, less foreign material in the wound, and less wound
trauma (KUMMELING and VAN SLUIJS, 1998). With the aim of combining the advantages
of simple continuous suture and interrupted double loop closure, a new suture technique,
known as continuous double loop closure (CDLC), was first introduced experimentally
in rats and then clinically in humans (NIGGEBRUGGE et al., 1997; NIGGEBRUGGE, 1999).
The aim of this study was to compare the bursting strength of a midline laparotomy
wound in the rat after closure using four different techniques. For each suture technique
the time of suturing and the length of suture required to close the wound were measured.

Materials and methods

Animal model. The study used 48 male Fisher rats weighing 370 g ± 55 g, between 7
and 9 months old, randomized into 4 groups, 12 animals in each group. They were placed
in cages, under the same conditions.
Rats were anaesthetized with ketamine hydrocloride (Narketan, Vetaquinol) 80 mg/
kg and xylazine (Rompun, Bayer) 8 mg/kg administered intramuscularly.
The skin was incised from xyphoid to pubis, undermined and reflected from the
underlying muscle fascias. The rectus sheath was exposed and imprinted with a stamp
to demarcate a standardized 5 cm midline incision and loci for suture bites 5 mm and

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 M. Kreszinger et al.: Wound strength after midline laparotomy

2.5 mm from the incision edge (MEEKS et al., 1995a; SEID et al., 1995). Distance between
sutures or suture interval along the incision line was 10 mm. The 12 stabbing points at 5
mm from the linea alba in SIS and SCS technique and 24 stabbing points at 2.5 and 5 mm
from linea alba in IDLC and CDLC technique were marked by the stamp. A longitudinal
midline incision was made in the linea alba of the rectus sheath and in the peritoneum.
Suture techniques. Surgical procedures were carried out by the same surgeon. The
suturing technique was determined by random assignment. Each time just before wound
closure a closed envelope with selected suture technique was opened. The laparotomy
wound was closed with one of the following techniques: simple interrupted suture (SIS),
simple continuous suture (SCS) (Fig. 1), interrupted double loop closure (IDLC) and
continuous double loop closure (CDLC). Wound closure was started from the cranial end
of the incision. Suture interval was 1 cm for all techniques. The abdominal wall in the
SIS and SCS closure technique was perforated 12 times. Suture bites were 5 mm from the
incision edge. In the IDLC and CDLC closure the needle perforated the abdominal wall
24 times. Far bites were placed 5 mm and near bites were placed 2.5 mm from the edge
of the incision. All sutures passed through all musculoaponeurotic layers and peritoneum.
Interrupted sutures were tied with a 2x1x1 square knot. Continuous sutures were anchored
at the cranial pole of the wound with a 2x1x1x1 square knot and at the caudal pole of the
wound with a 2×1×1×1×1 square knot. The sutures were tied with just enough tension to
loosely approximate the rectus sheath. All knots were positioned away from the incisional
region in order not to interfere with the regenerative process. All wounds were closed
with USP 4-0 absorbable monofilament polydioxanone (PDS® II, Ethicon) with a swaged
on 16 mm tapercut needle. The time for abdominal closure was recorded in seconds from
initial suture placement until the last knot was cut. The suture length required to close
the wounds was determined by suture length along the wound, in the knots and in the
knot ends (ears). The knot end was approximately 3 mm. The skin was closed by SCS,
with non-absorbable USP 5-0 monofilament polypropylene suture (Prolene®, Ethicon).
The rats received three subcutaneous injections of flunixin meglumine (Fynadine, Essex
Tierarznei) 1 mg/kg approximately 8 hours apart for postoperative analgesia.
Abdominal wound strength. On the 5th postoperative day animals were euthanized by
carbon dioxide asphyxiation. Abdominal wound strength was determined by combination
of the methods reported by POOLE et al. (1984) and UDUPA and CHANSOURIA (1969),
partially modified. The first part of the method that concerns corpse preparation for
the intra-abdominal pressure measurement relies on the method reported by POOLE
et al. (1984). We used an arthrotom for rectal perforation and balloon placement in the
abdominal cavity. A rectal perforation was made by a trocar originally used for arthrotomy.
The arthrotome was then connected to the trocar, covered with the balloon and placed
through the perforated rectum into the abdominal cavity. A nylon cord was tied around
the lower abdomen to prevent inguinal herniation (SANDERS et al., 1977; MEEKS et al.,

