Key gastrointestinal surgeries: Gastrotomy

Key gastrointestinal surgeries: Gastrotomy

When performed correctly, this procedure can help in the diagnosis and treatmentof many conditions—with minimal risk to patients. Follow this guide to the proper surgical technique.
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Apr 01, 2006

GASTROTOMY is a routine and relatively safe surgical procedure with several indications, but appropriate technique is vital to preventing complications. For general perioperative considerations when performing this procedure, including diagnostic testing, patient monitoring, and postoperative support, please see the symposium introduction.

INDICATIONS


Figure 1. A gastric foreign body in a dog that ingested a polyurethane adhesive (Gorilla Glue).
The most common indication for gastrotomy in dogs and cats is foreign body removal, particularly if objects are not amenable to endoscopic extraction because of their shape or size or because they have become fixed within the tissues (Figure 1).1-4 For example, surgically removing sharp foreign bodies is recommended because of the risk of perforation; linear foreign bodies that anchor in the pylorus also require surgical extraction.4,5 Foreign bodies in the distal esophagus can often be safely removed with forceps inserted through the lower esophageal sphincter via a gastrotomy, reducing the risks of pneumothorax, dehiscence, and leakage that have been commonly associated with thoracic esophagotomy.1,6 Gastrotomy has also been used to explore the gastric lumen and to decompress and evacuate the stomach of air and contents before repositioning in dogs with gastric dilatation or gastric dilatation-volvulus.1,2,7-10

Gastrotomy is a safe and effective way to collect full-thickness gastric biopsy samples of lesions that may be missed or misdiagnosed with endoscopic sampling.1,2,11,12 For example, gastrointestinal lymphoma arising from deeper layers of the submucosa can cause many of the same superficial inflammatory lesions as lymphocytic-plasmacytic gastroenteritis.11 Phycomycosis can only be definitively diagnosed with organism identification by fungal culture or by special histologic stains of fibrotic, firm tissues obtained from surgical incisional biopsy. Full-thickness incisional biopsy is also required for histologic examination to definitively diagnose gastric carcinomas.1,11,12

TECHNIQUE


Figure 2. Isolate the stomach with moistened laparotomy pads, and place stay sutures at either end of the proposed incision in the least vascular portion of the gastric body.
Make a ventral midline abdominal incision from the xiphoid to the caudal abdomen. Incisions that are farther cranial may penetrate the diaphragm, inadvertently causing a pneumothorax. Retract the abdominal wall with a Balfour retractor to expose the cavity, and perform a thorough exploration of the abdominal contents. Visually inspect and palpate the stomach for masses, thickening, or foreign bodies, and evaluate the pylorus for abnormalities.


Figure 3. To provide traction, drape the hemostats holding the stay sutures over the Balfour retractor.
If no gastric wall lesions are present, a gastrotomy is usually performed midway between the lesser and greater curvatures of the stomach, where the vasculature is less prominent.1,3,10 Elevate the stomach with full-thickness stay sutures or Babcock forceps at either end of the proposed incision site to improve visualization of the surgery site and reduce gastric content spillage (Figure 2). If no assistant is available, drape the hemostats holding the stay sutures over the Balfour retractor to provide retraction (Figure 3). Place moistened laparotomy pads around the stomach to limit peritoneal contamination.