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Small Animal Surgery
Final Exam
118
Veterinary Medicine
Graduate
04/21/2011

Additional Veterinary Medicine Flashcards

 


 

Cards

Term

When there is a foreign body in the small intestine, which section should be cut into?

 

A) Proximal

B) Distal 

Definition

Answer: DISTAL 

the proximal intestine will be distended, and it would be wiser to cut into undamaged intestinal wall. The distended wall will have disrupted cell wall structure and decreased healing capabilities.

 

Term
Which cellular layer of the small intestine has the greatest holding power?
Definition
SUBMUCOSA
Term
When preforming an enterectomy,  how do you prevent bowel contents from contaminating your incision?
Definition
You milk the intestinal contents AWAY from your incision and have someone use their fingers as a clamp
Term
When preforming an enterectomy for a foreign body, how should your forceps be placed to clamp off your intestines?
Definition

BECAUSE the proximal intestine will be dilated and the distal intestine comparatively smaller. So, the proximal is clamped at a perpendicular angle, where the distal (smaller) is clamped at a strong angle. 

(the angle should leave the omental side shorter) 

Term
How can you correction the lumen disparity when preforming an enterectomy?
Definition

1) 

2) suture spacing 

3) Make the small side bigger on the anti-omental side

 

Do NOT artificially close the big side like you can do in the stomach 

Term
What suture pattern is used to close enterectomies?
Definition

TWO simple continuous patterns.

On the omental side and the anti-omental side

Term
How can enterectomies be closed?
Definition

stapling - end to end anasatomosis, or triangulated skin stapling. 

Simple continuous split pattern 

Term
What is the last, and very important, step in entectomies before closing the abdomen?
Definition

Make an omental patch - 

this will help with leaking, healing, etc.

Term

What is an enteropexy?

Why is it preformed?

Definition

It is used to prevent intasusception, 

it involves engaging the submucosa of the small intestine through its entire length (giving an accordian apperance) 

Term
Where are the most bacterial in the intestines?
Definition

IN the ileum, colon and rectum

The duodenum and jejunum have less # of bacterial colonies 

Term
With what intestinal surgeries should you preform surgery SAME DAY?
Definition
PErforation, strangulation or complete obstruction
Term

VIsceral manipulation may cause tachycardia and twisting hypertension.

 

True or False?

Definition

FALSE 

Visceral maipulation may cause BRADYCARDIA and twisting HYPOTENSION. 

 

Term

What is the "leak test"?

What are the possible outcomes?

Definition
When preforming an enterectomy, isolate 10 cm and add 15 mL of saline in a syringe - inject into the loop of bowel.  This mimics peristaltic pressure, so if it leaks between sutures add more sutures. If it leaks from the suture holes - add a patch.
Term

Foreign body intestinal instructions where would you expect to have more severe clinical signs?

 

A) when it occurs more proximally

B) when it occurs more distally 

Definition

When it occurs more proximally 

 

Term
How can you prevent having to make many incisions when removing a linear foreign body?
Definition

You can use a red rubber catheter - feed in down the length of the foreign body.

 

This will not work if it has perforated or is embedded into the submucosa.

Term
When there is intusussception, what are the terms for the two involved portions of bowel?
Definition
The Intussusceptin is the outer portion, where the intussusceptum is on the inside.
Term
How do you tell the difference between a rectal intussuception and a prolapse?
Definition
Insert a probe along the outside of the protrusion, if you hit a dead end = prolapse!
Term

Which is better technique for cystotomy approach:

Ventral or dorsal?

 

Why?

Definition

Ventral

because there are important structures (like ureters) that enter through the dorsal aspect of the bladder

 

Term
What is the best type of suture to use in cystotomy?
Definition
MONOFILAMENT absorbable!
Term
What is the most common reason for preforming a cystotomy?
Definition
Calculi removal
Term
Which stones appear opaque on radiographs?
Definition
Calcium oxalate, struvite 
Term
Which urinary stones are non detectable by readiograph ?
Definition
Cystine, urate
Term
What are the clinical signs for urinary calculi?
Definition

Stranguria, hematuria, pollakiuria, inappropriate urination.

Can obstruct and become an emergency 

 

Signs can also be associated with just a urinary tract infection or a tumor 

Term
What is the first surgical line of defense in treating urolithaliasis?
Definition
Retrohydropropulsion
Term
What urinary stones can be dissolved with medical treatment?
Definition
Struvite, urate, cystine
Term

Which surgical removal is preferred for the removal of urinary stones:

Urethrotomy or Cystotomy?

