Abomasal displacements and volvulus

Abomasal Displacments and Volvulus

Dr. Satyajeet Singh

Greater Omentum

Consists of 2 leaves Superficial leaf (1)

Left longitudinal groove of rumen

Greater curvature of abomasum and duodenum (2)

Deep leaf (3) Right longitudinal groove of rumen

Decending duodenum

Both leaves form sling for intestine

1 3

2

2

2

Lessor Omentum (1)

Connects peritoneum between Liver (2) Lesser curvature of abomasum (3) Cranial duodenum (4)

Covers right side of omasum Key to other structures

Mesoduodenum (5) Greater omentum (6)

2

3

4

1

5

6

Normal Anatomy – Left Flank

Normal Anatomy – Right Flank

Normal Anatomy - Ventral

Incidence of Abomasal Displacement 10% RDA

90% LDA

91% occur within first 6 weeks of calving

Most likely to occur

Adult diary cattle in early postpartum period

Prevalence in well managed herd varies

0.2 – 2.5%

Predisposing Factors

Abomasal atony High grain/low roughage diets

[VFA] Gas accumulation Distention

Roughage (large particles)

Stimulates rumination via touch receptors

Increases salivary buffer action

Hypocalcemia Milk fever

smooth muscle tone and motility

4.8 x risk of developing LDA than normocalcemic

Predisposing Factors

Abomasal atony

Metritis, retained placenta, severe mastitis Endotoxins and endogenous pyrogens (IL-1) depress motility

Result in hypocalcemia

Electrolyte disturbances Lack of exercise/confinement

High producing diary cows

Large abdominal cavities more room for displacement

Genetic selection

LDA Clinical Signs

Anorexia

fecal output

rumen motility

milk production

2o ketosis

Sunken left paralumbar fossa

LDA Clinical Signs

Percussion left paralumber fossa Above/below line from point of

elbow to tuber coxae

Ping over gas filled portion of abomasum

LDA Differential Diagnosis

Rumen tympany

Peritonitis

Pneumoperitoneum

Physometra

LDA Diagnosis

Clinical signs

Percussion

Liptak test

Centesis area below gas ping in “abomasum”

Fluid pH < 4.5 Abomasum

Burnt almond odor of gas Abomasum

Normal Transit

Simple LDA cases normal serum electrolyte

levels Normal acid/base balance

Anion Gap

H2CO3

-

Cl-

K+

Na+

Normal Transit

Not a complete obstruction Chloride secreted in

abomasum Absorbed in small intestine

+ Mild hypochloremia

+ Mild metabolic alkalosis

LDA – Right Flank

LDA – Left Flank

LDA - Ventral

LDA Treatment

Medical techniques

Cast in right lateral recumbency Roll into dorsal recumbency/shake legs Roll over to left lateralrecumbency Stand

Surgical techniques

Right paralumbar fossa omentopexyLeft paralumbar fossa abomasopexyRight paramedian abomasopexyPercutaneous abomasopexy

LDA Prevention

Diet

Prepartum introduction of ensiled/concentrate feeds

Slowly introduce concentrates post-calving

Increase particle size of forage

Prevent hypocalcemia

Manage periparturient inflammatory diseases

RDA Clinical Signs and DDx

Clinical signs similar to LDA Differential diagnosis

Cecal dilitation or volvulus Gas in spiral colon Small intestinal obstruction or volvulus Torsion about root of mesentery Pneumorectum Pneumoperitoneum Physometra Abomasal volvulus

RDA Diagnosis

Clinical signs

Precussion

Ping under last 5 ribs in dorsal abdomen

Rectal palpation

Slow Transit

Potential for sequestration of HCl in abomasum Hyochloremia (loss of anions)

Obstruction

Reabsorption of Cl- by small intestine

Slow Transit

Metabolic alkalosis Compensate for loss of Cl- kidney produces H2CO3

-

Hypokalemia Stabilize blood pH

K+ (extracellular) H+ (intracellular)

Paradoxic aciduria Perfusion in peripheral tissue

Aldosterone Reabsorb Na+ Secrete K+

Deplete K+ Reabsorb Na+ Secrete H+

RDA – Right Flank

RDA Treatment

Medical techniques

Rolling contraindicated

Progression to Abomasal volvulus

Surgical techniques

Difficult to distinguish RDA vs. AV

Right paralumbar fossa omentopexy or abomasopexy

Right paramedian abomasopexy

AV Clinical Signs

Colic

Tachycardia (> 100 bpm)