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 M. Kreszinger et al.: Wound strength after midline laparotomy

1995a). The other (second) part of the method that concerns intra-abdominal pressure
measurement relies on the method reported by UDUPA and CHANSOURIA (1969). A blood
pressure manometer was connected to the arthrotome (Fig 4). With a manometer pump
normally used for blood-pressure measurement, the balloon was gradually inflated until
the abdominal wall ruptured (Fig. 5). The highest intra-abdominal pressure before rupture
was recorded in millimetres of mercury (mm Hg). The site and manner of abdominal
wound rupture was documented and classified as (1) midline herniation between suture
loops, (2) suture tearing through the tissue, (3) midline herniation rupture due to poor
knot security and (4) rupture away from the midline incision.
Statistics. Dehiscence pressure, length of suture and surgical time were compared
for the four closure techniques with multiple analyses of variance (MANOVA). The
minimum level of significance was defined as P<0.05. Significant differences were further
investigated using a multiple comparison test (least-square difference -LSD- test).

Results
Dehiscence pressure. Abdominal wall sutured by SIS tolerated the intra-abdominal
pressure of 281.25 ± 26.5 mm Hg (mean ± SD) until the moment of rupture. The
intraperitoneal pressure required to burst the abdomen closed by SCS was 287.91 ± 29.6
mm Hg; for the one closed by IDLC required pressure was 295.41 ± 31.9 mm Hg, and by
CDLC was 314.58 ± 24.7 mm Hg.
The highest intra-abdominal pressure that the abdominal wall sutured by CDLC could
tolerate was significantly higher than those sutured by SIS or SCS (P<0.05). Differences
between other closure techniques were not significant (Fig. 1).
Table 1. Type of rupture versus closure technique

Type of rupture SIS SCS IDLC CDLC

Herniation between suture loops 1 1
Suture tearing tissue 12 8 11 7
Poor knot security 1
Away from the wound 2 1 4

Type of rupture. The site and manner of abdominal wound rupture on the basis of
suture technique was recorded (Table 1). In 37 cases the wound dehiscence was caused
by suture tearing through the tissue: all 12 in the SIS group, 8 in the SCS group, 11 in the
IDLC group and 6 in the CDLC group. Two animals had midline herniation of the balloon
between suture loops: 1 in the SCS group and 1 in the CDLC group. Poor knot security
as the reason for wound dehiscence occurred only once, in the SCS group. Seven animals

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 M. Kreszinger et al.: Wound strength after midline laparotomy

were found to have ruptures at sites away from the midline: two in SCS group, 1 in the
IDLC group and 4 in the CDLC group (Table 1).
Time of suturing. The time required to close the abdominal incision was significantly
different for each tested suture technique (P<0.05). Suturing by SIS required 530.33 ±
37.5 sec (mean ± SD); suturing by SCS required 310.33 ± 20.5 sec; by IDLC 757.66 ±
41.9 sec, and suturing by CDLC required 757.66 ± 41.9 sec.
Length of suture. The length of suture material used was significantly different for
each suture technique (P<0.05). Suturing by SIS required 23.7 ± 2.2 cm (mean ± SD) of
suture material; by SCS 17.16 ± 0.9 cm; by IDLC 30.04 ± 2.1 cm, and suturing by CDLC
required 25.41 ± 1.7 cm.

Fig. 1. Maximal intra-abdominal pressure until the rupture of the abdominal wall in all rats
divided in four groups (mm Hg)

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 M. Kreszinger et al.: Wound strength after midline laparotomy

Fig. 2. SCS technique after midline laparotomy closure

Fig. 3. SCS technique on the 5th postoperative day

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Fig. 4. Modification of classic blood pressure manometer connected to the arthrotome and balloon
used for measurement of intraabdominal pressure.

Fig. 5. Rupture of the abdominal wall. The arthrotome connected with trocar and covered with
the balloon was placed through the perforated rectum in the abdominal cavity. A nylon cord was
tied around the lower abdomen to prevent inguinal herniation.

