小肠手术基本治疗原则切开术及肠切除术07 small intestines2016

SurgeryofSurgeryofthesmallintes2nes:principles,enterotomyand小肠手术：基本治疗原则，肠切开术及肠切除Jean-­­FrancoisSALOMON,DVM,BirkenfeldAnimalSurgeryofthesmallSurgeryofthesmallintes2ne=howtoopenclosesafelythesmallintes2ne小肠手术=如何安全的切开缝合小肠16%inthe2%now=theaimofall2%=现在所占手术的比Year16%以YearDehiscenceDehiscencerate(asmajorDehiscenceDehiscencerate(asmajorDehiscencerateDehiscencerate(asmajorIrregularsuturingSutureSutureDehiscence:4daysSutureDehiscence:4SutureDehiscence:4daysNeedletotestsutureWhopaysWhopays FreenFoundamentalprinciples:Foundamentalprinciples:FluidAllanimalsundergoingsurgeryareatriskforfluidandelectrolytes所有计划接受肠道手术的动物都有可能出现体液及电解质紊Intes8naldisordersIntes8naldisordersleadstodehydra2onelectrolytesProfuseSmallintes7nalobstruc8onorSmallintes7nalobstruc8onorSecre8onofintotheintes8nalAbsorp8onoffluidsand吸收肠腔内液体及HypovolemiaReduc8onoffluid血管内液体量ThehighertheThehigherthelevelofobstruc8on,theearliertheonsetfluidandelectrolytessolu8onorNaClInhighobstruc8on,metabolicalkalosisiscommonbecausefluidlossisInlowobstruc8on,Inlowobstruc8on,metabolicacidosisislikelybecausesequesteredfluidisLactatedAddi2onalmaybeneededPotassiuminfusionshouldnotexceed:0,5输钾时，速度不应超过0.5mEq/kg/hrFrequentreassessmentsFrequentreassessmentsoffluidandareneededbevorandaJer。An7bio7cprophylaxisSmallintes8neAn7bio7cprophylaxisSmallintes8neofdogsnormallycontainsm--Smallintes8nalsurgeryclassified•Cleancontaminatednobreakinasep2cContaminated=majorbreakinasep2ctechniqueorspillageofintes2nalcontent.•••TheneedTheneedforan8bio8ccoverageduringsurgeryiss8ll是否应在肠道手术中使用抗生素仍存争Ischemic肠道缺An8bio8csondogsurvivalhasbeendocumented!Nonstrangula7ngNonstrangula7ngStagna8onofwithsignificantmul8plica8onofthebacterialNeedofNonstrangula7ngNonstrangula7ngStagna8onofwithmul8plica8onthebacterialNeedofHasnotbeprovenPersonaldecisiontousePersonaldecisiontouseSeveralfactorsneedtobe•–Usetheappropriatean2bio2csac2veagainsttheencounteredatthesurgicalsite(prox.Vsdist.smallGram-­­EnterococcusGram+gram-­­革兰氏阳性和An2bio2csAn2bio2cspresentinthe2ssueatthe2mesurgery.术中手术部位使用抗1or2moreinjec2onupto24haJerinduc2oncanbedone.诱导麻醉后24小时内，再注射1-­­2次抗生素Extendeduseofan2bio2csdoesn´tpreventinfec2onsandincreasetheresistanceofresistantbacterias细菌产生耐药An2bio2cspresentinAn2bio2cspresentinthe2ssueatthe2mesurgery.术中手术部位使用抗1or2moreinjec2onupto24haJerinduc2oncanbedone.诱导麻醉后24小时内，再注射1-­­2次抗生素Extendeduseofan2bio2csdoesn´tpreventinfec2onsandincreasetheresistanceofresistantbacterias细菌产生耐药Useoffirst-cephalosporins:oneoftheeffec2vechoicesforsmallan2microbial22mg/kg,Smallintes7nesstructureSmallintes7nesstructureand粘膜下TheThesubmucosa粘膜下TheThesubmucosaisitisthekeystructuretobesutured!…andtheprimarybloodtotheGItract胃肠道供血的主Theconnec2ve2ssueofthesubmucosasuppor2ngskeletonofthegut…粘膜下层的结缔组织支撑起肠道Smallintes7neSmallintes7neLagfibrintogetridofMigra2onofepithelial0-‐‐4ImportanceofthesuturewhichholdalltheParietalwoundstrength!!HighriskofdehiscenceduringthisProlifera8vephase:cellularProlifera8vephase:cellular4-‐‐14AJer14days,thewundstrengthisalmostthesameasbyanormalintes2n.