小腸手術(shù)基本治療原則切開(kāi)術(shù)及腸切除術(shù)07 small intestines2016

SurgeryofSurgeryofthesmallintes2nes:principles,enterotomyand小腸手術(shù)：基本治療原則，腸切開(kāi)術(shù)及腸切除Jean---FrancoisSALOMON,DVM,BirkenfeldAnimalSurgeryofthesmallSurgeryofthesmallintes2ne=howtoopenclosesafelythesmallintes2ne小腸手術(shù)=如何安全的切開(kāi)縫合小腸16%inthe2%now=theaimofall2%=現(xiàn)在所占手術(shù)的比Year16%以YearDehiscenceDehiscencerate(asmajorDehiscenceDehiscencerate(asmajorDehiscencerateDehiscencerate(asmajorIrregularsuturingSutureSutureDehiscence:4daysSutureDehiscence:4SutureDehiscence:4daysNeedletotestsutureWhopaysWhopays FreenFoundamentalprinciples:Foundamentalprinciples:FluidAllanimalsundergoingsurgeryareatriskfor?uidandelectrolytes所有計(jì)劃接受腸道手術(shù)的動(dòng)物都有可能出現(xiàn)體液及電解質(zhì)紊Intes8naldisordersIntes8naldisordersleadstodehydra2onelectrolytesProfuseSmallintes7nalobstruc8onorSmallintes7nalobstruc8onorSecre8onofintotheintes8nalAbsorp8onof?uidsand吸收腸腔內(nèi)液體及HypovolemiaReduc8onof?uid血管內(nèi)液體量ThehighertheThehigherthelevelofobstruc8on,theearliertheonset?uidandelectrolytessolu8onorNaClInhighobstruc8on,metabolicalkalosisiscommonbecause?uidlossisInlowobstruc8on,Inlowobstruc8on,metabolicacidosisislikelybecausesequestered?uidisLactatedAddi2onalmaybeneededPotassiuminfusionshouldnotexceed:0,5輸鉀時(shí)，速度不應(yīng)超過(guò)0.5mEq/kg/hrFrequentreassessmentsFrequentreassessmentsof?uidandareneededbevorandaJer。An7bio7cprophylaxisSmallintes8neAn7bio7cprophylaxisSmallintes8neofdogsnormallycontainsm--Smallintes8nalsurgeryclassi?ed?Cleancontaminatednobreakinasep2cContaminated=majorbreakinasep2ctechniqueorspillageofintes2nalcontent.???TheneedTheneedforan8bio8ccoverageduringsurgeryiss8ll是否應(yīng)在腸道手術(shù)中使用抗生素仍存爭(zhēng)Ischemic腸道缺An8bio8csondogsurvivalhasbeendocumented!Nonstrangula7ngNonstrangula7ngStagna8onofwithsigni?cantmul8plica8onofthebacterialNeedofNonstrangula7ngNonstrangula7ngStagna8onofwithmul8plica8onthebacterialNeedofHasnotbeprovenPersonaldecisiontousePersonaldecisiontouseSeveralfactorsneedtobe?–Usetheappropriatean2bio2csac2veagainsttheencounteredatthesurgicalsite(prox.Vsdist.smallGram---EnterococcusGram+gram---革蘭氏陽(yáng)性和An2bio2csAn2bio2cspresentinthe2ssueatthe2mesurgery.術(shù)中手術(shù)部位使用抗1or2moreinjec2onupto24haJerinduc2oncanbedone.誘導(dǎo)麻醉后24小時(shí)內(nèi)，再注射1---2次抗生素Extendeduseofan2bio2csdoesn′tpreventinfec2onsandincreasetheresistanceofresistantbacterias細(xì)菌產(chǎn)生耐藥An2bio2cspresentinAn2bio2cspresentinthe2ssueatthe2mesurgery.術(shù)中手術(shù)部位使用抗1or2moreinjec2onupto24haJerinduc2oncanbedone.誘導(dǎo)麻醉后24小時(shí)內(nèi)，再注射1---2次抗生素Extendeduseofan2bio2csdoesn′tpreventinfec2onsandincreasetheresistanceofresistantbacterias細(xì)菌產(chǎn)生耐藥Useof?rst-cephalosporins:oneofthee?ec2vechoicesforsmallan2microbial22mg/kg,Smallintes7nesstructureSmallintes7nesstructureand粘膜下TheThesubmucosa粘膜下TheThesubmucosaisitisthekeystructuretobesutured!