Dehydration

Bilateral abdominal distention

Feces abscent or watery but scant

AV Compete obstruction of flow of ingestia through duodenum

AV Differential Diagnosis

Cecal dilitation or volvulus

Gas in spiral colon

Small intestinal obstruction or volvulus

Torsion about root of mesentery

Right abomasal displacement

AV Diagnosis

Clinical signs

Precussion

Ping

Extends from 8th rib to middle of right paralumbar fossa

Ventral border is horizontal

Fluid in abomasum

Ballottement

Rectal palpation

AV Clinical Pathology

Similar to RDA but more severe

Hypochloremia

Hypohalemia

Metabolic alkalosis Metabolic acidosis

More chronic cases

Dehydration

Poor peripheral perfusion

Shock

AV – Right Flank

Typical orientationCounterclockwise viewed from right flank

AV - Ventral

AV - Cranial

Typical orientationClockwise viewed from cranial

RDA Treatment

Surgical Emergency

Preoperative

IV fluids with KCl

Hypertonic saline

Normasol

0.9% NaCl

NSAIDs

Broad spectrum antibiotics

RDA Treatment

Surgical techniques

Right paralumbar fossa omentopexyBest choice Integrity of abomasum often compromisedAbomasopexy procedures do not work well

Progniosis

Depends on degree of damage to abomasal mucosa

Vagal indigestion syndrome common

Proximal Paravertebral Nerve Block

T13, L1, and L2

Sensory and motor to Skin Fascia Muscle Peritoneum


Nerve most localized Intervertebral foramen Walk needle of caudle edge of transverse process Single site rather than dorsal and ventral branches

individually Transverse process slopes forward

Technique Injection site 3 – 4 cm from midline Local bled of 2% lidocaine hydrochloride Use 1 in 16-ga needle as trocar for 10 cm 20-ga needle


Technique Once transverse process encountered

Needle walked off caudle border and advanced 0.75 cm

10 ml 2% lidocaine hydrochloride

Temporary lateral deviation of spine Lumbar muscle paralysis

Distal Paravertebral Nerve Block

Branches of T13, L1, and L2 blocked at ends of transverse processes of L1, L2, and L4 (not L3)

Technique 25 ml 2% lidocaine hydrochloride per site 18-ga needle inserted under each transverse

process 10 ml 2% lidocaine hydrochloride


Technique Withdrawn short distance and redirected craniad

and caudad 2% lidocaine hydrochloride

Infiltration of ventral branches


Technique Needle redirected dorsal and caudal to transverse

process 2% lidocaine hydrochloride

Infiltration of dorsolateral branches

No deviation of spine No lumbar muscle paralysis

Inverted L Nerve Block

Vertical line passes caudal to last rib Horizontal line passes ventral to transverse

processes 100 ml 2% lidocaine hydrochloride

Right Paralumbar Fossa Omentopexy

Vertical incision in middle of paralumbar fossa 3 – 5 cm ventral to transverse processes 20 – 25 cm long

Skin SQ

Right Paralumbar Fossa Omentopexy

External abdominal oblique muscle Internal abdominal oblique muscle Aponeurosis of transverse abdominal muscle Peritoneum

LDA Decompression

14 gauge needle attached to sterile suction hose

LDA Manipulation

Abomasum returned to normal position Follow peritoneal surfaces ventrally Hand between rumen and body wall Elevate caudal ventral blind sac of rumen

Right Paralumbar Fossa Omentopexy Gently pull omentum out through incision Retract dorsad and caudad until pylorus is visualized

Omentum on both sides of pylorus Palpable firmness of torus pyloricus muscle

Omentopexy Close to pyloroduodenal

junction 3 – 4 cm caudal Appendage “sows ear”

6 – 8 cm vertical section of greater omentum

Distribute pexy of wide area

Right Paralumbar Fossa Omentopexy #2 or #3 chromic gut Incorporate omentum in peritoneum and

transversus abdominal muscle closure

Right Paralumbar Fossa Omentopexy External/internal abdominal oblique muscles

closure Single layer, simple continuous pattern, #2 - #3

chromic gut

Skin closure Ford interlocking pattern, #3 polymerized

caprolactam (Vetafil)

AV Decompression

14 gauge needle attached to sterile suction hose

AV Manipulation

Typical orientationCounterclockwise

Viewed from right flank

Viewed from rear

Advantages and Disadvantages: Right Paralumbar Fossa Omentopexy

Prognosis LDA 86% - 90% Complications

Redisplacement 3.6% - 4.2% Incisional infection Peritonitis

Advantages Animal in standing position Surgeon can perform procedure alone Allows abdomial exploration Used to correct LDA, RDA, and AV

