Sometimes surgery is like Christmas. Sort of. My first foreign body removal surgery was certainly full of holiday cheer. Not enough eggnog. At 3pm one afternoon, a 1 yr old Shar-Pei plunged down the chimney vomiting a solid profuse amount of blood. 9am presentation with plenty of time to work-up the case, stabilize the patient, and get into surgery? No, it's much more fun to begin at 3pm when the clinic needs to close at 7pm. The Shar-Pei's owner had previously left him alone in the laundry room for the day. The owner returned home to discover a small pile of saliva next to a giant pool of blood and was obviously concerned. After working up the case, the most significant finding centered around the radiographs where I discovered 3 pieces of wire and 1 hair clip located in the stomach and 1 dime in the intestine. I could see these on the x-rays because the objects are radiopaque versus soft tissue in density. After sorting out the finances, the plan was to proceed to emergency abdominal foreign body removal surgery. And I knew how to do this surgery via textbook, but things are always different the first time around out in practice. I was scared out of my mind. These patients can potentially be unpredictable under surgery and locating the foreign bodies is always challenging...like an Easter egg hunt. You only know the radiopaque objects from the radiographs but the amount of soft tissue density objects are nothing short of jaw-dropping surprises sometimes.
So, for the Gastrotomy/Enterotomy/Foreign Body Removal Surgery:
A ventral midline abdominal incision was made with a #10 blade from the xiphoid to the cranial tip of the prepuce. The subcutaneous layer was bluntly dissected. The linea alba was incised to gain entry into the abdomen. The entire abdominal contents were explored before incising into the stomach. The stomach was isolated from the remainder of the abdominal contents with moist gauze pads. Stay sutures were placed to assist in the manipulation of the stomach and to help in prevention of spillage of any gastric contents. A 3 cm gastric incision was made in the hypovascular area of the ventral aspect of the stomach between the greater and lesser curvatures. A stab incision was made into the gastric lumen with a scalpel at a mid-body location away from the pylorus. The incision was enlarged with metzenbaum scissors. Here's the Christmas part: The gastric contents were removed including 3 large hair ties, 3 small hair ties, 1 large sock, 1 animal silly band bracelet, 3 metal trash bag twist ties, 1 metal hair barrette, 1 paper towel, 1 rubber band, 2 plastic sharp pieces from a cell phone, and undigested food. This dog was a vaccum. The stomach was closed with 3-0 PDS in a two layer inverting seromuscular pattern. The serosa, muscularis, and submucosa was included in the first simple continuous pattern layer. A partial thickness Cushing suture pattern was used on top of the first layer that incorporated the serosal and muscularis layers. The stomach was leak-tested with sterile saline with the help of a surgical assistant. The entire intestinal tract was explored for foreign bodies. The transverse colon was exteriorized and isolated from the abdomen in a similar manner to the previous gastrotomy. The intestinal contents were gently milked away from the foreign body to minimize spillage of chyme. Stay sutures were placed. Doyen forceps were not available. Surprise. A full thickness stab incision was made into the antimesenteric border of the transverse colon with a No. 10 scalpel blade distal to the foreign body. A plastic/metal 2 cm piece was removed from the colon. The incision was closed with gentle appositional force in a transverse direction using full thickness simple interrupted sutures, 3-O PDS. Sutures were placed 2-3 mm apart with extraluminal knots. Sterile saline was used to leak test the incision with the help of a surgical assistant. Another foreign body was observed in the descending colon. An enterotomy was again performed in a similar matter removing a dime. Additional simple interrupted sutures were necessary as the leak test did not pass the first time during testing. All gauze sponges were removed from the abdomen and counted. Counting the sponges is an important step not to be overlooked. 1 liter of sterile saline was used to flush the abdomen for diagnostic peritoneal lavage. The linea alba/external rectus sheath was closed in simple interrupted pattern with 0-PDS. The subcutaneous layer was closed using 2-O PDS in a simple continuous pattern. The skin was closed with 2-0 PDS in a subcuticular intradermal pattern. Skin glue was applied over the incision. A convenia injection was used for antibiotic coverage post-opertively as well as iv cefazolin used intra-operatively. Rimadyl was given for post-op pain for 3 days. Post-op care consisted of feeding the patient later that evening to maintain gastric and intestinal function 1/4 the normal amount of food. Return to normal feeding by the next evening. An elizabethen collar was kept on the patient as well as enforcing strict exercise restriction for 10 days. The patient needs to not be left alone in the house unless confined in a room/crate where he does not have access to ingestion of foreign materials. He is a patient that needs to be continually monitored. And upon picking up the patient, the owner confessed that they have had to pull the children's socks from the dog's rectum before. Really? At what point does it become important to pick things up off the floor? I suppose after $1,800.00.
~One gastrotomy, 2 enterotomies, emergency multiple foreign body removal surgery: $1,800.00.
~1st time experience of a foreign body removal at 4pm: a little bit of sweating plus a lot of baptism by fire.
~One much happier, alive dog: priceless.
The family did have to cancel their Christmas holiday ski trip plans thanks to their dog though. Or thanks to their nonchalant behavior. The verdict's still out.
Congratulations for the successful surgery !! Glad that the dog is doing good.
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