Incisional Gastropexy

One of the earliest described and still one of the most commonly performed gastropexy techniques is the incisional gastropexy, which was described by MacCoy et al. in 1982.¹⁹ This procedure was performed by suturing the serosa‐muscular layers of the stomach wall to the internal intercostal musculature between the 11th and 12th ribs on the right side and approximately 1/3 of the distance from ventral midline to the dorsal aspect of the patient, which presumably allows the stomach to be in an anatomically normal position. To promote avoidance of the diaphragm and possible iatrogenic pneumothorax, an ideal position for the body wall incision is now caudal to the last rib with suturing of the transversus abdominis, as opposed to the intercostal musculature. The recurrence rate of GDV after gastropexy varies greatly, and, in most of the literature, an incisional gastropexy has a 0–5% recurrence rate.

Due to the relative ease, rapidity, effectiveness, and low recurrence rate associated with the incisional gastropexy, this is the technique that is recommended and is described below. As with all gastropexies, ~4 cm incisions in both the right abdominal wall and seromuscular layer of the pyloric antrum are recommended, both because of approximately 47% contraction of the incision with healing and remodeling over time^44,45 and because of a 4 cm incision having a higher load to failure compared to a 2 cm incision in a cadaveric study.⁴⁶ There have been many varieties of incisional gastropexy described using several materials for apposition, including suture (both barbed^47,48 and smooth), staples,^49,50 and others, in addition to using one or two suture lines. Although one suture line was recently shown in a cadaveric biomechanical study to have a similar load to failure as two suture lines for incisional gastropexy,⁴⁶ the traditional use of two suture lines will be described in this chapter.

This technique may be performed either solo⁵¹ or with the help of an assistant, and since some veterinarians are alone when performing this surgery on an emergency basis, both techniques will be described in detail.

Belt‐Loop Gastropexy

A belt‐loop gastropexy is a technique described by Whitney et al. in 1989²¹ and is a method that involves a U‐shaped flap from the seromuscular layer of the pyloric antrum (incorporating a branch from the right gastroepiploic artery and vein at the base) that is passed through a muscular tunnel (under a segment of transversus abdominis muscle on the right lateral body wall caudal to the last rib) then sutured back to the pyloric antrum. Although slightly stronger than an incisional gastropexy adhesion, which are both believed to be supraphysiologic in their strength, this technique is more time‐consuming and more difficult for a novice surgeon to perform.⁵² A modified belt‐loop gastropexy utilizing an antral fold instead of an antral flap was recently described,⁵³ which, based on the results of the study, prevents recurrence of GDV in dogs.

Circumcostal Gastropexy

A circumcostal gastropexy, which is technically the strongest of the gastropexy options, is a technique described by Fallah et al. in 1982.²² This technique involves the creation of a flap from the seromuscular layer of the pyloric antrum that is passed around a rib through a tunnel under the 11th or 12th ribs at the level of the costochondral junction and then sutured back to the pyloric antrum. Potential complications include pneumothorax, rib fracture, and a 3.3–9% recurrence rate of GDV.^{24, 54–58}

Laparoscopic‐Assisted and Total Laparoscopic Gastropexy

The first laparoscopic‐assisted gastropexy was described by Rawlings et al. in 2001,²⁹ and this development, along with the increasing interest in and availability of laparoscopy, led to total laparoscopic gastropexy techniques. These minimally invasive procedures allow for a faster return to normal activity, have smaller incisions, and result in decreased post‐operative pain; however, compared to the incisional gastropexy, these require advanced minimally invasive surgery (MIS) training and expensive laparoscopic equipment. Description of each type of laparoscopic gastropexy is beyond the scope of this chapter, and for those who prefer minimally invasive options for this procedure, particularly for prophylactic purposes, other textbooks are available.

Those gastropexy techniques that are described, but are not recommended, by the author include incorporating, gastrocolopexy, and fundic.

Splenectomy – To Pexy or Not to Pexy?

Splenectomy may or may not predispose a dog to developing GDV,^71–75 but the general recommendation is to perform a gastropexy when in the abdominal cavity of patients with risk factors, such as breed, conformation, temperament, or a history of gastrointestinal disease; a gastropexy is a quick additional procedure to perform if already in the peritoneal cavity with minimal potential for unwanted long‐term effects. One theory as to why GDV may follow splenectomy is that stretching and disruption of gastric ligaments (e.g., gastrosplenic ligament when removing head of spleen) increases stomach mobility.^76,77 Some studies^72,73,75 found no evidence that splenectomy was associated with an increased incidence of subsequent GDV, while other authors have recommended prophylactic gastropexy at the time of splenectomy for splenic torsion,^74,78 splenic neoplasia,⁷⁶ and other causes of splenomegaly.^11,77,79 In summary, because both splenic disease and GDV are more prevalent in large breed, deep‐chested dogs, the author recommends prophylactic gastropexy if already in the abdomen and performing a splenectomy in at‐risk breeds or those with other risk factors.

One‐Person Technique

The surgeon should stand on the right side of the patient, and no assistant is needed with this procedure. With four fingers of both hands on the peritoneal surface of the right body wall and thumbs of both hands on the skin along the palpable costal arch, the right ventral body wall is folded over the ribs of the costal arch, which are pushed in toward the abdomen and ventrally using the thumbs to essentially evert the peritoneum. This results in the pronounced palpable ribs just beneath the peritoneal surface of the transversus abdominis muscle. Two Backhaus towel clamps are placed around the costal arch ~5 cm apart, ensuring that the cranial most clamp is at least 2 cm caudal to the white line costal origin of the diaphragm (Figure 21.1a–c). Once these towel clamps are in place, they are pulled laterally and dorsally to further push the costal arch into a ventral position, and the rings are secured to the patient’s sterile lateral body wall skin using an additional towel clamp (Figure 21.2).

