TECHNIQUE

Enterotomy in Rabbits (Disease Investigation & Management - Treatment and Care)

Summary Information
Type of technique Health & Management / Disease Investigation & Management / Techniques:
Synonyms and Keywords --
Description
Pre-operative
  • Stabilise the rabbit's condition if possible: (B601.17.w17)
    • Give intravenous fluids. (B601.17.w17)
    • Provide analgesia. (B601.17.w17)
  • Use abdominal radiography and ultrasonography to confirm the presence of an intestinal foreign body. (B601.17.w17)
Surgical preparation
  • Anaesthetise the rabbit.
  • Place the rabbit in dorsal recumbency.
    • On a circulating water blanket. (B602.22.w22)
  • Clip and scrub the rabbit's abdomen from the inguinal to midthoracic area for laparotomy. (B602.22.w22)
  • Place an intravenous catheter into a cephalic or lateral saphenous vein. (B602.22.w22)
Abdominal incision
  • Make a midline incision through the skin from just caudal to the xiphoid down to the pubis (or from the umbilicus to the pubis). (B601.17.w17)
  • Incise the thin subcutaneous tissue to expose the linea alba. (B601.17.w17)
  • Isolate the linea alba and use fine toothed thumb forceps to tent it away from the abdominal viscera. (B601.17.w17)
  • Using an inverted number 10 or number 15 scalpel blade (cutting edge of the blade directed upwards), make a stab incision through the linea alba, parallel to the linea alba. (B601.17.w17)
    • Care is required to avoid damaging the caecum, which has a thin wall, is usually distended with ingesta, and lies directly under the abdominal wall. (B601.17.w17, B602.22.w22)
  • Place a small thumb forceps into the abdomen and directed parallel to the linea alba; use this to lift the linea alba away from the underlying viscera. (B601.17.w17)
  • Using a scalpel, cut cranially and caudally along the linea alba between the jaws of the forceps.(B601.17.w17)
    • Or use blunt-topped fine tissue cutting scissors, with one blade inserted into the abdomen parallel to the linea alba and used to lift the abdominal wall away from the viscera while cutting cranially and caudally. (B601.17.w17)
  • Note: the incision should be long enough to allow exploration of the whole gastrointestinal tract.
  • Place laparotomy pads, moistened with saline, along the incision line on both sides and use a retractor (e.g. a Lonestar Veterinary Retractor or Balfour retractor) to give better exposure of the abdomen. (B601.17.w17, B602.22.w22)
Abdominal exploration
  • Palpate the entire gastrointestinal tract from the distal oesophagus to the descending colon.
Enterotomy
  • Note: handle the bowel gently to avoid development of postoperative ileus and shock. (B602.22.w22)
  • Identify the intestinal area of interest. (B600.10.w10, B601.17.w17)
    • With an intestinal obstruction, follow along the small intestine until the point where it changes from distended and fluid-filled to flat and empty. (J29.16.w3)
  • Check the intestinal tissue for signs of devitalization, or abnormalities which may have increased the risk of obstruction. (J29.16.w3)
  • Isolate the bowel section - exteriorise the section and use sterile absorbent material to protect the surrounding tissues - surround the exteriorised section with moistened laparotomy sponges. (B600.10.w10)
  • "Milk" the intestinal contents away from the obstruction. (B600.10.w10)
  • Place atraumatic forceps or bowel clamps, or have an assistant place their fingers to prevent ingesta contaminating the surgical field.
  • Make an incision longitudinally in the intestine, along the opposite edge from the mesenteric attachment.
    • Ideally, incise healthy bowel caudal to the foreign body (i.e. not in possibly devitalised tissue).
    • Or incise at the junction of the foreign body and normal intestine.
  • Manoeuvre the foreign body to the incision and remove it.
    • Note: on occasion, with a linear foreign body (which may be accompanied by plication of the bowel or intussusception), several enterotomy sites may be needed. (B602.22.w22)
  • Trim off any everted mucosa. (B600.10.w10)
  • For foreign bodies at the fusi coli:
    • If possible, avoid enterotomy by massaging the offending material (usually hard faeces or caecoliths) past this point and into the descending colon. (B602.22.w22)
  • Closing small intestine
    • Use a simple interrupted pattern and synthetic absorbable monofilament suture material.
    • Use a fine, strong, inert, absorbable monofilament material (e.g. 4/0 or 5/0 (1.5 or 1 metric) poliglecaprone (Monocryl) or polydioxanone (PDS II, Ethicon). (B600.10.w10, J29.16.w3)
    • Use a single layer of appositional sutures, ensuring they include the submucosa and minimising reduction in intestinal diameter. (B600.10.w10, J29.16.w3)
    • Place sutures in the submucosa if identifiable, otherwise full-thickness.
    • Either close the longitudinal incision longitudinally.