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 M. Kreszinger et al.: Wound strength after midline laparotomy

Discussion
Strength of the healing wound can be measured by several methods (ROSIN and
RICHARDSON, 1987). There are two mechanical reasons for abdominal wound rupture:
intra-abdominal pressure is too high, or the bursting strength of the wound is too low
(EFRON, 1965). This led us to study wound strength of the abdominal midline incision on
the basis of intra-abdominal pressure required to burst the abdomen.
The mechanical characteristics of different suture techniques have a direct influence
on wound strength (POOLE et al., 1984). Problems in biomechanical testing of soft tissue
strips include crushing of tissue and failure at the grip, and variation of mechanical
parameters with regard to time after sacrifice, and storage temperatures (ROSIN and
RICHARDSON, 1987). Methods of measuring wound strength in vivo more closely
correspond to clinical situations. Accordingly, we decided to use the methods reported
by UDUPA and CHANSOURIA (1969) and POOLE et al. (1984). Both methods use sutured
midline laparotomy wounds in rats as a wound model. We think that a placement of
needle with an attached balloon through a stab wound in the abdominal wall affects the
bursting strength of the abdominal wall. Instead, in that part of study we used the method
described by POOLE et al. (1984). Our modification was the use of an arthrotome to make
a rectal perforation and to place a balloon in the abdominal cavity, which prove simple
and efficient.
The time of abdominal wound dehiscence is usually between the 5th and 8th
postoperative day (SANDERS et al., 1977). In similar studies wound strength was measured
on the 7th postoperative day (MEEKS et al., 1995a; SEID et al., 1995). The healing process,
mainly associated with cross-linking of new collagen, does not really begin until 5-8 days
after surgery (HUGH, 1990). Fibroblastic activity begins at approximately the 4th day after
wounding (STONE et al., 1986). It is obvious that wound rupture in this period represents
a failure of suture technique. On the basis of these facts we decided to measure wound
bursting strength on the 5th postoperative day.
Wound studies historically have used rabbits, rats and piglets. Wound strength in
rats is most equivalent to humans (MEEKS et al., 1995). We used an investigatory animal
that best approximates the human situation. Although caution should be exercised in
extrapolating experimental animal data to other species or humans, these results are
applicable to clinical situations.
Suture length: wound length (SLWL) ratio depends on the size of tissue bites, the
distance between bites and tension on the suture (ISRAELSSON and JONSSON, 1993). In
order to compare different suture techniques we kept suture intervals and suture bites
the same for all closure techniques. Due to that study design the SLWL ratio in our SCS
technique was 3.43, slightly less than the recommended ratio (JENKINS, 1976). The mean
SLWL ratio in clinical use of SCS on human midline laparotomy usually amounts to

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3.6 (ISRAELSSON and JONSSON, 1993). It could be assumed that strict application of
the Jenkins rule in this study would result in greater bursting strength than in our SCS
technique. In that case a greater number of stitches and larger suture bites are consequences
that would have confounding influences on assessment of suture techniques in this study.
That is the object of other similar studies (HÖER et al., 2001).
In this study abdominal wounds sutured by SCS technique withstand higher intra-
abdominal pressure than by SIS or by IDLC technique, but those differences had no
statistical significance (P>0.05). Reduction in operative time may have a significant
impact on morbidity and mortality of the animal (ROSIN, 1985). Suture material makes
the tissue subject to foreign body reaction and wound infection (VAN RIJSSEL et al., 1989).
Closure with SCS technique according to this study is 41.5% faster and the length of
suture is 27.6% reduced in comparison to SIS technique.
Different methods of measuring intra-abdominal pressure showed that wounds closed
by CDLC technique could resist higher intra-abdominal pressure than those reconstructed
by SCS technique (MEEKS et al., 1995a). Results of this study confirm that conclusion.
Wounds closed by CDLC technique can tolerate significantly higher (9.3%) intra-
abdominal pressures than wounds closed by SCS. However, the cost of this advantage is
82.9% prolonged time of suturing and 48% greater length of suture material. The mean
SLWL ratio was higher in CDLC technique (5 : 1) than in SCS technique (3.4 : 1).
Wounds reconstructed by CDLC can tolerate higher intra-abdominal pressures than
those sutured with IDLC, but that difference is not statistically significant (P>0.05). The
time of suturing is essentially shorter (33.45%) and length of suture is considerably less
(18.2%), both making the CDLC technique favourable.
The type of abdominal rupture provides an additional parameter to compare methods
of closure. Wound dehiscence due to sutures tearing through the tissue occurred in 77% of
cases. However, this type of rupture was more frequent in interrupted closure techniques.
All the cases of SIS and 11 of 12 cases of IDLC group showed this type of rupture.
Knots used on the beginning and at the end of continuous sutures are well-disposed to
knot slippage and untying (ROSIN and ROBINSON, 1989). Poor knot security appears
to be a minor cause of dehiscence if adequate knot tying technique is applied, as we
demonstrated in this study. However, one case of rupture with minimal intraperitoneal
pressure due to knot slippage in the SCS group suggests that inadequate knot tying could
cause wound dehiscence. Rupture of the abdominal wall away from the midline incision
is an additional parameter that indicates a stronger wound. Abdominal ruptures have
occurred at a site away from the incision in 2 out of 12 tests (16.7%) sutured by SCS
technique, and in 4 out of 12 (33.3%) cases sutured by CDLC technique. This indicates
that incisions reconstructed by continuous suture could be as strong as the other intact
part of the abdominal wall.

