InTown Veterinary Group
Massachusetts Veterinary Referral Hospital
Volume 8, Issue 2
Spring 2007
Becoming One with the Abdomen
InTown Veterinary
Group is dedicated to
providing referring
veterinarians and their
clients with an
unparalleled range of
emergency & specialty
services.
Mass Vet provides 24hour
emergency/critical
care, internal medicine,
neurology, oncology,
ophthalmology,
radiology, surgery, &
physical therapy &
rehabilitation at our
26,000 sq. ft. facility in
Woburn,
Massachusetts.
Please do not hesitate
to call if you have any
questions regarding
our services.
Mass Vet is located at
20 Cabot Road
Woburn, MA 01801
T: (781) 932-5802
F: (781) 932-5837
www.InTownMassVet.com
Karen F. Pastor, DVM, DACVS
Diplomate of the American College of
Veterinary Surgeons, Dr. Pastor practices at
Massachusetts Veterinary Referral Hospital
An abdominal exploratory is one of the most common surgeries a veterinarian performs,
as it allows for detection of a significant number of diseases. In performing an abdominal
exploratory, be prepared for both positive and negative outcomes or disease processes.
It is important to perform a thorough abdominal exploratory so as not to miss subtle
abnormalities or symptoms of disease. A systematic approach to the abdomen is
imperative. If one performs all abdominal exploratories in a consistent manner, one will
become proficient and more comfortable in detecting abnormalities.
Abdominal Exploratory Surgery:
To begin, clip and prep the entire abdomen including the caudal thorax and inguinal
areas. The incision should be made from the xyphoid to the pubic bone to adequately
visualize all abdominal structures. A common mistake is to create a small incision. A
small incision limits your visualization and may limit your ability to perform an
unexpected procedure. Remember that an incision heals side to side. A 12-inch incision
will heal in the same time as a 1-inch incision. Stand on the same side of the animal.
Most surgeons stand on the right side. This allows one to learn the anatomy and
geography of the abdomen. It becomes second nature. You can change sides at times
for specific procedures (e.g. left adrenalectomy). Remove the falciform fat if it interferes
with visualization (ligate the cranial end). Evaluate all organs in a consistent manner.
Work cranially to caudally. Use moistened laparotomy sponges. Count all laparatotomy
sponges at the start of the surgery, and repeat this process at the end of the procedure.
Organs to be evaluated are the diaphragm, body wall, liver, gall bladder, biliary tree,
stomach, pancreas, small and large intestines, lymph nodes, spleen, kidneys, adrenal
glands, bladder, ureter, and prostate or ovaries/uterus.
Diaphragm:
Inspect the diaphragm for nodules or defects (hernias). Inspect the esophageal hiatus,
caval foramen, and aortic hiatus. Be thorough especially in trauma patients (small
defects can be very dorsal and there can be more than one tear).
Liver:
Know your anatomy. Inspect all six lobes. The liver normally has sharp edges. The edges
are more rounded in young animals and in those infiltrated
with disease. The liver is the organ most commonly
infiltrated with metastatic disease. A liver biopsy is a simple
procedure. It is indicated in all patients with suspect hepatic
disease (even if an incidental finding), with suspect
neoplasia and a negative abdominal exploratory. Biopsy
techniques include the guillotine method, punch biopsy,
partial lobectomy, or complete lobectomy. The guillotine
method is the easiest and most commonly done (fig. 1). A
Fig. 1. Guillotine method biopsy
punch biopsy may be performed on a specific lesion. A
partial lobectomy is indicated where there is focal
disease involving one lobe. A complete lobectomy is
indicated with extensive disease involving one
lobe. Both procedures may be carried out with
a stapling device, finger fracture and individual
ligation.
biopsy is in obtaining a full thickness biopsy. A single
layer closure is sufficient (simple interrupted or
continuous). A mesenteric lymph node biopsy is also
easy to perform. A lymph node biopsy is
indicated in all patients with suspect
neoplasia, with enlarged or abnormal
lymph nodes, and with a negative
exploratory.
Gall bladder
Large intestine
The extrahepatic biliary system includes the
Run the cecum to the descending colon.
gallbladder, cystic duct, hepatic ducts and Fig. 2. Small intestine biopsy
Palpate as much of the large intestines as
common bile duct. The common bile duct
you can, particularly where it enters into the pelvic canal.
empties into the major duodenal papilla. The
Evaluate all vasculature and lymph nodes. Colonic
gallbladder is located between the right medial and
healing is similar to that of the small intestines but is
quadrate lobes. Express the gallbladder to ensure the
delayed. Wound tensile strength lags behind return of
biliary tree is patent.