Definition

Cystotomy

Remember to REMOVE ALL STONES (duh)

Term
What type of samples should be taken when preforming a urinary stone removal?
Definition

Calculi analysis 

Calculi (crushed) for culture

Bladder mucosa for bacterial culture

***Radiograph to document post-op that all stones were removed****

Term
How often do cases of urolithiasis REoccur?
Definition
12-25 % of cases 
Term
What is the most common type of tumor found in the urinary bladder or urethra?
Definition
Transitional cell carcinoma
Term
What work up should be preformed when diagnosing urinary tumors?
Definition

Physical exam

rectal exam (can feel for thickened urethra)

Blood work 

urinalysis 

Abdominal radiography, contrast radiography

abdominal ultrasound 

transurethral biopsy 

traumatic catheterization - good at diagnosing

Term
What is the most common location in the urinary tract for tumors?
Definition
Trigone area of the bladder 
Term
What are some differential diagnosises for hematuria?
Definition

POlypoid cystitis (masses in cranioventral area) 

Urinary tract infection 

urolithiasis 

prostatic disease 

urinary neoplasia

Term
What structure is the most common source of uroabdomen?
Definition
Urinary bladder 
Term
What are some common causes of uroabdomen?
Definition

Trauma (HBC- Hit By Car)

Iatrogenic (overagressive catheterization, cut during surgery, etc) 

Neoplasia

Severe cystitis

obstruction causing rupture

Term
What type of life threatening electrolyte imbalance is common with uroabdomen?
Definition
Hyperkalemia
Term
What is the best method for diagnosing uroabdomen?
Definition

Comparing abdominal fluid creatinine to serum creatinine levels.

If the creatinine is higher in the fluids than the serum = uroabdomen!

Term
What is the best method for diagnosing ectopic ureters?
Definition

CYSTOSCOPY

can determine both presence and conformation 

You can use excretory urography but not definitive and cannot determine if intra or extramural

Term
What secondary changes may occur if treatment of ectopic ureters is not surigcally treated in a timely manner?
Definition

Hydroureter

Hydronephrosis 

Ascending urinary tract infection

Term
What is a neoureterostomy?
Definition
Surgical treatment of ectopic ureters where a new stroma is made by ligating distal intramural portion.
Term
What is a ureteroneocystostomy?
Definition

Surgical treatment of ectopic ureters.

Ligation of distal ureter, resect and reimplant the ureter into urinary bladder.

Term
What is the success rate of surgical treatments of ectopic ureters?
Definition

about 50% 

30-55% of dogs continue to have incontinence 

and may need medical treatment also 

Term
What is the best portion of the kidney to take for biopsy sampling?
Definition
The parenchyma - this way you avoid excessive bleeding from arcuate arteries 
Term
What type of sutures and patterns should be used when preforming a biopsy of the kidney?
Definition

IF done with a needle - only digital pressure needed

Wedge - mattress suture, monofilament absorbable 

Term
What characteristics of liver parenchyma make it difficult to work with?
Definition

Itis very friable

if you cut a vessel or duct it will be difficult to find and ligate because they retract back into the tissue. 

This makes sharp dissection difficult.

Term
What are the major functions of the liver?
Definition

Production of : Coagulation factors, plasma proteins, cholesterol, bile salts

Metabolism and conversion of nutrients and drugs

removal of microbes from circulation (reticuloendothelial)

 

Term
What coagulation factor is NOT made in the liver?
Definition

Factor VIII

(maybe released from glomerular, vascular and tubular endothelium) 

Term
What are some pre-operative concerns for patients with liver disease?
Definition

Lowered liver production:

hypoalbuminemia, hypoglycemia, coagulopathies

Anemia

hypokalemia

ascites 

hepatic encephalopathy and seizures

*impaired drug metabolism*

Term
What is the best anesthetic protocol for patients with liver disease?
Definition

Pre med and induction: Diazepam + Opoid

Maintenance: Isoflurane

Term
What anesthetic agents should be avoided in patients with liver disease?
Definition

Thiobarbituates 

Ketamine (dogs)

Acepromazine 

 

(metabolism in the liver impeded)

