Exploratory celiotomy is commonly done for diagnosis and treatment of a variety of medical conditions in dogs and cats. Specific indications may include intraabdominal foreign bodies, masses, abscesses, or granulomas; uncontrolled abdominal hemorrhage; gastrointestinal or urinary tract obstruction; radiographic evidence of pneumoperitoneum; persistent vomiting, diarrhea, or abdominal pain with no detectable cause; findings on cytologic evaluation of abdominal fluid consistent with peritonitis or leakage of urine or bile; estrus in spayed female dogs; or cryptorchidism. Exploratory celiotomy can also be used to obtain biopsies, cytologic evaluation, and cultures for diagnosis of the underlying disease or as a prognostic indicator, as in the case of nonresectable neoplasia.
Types
Complications are observed in 26% to 30% of dogs and cats surviving the procedure.1,2 Most complications result from the underlying disease process; however, they can also be related to the incision (7.5%), anesthesia (5% to 22%), or the procedure itself (17% to 28%).1,2 In one study, complications were highest in patients with gastrointestinal foreign bodies, hepatic lipidosis, ureteral abnormalities, intestinal intussusception, pancreatitis, hepatic neoplasia, and lymphoreticular neoplasia.1 Wound-related complications and infections are higher with surgery duration greater than 90 minutes. Overall mortality rates range from 17% to 27%; euthanasia, done because of the extent of the underlying disease or poor prognosis, is the most common cause of death.1,2
Complications can occur both during and after the procedure. Intraoperative complications may include hemorrhage, inadequate ventilation or perfusion, and inadvertent damage to tissues. Postoperative complications are associated with the abdominal incision (i.e., pain, swelling, seroma formation, infection, dehiscence, or suture reaction), surgical manipulation (i.e., diarrhea, ileus, adhesions, seeding of tumor cells, pancreatitis, hemorrhage); surgical error (i.e., iatrogenic foreign bodies, peritonitis, pneumothorax, sinus tracts from nonabsorbable braided ligatures or nylon cable ties); or primary disease. Some complications, such as hypothermia, pain, and swelling, are so common that clinicians may not consider them to be complications.
Prevention
Blood Analysis
Because severely ill patients are more likely to have complications, preoperative diagnostics and stabilization are critical.
- Perform a CBC and analysis of serum biochemistries and electrolytes.
- Evaluate urine for evidence of renal insufficiency (i.e., decreased urine specific gravity in the presence of azotemia), infection, hemorrhage, or protein loss.
- Perform platelet counts, measurement of buccal mucosa bleeding time, and coagulation profiles in patients with sepsis, liver disease, significant hypoproteinemia, or suspected bleeding tendencies. Low platelet counts confirm thrombocytopenia, whereas prolonged buccal mucosal bleeding time in an animal with a normal platelet count is an indicator of platelet dysfunction or von Willebrand's disease.3
- Activated clotting time measures deficiencies of all clotting factors except factor VII and can be used as a screening test for disorders of secondary hemostasis. If activated clotting time is abnormal, prothrombin time and activated partial thromboplastin time should be measured.3
- Perform crossmatches in animals that may require transfusions.
Corrective Measures
If possible, correct electrolyte, acid-base, and glucose abnormalities before anesthesia. Animals with coagulopathies usually require perioperative transfusions of fresh frozen plasma or fresh whole blood, and animals with PCV 25% or less are often given packed red cells. Vitamin K therapy (2.2 mg/kg SC followed by 1.1 mg/kg SC Q 12 H) can be initiated in animals with prolonged clotting times secondary to cholestasis or other malabsorptive syndromes; this therapy should correct the coagulopathy within 1 to 2 days.3 In patients with pressure abnormalities or expected fluid loss, place a jugular catheter to measure central venous pressure. Use hetastarch (5 to 40 ml/kg/day IV) for oncotic support in animals with hypoproteinemia; hetastarch can be combined with crystalloids in patients with IV fluid-volume deficits.4
Pain
Many animals that undergo exploratory celiotomy are already in pain, and postsurgical discomfort is to be expected. Preemptive analgesia reduces intraoperative anesthetic requirements and potentially decreases the duration and severity of postoperative pain.5 Options include systemic opioids, nonsteroidal antiinflammatory drugs, fentanyl patches, local or regional blocks, and CRI of lidocaine or ketamine. A combination of therapies is often given. In addition to analgesic effects, lidocaine may have other positive benefits, such as improving gastrointestinal motility, decreasing neutrophil chemotaxis and platelet aggregation, and protecting cells through weak inhibition of calcium channels. A CRI of lidocaine (10 to 25 µg/kg/minute in cats or 25 to 50 µg/kg/minute in dogs) can be delivered by syringe pump or diluted in crystalloid fluids. Use lidocaine CRI with caution in cats since they are susceptible to dose-related neurotoxicity or decreased cardiac function.
Anesthetic Monitoring & Antibiotics
Monitor ECG, blood pressure, SPO2, and end-tidal CO2 once the animal is anesthetized. Mechanically ventilate patients with conditions that may cause respiratory compromise, such as diaphragmatic hernia, ascites, or gastric distention. Animals with hypotension (systolic BP < 90 mm Hg, mean BP < 60 mm Hg) that do not respond to IV fluids or reduction in anesthetic delivery may require positive inotropic support (i.e., IV dopamine CRI 4 to 6 µg/kg/minute).6
Give broad-spectrum antibiotics intravenously at induction if contamination is expected, although administration can be delayed until intraoperative cultures are obtained. In animals without infection, severe contamination, or tissue necrosis, discontinue antibiotics within 6 hours after the procedure.
Preoperative Preparation
Preoperative preparation should be thorough but efficient, since duration of anesthesia correlates with infection rates. If possible, clip the patient immediately before surgery to prevent bacterial colonization of microscopic nicks from clippers. In the surgical suite, place the animal on or under a forced-air warming system to reduce heat loss, and perform a final preparation of the surgical site.
Surgical Procedure
- If possible, make the incision directly on the linea alba, particularly if the patient has a bleeding tendency. Incisions can be extended cranially to the xyphoid; however, pneumothorax may occur if it is extended too far or if the cranial portion of the incision tears from excessive retraction.
- To reduce bacterial translocation and hypothermia, moisten the laparotomy pads placed along the incision only on the surfaces that contact the intraabdominal tissues, especially if cloth drapes are used.
- Perform a thorough, systematic exploration before undertaking definitive therapy.
Surgical technique should be guided by Halstead's basic principles: maintenance of asepsis, gentle handling of tissue, accurate hemostasis, closure of dead space, accurate tissue apposition, and avoidance of tension or vascular compromise.
- Do the cleanest procedures first-for example, perform liver biopsy before enterotomy.
- Isolate organs with moistened laparotomy pads to contain spillage and reduce generalized contamination.
- If no primary lesion is found or the primary disease cannot be resolved, sample organs and fluids for cytologic evaluation, biopsy, or culture.
- Consider feeding tubes for patients that are malnourished, anorexic, or vomiting.
- Once a contaminated organ or structure has been closed or removed, change gloves and instruments. Continuous suction drains can be placed in local areas of infection, or in multiple sites throughout the abdomen if peritonitis is present. Before closure, flush the abdominal cavity with warm sterile saline and suction it dry to remove contaminants.
Postsurgical Measures
After surgery, measure PCV, total protein, and blood glucose to provide a baseline for future comparison. Administer analgesics on a scheduled basis for the first 12 to 24 hours and then on an as-needed basis. Many animals require continued fluid administration and monitoring of vital signs.
Specific Complications: Prevention and Treatment