strength in the small intestines and dehiscence is more
Stomach
likely. Optimum healing depends on a good blood
Palpate all areas of the stomach for foreign bodies, supply, accurate mucosal apposition, minimal surgical
masses, and/or thickening. Palpate the pylorus in every trauma and tension free closure. Healing is delayed in
animal to determine normalcy. This will allow you to the colon because collateral circulation is poor
notice subtle hypertrophy or masses. The gastric mucosa compared to the small intestines; there are more
is easily separated from the seromuscular layer. Inspect anaerobic bacteria vs. aerobes, and intraluminal
the serosal surface for color and texture. Do not use pressure is high. This mechanical stress on the suture line
mucosal color to predict gastric viability. The mucosa is may lead to dehiscence. The risk of dehiscence is highest
commonly black in dogs with GDV. Gastric biopsy is an on day 3-4 because the collagen lysis exceeds synthesis.
easy procedure to perform. Indications for a gastric Due to this higher rate of dehiscence, a colonic biopsy is
biopsy are all patients with suspect gastric disease, with not always performed. Indications for a colonic biopsy
lesion/abnormality and with a negative exploratory. A are in all patients with suspect colonic disease and with
gastric biopsy is performed at the same site as a specific lesion/abnormality.
gastrotomy between the greater and lesser curvature. If
Pancreas
there is a focal lesion, perform a full thickness biopsy of
Palpate the pancreas gently to avoid iatrogenic
the specific lesion. A gastrectomy can be performed for
pancreatitis. Visualize the right lobe by lifting the
masses, thickness or a compromised area of the stomach
descending duodenum. Visualize the left lobe of
(in a GDV). Always perform a two-layer closure.
pancreas by looking in the deep leaf of the greater
Small Intestines
omentum while retracting the stomach cranially (or
Run the bowel from the pylorus to the cecum. Palpate lifting the spleen) and transverse colon caudally.
for foreign bodies, masses or thickening. Evaluate the Evaluate the pancreas for color and masses. A normal
integrity of the tissue as well as the mesenteric pancreas is white or pale pink. Regular inspection of the
vasculature and lymph nodes. The duodenal-colic pancreas is imperative for normal pancreas recognition.
ligament can be transected to allow more visualization The proximity and shared blood supply, of the right limb
of the duodenal flexure. To assess tissue integrity assess of the pancreas and the descending duodenum make
intestinal color, wall texture, peristalsis and pulsation of duodenal resection very difficult. The splenic artery is
arteries. Trim the edge to evaluate for active bleeding. the main blood supply to the left limb. The accessory
Other ways to assess tissue integrity include doppler pancreatic duct opens into the minor papilla. The
ultrasonic
flow
probes,
pulse
oximetry, pancreatic duct is the largest, and often the only duct in
electromyography,
radioactive
microspheres, cats. Pancreatitis is the most common cause of
microtemperature probes and pH measurements. The extrahepatic biliary obstruction because the swelling
latter are expensive and impractical. A small intestinal impinges on the common bile duct as it enters the major
biopsy is an easy procedure (fig. 2). A small intestinal duodenal papilla. The majority of abdominal
biopsy should be performed in all patients with suspect exploratories do not require a pancreatic biopsy.
intestinal disease, with specific lesion/abnormality, and Indications for a pancreatic biopsy are all patients with
with a negative exploratory. The advantage of a surgical pancreatic disease and with specific lesion/abnormality.
20 Cabot Road, Woburn, MA 01801
www.InTownMassVet.com
A pancreatic biopsy is best accomplished by suture
fracture technique or use of hemaclips. Culture the
sample as well if you suspect a pancreatic abscess. The
most common complication of pancreatic surgery is
pancreatitis.
Spleen
The spleen is normally red in color. It may have siderotic
plaques (deposits of iron and calcium) or fibrin deposits.
The short gastric vessels are often torn with GDV
patients causing compromise to the splenic vasculature.
Total splenectomy is a common surgery performed for
neoplasia, torsion, severe trauma, GDV, and immune
mediated disease. Complications of a splenectomy
include
hemorrhage,
abscessation,
traumatic
pancreatitis, gastric fistulation, cardiac arrythmias and
sepsis in immunocompromised patients.
Kidney
Visualize the right kidney by elevating the duodenum
and displacing the intestines to the left (fig. 3a). Visualize
the left kidney by elevating the mesocolon and
Fig. 3a - Visualizing the right
kidney
Fig 3b - Visualizing the left
kidney
descending colon, and retracting to the right (fig 3b).
Examine for size, masses and disease. A renal biopsy is
indicated only if you suspect renal disease, neoplasia or
if any abnormalities are noted. A wedge biopsy is most
commonly performed.
Adrenal Glands
Located at cranial pole of kidneys. Visualize right and left
adrenals at time of inspection of kidneys. The right
adrenal gland often sits under the caudate liver lobe and
is intimately associated with the vena cava. It may be
difficult to visualize, always palpate the glands.