Term
What are some clinical signs of hepatobiliary disease?
Definition

Stunted growth 

thin body condition 

Ascites 

Blood clotting disorders

JAUNDICE 

Seizures 

Sepsis 

Term
What are the six liver lobes?
which is the largest?
Definition

Caudate 

quadrate 

right lateral 

left medial 

right medial 

left lateral - BIGGEST

Term
Which liver lobe is the most likely to be involved in torsion? Why?
Definition

LEFT LATERAL 

it is the largest 

Term
Where is the afferent blood supply to the liver from?
Definition

20% is arterial 

80% is venous from PORTAL VEIN

(from pancreas, stomach, spleen, intestines)

Term
Where does the blood from the liver drain to (venous)?
Definition
VENA CAVA
Term
What is the importance of portal venous blood to go through the liver BEFORE entering the vena cava ?
Definition

Protects systemic circulation from substances that are metabolized by the liver or excreted from the liver to the GI.

Also many substances are metabolized in the liver, so this prevents them from being in systemic circulation.

Term
What fetal structure shunts portal blood to directly enter the vena cava (thus bipassing the liver)?
Definition
Ductus venosus
Term
What are some consequences of liver shunting that continues after birth?
Definition

Retarded development of the liver 

hepatic insufficiency 

hepatoencephalopathy

Term
What are some diseases of the hepatobiliary system that can be treated with surgery?
Definition

Portosystemic shunts 

hepatic abscesses and cysts 

hepatic neoplasia 

hepatic lobe torsion

biliary tract obstruction 

 

Term

Neoplasia of the liver is often primary.

True or False?

Definition

FALSE 

Because the liver is filtering blood from all over the body, it usually a secondary (metastatic) lesion.

Term
How should patients be preapred for a percutaneous biopsy of the liver?
Definition

Dorsal recumbancy 

HEAVILY SEDATED

Term
What are the advantages of using a tru-cut biopsy needle on the liver?
Definition

it is inexpensive 

easy if guided with an ultrasound 

Sensitive for FOCAL lesions

Term
What are some advantages for using a tru-cut biopsy needle on the liver?
Definition

Not sensitive for diffuse lesions

uncontrollable hemorrhage

surgical biopsy better because it is easier to visualize 

Term
What is the procedure in preforming a punch biopsy of the liver?
Definition

insert metal butting cylinder 

stop when hub contacts liver surface

withdrawl punch 

grab biopsy sample 

trim at base with metzenbaum scissors

use gelfoam sponge to stop bleeding

Term
What is the "guillotine" suture method of liver surgery?
Definition

It is where a suture material (of good knot security - like monocryl) is wrapped around the effected liver lobe. 

This is then pulled tight, crushing thru friable hepatic tissue.  Place overlapping sutures around the margin, cut 5 mm distal to them and excise!

Term
What instrument should be used when preforming a partial liver lobectomy? Why?
Definition

Scapel for CAPSULE ONLY

Then your fingers - or the scapel handle

this sort of blunt dissection will split the parenchyma, 

but will not break the ducts or vessels.

 

Alternative: use surgical stapling device

Term
What conditions as most common for requiring a complete liver lobectomy?
Definition

Traumatic laceration

AV fistula

torsion 

neoplasia

Term
What veins feed into the portal vein?
Definition

Gastroduodenal v

Splenic v

Caudal mesenteric v

cranial mesenteric v

 

Term
What considerations regarding vascular supply need to be applied in complete liver lobectomies?
Definition

Medial and lateral left lobes are easier - because there is a more distinct separation, so its easier to access vessels

 

Right lateral and caudate lobes need to be freed from caudal vena cava (via umbilical tape tourniquet round cranial and caudal vena cava, portal vein, celiac art, cranial mesenteric art)

Term

Where is the gall bladder located?

(ie. between which lobes)

Definition
Between right medial and quadrate lobe
Term

The liver has good regenerative properties, so function can be restored in most surgeries.

True or False?

Definition

TRUE 

(unless there is still underlying disease that is causing the liver not to function or regenerate properly)

Term
How could a wedge biopsy celiotomy be preformed?
Definition

Several overlaying mattress sutures are placed around margins (to crush tissue but not cut).

then excise wedge - and more sutures or sponge to stop bleeding

Term
What different tests should be preformed on liver biopsies?
Definition

Histopathology 

mineral analysis 

Culture 

Term
Which problems might be seen clinically in a patient with a portosystemic shunt?
Definition

Toxin build up 

hepatic encephalopathy

decreased liver size 

hepatic insufficiency 

Term
What is the main cause of acquired extrahepatic shunts?
Definition

typically a result of portal hypertension

Often there are multiple shunting vessels 

accounts for 20% of canine portosystemic shunts

Term

Congenital extrahepatic shunts are usually:

singular or multiple?