Disadvantages More skill

Proper position of abomasum Proper area for fixation

Abomasum position less anatomically correct than abomasopexy Not good if suspect adhesions beteen abomasum and left body wall

Left Paralumbar Fossa Abomasopexy

Identify abomasum

Left Paralumbar Fossa Abomasopexy Well distented abomasum Along greater curvature

2 – 3 cm from attachment of greater omentum

Ford interlocking pattern 5 – 7 cm Bites through submucosa

#2 - #3 monofilament, non-absorbable 2 m long 2 long tags with straight needles

Decompress abomasum

Left Paralumbar Fossa Abomasopexy Anchor suture tags

Cranial site 10 cm caudal/right of xiphoid process

Pass cranial suture through ventral abdomin

Assistant applies pressure of site with hemostats

Assistant pulls needle through skin

Repeat with caudal suture

Left Paralumbar Fossa Abomasopexy Reduction of abomasum Each suture is placed through a sponge

before being tied

Advantages and Disadvantages: Left Paralumbar Fossa Abomasopexy

Prognosis 83.5% - 94%

Complications

Entrapment of small intestine between abomasum and body wall

Abomasal fistula formation if

Suture penetrates abomasal mucosa

Suture not removed in 2 – 3 weeks

Advantages Animal in standing position Best choice for cows in advanced pregnancy (> 7 months) Best choice for rumenotomy with concurrent TRP

Disadvantages Only for LDA not for RDA or AV Requires assistant to guide needle placement

Percutaneous Abomasopexy

Toggle 5 cm long plastic rod

30 cm long nylon suture

Trocar with stylet Used to place toggle in the

abomasum


Abomasum repositioned Position of abomasum

identified


Trocar with stylet inserted into abomasum Stylet removed

Abomasal odor confirmed

First toggle passed through cannula to abomasum


Trocar with stylet inserted into abomasum Stylet removed

Abomasal odor confirmed

Second toggle passed through cannula to abomasum


Ends of suture tied around a sponge

Advantages and Disadvantages: Percutaneous Abomasopexy

Prognosis 80% - 88%

Complications

Pexy viscera or omentum

Abomasal rupture at suture site

Peritonitis

Abomasal obstruction

Advantages Quick, inexpensive, easy to perform

May be good choice for cows that are poor surgical candidates

Disadvantages Requires dorsal recumbency

Only for LDA not for RDA or AV

Requires assistants

Abomasum must be distended with gas

Laparascopic Assisted Abomasopexy Minimally invasive technique for surgical correction of LDA

Developed to reduce incidence of complications

Traditional laparotomy

Percutaneous toggle placement

Laparascopic Assisted Abomasopexy Advantages

Reduced surgical time and cost

Reduced healing time

Can immediately go back into production

Reduced milk discarding

Antibiotics not required

Allows abdominal exploratory

Any degree of gas distention

Even minimally dilated

Laparascopic Assisted Abomasopexy Two-step technique

Toggle placement – standing

Suture retrieval – dorsal recumbency

One-step technique

Dorsal resumbency

One-step technique

Standing

Laparascopic Assisted Abomasopexy Single toggle

Toggle bar

Stainless steel with central recess

Epoxy filling recess securing suture to toggle

Suture

Twin 80cm strands

Marker 4.5 cm from toggle bar

Marker

Two-Step Technique: Step 1 - Standing

Left paralumbar fossa and last 3 ribs aseptically preped

2 local blebs (5 ml) 2% lidocaine

2 stab incisions (1 cm)

Laparascope portal (I)

10 cm caudal to last rib 10 cm ventral to transverse process

Instrument portal (II)

11th intercostal space 20 cm ventral to spinous process

II I


Pneumoperitoneum

Left paralumbar fossa

Position I

Veress needle with silicon tubing

Insufflation pump


Trocar-cannula assembly inserted in left paralumbar fossa (I) through stab incision

Laparascope inserted into cannula

Abdominal exploratory


Endoscopic picture of LDA


Trocar-cannula assembly inserted in 11th ICS (II) through stab incision

Instrument portal


Toggle trocar passed through instrument portal and inserted into abomasum

Toggle bar passed through trocar into abomasal lumen


Abomasum decompressed Excess toggle suture fully

inserted into abdomen Toggle trocar & laparascope

removed Skin incisions closed

Single interrupted suture

Two-Step Technique: Step 2 – Dorsal Recumbency

Right parameadian area aseptically preped 2 local blebs (5 ml) 2% lidocaine 2 stab incisions (1 cm)