    • Or close the longitudinal incision transversely to avoid reducing the intestinal luminal diameter. (B601.17.w17, B602.22.w22)
    • Wrap omentum around the incision site; if necessary, tack this to the serosa to ensure it stays in place. (B601.17.w17)
  • Closing descending colon
    • Close the longitudinal incision transversely to avoid reducing the intestinal luminal diameter. (B602.22.w22)
    • Use interrupted sutures and an appositional or crushing technique. (B602.22.w22)
  • Closing the caecum
    • Use a double-layer inverting technique.
    • Use fine synthetic absorbable suture material (0.3 - 0.7 metric, 6/0 - 7/0 USP) on a small atraumatic needle. (B601.17.w17) Use 4-0 to 6-0 (1.5 - 0.7 metric) absorbable synthetic monofilament. (B602.22.w22)
      • If the needle is too large, caecal contents will leak through the needle holes.
    • Use a simple continuous suture in the first layer. (B601.17.w17)
    • Oversew with an inverting suture. (B601.17.w17)
    • Place sutures every 2 - 3 mm. (B602.22.w22)
    • Omentum can be included in the incision line. (B602.22.w22)
    • Or Wrap omentum around the incision site; if necessary, tack this to the serosa to ensure it stays in place. (B601.17.w17)
Intestinal resection and anastomosis
  • If an area of duodenum/intestine is necrotic, this must be resected. (B600.10.w10, B602.16.w16)
    • Section at an angle to preserve vascularity. (B600.10.w10)
    • Anastomose end-to-end, ensuring a good seal to minimise the risk of leakage of intestinal contents. (B600.10.w10)
  • Examine the bowel and confirm the area to be removed. This includes the diseased area plus a few cm to either side. (B601.17.w17)
  • Double-ligate and transect mesenteric vessels to the selected area of intestine.
  • Massage the intestine to move ingesta cranially and caudally away from the incision site.
  • Use atraumatic clamps or an assistant's fingers to keep ingesta from the surgical site.
  • Place straight haemostats on the intestine at an acute angle so that the mesenteric side of the remaining bowel is longer than the anti-mesenteric side (i.e. the mesenteric side of the removed piece of bowel is shorter than the antimesenteric side).
    • This increases the luminal diameter and assists in ensuring an adequate blood supply to the antimesenteric aspect.
  • Incise the intestine at an acute angle so that the mesenteric side is longer than the anti-mesenteric side. (B602.22.w22)
  • Anastomose the intestine
    • Use a fine 4-0 to 6-0 synthetic monofilament suture material. (B602.22.w22) 0.3 - 0.7 metric, i.e. 6/0 to 7/0 USP with a small needle. (B601.17.w17)
    • Use an appositional closure. (B602.22.w22)
    • Place sutures through the submucosa (holding layer) if this is identifiable, otherwise place the sutures full-thickness. (B601.17.w17)
    • Either: Initially pre-place three sutures on the mesenteric side. Tie these three sutures, then place simple interrupted sutures around the anastomosis site. (B601.17.w17)
    • Or: Initially place one suture at the mesenteric border and a second at the antimesenteric border. Then approximate the circumference of the intestinal wall on one side and place sutures on that side, 3-4 mm apart, equally spaced to ensure gentle apposition, then turn the intestine over and repeat on the other side. (J495.32.w4)
    • Close the defect in the omentum using a fine monofilament absorbable suture material in a continuous suture pattern. (B601.17.w17)
      • or simple interrupted sutures. (J495.32.w4)
Abdominal closure
  • If the abdomen has been contaminated with intestinal contents irrigate the abdomen with warm saline and apply suction; repeat several times. (B602.22.w22)
    • Take samples for aerobic and anaerobic culture and sensitivity. (B602.22.w22)
  • Close the linea alba in a simple continuous or interrupted pattern. (B601.17.w17)
    • Use a synthetic monofilament absorbable suture material. (B601.17.w17)
  • If there is enough subcutaneous tissue available, close this in a simple continuous suture pattern. (B601.17.w17)
    • Use a synthetic absorbable suture material, monofilament or braided. (B601.17.w17)
    • Braided material is easier to handle but has more drag, so causes more tissue damage, and may allow bacterial growth. (B601.17.w17)
  • Close the skin using a simple continuous subcuticular suture. (B601.17.w17)
    • Use a synthetic monofilament absorbable suture material. (B601.17.w17)
Post-operative care
  • Supportive care is important. (B601.17.w17)
    • Intravenous fluids. (B601.17.w17)
    • Analgesia. (B601.17.w17)
    • Nutritional support. (B601.17.w17)
  • Aggressive antibiotic treatment if the abdomen has been contaminated by gut contents during the procedure. (B602.22.w22)
  • Note: there is a relatively high perioperative mortality rate in rabbits following gastrointestinal foreign body obstruction.