•Matura8onphase:reorganiza2onremodelingofdesired17-Inflamma8ondelaysInflamma8ondelaysthelagHowtoprocessthisInflamma8ondelaysInflamma8ondelaysthelagIncisethenoninflam-matoryHowtoprocessthisIfIfinDoubtcutitoutIfIfinDoubtcutitoutChoiceofsuturepaeernChoiceofsuturepaeernforentericInver8ng,Ever8ng,Inver8ngsutureGreateroftheintes2nallumen:40-­­60%SecondInten2on(=prolongedhealing外翻缝Ever2ng外翻缝Ever2ngsutureSecondInten8onApposi7onalsutureLessApposi7onalsutureLessbutmildeversionispresent不会明Withoutsignificantconcern2mmfrom2mmfromtheApposi7onalsutureLessbutmildeversionispresent不会明Withoutsignificantconcern2-‐‐3mmfromeach2mmfromtheApposi7onalsuture2mmfromtheApposi7onalsutureLessbutmildeversionispresent不会明RemembrhtsignificantKnotthroughtheSubusnrn2-‐‐3mmfromeachIsasecondIsasecondlayerpossibleorDelayedYesitYesitispossiblewiththe2nd-‐‐layerAndtheesophagusandAndtheesophagusand1stlayer(mucosaandsubmucosa)withintraluminalknots.2ndlayer(muscularisandadven2a)withextraluminalknots.SuturepaeernSuturepaeernforSIMPLESuturePaeernforSuturePaeernforSIMPLE58dogsand2558dogsand25catsunderwententerotomyorenterectomy.接Sutureonlywithpdsorprolene.pds2casesofwounddehiscence2个病例出现了伤口开••––––oneaJercon7nuousclosureoneaJerinterruptedclosur(=4%)Comparisonofacon8nuoussuturepagernwithasimpleinterruptedpagernforentericclosureindogsandcats:83cases比较83例（1991-‐‐1997）连续缝合与简单结节缝合犬猫Weismanetal,JAVMA,1999May15;214(10):1507--Con7nuousvsCon7nuousvsInterruptedCClofthe„Thesimplecon2nuousclosurepaeernisanacceptablealterna2vetosimpleinterruptedclosureforsmallintes2nalanastomosisorenterotomyclosure“.„One„Onesimplecon8nuoussuturepagernisthegoldstandardtechniqueforsmallIncludingthe Suturetobe Suturetobe 避开毛Peri-­­opera7veenvironment:ImportancePeri-­­opera7veenvironment:Importanceofenteralnutri8onPreopera2ve(x208mesmoresutureIntes2nalforeignSerum[ALB]<2,5Riskfactorsforleakagefollowingintes8nalanastomosisindogsandcats:115cases(1991–2000),S.C.Ralphsetall.JAVMA,Vol223,N°1,july1,2003.（1991-­­2000）),S.C.Ralphsetall.JAVMA,Vol223,N°1,july1,SURGEON´SSURGEON´SThinkatrauma8csurgeryIsola8onIsola8onoftheinjuredfromtheabdominalNonadequateNonadequate8ssuehandlingNonadequateNonadequate8ssuehandlingNonadequateNonadequate8ssuehandlingExtrac8onofExtrac8onofalinearforeignbody:取线性••Spillageonint.Content肠内容物泄Injuryofthemesentericborderlikeasaw会像锯子一样割伤Extrac8onofExtrac8onofalinearforeignbody:取线性••Spillageonint.Content肠内容物泄Injuryofthemesentericborderlikeasaw会像锯子一样割伤RespecttheRespectthevascularisa2onVasaHypovolemiaandanemiainfluencetheoxygenapporttothesmallIntes8nalIntes8nal肠道活检/肠切开NotNoteasytocarefullyhandlethesmallestrepresenta8vefullWhatkindWhatkindofsuturematerialwouldyouWhatkindWhatkindofsuturematerialwouldyouEnterotomy:Enterotomy:forcatchingbodiesWrapWraptheenterotomywoundwiththeSome7mesSome7mesmoreenterotomiesSome7mesSome7mesmoreenterotomies=6=6VasaVasarecta,v.1st1stSuture:2nd2ndsuture:SutureSutureofthe1stside:fromricborderwithcon8nouspagernSutureSutureofthe2ndside:frommesenterictoan8-‐‐mesentericborderwithcon8nouspagernClosureClosureoftheholetoavoidanoftheDiametersshouldbeObliqueDiametersshouldbeObliquecutandDiametersshouldbeObliqueDiametersshouldbeObliquecutandDirec8onoftheDiametersshouldbeObliqueDiametersshouldbeObliquecutandDirec8onoftheIsthisIsthisbowelviable?ShoulditbeorTransientmassagetos8mulatePeristalsis--­e--­蠕动-­­脉搏-­­IsitViable?•OtherIsitViable?•OthertechniquesFluorescein95%–DopplerPulse–Mostusualdecision:resec2onofaviableIsItIsItviable还有活性么LO-ShouldShouldItrytopullitout?接着拉接着拉ShouldIgoon„En„EnblocResec2on?