Intestinal evisceration injuries are devastating events due to trauma or dehiscence of surgical incisions. Often if the event is not recognized and treated immediately, exposed intestines are severely contaminated and damaged from trauma or self–mutilation by the patient. Although many of these patients cannot be saved due to massive devitalization of bowel, secondary injuries and/or financial constraints, some of these patients are treatable and can survive with the help of aggressive medical and surgical management and committed owners.
Tenets of treatment include:
- Emergency triage—Treatment for shock, assessment and management of secondary injuries, protection of the exposed abdominal organs, and initiation of antimicrobial therapy.
- Wound decontamination—Conversion of the dirty wound into a clean contaminated wound and temporary closure of the abdomen for surgical prep.
- Surgical exploration—Identification and definitive treatment of lesions affecting the abdominal organs, abdominal lavage, culture sampling, and placement of closed suction drains, if applicable.
- Post–operative management—Broad spectrum antimicrobial therapy tailored by culture results, abdominal drainage and/or lavage, fluid and colloid support, pain management, and early refeeding.
Chance, a 4 ½ year old male neutered border collie was referred to DoveLewis for emergency evaluation and treatment of an intestinal evisceration injury that had occurred when the dog fell 15 feet from a cliff to a ledge while on a trip in the Columbia Gorge area. Chance could not walk and was hoisted to safety with a rope. At that point, evisceration of intestines was apparent. Luckily several veterinarians were at the site and able to immediately cover the contaminated segments so that Chance could be transported to a local hospital.
Emergency triage and stabilization
Chance received emergency stabilization treatments at Alpine Veterinary Hospital consisting of rebandaging, IV catheter and resuscitative fluids, pain medications, corticosteroids and antibiotics. He was then transferred to DoveLewis for definitive evaluation and treatment. On admission to DoveLewis, Chance was responsive, but recumbent. He did not appear to have any musculoskeletal or neurologic injuries. Vital signs were relatively stable, thanks to aggressive initial stabilization by the referring DVMs. The bandage was removed and brief inspection revealed evisceration of multiple loops of small intestine from the caudal abdomen. The bowel was dark red, slightly dry and covered with dirt and plant debris. The bowel was covered with wet lap pads, and the abdomen rewrapped to await surgery.
Initial diagnostics included CBC and chemistry. Urinalysis could not be performed due to the position of the injury and eviscerated intestines. Blood tests revealed Chance was anemic, leukopenic, thrombocytopenic and panhypoproteinemic. He was mildly hypocalcemic (ionized and corrected for low TP) and hypokalemic. Thoracic radiographs were within normal limits.
Initial therapy included fluid and electrolyte resuscitation, antibiotic administration, colloid support, and pain control via fentanyl CRI. He was placed on continuous ECG, blood pressure and pulse oximetry monitoring and was blood typed and cross matched.
Chance was moved to surgical prep, preoxygenated, and then anesthetized with etomidate. The fentanyl CRI was continued at an appropriate surgical rate to minimize use of inhalant anesthesia. A double lumen central venous catheter was placed to allow administration of fluids (crystalloids and colloids), blood transfusions, medications and to allow for intraoperative venous sampling. At the same time, the abdominal bandage was removed and surgical preparation started.
Multiple loops of jejunum were herniated through a 4–5 cm midline, Z shaped body wall rent just rostral to the prepuce. A central flap of skin was strangulating one 38 cm loop of bowel, and several other smaller segments (9 cm and 6 cm) were avulsed from their blood supply. The exposed omentum, bowel, and surrounding skin were extremely contaminated with dirt, plant debris, and hair. The bowel and surrounding skin were rinsed with 2 L warm saline to remove loose debris. The abdominal haircoat was shaved. The strangulating section of skin was cut to release the bowel. The three necrotic sections of bowel were double clamped then double ligated/transfixed and the segments removed. Segment ends were trimmed of exposed mucosa to preclude the need for inversion of each end, and thus decrease operative time. Where blood vessels were still intact, they were ligated. The exposed, contaminated omentum was exteriorized an additional 3 cm then the omentum divided, clamped, ligated with 2–0 maxon, and the contaminated portion removed. The remaining exposed bowel and omentum were lavaged with another 2.5 L saline and debris manually debrided with moistened lap sponges. The decontaminated healthy bowel and omentum were then returned to the abdomen and the rent closed with skin staples to allow for surgical preparation of the abdominal skin. A urinary catheter with closed collection system was placed aseptically and a sample saved for urinalysis. A rough prep was performed with chlorhexidine scrub/solution and the patient moved to the operating room.