Laparascope portal (III) 5 cm lateral from midline

20 cm distal to xyphoid

Instrument portal (IV) 5 cm lateral from midline

10 cm distal to xyphoid


Laparascope and grasping forceps inserted through portals


Abomasum and suture material identified

Suture retrieved using grasping forceps


Excess suture withdrawn through instrument portal up to preset marker on suture

Abomasum in proper anatomical position

Remove laparasope and cannulas

Skin incisions closed Single interrupted suture


Suture ends each passed through separate 14 ga needles inserted through gauze stent

Needles removed Suture tied over gauze stent

Leave 3 cm of play in suture

Suture removed after 3 – 4 weeks

One-Step Technique - Dorsal Recumbency

Animal is sedated and placed in dorsal recumbency

Area aseptically prepared from

Xyphoid process to 10 cm caudal to umbilicus Width of 20 cm each side of ventral midline


3 local blebs (5 ml) 2% lidocaine 3 stab incisions (1 cm) Portal site I (laparoscope)

2 cm left of umbilicus

Portal site II (grasping forceps) 3 cm caudal and 7 cm right of xyphoid process

Portal site III (needle holder) 5 cm right and 3 cm cranial to umbilicus


Fixation site IV 10 cm long line block using 2% lidocaine 3 - 5 cm right of linea alba Centered between umbilicus and xyphoid

process Four 1-cm long skin incisions

Perpendicular to ventral midline

Spaced 2.5 cm apart


I

II III

IV


Grasping forceps used to locate abomasum

Grasp abomasum in middle of greater curvature

2 – 3 cm from greater omentum attachment Fixation site


2 PDS suture with curved needle (1/2, 40mm) is used Needle straightened to facilitate manipulation of

needle

Needle introduced into abdomen through one of cutaneous incisions

Needle grasped intra-abdominally using needle holder


Needle and suture passed through serous and muscular layers of abomasum Stitch measuring 2 cm Running perpendicular to greater curvature

Site inspected for gas or fluid leakage


18 G needle inserted through abdominal wall Used as guide to exteriorize needle and suture

Suture pulled out of abdominal cavity


3 other sutures are placed in similar fashion

Correct positioning of abomasum verified by pulling gently on sutures to approximate abomasum to body wall


Sutures are knotted

Cutaneous incisions closed


Adhesions 3 months post-operatively


Follows two-step technique Except once toggle bar inserted into abomasum,

suture ends not passed into abdominal cavity

Specially designed instrument is used to drive toggle suture from left flank to ventral abdomen

Suture is tied as in two-step technique

Right Paramedian Abomasopexy Incision

15 – 20 cm long, parallel and 3 – 4 cm right of midline Extending caudal from a point 4 – 8 cm caudal to xiphoid

Six distinct layers Skin SQ fascia

Deep pectoral muscle in cranial 1/3 External rectus sheath Rectus abdominus muscle Internal rectus sheath Peritoneum

Right Paramedian Abomasopexy Exploratory Decompress abomasum and

exteriorize Identify pylorus

Omentum on both sides of pylorus

Palpable firmness of torus pyloricus muscle

Identify greater omentum Greater curvature (arrow)

Sweeps to left side of rumen Covering ventral surface of rumen

Right Paramedian Abomasopexy Abomasopexy

3 horizontal mattress sutures

Lateral aspect of greater curvature of abomasum free of omentum

Seromuscular layer

Peritoneum and internal rectus sheath #2 chromic gut

Simple continuous pattern Peritoneum and internal rectus sheath At least 6 bites incorporating abomasum

Seromuscular layer

Right Paramedian Abomasopexy Closure

External rectus sheath Horizontal mattress pattern

#3 chromic gut

Skin Ford interlocking pattern

#3 polymerized caprolactam (Vetafil)

Advantages and Disadvantages:

Right Paramedian Abomasopexy

Prognosis 83.5% - 95% Complications

Incisional hemorrhage, dehiscence, herniation or fistulation

Advantages Strong adhesions develop between abomasum and body wall Abomasum returns near normal position during placing in dorsal recumbency Correct LDA, RDA or AV

Disadvantages Dorsal recumbency

Bloat, regurgitation, aspiration

Requires assistants

Abomasal displacements and volvulus

Health & Medicine

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