Adrenalectomy is most commonly performed for
neoplasia. Most common tumors are adenoma,
adenocarcinoma and pheochromocytoma.
Ovary/Uterus
Not usually present. If present, or evidence of disease is
noted, treatment is always ovariohysterectomy.
20 Cabot Road, Woburn, MA 01801
Bladder
Palpate the bladder for masses, calculi and ectopic
ureters. Cystotomy is the most common bladder surgery.
Indications for cystotomy are cystic and urethral calculi,
neoplasia and diagnosis/repair of ectopic ureters.
Ventral cystotomy is preferred because it avoids the
ureters and allows easier access to ureters for
catheterization. The goal of closure is a watertight seal
that will not promote calculi formation; use a single or
double-layer closure with absorbable sutures which do
not penetrate the bladder mucosa.
Urethra
Palpate as far as you can into the pelvic cavity for calculi
and masses.
Prostate
Examine for size, neoplasia, cysts and abscess. Incisional
biopsy is only indicated if you suspect prostatic disease.
Abdominal Wall
Palpate and inspect entire abdominal wall for hernias,
tears, trauma and masses (including metastatic disease).
Repair or biopsy as indicated
Abdominal Wall Closure
Thoroughly lavage abdomen with
sterile saline and remove all lavage fluid
and blood. Inspect abdominal cavity for
hemorrhage,
foreign
material,
instruments and sponges. Perform the
fig. 4 - Linea Alba
second sponge count and compare
with preoperative count. Linea alba is the holding layer
(fig. 4). Simple interrupted or continuous suture pattern
is recommended. Inspect linea incision after suturing for
any defects (especially at the most cranial and caudal
aspects of incision).
Negative Abdominal Exploratory
A negative exploratory is determined after inspecting all
organs in a systematic way and finding no gross disease.
Despite a negative finding, it is always imperative to
perform biopsies of the liver, stomach, duodenum,
jejunum, ileum and lymph node.
Pearls of Wisdom
Evaluate all organs/structures in the abdomen
(regardless of disease). There can be more than one
disease process. Always biopsy if no gross disease is
found. Do not assume metastatic disease if nodules are
seen in the liver or spleen, nodular hyperplasia is very
common in older pets. Develop your own method, but
be consistent every time. You will become proficient and
subtle abnormalities will become more apparent with
time and practice. Most importantly: be ready for
anything, nothing is as it appears.
www.InTownMassVet.com
Notes :
Details on upcoming seminars as part of our continuing education series for veterinarians can be found on our
website at www.intownvet.com/intown/seminars.html
Upcoming Veterinarian CE Lecture:
Tues. April 10, 2007 at 7:00pm at Mass Vet
Becoming One with the Abdomen, presented by Karen F. Pastor, DVM, DACVS
Tues. May 29, 2007 at 7:00pm at Mass Vet
Uncommon or Atypical Feline Endocrine Disease, presented by Karen L. Campbell, DVM, DACVIM
Upcoming Technician CE Lecture:
Wed. May 2, 2007 at 7:00pm at Mass Vet Referral Hospital in Woburn
Thurs. May 3, 2007, at 7:00pm at Bulger Animal Hospital in N. Andover
Animal Handling and Restraint - Working with Anxious Patients, presented by Erin Spencer, CVT.
Please note: there is always a $50 fee to attend Veterinary Techncian CE lectures.
For more information, or to sign up, please contact Betsy Hensley, CVT at [email protected],
or call: (978)651-2278
Physical Therapy & Rehabilitation services are now available 6 days a week at Mass Vet. If you have any questions about
any of our services or offerings, please give us a call or check out our website:
www.InTownMassVet.com
247 Chickering Road, N. Andover, MA 01845
PRSRT STD
U.S. POSTAGE
PAID
ANDOVER, MA
PERMIT NO. 58
InTown Veterinary Group
Massachusetts Veterinary Referral Hospital
Announcement
New Ophthalmologist
Referring Veterinarians,
We are very pleased to announce that Massachusetts Veterinary Referral Hospital will be
adding a full time ophthalmologist to our staff in May. We are excited to welcome Nancy B.
Cottrill, DVM, MS, DACVO to our accomplished group of highly trained veterinary
professionals. Prior to joining us at Mass Vet, Nancy had been in private practice in both
Louisiana and Western Massachusetts for 18 years.
Nancy Cottrill,
DVM, MS, DACVO
With the arrival of Dr. Cottrill we will be able to offer ophthalmology services at Mass Vet
Monday through Friday. Dr. Ruth Marrion, Dr. Nancy Cottrill and our staff will work together
to ensure a smooth transition so that your clients and their pets will continue to receive the
best care possible. After a short overlap period, Dr. Marrion will be able to offer
ophthalmology services at Essex County Veterinary Specialists in North Andover Monday
through Thursday. www.InTownEssexSpecialists.com.