Abdominal exploration and definitive treatment
Staples were removed from the body wall rent and a midline abdominal incision was made starting at the body wall rent and extending to the xyphoid. It appeared that Chance had been impaled during his fall down the cliff, causing the rent in the body wall and damage to retroperitoneal tissues and caudal abdominal structures. There was a 5–6 cm rent in the retroperitoneal space just caudal to the left kidney, with hematoma formation around the kidney. The ureteral mesentery was torn but the ureter appeared intact. The kidney was normal in size and color, but pulses were not digitally palpable. The colonic mesentery was torn in the mid–descending colon approximately 15 cm from the junction with the transverse colon. One vein was actively bleeding and several others were avulsed but the colon color was normal. The actively hemorrhaging vein was in close apposition with the remaining arterial branch of the left colic artery supplying the damaged segment. It was ligated with 6–0 prolene taking care not to damage the artery. The three areas of bowel where segments of contaminated and necrotic bowel were previously removed were inspected. In addition, another 18 cm of jejunum/proximal ileum appeared devitalized. The previously exposed bowel and omentum were markedly erythematous but the rest of the abdomen was normal in color. Gross contamination of the abdominal cavity was relatively minimal. Chance’s owners were contacted intraoperatively and informed of the need for extensive small intestinal resection (about 65%) and warned of potential complications including short bowel syndrome. They elected to continue with treatment.
The bowel was exteriorized and examined for potential anastamosis sites. The distal 15 cm of jejunum and 2 cm of ileum were devitalized. There were several short segments of previously contaminated and erythematous bowel in between the already resected areas, but in order to limit the number of anastamoses and remove as much grossly contaminated tissue as possible, the resection was extended aborally to the ileum and orally 64 cm from the junction with the duodenum and a single end to end jejunoileal anastamosis performed (The colonic mesenteric rent was closed. The abdomen was lavaged with 2.5 L warm saline then gloves, instruments and drapes were changed.
The abdomen was lavaged with another 3 liters of warm saline and a swab taken for culture and sensitivity. Two fenestrated, closed suction, Jackson Pratt drains were placed through the body wall into the cranial and caudal aspects of the abdomen and secured with purse string and Chinese finger trap sutures. The skin and body wall rent were sharply debrided then the incision closed routinely. The entire procedure took 3 hours and 45 minutes.
Chance recovered uneventfully from anesthesia. A nasogastric feeding tube was placed as well as a nasal oxygen cannula to maximize oxygenation through the recovery period. Active warming with the Bairhugger® was continued to treat postoperative hypothermia. Other than hypothermia, his vitals were normal. Chance was continued on hetastarch, Norm–R with potassium supplementation, and a fentanyl CRI as well as intravenous ampicillin sulbactam, enrofloxacin, and metronidazole. Chance had a gradual recovery over the next few days. Fluid samples from the abdomen were collected from the drains and cytology performed every 24 hours to evaluate WBC numbers and characteristics and to screen for bacteria. On day three, abdominal ultrasound was performed to evaluate the left kidney and assess fluid accumulation after closed suction drain removal. Blood flow to the kidney was normal and only a small amount of peritoneal effusion was identified. Chance was discharged from the hospital 5 days post–op on oral antibiotics (amoxicillin clavulonic acid, enrofloxacin) and a low residue intestinal diet. Abdominal cultures grew coagulase negative hemolytic staphylococcus and a nonenteric gram negative rod, both sensitive to the selected antibiotics.
At the time of this report, Chance was 10 weeks post–op. He is bright and alert and back to normal activity He has loose feces, presumably due to extensive small bowel resection, but is maintaining his weight easily. His owners report that they are very satisfied with the outcome. Many patients that undergo extensive small bowel resection take several months to adjust to shortened bowel length and some require chronic management with a low fat low residue diet. According to a recent study, the percentage of bowel resected (from 50 to 90 percent), does not significantly impact outcome and most patients have a satisfactory outcome.
Appropriate triage at the incident site, immediate care at the local hospital, then aggressive stabilization, decontamination and repair procedures at DoveLewis (combined with one very tough dog!) all worked together to effect a good outcome in this case. We would like to thank the veterinarians at Alpine Veterinary Hospital for the referral of this very challenging case.
Have you have seen a case like this? Did you treat it at your hospital or refer it to a specialist?
1. Gorman, SC et.al., Extensive small bowel resection in dogs and cats: 20 cases (1998–2004) JAVMA 228 (3) 2006