Stomach: gastrotomy

• Incision into the stomach to gain access to the lumen.

• Most commonly for the removal of gastric foreign bodies Stomach: foreign body when endoscopic retrieval is not possible.
• To obtain gastric biopsies when an endoscope is not available or endoscopic biopsy is not appropriate, eg submucosal lesion.
• Exploration/treatment of gastric ulceration Gastric ulceration or neoplasia Stomach: neoplasia.
• Exploration/treatment of gastric mucosal hypertrophy Stomach: chronic hypertrophic gastritis.
• Removal of esophageal foreign body Esophagus: foreign body.

Advantages

• Open surgical gastrotomy allows thorough evaluation of the mucosal surface by direct inspection and palpation.

Disadvantages

• Gastrotomy is a major surgical procedure cf endoscopy.

• Endoscopic retrieval of gastric foreign bodies Gastroscopy or for mucosal examination/biopsy:
  • In skilled hands is less invasive, simpler and quicker than open gastrotomy.
  • Should be used whenever practicable, either as definitive treatment or as part of the pre-operative investigation of the patient.

Preparation

• 15 min.

Procedure

• Approximately 60 min.

Criteria for choosing test

• Note that gastric foreign bodies may sometimes occur incidentally on survey radiographs; try to ensure that there are no other lesions which might cause the clinical signs.
• Explore the entire gastrointestinal tract by clinical examination, diagnostic imaging and at surgery.

Risk assessment

• Stabilization of the vomiting patient should be commenced before surgery, consider hydration, acid-base and electrolyte status.

Minimum equipment

• Standard surgical pack.
• Balfour retractors .

Ideal equipment

• Suction.

Minimum consumables

• Synthetic absorbable suture material, eg polydioxanone 2/0 or 3/0.
• Sponges.
• Scalpel blade.
• Sample container with formalin for preservation of biopsy specimens.
• Readily accessible warmed lavage fluids in case of gastric content leakage.

Ideal consumables

• Laparotomy sponges.

• Standard premedication Anesthetic premedication: overview , eg acepromazine Acepromazine maleate plus opioid Analgesia: opioid.

• Fast animal for 12 hours prior to anesthetic for elective procedures to prevent reflux esophagitis.

• Standard surgical preparation for a ventral midline laparotomy Laparotomy: midline 

• General anesthesia General anesthesia: overview.
• Dorsal recumbency.

Step 1 - Inspection of the abdomen; elevation of the stomach

• Systematically explore the entire abdomen, including the full length of the intestinal tract   .
• Place Balfour retractors  to retract abdominal wall from the cranial abdomen area .
• Isolate the stomach using moistened laparotomy sponges.
• Place stay sutures or Babcock forceps  to elevate and stabilize the portion of the stomach to be incised .

Step 1 - Gastrotomy

• Select an area in the ventral aspect of the stomach between the gastric curvatures that is relatively hypovascular.
• Make a stab entry into the gastric lumen using a scalpel blade.
• Extend the incision to several cm length with Metzenbaum scissors .
• Use suction to remove gastric content if applicable  .
  Take great care to avoid spillage of gastric contents into the abdomen. Use stay sutures/Babcocks to elevate the operative zone and wall-off the operative zone using large moistened laparotomy sponges.If inadvertant spillage occurs, copious abdominal lavage and suction with warmed sterile saline is indicated.

Step 2 -

• Inspect the gastric mucosa and retrieve foreign bodies, take biopsies etc as appropriate for the procedure being undertaken  .

Step 1 - Closure

• Two-layered techniques incorporating inversion of one or both layers are commonly employed.
• Use swaged-on synthetic absorbable suture material of an appropriate gauge, eg 2/0 or 3/0 polydioxanone.
• Employ one of the methods below.

• Most frequently employed.
• 1st layer: Cushing or simple continuous suture of submucosa, muscularis and serosa  .
• 2nd layer: Cushing or Lembert suture of muscularis and serosa  .

• 1st layer: simple appositional suture through all 4 layers.
• 2nd layer: Cushing or Lembert suture of muscularis and serosa.
  Some surgeons close the mucosa as a separate layer with a simple continuous suture, which reduces bleeding.
• Lavage the operative site.
• Lay a piece of omentum across the suture line  .

Step 2 -

• Close the laparotomy incision in standard three-layered fashion.

Fluid requirements

• Continue intravenous fluids Fluid therapy until oral intake is established.

General Care

• Monitor for vomiting and signs of peritonitis Peritonitis.

Analgesia

• Post-operative analgesia Analgesia: overview as required by the individual patient.
• All laparotomy patients should be assumed to require analgesia.

Antimicrobial therapy

• Not indicated for straightforward foreign body removal in most cases.

Potential complications

• Peritonitis Peritonitis due to intra- or post-operative gastric leakage: a grave sign.
• Affected animals are severely depressed, may be vomiting, and may show signs of abdominal boarding and fluid leakage from the laparotomy wound.

• Peritonitis Peritonitis before, during or after surgery.
• Leakage of gastric contents constitutes a major surgical complication and emergency as fulminating peritonitis and shock is likely.

• Usually excellent in uncomplicated foreign body retrieval.
• The stomach normally heals rapidly.

• Failure to diagnose and/or treat a simultaneous lesion further distal in the intestinal tract, eg an incidental gastric foreign body but clinical obstruction of the intestine distally.
• Hypoproteinemia → wound breakdown.

Refereed papers

• Recent references from PubMed and VetMedResource.
• Haragopal V, Suresh Kumar R V (1996) Surgical removal of a fish bone from the canine esophagus through gastrotomy. Can Vet J 37 (3), 156 PubMed.
• Fossum T W, Rohn D A, Willard M D et al (1995) Presumptive, iatrogenic gastric outflow obstruction associated with prior gastric surgery. JAAHA 31 (5), 391-395 PubMed.

Other sources of information

• How to perform a canine gastrotomy. dvm360: www.youtube.com/watch?v=rtNwyBxZk0o