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Practical Ultrasound: Recognition of Surgical Disease

Practical Ultrasound: Recognition of Surgical Disease. Lauren E. Sikorski DVM, DACVIM (Internal Medicine) Jeffrey A. Seaman, DVM, MS DACVS (Small Animal) Atlantic Coast Veterinary Specialists. Outline. Pyometra Urinary bladder calculi Splenic masses Intestinal Obstruction Mucoceles.

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Practical Ultrasound: Recognition of Surgical Disease

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  1. Practical Ultrasound: Recognition of Surgical Disease Lauren E. Sikorski DVM, DACVIM (Internal Medicine) Jeffrey A. Seaman, DVM, MS DACVS (Small Animal) Atlantic Coast Veterinary Specialists

  2. Outline • Pyometra • Urinary bladder calculi • Splenic masses • Intestinal Obstruction • Mucoceles

  3. Friday 5 PM

  4. Female Anatomy

  5. Pyometra Thick walled uterus Distended with echogenic material

  6. Pyometra No wall layering = Not small intestine! Difference of echogenicity indicates settling of cells

  7. Pyometra

  8. Key Points • Typical signalment, history and bloodwork findings • Uterus appears enlarged between descending colon and urinary bladder • Thick uterus distended with echogenic material (cells)

  9. Pyometra: Management Options • OVARIOHYSTERECTOMY IS TREATMENT OF CHOICE. • Pre-operative stabilization: Can use “Rule of 20”

  10. Sidebar: Checklist Manifesto! • AtulGawande, MD • Complications: A Surgeon’s Notes on an Imperfect Science • Better: A Surgeon’s Notes on Performance • The Checklist Manifesto: How to Get Things Right

  11. Pyometra: Management Options • OVARIOHYSTERECTOMY IS TREATMENT OF CHOICE. • Pre-operative stabilization: Can use “Rule of 20” • Medical management only considered if: • Draining (“open pyo”) • NOT systemically ill • Breeding potential • “Right owner”

  12. PyometRA • OVH – additional considerations: • Large incision • Delicate tissue handling • Pack off with Lap Pads. • Avoid clamping uterus; don’t oversew “stump” • Larger suture • Mortality Rate: 0-8% • worse with septic peritonitis • Prognosis suggested to be better than other causes of SIRS • 48 hours: Increased WBC, Decreased %Neut • 7d: WBC often normalized.

  13. Stranguria

  14. Urinary Bladder Calculus 2 small hyperechoic structures associated with the ventral wall of the urinary bladder

  15. Urinary Bladder Calculus

  16. Urinary Bladder Calculus

  17. Urinary Bladder Calculus

  18. Which Patient has a Urinary Bladder Calculus?

  19. Key Points • Usually mobile • Dependent portion of the bladder • Spherical with a hyperechoic curvilinear interface • Presence of distal acoustic shadow is variable • Can be confused with sediment

  20. Cystic Calculi – Management Options • Medical • Interventional/Surgical • Catheter-assisted retrieval • Voiding hydropropulsion • Cystoscopy/Lithotripsy • Laparoscopically Assisted • Cystotomy

  21. Cystic Calculi: Cystotomy • Pre-operative evaluation/stabilization • Draping • Should provide access to external genitalia for intra-op catheterization. • Ventral midline celiotomy • Skin and SQ curves parapreputial in males • Start with caudal celiotomy unless needs further exploration • Ventral cystotomy • pack off abdomen • stay sutures • avoid exteriorization

  22. Cystic Calculi: Cystotomy • Culture mucosa and crushed stone • Stone analysis • Catheterize, preferably retrograde. • Closure • various options for pattern – submucosa is critical holding layer! • 2 layer continuous Inverting for normal bladder • 1 layer interrupted for chronic cystitis • suture material • monofilament • type – consider microbiologic environment • poliglecaprone 25 (Monocryl) • polydioxanone (PDS) • polyglyconate (Maxon) • POST-OP RADS ARE MANDATORY!

  23. Splenic Disease

  24. Normal Canine Spleen

  25. Nodular hyperplasia

  26. Hemangiosarcoma 0.6 cm, Ill-defined mass of mixed echogenicity replacing most of the normal parenchyma

  27. Splenic Lymphoma Diffuse, small hypoechoic nodules; spotted echotexture

  28. Splenic Lymphoma Solitary, irregular hypoechoic nodule

  29. Key Points • Variable appearance • Hematomas and nodular hyperplasia can mimic hemangiosarcoma • Indolent splenic lymphoma has a good prognosis for long term survival

  30. SplenicNeoplasia • Statistics: • Dogs • 33-66% neoplastic • May be skewed higher with concurrent hemoabdomen (~80%) • ~60-90% of neoplastic are hemangiosarcoma • Prognosis (surgery alone) • Old studies 19-65d • Newer studies 14-470d • Cats • 37-73% neoplastic • lymphosarcoma and mast cell are most common

  31. Splenectomy: Considerations • Considerations: • Incidental Mass vs. Hemoabdomen in crisis • OR Equipment: electrocautery, suction, Ligasure, LDStapler, Carmalts • Facilities: pRBCs, availability of critical care monitoring etc. • Technical Considerations: • Always complete splenectomy (never partial) • Always perform liver biopsy (guillotine or biopsy punch) • Assess pancreas, portal vein • Monitor for VPCs during and after • Monitor for DIC Other Considerations: Infection Oxygen Transport

  32. The Yellow Dog

  33. The Yellow Dog

  34. Gallbladder Mucocele Hypoechoic mucus displaces the echogenic biliary sludge centrally

  35. Gallbladder Mucocele Complete gallbladder mucocele. Gallbladder is distended. Hyperechoic striations radiating toward its center. Central hyperechoic region. Surrounding fat is hyperechoic = rupture.

  36. Gallbladder Mucocele Triagular shape of hypoechoic foci = Stellate pattern AKA Kiwifruit pattern

  37. Gallbladder Mucocele

  38. Gallbladder Mucocele

  39. Gallbladder Mucocele • Mucus accumulation leads to overdistension, necrosis and rupture • Hypoechoic mucus borders gallbladder wall • Mucus centrally displaces echogenic billiary sludge • Stellate pattern forms initially • Followed by immobile hyperechoic radiating striations

  40. Gallbladder mucocele • In general, a surgical disease • Surgical timing is controversial. • Higher M&M with EHBDO and/or bile peritonitis • Prognosis: • Reportedperioperative mortality is ~22-32%. • In my opinion and personal experience this is lower in relatively healthy patients. • Long term survival is very good for those that survive the perioperative period.

  41. Intestinal Obstruction

  42. Cloth in a Cat Bright interface associated with a strong acoustic shadow is suggestive

  43. Dog Toy Must be sure to differentiate FB from colon

  44. Which one is the Foreign Body?

  45. Key Points • Dilated, fluid-filled small intestinal loops oral to obstruction • Bright interface associated with strong acoustic shadowing • Sudden decrease in bowel diameter distal to obstruction • Hyperechoic mesentery, free fluid or free gas • Do not confuse with feces in colon

  46. Intestinal obstruction • Emergency vs. Scheduled • Pack off abdomen well, Clean vs. dirty field, Flushing options, Re-glove and reinstrument • Antimesenteric longitudinal incision: Human “doyens”, Doyens, bobby pins • Subjective evaluation: Color, pinch, palpate • Trim redundant mucosa, 4-0 pds s/c • Linear (cut pyloric anchor first) • R & A: Start at mesenteric side, 4 quadrant s/c • Leak & Poke test • Omentopexy

  47. QUESTIONS?

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