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Conclusions
On the basis of the intraperitoneal pressure required to burst the abdomen, closure
of the abdominal midline incisions using SCS technique has the same wound strength as
with SIS or IDLC technique.
The CDLC technique ensures the greatest wound strength, but requires a longer
suturing time and more suture material in comparison with SCS technique.
Considering abdominal midline wound strength, time of suturing and length of
suture, continuous suture techniques are preferable to the interrupted suture techniques
from which they were derived.

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Received: 20 December 2006

Accepted: 28 September 2007

KRESZINGER, M., D. DELIMAR, J. KOS, N. JOVANOV, D. VNUK, D. MATIČIĆ,

B. PIRKIĆ, M. STEJSKAL, D. CAPAK: Utjecaj šavova na čvrstoću rekonstruirane
operacijske rane u bijeloj liniji štakora. Vet. arhiv 77, 397-408, 2007.
SAŽETAK
Glavna svrha ovog istraživanja bila je određivanje koja od pretraživanih kirurških tehnika šivanja,
jednostavnim pojedinačnim šavom (SIS), jednostavnim produžnim šavom (SCS), pojedinačnim šavom s dvije

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omče (IDCL) ili produžnim šavom s dvije omče (CDLC), dovodi do snažnije rane nakon laparotomije u bijeloj
liniji. Operacije su izvedene na 48 štakorskih mužjaka. Petoga dana nakon operacije životinje su žrtvovane,
a snaga rane bila je mjerena umetanjem balona u trbušnu šupljinu i upuhivanjem zraka do trenutka rupture
trbušne stijenke. Intraabdominalni tlak mjeren je u milimetrima žive. Intraabdominalni tlak u času rupture
iznosio je 281,25 ± 26,5 mm Hg u SIS skupini, 287,91 ± 29,6 mm Hg u SCS skupini, 295,41 ± 31,9 mm Hg u
IDLC skupini i 314,58 ± 24,7 mm Hg u CDLC skupini (P<0,05). Šivanjem incizijske rane u bijeloj liniji SCS
tehnikom postiže se gotovo ista snaga rane kao šivanjem SIS ili IDLC tehnikom, zato se ona preporučuje osobito
zbog jednostavnosti i brzine izvođenja te manjih troškova. CDLC tehnika omogućuje postizanje najveće snage
rane s osnove intraabdominalnog tlaka potrebnog za nastanak rupture trbuha. Rezultati usporedbe jednostavnog
produžnog šava s jednostavnim pojedinačnim (čvornim) šavom, kao i usporedbe produžnog šava osmice s
pojedinačnim šavom osmice idu u prilog produžnih šavova.
Ključne riječi: kirurška tehnika šivanja, laparatomija, čvrstoća rane, štakor

408 Vet. arhiv 77 (5), 397-408, 2007