Abdominal Exploratory Surgery

Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

 

Key Points

Abdominal exploratory is both a diagnostic and therapeutic procedure

Vomiting is the primary sign seen with a variety of diseases affecting the GI tract

After surgery has been completed, intensive care must be provided for the best chance for a successful outcome


Introduction

  • Surgery of the stomach or intestines is very common. Reasons for operating on the gastrointestinal tract include ingested foreign bodies, cancer, twisted intestines, intussusception, bloat, and to collect full-thickness biopsies of the intestines. A variety of diagnostic tests are done prior to the abdominal exploratory in order to pin point where the problem is and what the nature of it is.
  • As a starting point blood work is done to determine if there are liver, kidney, pancreas, or electrolyte abnormalities. A complete blood cell count is used to look for signs of infection and anemia. Radiographs (x-rays) can be very helpful to indicate the presence of a problem in the gastrointestinal tract. Unfortunately, plain radiographs frequently are only suggestive of a problem and do not give us a definitive answer. As a result additional tests such as ultrasound or contrast radiographs (barium swallow) may be indicated.
  • Sometimes these tests also do not give us a final answer and exploratory surgery is needed. A negative exploratory may be the result; that is, all of the internal organs appear normal. If we do not find any obvious problem with the internal organs, biopsies still are done as microscopic disease may be causing the clinical signs. Even though it may seem disappointing to not find a problem that can be surgically corrected, it is better to explore the abdomen than ignore a surgical problem that the pet otherwise could die from. Fortunately, most abdominal exploratories yield a surgically correctable disease.

 

Signs of gastrointestinal disease

  • Vomiting is the primary sign seen with a variety of diseases affecting the GI tract. Generally if an obstruction of the GI tract is present, diarrhea is not a symptom, but occasionally it is. If the problem is acute (like ingestion of a foreign body), acute vomiting is almost always present. Chronic signs such as intermittent vomiting or diarrhea may be due to inflammatory bowel disease or cancer. Weight-loss can also be a problem in chronic diseases.
  • Age can give us an indication of the type of problem. Ingested foreign bodies are more common in young animals and cancer is more common in older pets. The underlying problem that a pet may be having, frequently requires abdominal exploratory and sometimes biopsy of various internal organs.

 

Abdominal exploratory and GI surgery

  • Frequently the decision to do an abdominal exploratory is based on radiographs or ultrasonic evaluation. Many times these tests are suggestive of a specific problem involving the stomach or intestines. As a result surgery is done in order to confirm what is suspected. Occasionally the abnormal gas pattern seen on the radiographs is not due to an obstruction of the intestine and no gross abnormality is found. In this situation the pet still may have a form of infiltrative cancer or viral infection (flu-like syndrome), or bacterial infection. If this is the situation, biopsies are taken to rule out any serious problem.
  • Even though it may seem disappointing to not find a problem that can be surgically corrected, it is better to explore the abdomen than ignore a surgical problem that the pet otherwise could die from. Fortunately, most abdominal exploratories yield a surgically treatable disease.
  • If a foreign body is found in the stomach or intestines, the object is removed by making an incision in the intestine or stomach. If a foreign body has caused a portion of the intestine to die off, this part of the bowel may need to be removed. A foreign body was found in the intestine of this dog (fig 1) at the time of surgery; the bowel was healthy enough so that the surgeon was able to simply make an incision in the intestine to remove the foreign body (Fig 2).
  • In the event that a tumor of the intestine or stomach has been found, surgical removal will be performed if possible.
  • Feeding tubes may need to be placed, especially if the patient is very malnourished from chronic disease. This tube can be removed in approximately 10 days if the pet is doing well. 