…andtheprimarybloodtotheGItract胃腸道供血的主Theconnec2ve2ssueofthesubmucosasuppor2ngskeletonofthegut…粘膜下層的結(jié)締組織支撐起腸道Smallintes7neSmallintes7neLag?brintogetridofMigra2onofepithelial0-‐‐4ImportanceofthesuturewhichholdalltheParietalwoundstrength!!HighriskofdehiscenceduringthisProlifera8vephase:cellularProlifera8vephase:cellular4-‐‐14AJer14days,thewundstrengthisalmostthesameasbyanormalintes2n.?Matura8onphase:reorganiza2onremodelingofdesired17-In?amma8ondelaysIn?amma8ondelaysthelagHowtoprocessthisIn?amma8ondelaysIn?amma8ondelaysthelagIncisethenonin?am-matoryHowtoprocessthisIfIfinDoubtcutitoutIfIfinDoubtcutitoutChoiceofsuturepaeernChoiceofsuturepaeernforentericInver8ng,Ever8ng,Inver8ngsutureGreateroftheintes2nallumen:40---60%SecondInten2on(=prolongedhealing外翻縫Ever2ng外翻縫Ever2ngsutureSecondInten8onApposi7onalsutureLessApposi7onalsutureLessbutmildeversionispresent不會(huì)明Withoutsigni?cantconcern2mmfrom2mmfromtheApposi7onalsutureLessbutmildeversionispresent不會(huì)明Withoutsigni?cantconcern2-‐‐3mmfromeach2mmfromtheApposi7onalsuture2mmfromtheApposi7onalsutureLessbutmildeversionispresent不會(huì)明Remembrhtsigni?cantKnotthroughtheSubusnrn2-‐‐3mmfromeachIsasecondIsasecondlayerpossibleorDelayedYesitYesitispossiblewiththe2nd-‐‐layerAndtheesophagusandAndtheesophagusand1stlayer(mucosaandsubmucosa)withintraluminalknots.2ndlayer(muscularisandadven2a)withextraluminalknots.SuturepaeernSuturepaeernforSIMPLESuturePaeernforSuturePaeernforSIMPLE58dogsand2558dogsand25catsunderwententerotomyorenterectomy.接Sutureonlywithpdsorprolene.pds2casesofwounddehiscence2個(gè)病例出現(xiàn)了傷口開(kāi)??––––oneaJercon7nuousclosureoneaJerinterruptedclosur(=4%)Comparisonofacon8nuoussuturepagernwithasimpleinterruptedpagernforentericclosureindogsandcats:83cases比較83例（1991-‐‐1997）連續(xù)縫合與簡(jiǎn)單結(jié)節(jié)縫合犬貓Weismanetal,JAVMA,1999May15;214(10):1507--Con7nuousvsCon7nuousvsInterruptedCClofthe?Thesimplecon2nuousclosurepaeernisanacceptablealterna2vetosimpleinterruptedclosureforsmallintes2nalanastomosisorenterotomyclosure“.?One?Onesimplecon8nuoussuturepagernisthegoldstandardtechniqueforsmallIncludingthe Suturetobe Suturetobe 避開(kāi)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:取線性??Spillageonint.Content腸內(nèi)容物泄Injuryofthemesentericborderlikeasaw會(huì)像鋸子一樣割傷Extrac8onofExtrac8onofalinearforeignbody:取線性??Spillageonint.Content腸內(nèi)容物泄Injuryofthemesentericborderlikeasaw會(huì)像鋸子一樣割傷RespecttheRespectthevascularisa2onVasaHypovolemiaandanemiain?uencetheoxygenapporttothesmallIntes8nalIntes8nal腸道活檢/腸切開(kāi)NotNoteasytocarefullyhandlethesmallestrepresenta8vefullWhatkindWhatkindofsuturematerialwouldyouWhatkindWhatkindofsuturematerialwouldyouEnterotomy:Enterotomy:forcatchingbodiesWrapWraptheenterotomywoundwiththeSome7mesSome7mesmoreenterotomiesSome7mesSome7mesmoreenterotomies=6=6VasaVasarecta,v.1st1stSuture:2nd2ndsuture:SutureSutureofthe1stside:fromricborderwithcon8nouspagernSutureSutureofthe2ndside:frommesenterictoan8-‐‐mesentericborderwithcon8nouspagernClosureClosureoftheholetoavoidanoftheDiametersshouldbeObliqueDiametersshouldbeObliquecutandDiametersshouldbeObliqueDiametersshouldbeObliquecutandDirec8onoftheDiametersshouldbeObliqueDiametersshouldbeObliquecutandDirec8onoftheIsthisIsthisbowelviable?ShoulditbeorTransientmassagetos8mulatePeristalsis---e---蠕動(dòng)---脈搏---IsitViable??OtherIsitViable??OthertechniquesFluorescein95%–DopplerPulse–Mostusualdecision:resec2onofaviableIsItIsItviable還有活性么LO-ShouldShouldItrytopullitout?接著拉接著拉ShouldIgoon?En?EnblocResec2on?