Exercise 4
Exploratory Laparotomy In The Dog
Welcome to exercise 4. The aim of this exercise is to put into practice all of the aseptic techniques you have learnt over the past 8 weeks in order to perform an exploratory laparotomy.
You will perform a ventral midline laparotomy and examine the abdominal viscera by direct visualisation and palpation before surgically closing the wound.
The group will be divided into groups of 3 students who will all scrub and participate in the laboratory.
Whilst cadavers will be used for this class, full preparation of the surgeon and patient will be performed and aseptic technique practiced throughout the surgery.
Dress Requirements
It is essential that you wear clean scrub suits for this exercsie. It is also important to wear clean shoes (not open footwear).
Eating and drinking are not permitted in the surgery laboratory.
Equipment
Caps, gowns and masks, instruments and drapes will be supplied.
Preparation
The most common approach to the abdomen is through the ventral midline.
Other approaches include the paracostal, flank and paramedian approaches.
The entire ventral abdominal area should be clipped from the posterior pelvic region anteriorly beyond the xiphisternum. The clipped area should extend well beyond the mammae on each side.
The clipped area is surgically prepared in the routine manner and field drapes applied as practiced in exercise 3..
Surgical technique
A ventral midline skin incision is made from the xiphisternum to the cranial edge of the pubis. Skin bleeders are clamped and haemostasis maintained by torsion or ligation of the vessels with fine suture material. Skin towels are applied.
Dissection is continued through the soft tissues to fully expose the linea alba. Moderate tension applied to the body wall laterally by the assistant will aid in this process.
By lifting the linea alba near the umbilicus with a pair of toothed thumb forceps, the surgeon decreases the risk of damaging abdominal contents. A small nick can be made through the body wall and peritoneum. This nick is then extended along the linea alba using a “push-cut” technique with blunt-blunt (Mayo) scissors. Holding the scissors in a mostly closed position, push along the linea alba using two fingers as a guide and to lift the abdominal wall. Do not extend the body wall incision beyond the skin incision. The falciform ligament lies beneath the linea alba anterior to the umbilicus. One side of the falciform ligament can be separated from the ventral body wall to expose the underlying viscera. Balfour abdominal refractors can now be inserted taking care not to include any viscera between the blades and the wall.
The viscera can now be inspected. It is important to use a systematic approach so that no lesion is missed in a real exploratory laparotomy. It is routine to examine the hepato-biliary system, the gastrointestinal system and lymph nodes, the urinary system, the genital system, the adrenal glands, the serosal surfaces and regional lymph nodes.
To facilitate examination of deeper structures two techniques are useful. To examine the deeper structures on the left side of the abdomen, the descending colon is identified and lifted up allowing the rest of the small bowel to be packed off below and retracted by the mesocolon. One can then see the left kidney, adrenal, ureter etc. To facilitate examination of the deeper structures on the right side of the abdomen, locate the duodenum and gently lift it, allowing the small bowel to be packed off and retracted by the mesoduodenum and pancreas.
The alternate technique is to pack off the viscera with moist abdominal packs exteriorising only the piece of viscera required for inspection.
After examination the viscera are replaced and the omentum placed on top. The abdominal packs and retractors are then removed.
Closure
Closure is made in the following manner:
- Linea alba and abdominal wall (including the rectus sheath)size 2/0, or 0 absorbable suture material as simple interrupted sutures.
- Subcutaneous tissue - simple continuous 3/0 absorbable suture material.
- Skin incision - simple interrupted, vertical or horizontal mattress sutures using 3/0 or 2/0 nylon suture material.
Clean-up
Following the completion of surgery, or at 11.50am, each group of students are responsible for clearing the instrument table, disposal of the cadavers and cleaning of the surgery table.
- Surgical instruments should be placed in the green plastic tray provided. All hinged instruments should be opened, with the ratchet mechanism disengaged to allow for thorough cleaning.
- All sharps (scalpel blades, needles etc) should be placed in the sharps bins.
- Blood soaked swabs and other waste materials, including surgical gloves should be placed in the surgery bucket provided with each table. At the end of the surgery, this bin should be emptied into the large yellow biological waste bin.
- All drapes and gowns should be placed in the laundry trolley.
Exercise Tasks
- Review the relevant units to be practiced in this execise. (Links to be made to each unit here as below)
- View the video demonstrating important aspects of an exploratory laparotomy and closure.
- Complete Exercise 1 exit quiz in the Virtual Veterinary Surgery program.
Exercise 4 Exit Quiz
How to complete the Exit Quiz associated with this exercise.
Answer
each of the questions in the quiz and then submit your answers by
clicking on the “submit” button at the end of the quiz.
You will then receive a response to your answers (ie. Correct or
Incorrect). If you have answered a question incorrectly, you will be
invited to re-consider your answer. Use the information provided to
you in the exercise tasks to assist you in providing the correct answer.
On completion of your revised answers you may then re-submit the answers
by clicking on the “submit” button.
Correct answers will be accompanied by a supporting statement for
your answer.
Completion of the exit quiz and tasks set for each exercise will provide you with an opportunity to develop your clinical competencies in basic surgical practice and contribute to the completion of your “skills acquisition checklist”.