 

Aftercare and convalescence

  • After surgery has been completed, intensive care must be provided for the best chance for a successful outcome. Intravenous fluids may be continued over night.
  • Pain control is managed after surgery to keep your pet comfortable.
  • Close observation is maintained to make sure that your pet is not developing a life-threatening infection of the abdominal cavity called peritonitis. Antibiotics are administered for 24 hours.
  • Fluids are administered intravenously to combat dehydration.
  • Feeding of the patient is started within 24 hours after surgery. If your pet is still too nauseated, food and water are with held. If your pet has a lot of vomiting a tube may be placed down the nose to the stomach in order to remove excess fluid that may be in the stomach.
  • Exercise is restricted for a period of 3 weeks. During this time no rough-housing with other pets or people, jumping, or bounding up stairs is permitted.
  • Most pets will start to feel better 2 to 4 days after surgery. By 2 weeks after surgery they should have recovered completely. Healing of the internal tissues takes longer, therefore restricted activity on a leash should continue for a period of 3 weeks after surgery.
  • If your pet has cancer and chemotherapy is needed it usually is started 2 weeks after surgery. In some cases it is started earlier. In general chemotherapy is given every 2 to 3 weeks for a total of 5 treatments. Our oncologist may elect to choose a protocol is different from the standard one if there is a need for this.

 

Potential complications

  • As with any surgery, complications may arise. Even though rare, anesthetic death can occur. With the use of modern anesthetic protocols and extensive monitoring devices (blood pressure, EKG, pulse oxymetry, inspiratory and expiratory carbon dioxide levels, and respiration rate), the risk of problems with anesthesia is minimal.
  • Infection is also an unusual complication as strict sterile technique is used during the surgery and antibiotics are administered.
  • Seroma formation or fluid accumulation under the skin incision although uncommon can also occur. This problem in general will resolve with time. Occasionally the seroma or fluid that has build up may require draining.
  • Peritonitis is a very serious problem that fortunately does not occur very often. The most common cause of infection of the abdominal cavity is due to leakage of bowel contents through the enterotomy or anastomosis site. If this problem is to occur clinical signs become evident 2 to 5 days after surgery. Emergency surgery is needed if this occurs.
  • Intussusception can occur following intestinal surgery. This problem is where the small intestine telescopes on itself. In this situation another surgery is needed to correct the problem.
  • If a cancerous portion of intestine has been removed, recurrence is possible especially if the tumor is malignant. Spread of cancer to another location (metastasis) may also occur.

FOR VETERINARIANS - HOW TO DO AN EXPLORATORY AND BIOPSY OF INTERNAL ORGANS

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when the go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as tylenol with codeine, tylenol 3, tylenol 4, morphine) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home a stool softener such as metamucil can be fed
    • Dose of metamucil 1 tsp per 25 Kg mixed in with each meal (canned dog food)

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low fat and should be cooked and any residual fat skimmed off.   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should  be only luke-warm.
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting now that he/she is at home.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the dog usually just opens the mouth and fluid or food will be expelled.  Usually the regurgitant will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be happening the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics or tylenol/codeine are are common cause of vomiting after surgery.  In order to see which medication is causing the problem the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued.  The tylenol/codeine should be discontinued and another type of pain medication tried to help minimize vomiting.
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • Unusual cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves with holding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then.  In order to decrease the acidity of the stomach Pepcid AC 0.5 mg/kg given by mouth twice daily for 5 days can sooth an upset stomach.  Metoclopramide is a good anti-vomiting medication for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, which is called esophagitis.  This results in poor motility of the esophagus so water and food will accumulate in this structure.  In most cases esphagitis is self-eliminating and will resolve within two or three days. 
    • Regurgitation also can be caused by a neuromuscular degeneration of the esophagus and this problem will persist.  It is not associated with surgery, rather other underlying diseases.
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus, does not allow passage of food down the esophagus, thus the pet has persistent regurgitation.  This problem should be brought to the attention of your doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent such as sucralfate.  You should consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic look of the face
    • restlessness and not wanting to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can be done for pain at home for my dog?

  • Pain medication such as tylenol with codeine, butorphanol, Duragesic (fentanyl patch) anti-inflammatories such as Deramaxx, Rimadyl, or Etogesic; in some cases a sedative such as acepromazine will augment the effect of pain medication and allow your pet to sleep
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out and in circular motions (directly on skin) cool the surgical site around the incision.  Cooling the surgical site helps to numb the area

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs as signs can be more subtle and they usually do not vocalize
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs and they should be given only for a few days

Is it okay for my pet to lick the incision?

  • If a dog licks his incision it will actually delay the healing process because they usually lick too much and traumatize the area.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • If the incision is over the chest a tee shirt can be put on your pet and the waist of the shirt fastened in place with an ace bandage or duct tape.
    • If the incision is over the paw or lower limb a bandage or sock could be put on and kept up with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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