Definition
Singular, but often many other vessels are abnormally formed as well.
Term

A extrahepatic shunt redirect blood:

- from systemic to portal circulation

- from portal to systemic circulation

Which is correct?

Definition

Portal to systemic 

this causes blood that needs to be filtered to bypass the liver and continue to systemic circulation

Term

What is a more common occurance:

extrahepatic or intrahepatic single shunts?

Definition

Extrahepatic = 60% of single shunts 

intrahepatic = 35% of single shunts 

both are usually congenital and are accompanied by abnormalities in other vessels.

Term

Intrahepatic shunts are usually acquired and multiple.

True or False?

Definition

FALSE

Usually congenital and single

Term

Getting a dog from the pound is risky because you dont know their genetics, and they are likely to have congenital anomalies like portosystemic shunts.

True or False?

Definition

FALSE 

purebreds are more likely to acquire congenital abnormalities like portosystemic shunts

Term

Extrahepatic shunts most commonly effect:

Miniature or large pure bred dogs?

Definition

Extrahepatic = MINIATURE/toy pure breds

that are less than a year old

Term

Intrahepatic shunts most commonly effect:

Miniature or large pure bred dogs?

Definition

Intrahepatic = Large pure bred dogs 

that are less than a year old 

Term
When do clinical sign typically present with portosystemic shunts?
Definition
When purebred dogs are less than a year old.
Term
What are some clinical signs assocaited with portosystemic shunts?
Definition

Stunted growth 

hepatic encephalopathy (lethargy to seizures)

PU/PD

Urinary dysfunction 

ammonum biurate calculi in urine 

prolonged drug effects

CATS: ptyalism, blindness

Term

Nuclear scrintigraphy can confirm the presence of a portosystemic shunt.

True or False?

Definition

TRUE 

***but it will NOT indentify the shunting vessel!!!

Term
What imaging can be preformed to confirm the presence of a portosystemic shunt?
Definition

Abdominal ultrasound 

positive contrast portography 

nuclear scinitigraphy

Term
Medical treatment of portosystemic shunts is not feasible long term treatment, but still used, why?
Definition
Medical treatment is used to prepare the patient for surgery.  This is also done to minimize the risk of hepatic encepahlopathy
Term

Which is the preferred method of portosystemic shunt occulsion:

Acute or Gradual? Why?

Definition

GRADUAL 

because there is a higher incidence of complications with the acute - the liver has to adjust to doing its job again and handling all that blood.  

Complications include portal hypertension - death

Term
What can be used to gradually occlude portosystemic shunts?
Definition

Ameroid ring constrictor 

cellophane banding 

Term
What is the most important measurement post-op of portosystemic shunts?
Definition

Portal pressure!

Because the liver needs to adjust to all the new blood it is receiving, the pressure needs to be measured and be cautious of hypertension.

Term
What are some complications associated with gradual attenuation of portosystemic shunts?
Definition

Hemorrhage

seizures

ascites 

portal hypertension

recanalization 

acquired shunting (compensatory to hypertension)

Term
What is the prognosis for surgically corrected portosystemic shunts?
Definition

Although there is a 10% mortality rate, 

many that survive the perioperative period have excellent long term prognosis.

Some may need continued medical managment 

Term
What is the survival rate of gradual acclusion devices in correcting intrahepatic shunts?
Definition

Trick question

You cant use an occulsion device IN the liver for the most part, it would be weird.

Term
[image]
Definition
[image]
Term
What are the methods for surgical treatment of intrahepatic shunts? Which is better?
Definition

Acute or staged ligation - 20% mortality rate 

percutaneous caval stent and coil embolism - may be better 

Term
What are some disease states that may require extrahepatic biliary surgery?
Definition

Extrahepatic biliary obstruction (benign or malignant)

Biliary mucocele

Biliary tract rupture causing bile peritonitis

(can be caused by trauma or necrotizing cholecystitis)

Term
What can cause Extraheptic Biliary Obstruction (EHBO)?
Definition

BENIGN: 

Cholelithiasis, biliary sludge, pancreatitis/pancreatic abscess, stricture

 

MALIGNANT:

Pyloric, duodenal, pancreatic, hepatic, biliary tract 

Term

How can EHBO be surgically corrected?