To create an incision into the pyloric antrum, a 3–5 cm longitudinal incision is made into the ventral aspect of the pyloric antrum halfway between the greater and lesser curvatures, which may be accomplished in two ways. The preferred method by the author is to pinch the stomach with the non‐dominant hand as if assessing for a gastric slip, and when the seromuscular layer is isolated after slipping away of the mucosal–submucosal layer, Mayo tissue scissors are used to cut the pinched seromuscular layer. The submucosa is then exposed, and the Mayo scissors may be used to extend the longitudinal incision both orad and aborad, ensuring that the incision remains halfway between the greater and lesser curvatures of the stomach and their associated vasculature. The alternative method is to use a #15 blade to incise through the seromuscular layer of the pyloric antrum, and once appropriate depth is achieved, Mayo scissors may be used to extend the incision orad and aborad, similarly as described above. The gastric incision may then be manipulated to the transversus abdominis muscle isolated between the towel clamps to match incision length (Figure 21.2).

A scalpel blade (#10, #11, or #15 preferred) is then used to incise the transversus abdominis muscle between the two towel clamps along the ventral‐most edge of the costal arch with resistance being met by the ribs of the costal arch, and the muscle should fall away on either side to reveal the white portion of the costal arch deep to the muscle. This incision should be at least 2 cm lateral to the approximate lateral aspect of the rectus abdominis musculature, which prevents the gastropexy from being too far ventral. Minimal self‐limiting hemorrhage may be encountered (Figure 21.3). Ensure adequate length of this incision prior to suturing.

The suturing may proceed with one or two packs of long‐lasting synthetic monofilament absorbable suture (e.g., polyglyconate or polydioxanone), usually 2‐0 in size for most large breed dogs and 0 for giant breed dogs. If two suture lines are chosen, each simple continuous suture line is initiated with one corner apposing the cranial transversus incision and the aborad antral incision and the other corner apposing the caudal transversus incision and orad antral incision (Figures 21.4 and 21.5). A Kelly hemostat may be used to clamp the end of the suture tag left long from each corner’s simple continuous suture lines, which may be used for tying the knot of the opposite strand’s line. Suturing of the simple continuous suture line proceeds with the dorsal aspect first to appose the antral muscular flap (the edge closer to the greater curvature) to the transversus cut edge (the dorsal edge), and this simple continuous line terminates by tying a knot using the suture tag of the opposite corner’s simple continuous suture line (Figure 21.5). Once this is done, hemostasis is confirmed, the area is locally lavaged, and standard celiotomy closure may commence.

Two‐Person Technique

The surgeon should stand on the left side of the patient to better visualize the right lateral body wall while suturing, and the assistant should stand on the right side of the patient. The assistant will place two Backhaus towel clamps on the right body wall (not to include the skin) in order to provide ventral traction via lifting of the clamps when needed (Figure 21.6).

A 3–5 cm longitudinal incision is made into the ventral aspect of the pyloric antrum halfway between the greater and lesser curvatures, which may be accomplished in two ways. The preferred method by the author is to pinch the stomach with the non‐dominant hand as if assessing for a gastric slip, and when the seromuscular layer is isolated after slipping away of the mucosal–submucosal layer, Mayo tissue scissors are used to cut the pinched seromuscular layer. The submucosa is then exposed, and the Mayo scissors may be used to extend the longitudinal incision both orad and aborad, ensuring that the incision remains halfway between the greater and lesser curvatures of the stomach and their associated vasculature. The alternative method is to use a #15 blade to incise through the serosa and muscular layers (grossly seem to palpate as one seromuscular layer) of the pyloric antrum, and once appropriate depth is achieved, Mayo scissors may be used to extend the incision orad and aborad, similarly as described above (Figure 21.7).

The stomach is gently lifted ventrally toward the right lateral transversus abdominis to assess where the stomach may naturally appose, ensuring that the “kissing mark” of blood of the gastric incision onto the body wall is at least 2 cm caudal to the white line denoting the costal origin of the diaphragm. Along this mark, a 3–5 cm incision is made with a scalpel blade through the transversus abdominis muscle from ventral to dorsal (Figure 21.8). This incision should be at least 2 cm lateral to the approximate lateral aspect of the rectus abdominis musculature, which prevents the gastropexy site from being too far ventral.

The suturing should proceed with two packs of long‐lasting synthetic monofilament absorbable suture (e.g., polyglyconate or polydioxanone), usually 2‐0 in size for most large breed dogs and 0 for giant breed dogs. With two edges to each incision, two simple continuous suture lines are used to appose the stomach to the body wall from dorsal (aborad aspect of pyloric antrum) to ventral (orad aspect of pyloric antrum). Especially at the initiation of the two separate suture lines with the aborad gastric flaps being apposed to the dorsal transversus abdominis mm flaps, it is helpful for the assistant to elevate the body wall by lifting the towel clamps. A minimum of four to seven suture bites per simple continuous line is recommended prior to ending the pattern (Figure 21.9).