Two Techniques of Intestinal Wall Suture in Surgical Treatment of Ileus in Dogs and the Importance of Omentalisation

Crha M., J. Lorenzová, L. Urbanová, T. Fichtel, A. Nečas: Two Techniques of Intestinal Wall Suture in Surgical Treatment of Ileus in Dogs and the Importance of Omentalisation. Acta Vet. Brno 2008, 77: 263-267. Model experimental studies focused on the intestinal suture techniques in relation to healing, postoperative narrowing of the intestinal lumen or adhesion formation can not comprise a number of clinical factors (foreign body presence in the intestine, haematological abnormalities, septic peritonitis, different age of patients, etc.) that under clinical practice conditions may have an effect on the healing of the intestinal suture. The aim of this clinical study was to confirm in a group of dogs surgically treated for small bowel obstruction, whether different techniques of its wall suture may affect the frequency of possible dehiscence occurrence. This study compares two different techniques of intestinal wall suture in relation to postoperative dehiscence of the intestinal wall closure. Based on the clinical observation with regard to the risk of postoperative dehiscence and possible complications in form of adhesions, also the importance of omentalisation in the suture of small bowel was evaluated. No significant difference was demonstrated (p > 0.05) in the frequency of postoperative dehiscence at the site of the intestinal wall closure between the two-layer inverting and singlelayer appositional techniques of suture. Likewise, no significant difference was demonstrated (p > 0.05) in the frequency of dehiscence of intestinal wall suture between patients that underwent intestinal suture omentalisation and those whose intestinal wall suture was not complemented with omentalisation. Based on the results of this clinical study it may be stated that both manual single-layer approximation technique and two-layer inverting technique of the intestinal wall suture are equally safe from the viewpoint of possible dehiscence, and it depends on the surgeon’s preference, which one of the said techniques he or she chooses. Concurrently it may be assumed that an exactly performed suture of the intestinal wall does not necessarily require omentalisation. Intestine, obstruction, dehiscence Several experimental studies may be found in literature, dealing with individual techniques of intestinal suture in relation to healing, postoperative narrowing of the intestinal lumen or adhesion formation (Bennett and Zydeck 1970; Ellison et al. 1982; Bone et al. 1983). For this purpose, mainly approximation, inverting, or everting sutures were studied. These studies were done under experimental conditions, which exclude the effects of a number of clinical factors (e.g. presence of a foreign body in the bowel, haematological abnormalities, septic peritonitis, different age of patients, etc.) on the healing of the intestinal wall closure. We therefore decided to determine under conditions of clinical practice, whether different techniques of the intestinal wall suture may affect the frequency of occurrence of intestinal anastomotic dehiscence. Omentalisation and “serous patch” are surgical techniques that aim to form a permanent adhesion, either between the omentum and the intestine in the case of omentalisation; or in the case of the “serous patch”, between two serous surfaces of neighbouring bowel loops (Hedlund 2002; Brown 2003). The purpose of these techniques is to decrease the risk of dehiscence and leakage of the bowel content in the ACTA VET. BRNO 2008, 77: 263-267; doi:10.2754/avb200877020263 Address for correspondence: MVDr. Michal Crha, Ph.D. Department of Surgery and Orthopaedics Small Animal Clinic Faculty of Veterinary Medicine University of Veterinary and Pharmaceutical Sciences Brno Palackeho 1-3, 612 42 Brno, Czech Republic Phone: +420 541 562 362 E-mail: [email protected] http://www.vfu.cz/acta-vet/actavet.htm intestinal wall suture in cases with uncertain prognosis. The serous patch may be also used for the purpose of decreasing the number of recurrences of intussusception (Brown 2003). Omentalisation positively influences intestinal healing, as the omentum provides blood supply and lymphatic drainage, and by formation of fibrinous adhesions to the surgical incision it prevents the leakage of the bowel content from the intestinal lumen into the abdominal cavity (McLachlin and Denton 1973; Ellison 1989). The omentum also plays an important immune and haemostatic role, and due to its characteristics it is likened to “abdominal police”. Apart from abdominal surgery, the omentum has a wide use also in thoracic, urogenital, or vascular surgery and techniques of its use are even described for the treatment of poorly healing skin wounds (Smith et al. 1995; Bray et al. 1997; Birchard et al. 1998). For the purpose of the protective function of the omentum in the intestinal wall healing, some authors recommend omentalisation of the suture immediately after performing intestinal anastomosis (Hedlund 2002; Kirby 2003). The aim of this clinical study was to 1) compare the results of surgical treatment while using the manually sutured singlelayer approximation technique and the two-layer inverting technique in the intestinal wall suture in dogs (enterotomy and enterectomy), 2) determine the clinical importance of omentalisation in surgical interventions in the small intestine in dogs with regard to the occurrence of postoperative complications in form of the leakage of the bowel content into the abdominal cavity or the occurrence of complications resulting from the adhesions of serous organs in the abdominal cavity. Materials and Methods The clinical study included 52 patients treated for small bowel ileus, of a total number of 10,776 patients treated at the Department of Surgery and Orthopaedics of the Small Animal Clinic at the University of Veterinary and Pharmaceutical Sciences Brno in the period from January 2003 to December 2005. All patients underwent preoperative clinical examination, haematological and biochemical examination of blood samples, as well as radiological and ultrasonographic examination of the abdominal cavity organs. In the framework of surgical treatment, the type of the suture used was recorded, and whether it was, or conversely, was not omentalised (Plate IV, Fig. 1). The intestinal suture was hand-sewn, by single-layer appositional technique using individual Gambee sutures (Plate IV, Fig. 2), or by two-layer inverting technique (simple continuing suture on the mucosa and submucosa in the first layer; Cushing suture on the seromuscular layer of the intestine in the second layer). In all cases of anastomosis, monofilament suture material polyglecapron 25 (Monocryl) was used. We also compared frequencies of dehiscence of the surgical wound of the intestine in relation to the intestinal wall suture techniques used, without regard to the surgical intervention performed (enterotomy or enterectomy). The patient was clinically monitored during hospitalisation, and then on days 10 to 14 after surgery during a follow-up connected with the extraction of skin sutures from the laparotomy incision. Monitoring of postoperative complications focused on the occurrence of apathy, loss of appetite, diarrhoea, vomiting and the occurrence of postoperative peritonitis resulting from the leakage of the bowel content into the peritoneal cavity. Long-term postoperative monitoring of these patients focused on weight loss, signs of pain in the abdominal cavity, vomiting or diarrhoea. Results were recorded on the basis of clinical examination or a phone consultation with the owner, minimally 6 months after the surgical intervention. For statistical evaluation of the qualitative indicators in groups of patients χ2‐test was used; for comparison of files of a small number of data Fisher’s exact test was used (Göpfertová et al. 1999). All data were statistically evaluated and mutually compared using the programme Microsoft Excel 2002, SPSS 11.0.0., or SISA (Göpfertová et al. 1999).