(extrahepatic biliary obstruction)

Definition

Choledochotomy (if duct dilated and obstuction can be removed adequately)

Biliary diversion 

surgical stapling (GIA stapler)

Term
What is bile peritonitis? What can be done?
Definition

It is where there is rupture or leakage of the biliary tract into the abdomen, causing peritonitis.

This needs to be addressed immediately and patients will recover quickly if the peritonitis remains sterile.

septic bile peritonitis has 73% mortality rate

Term
What is the most common surgery preformed on the spleen? Why?
Definition

SPLENECTOMY

why? because patients do fine without a pancreas, and since you are going in there (for a biopsy or partial slenectomy) you might as well just remove the whole thing - prevent having to go back in.

Term
What are some indications for preforming a splenectomy?
Definition

Diffuse splenomegaly (from torsion, congestion, infarction)

neoplasia

trauma - rupture

immune mediated disease

Term
What arterial vessels need to be ligated to preform a splenectomy?
Definition

Splenic a: distal to last branch to pancreas AND 

where is courses towards short gastrics

Left gastroepiploic a

short gastric arteries

Then the vessels to the omentum need to be ligated as well

Term
How can you locate the spleen?
Definition

Parallel to greater curvature of the stomach 

connected by the gastrosplenic ligament (part of the omentum)

Term
Why MUST the splenic artery be ligated at the last branch to the pancreas? 
Definition

The branches just prior feed the pancreas.

If these are ligated instead, blood flow to pancreas would be compromised.

Term
How can you definitively determine malignancy of a splenic mass?
Definition

HISTOPATH 

FNA, ultrasound, CT scan do NOT determine malignancy

Term
Non traumatic hemoabdomen from splenic mass is most often caused by what???
Definition

HEMANGIOSARCOMA

70% 

At this time there is often metastasis - esp in the right atrium.

Ruptured tumor puts cancer cells in the abdomen.

Term
Where is the most common metastatic sight for hemangiosarcomas?
Definition
Splenic hemangiosarcomas - in the right atrium
Term
What is the prognosis for a splenic hemangiosarcoma?
Definition

POOR 

even with Chemo 

Surgery does NOT effect prognosis 

Term

Surgical removal of hemangiosarcomas improves prognosis, especially if chemo is used post-operatively.

True or False?

Definition

FALSE 

Prognosis of hemangiosarcomas are VERY POOR, with or without chemo.  And surgical removal does not improve these poor chances. 

<10% sruvive past 12 months.

Term
Surgery on which portion of the pancreas is has the worst prognosis? Why?
Definition
The central body - becuase it is the hardest to get to and there are many vessels that will be disrupted in getting to it. 
Term

Partial removal of the pancreas is indicated only if it involves the distal portions of the limbs.

True or False?

Definition

TRUE

This distrupts the least amount of vasculature

Term
Which limb of the pancreas may compromise some vessels to the duodenum when surgery is preformed?
Definition

The left limb

 

Term

Which lesions benefit the most from pancreatic surgery?

a) insulinoma

b) Pancreatic abscess 

c) adenocarcinoma

Definition

B) pancreatic abcesses 

as well as pseduocysts 

Both are non-neoplastic diseases where surgery is curative.

Term
How are pancreatic abscesses formed?
Definition

Usually a consequence of pancreatitis 

but contain NO bacterial components

Almost always these are sterile.

Term
What is the procedure for surgically treating pancreatic abscesses?
Definition

Drain 

Debride fibrous wall of pseduocyst/

remove necrotic or purulent areas of abscess

OMENTALIZE (tack down to pancreas with sutures)

Term

Treatment of Pancreatitis is be done:

medically or surgically?

Definition

MEDICALLY - it is not a true surgical disease 

and should always be agressively treated medically.

Surgery can help diagnose, and may be needed from consequences of pancreatitis. 

**Jejunostomy feeding tube - tx of pancreatitis that bypasses inflammed area and can replenish lost proteins.

Term
How can surgical intervention, not removal,  help with treatment of pancreatitis?
Definition

JEJUNOSTOMY feeding tube

by placing a feeding tube distal to the inflammed region there is a way to replenish lost proteins 

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