Dr. Cottrill obtained her BS from Michigan State University in 1981. In 1983 she acquired her
DVM. In 1986 Dr. Cottrill completed her residency at Louisiana State University and attained
a Masters of Science in Veterinary Anatomy and Fine Structure in 1987. She became board
certified in 1989. Dr. Cottrill was practice owner and manager of Animal Eye Clinic, Metairie
in New Orleans, LA from 1988 - 1999. In 1999 she became staff ophthalmologist at Angell
Animal Medical Center in Springfield, MA.
Ruth Marrion,
DVM, DACVO, PhD
Mass Vet is located at
20 Cabot Road
Woburn, MA 01801
T: (781) 932-5802
F: (781) 932-5837
www.InTownMassVet.com
Dr. Marrion obtained a BS from Penn State University, following which she spent several
years in biomedical research. She graduated from the University of Missouri with a DVM in
1991, and spent one year as a small animal intern at Angell Memorial Animal Hospital in
Boston, MA. Dr. Marrion then returned to the University of Missouri as an ophthalmology
resident. She finished her residency and became board certified in 1997. Concurrently with
her residency she received a Ph.D in infectious diseases of the eye from the University of
Missouri.
We are very excited about the addition of another full time ophthalmologist to the InTown
Veterinary Group staff, and thus the ability to better serve your clients.
Please feel free to call with any questions you may have regarding our service offerings, new
doctors and services. We are always happy to discuss your concerns.
Sincerely,
Timothy H. Smith, DVM, DABVP
Regional Medical Director
20 Cabot Road, Woburn, MA 01801
Phone: (781) 305-2240
www.InTownMassVet.com
Q
Q
Fax: (781) 932-5837
InTown Veterinary Group
Massachusetts Veterinary Referral Hospital
Announcement
CT Scan coming to Mass Vet
Referring Veterinarians,
The Radiology department at Massachusetts Veterinary Referral Hospital has expanded
service offerings significantly in recent months. As you are aware, Tonya Tromblee, DVM, MS,
DACVR already provides a comprehensive range of digital imaging services to your clients on
an inpatient basis, including extracardiac thoracic and abdominal ultrasound, ultra-sound
guided fine needle aspirates and biopsies, and radiographic contrast studies. In February
2007, we were excited to be able to increase the range of offerings to include outpatient
ultrasounds to non-critical patients.
Tonya C. Tromblee,
DVM, MS, DACVR
Mass Vet is located at
20 Cabot Road
Woburn, MA 01801
T: (781) 932-5802
F: (781) 932-5837
www.InTownMassVet.com
In April 2007 our new Computed Tomography (CT) Scanner will further expand service
options available to your clients at Mass Vet.
CT is an established and important diagnostic tool in veterinary medicine and is a useful
alternative to conventional radiography or MRI. X-ray images are obtained 360 degrees
around the patient in thin slices, which results in high resolution images. These can be
displayed in multiple planes, optimizing visualization of lesions and anatomic relationships.
This allows doctors to assess extent and severity of disease and helps to facilitate biopsy,
surgical planning, or radiation therapy. Newer, high speed helical CT scanners have
advanced technology with faster acquisition times allowing studies to be completed within
seconds or minutes, thereby minimizing motion artifacts and significantly reducing
anesthesia time.
Compared to conventional radiography, CT has superior contrast resolution and provides
excellent detail of bone and soft tissues.
CT is more sensitive for bone lysis and is instrumental for early detection of aggressive
nasal or bone disease.
CT is particularly useful for evaluating complex structures such as the skull, nasal cavity
and paranasal sinuses, middle ear, spine and pelvis that are often obscured in radiographs.
Likewise, CT is useful for evaluation of complex joints such as the elbow or tarsus for
developmental disease or fractures.
In addition to neuroimaging, CT is routinely used for characterizing pulmonary disease,
detection of metastases, and evaluation of mediastinal, cervical, or abdominal masses that
encroach on vital vascular or neural structures.
Intravenous contrast can also be administered to evaluate hepatic or splenic lesions,
portosystemic shunts, and ectopic ureters that may not be clearly defined with ultrasound
examination.
We are always pleased to discuss any questions you may have regarding developments,
services and new doctors at Mass Vet. Please feel free to call if we can answer any questions.
Best Wishes,
Timothy H. Smith, DVM, DABVP
Regional Medical Director
20 Cabot Road, Woburn, MA 01801
Phone: (781) 305-2240
www.InTownMassVet.com
Fax: (781) 932-5837