(B600.10.w10, B601.17.w17, B602.22.w22, J29.16.w3)

Appropriate Use (?) For the treatment of:
  • Intestinal foreign bodies. (B601.17.w17, B602.22.w22)
  • Intestinal trauma. (B602.22.w22)
  • Caecolith removal. (B601.17.w17)
  • Intestinal neoplasia. (B601.17.w17)
    • Note: primary intestinal neoplasia is uncommon; more commonly, tumours are metastases from uterine adenocarcinoma. (B602.22.w22)
Notes
  • The intestinal wall is thin and the lumen diameter narrow. (B601.17.w17)
  • The bowel must be handled gently to avoid development of postoperative ileus and shock. (B602.22.w22)
  • Particular care must be taken to maintain the blood supply to the intestine. (B602.22.w22)
  • Particular care must be taken to maintain the luminal diameter. (B602.22.w22)
Complications/ Limitations / Risk
  • Prognosis is guarded because acute gastrointestinal obstruction is a life-threatening condition.
  • Major complications include:
    • Leakage. (J495.32.w4)
    • Stenosis - luminal diameter may be excessively reduced at closure. (B602.22.w22, J495.32.w4)
Equipment / Chemicals required and Suppliers
  • Standard anaesthetic equipment for rabbits.

  • Surgical equipment appropriate for rabbits.

  • Suture materials.

Expertise level / Ease of Use
  • This procedure should only be carried out by an individual with appropriate clinical training and practical experience.
Cost / Availability

The costs of a surgical operation include those associated with: (J15.30.w1)

  • Pre-operative diagnostics (e.g. radiography, ultrasonography, blood tests)
  • Anaesthesia.
  • Perioperative medication (e.g. analgesics, antibiotics, fluids).
  • Surgical preparation (of the operating theatre and the patient, including staff time).
  • Consumables and equipment.
  • Time of the surgeon and assistant(s).
  • Post-operative hospitalisation.
Legal and Ethical Considerations In some countries there may be legislation restricting the use of this type of technique to licensed veterinarians. For example in the UK: "The Veterinary Surgeons Act 1966 (Section 19) provides, subject to a number of exceptions, that only registered members of the Royal College of Veterinary Surgeons may practice veterinary surgery." (See: LCofC1 - RCVS Guide to Professional Conduct 2000 - Treatment of Animals by Non-Veterinary Surgeons).
Author Debra Bourne MA VetMB PhD MRCVS (V.w5)
Referee Frances Harcourt-Brown BVSc FRCVS (V.w140)
References B600.10.w10, B601.17.w17, B602.22.w22, J15.30.w1, J29.16.w3, J495.32.w4

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