ABDOMEN

Chapter 6 THE ABDOMEN


The symmetry, size and shape of the abdomen varies considerably from breed to breed. In the bitch, the mammary glands are an important pre- and post-natal feature and in the pregnant bitch the topography may be altered and caesarean section required. This is carried out as for any abdominal laparotomy described below.


The abdomen has basically three regions; cranial abdominal, middle and caudal abdominal, with hyposplanchnic and xiphoid regions. The region is limited by the diaphragm, iliocostal line and pelvic brim. It contains a wide range of organ systems with plenty of opportunity for these to go wrong and require surgery. Many of these surgical interventions are carried out through a midline laparotomy anywhere along a line from the xiphisternum to the umbilicus, although most extend much further caudally than the umbilicus even in males where the penis deflected and the incision continued. This is along the linea alba (white line) and the incision here once through the skin can be accomplished with minimum bleeding, as this is the junction of the aponeuroses of the ventral abdominal musculature. The tissue or organ that requires surgery can then be brought to the exterior without damage to other structures and allows them to be kept moist. This site also produces a strong tissue for suturing.


An exploratory laparotomy is carried out to see what is going on and to possibly make a definitive diagnosis, otherwise this site may be used for: ovarohysterectomy (spaying) of the bitch, and for pyometra (uterus fills with a pus-like material), often in nulliparous, aged, and usually post-season bitches. This requires complete surgical removal. Likewise, ovarian cysts and tumours are similarly removed. The same site can also give good access for removal of intestinal neoplasia; enterotomies for foreign body removal such as bones, fish hooks or bouncing rubber balls; enterectomy for intussusception (bowel telescopes into bowel) with subsequent end-to-end anastomoses of the bowel after removal of necrotic portions. Gastric dilation and torsion can be approached through the same site. Here needle decompression to release gas is necessary and a stomach tube tightly in place will remove gas and fluid, and then the re-positioned stomach can be held in place by stitches. This midline ventral laparotomy can also be used for partial gastrectomy for tumours and for operations on the pylorus – particularly pyloric stenosis. Torsion of the spleen may be relieved and splenic tumours can also be removed via a midline ventral incision and good exposure of the kidneys is also achievable. The ventral midline approach also gives good exposure to repair rupture of the diaphragm. The midline laparotomy is used in some circumstances to inject into the intestinal veins for the purpose of portography so that the circulation through the liver can be visualized.


Portosystemic shunts are a not uncommon condition in the dog and require diagnosis by catheterization of the celiac or cranial mesenteric artery via the mesenteric vessels. Surgical correction of the shunt is the only specific treatment. Structures in the upper abdomen (kidneys, thoracolumbar vertebrae) can also be reached by flank laparotomy. This involves cutting the abdominal musculature along the direction of their fibers and therefore there is considerably more potential hemorrhage because the incisions run three ways in the muscle layers (exterior abdominal oblique, interior abdominal oblique and transverse). The exposure is not as good as in a straight midline incision. The other problem is that the ventral branches of the spinal nerves innervating the ventral abdomen, mammary and inguinal region run over the transverse muscles and they should be avoided.


Nowadays, many surgeons use the laparoscopic techniques to routinely spay bitches. Some people, particularly in former times, have always recommended ‘spaying’ bitches from the right flank as the left ovarian ligament is longer than the right and therefore the left ovary is more easily exteriorized for ligation across the abdomen. Lateral thoracolumbar fenestration for disc problems over the large iliocostal muscle is also a possibility. I have left the discussion of the urogenital system to a discussion of the pelvis, but the mammary glands are an important abdominal feature. They are a frequent site of both benign and malignant tumours requiring surgical incision of single glands or sometimes both complete lines of glands. Each has a good segmental blood supply which requires careful ligation. It is important to note the lymphatic drainage when tumours may be seeded or infection spread as the cranial glands drain to the axillary (possible palpable) and sternal lymph nodes (inside thorax) – caudal abdominal glands drain to both the cranial glands and caudal to the inguinal glands and the inguinal mammary glands to the inguinal (mammary) lymph nodes, which again may be palpable.


Laparoscopy using a fibroscope to investigate the abdominal contents can also be used through the ventral midline incision. Abdominocentesis, which is the withdrawal of fluid from the peritoneal cavity, can be performed at a site 1 to 2 cm caudal to the umbilicus. In younger animals, it may be necessary to repair a hernia at the umbilicus, and in these cases the falciform fat or even small intestine may fill the cavity of the umbilicus, possibly leading later to strangulated hernia.


Other abdominal diagnostic techniques include liver biopsy. This used to be done from the left side of the abdomen to avoid damage to the right-sided gall bladder, large vessels and bile ducts at the hilus of the liver, i.e. dog is in right lateral recumbency after fasting, as it is not easy with a full stomach. To take just liver cells, it is possible to carry out a fine-needle biopsy in the 10th intercostal space on the right hand side, at the level of the costochondral junction. Nowadays, many surgeons tend to do this using ultrasound or laparoscope.


The last area that may require surgery is the inguinal region, with incisions over the inguinal canal to repair either an inguinal hernia or to search for a retained testicle somewhere between the internal inguinal ring and the caudal pole of the kidney from where in embryological terms the testicle originates before its traverse to the scrotum.


The vaginal process of the peritoneum in males exits from the inguinal region through the deep and superficial inguinal rings; 80% of female dogs also have a peritoneal vaginal process. The round ligament of the uterus passes through the inguinal canal and is contained within the vaginal process, and the canal itself is filled with connective tissue.


In ‘open’ castration of the dog, the parietal layer of the vaginal tunic is incised and thus the potential space of the peritoneal cavity is invaded.


Surgery of the bladder for removal of bladder stones or debris is also carried out through a caudal midline intervention with the incision avoiding the dorsal bladder surface where the ureters enter the bladder. Removal of kidney or ureteric stones may also be required.





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Fig. 6.2 Skeleton related to the abdomen: left lateral view. The palpable bony features shown bordering the abdomen in the surface view on Fig. 6.1 are colored green for reference. It should be noted that caudal to the large thoracic outlet (bounded by the xiphoid cartilage of the sternum, the costal arches and floating ribs) the abdominal wall is entirely muscular. The considerably restricted pelvic inlet, bounded by the sacrum above and pelvic bones bilaterally, marks the caudal boundary of the abdomen.


























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Fig. 6.15 Abdominal wall (2). Internal abdominal oblique muscle: left lateral view. The external oblique has been removed except where it forms part of the external layer of the rectus sheath. Here it is inseparable from the underlying aponeurosis of the internal oblique (see also Figs 6.696.71). The pelvic tendon of the external oblique has also been removed, in consequence the inguinal canal is completely opened on its cranial and lateral aspects. Cranially the contribution of the aponeurosis of the internal oblique to both deep and superficial layers of the rectus sheath is exposed. This relationship is shown to advantage in the next few figures and in Figs 5.165.19.






















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Fig. 6.26 Descending colon: left lateral view (1). The transverse and much of the descending part of the colon have been exposed following removal of the deep layer of the greater omentum and a number of jejunal coils. The colon in this specimen is somewhat enlarged and appears sacculated. For a more ‘normal’ appearance see Fig. 6.61 from a right medial view and Figs 6.80 and 6.82 from a ventral view. Dorsal to the colon the left kidney is exposed further by removal of perirenal fat. In the caudal abdomen the iliacus component of the iliopsoas muscle has been removed, and the psoas major has been additionally trimmed as far cranially as the tuber coxae.





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Fig. 6.28 Left kidney and mesocolon: left lateral view. The descending colon has been removed except for its terminal part dorsal to the bladder. Cranially, the cut surface of the transverse colon is clearly observed immediately cranial to the duodenojejunal flexure (its position is shown to advantage in section in Fig. 6.97). Extending caudally from the transverse colon, below the kidney, the fat infiltrated mesocolon and its cut edge are visible. Medial to the duodenojejunal flexure and caudal to the transverse colon the mesenteric root is just exposed. The relationship of structures to the root is shown to advantage in ventral view (Figs 6.80, 6.81) and in section (Figs 6.98, 6.99).

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Jul 8, 2016 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on ABDOMEN

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