SMALL ANIMAL I CONTINUING EDUCATION

Intestinal surgery in small animals – how

to prevent it leaking?
Kathryn Pratschke MVB MVM CertSAS DiplECVS MRCVS RCVS, European specialist
in small animal surgery, provides a brief historical context for intestinal surgery and
explains how we have reached our current recommendations for closing intestinal
incisions, as well as addressing the question of how to prevent surgical sites leaking
Intestinal surgery is required on a reasonably frequent basis in intestinal segments during anastomosis, identifying that
veterinary practice, whether to remove a foreign body, obtain leaving big gaps between sutures led inevitably to leakage
biopsies for diagnosis or to deal with an intussusception. although he incorrectly described the peritoneum as the
Where a skin wound is sutured and subsequently breaks crucial layer (Travers, 1812). In 1826, Lembert introduced an
down, although inconvenient, the result is rarely life- inverting vertical mattress suture, based on the belief that
threatening. healing was dependent on full and complete apposition
If an intestinal wound breaks down, however, there can of the serosa/peritoneal layer, and Czerny then modified
be significant morbidity and also, potentially, mortality this into a two-layer inverting closure to reduce the risk of
associated with the resulting septic peritonitis. Surgery of leakage further. Halstead correctly identified the submucosa
the gastrointestinal tract (GIT) can be considered clean as the crucial layer for suture-line integrity in 1887, with his
contaminated at best, with the bacterial load increasing as preference being a single layer of interrupted horizontal
you progress distally along the tract. For this reason, the mattress sutures, modified into a continuous inverting suture
severity of the complications associated with dehiscence of by Connell a few years later (Connell, 1892).
an ileal or colonic incision will typically be more severe than These historical developments and recommendations for
for a more proximal leak (see Figure 1). intestinal surgery were predominantly based on extensive,
and often barbaric, animal experimentation but relatively
limited experience in people. The attitude towards intestinal
surgery in human patients is nicely summarised in a paper
regarding circular enterorrhaphy from 1891, which opens
with the statement that intestinal surgery was, until recently,
recognised as ‘quite fatal’ to the patient (Frank, 1891). This is,
perhaps, not so surprising given the anaesthetic, analgesic
and surgical protocols at the time coupled with the absence
of antibiotics. Anaesthesia meant (at best) chloroform and/or
ether, and sutures commonly reported for intestinal surgery
in the late 19th and early 20th century included silk, linen and
catgut. By convention, suture material was typically boiled
in either a 5% carboxylic acid solution or phenol solution
for at least 30 minutes prior to surgery to sterilise it (Bull,
1886). Following closure of intestinal incisions or perforations
it was not uncommon to lavage the intestines with warm
Figure 1: An enterotomy was made in the ileum of this
Labrador to remove a foreign body 36 hours prior to this carboxylic acid solution, dilute formaldehyde and/or flush the
photo being taken; the dog was referred for management intestinal tract through with salt solutions to remove toxins.
of septic generalised peritonitis secondary to leakage Peri-operative management often included multiple enemas
and dehiscence, but unfortunately despite aggressive
management he progressed rapidly to systemic inflammatory in the post-operative period to maintain this ‘cleansing’.
response syndrome and multiple organ failure. Intestinal anastomosis was an even more problematic issue,
and many patients with intestinal obstruction ended up with
INTESTINAL SURGERY – A SHORT HISTORY an ‘artificial anus’, meaning the intestine was transected
Intestinal surgery has, somewhat surprisingly, been around proximal to the obstruction and marsupialised to the skin
for a long time; it pre-dates anaesthetics, antibiotics and to relieve the obstruction, rather than attempting to resect
analgesics. There are written records of 12th century and anastomose (Wagstaffe, 1885). At the time, many
surgeons in London and Paris performing intestinal surgery, surgeons felt that suture closure of anastomoses was highly
using “…elder pypes in the guttes under the seame…”, the risky due to the risk of stenosis, prolonged surgical time
seame being the incision site; segments of dried intestine, leading to shock and leakage through needle tracks. A two-
bone, wax, tallow and dried tracheal segments from dead piece metal coupling device called the Murphy button was
animals have also been described for support of intestinal developed for sutureless anastomosis in the late 19th and
incisions (Robinson, 1891). In 1812, Travers reported the early 20th centuries but was associated with reasonably high
importance of getting ‘complete’ apposition of both complication rates from intestinal necrosis, displacement

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and the fact that it was, itself, a foreign body (Murphy, 1892; obstructive pulmonary disease, sepsis, hypertension,
Frank, 1902). In the first years of the 20th century, mortality diabetes mellitus, and congestive heart failure (Allen et al,
rates were stated in one report as 10.5-16% with Murphy 1992; Ralphs et al, 2003).
button anastomoses, but 58-100% with hand sutured (Frank, Although a direct causative link has not been clearly shown,
1902). The first ‘surgical stapler’ was described in by a it is recognised that chronic weight loss of 15-20% is linked
Hungarian surgeon called Hültl in 1906, with modern-day to poor visceral wound healing in general, and that certain
surgical stapling devices evolving from extensive work carried medications (glucocorticoids, chemotherapeutics) have
out in Russia in the wake of World War II (Ballantyne, 1984). the potential to disrupt intestinal wound healing (Ellison,
In terms of hand-sutured intestinal wounds, true progress 2011). Delayed enteral feeding after surgery has also been
only followed the discoveries of Lister and the application of implicated in an increased risk of leakage, hence the move
principles of aseptic surgery, combined with the development towards early resumption of oral feeding.
of more sophisticated surgical equipment and consumables,
in tandem with progress in anaesthetic, analgesic and 2. GENERAL PRINCIPLES
antibiotic medications in the 20th century. Gentle tissue handling and atraumatic surgical technique are
both very important to minimise trauma and therefore the risk
INTESTINAL SURGERY – CURRENT of complications.
RECOMMENDATIONS FOR BEST PRACTICE Steps should be taken to avoid desiccation of tissues under
1. PATIENT FACTORS surgery lights, for example through regular lavage with
Thorough patient assessment is required prior to any surgery, warmed sterile fluids. It is also advisable to keep as much
to ensure that the patient is genuinely an appropriate of the intestinal tract as possible within the abdomen and
candidate for surgery, and also to identify any negative or covered by soaked swabs.
positive prognostic indicators. Strict adherence to aseptic technique reduces the risk of
Pre-operative assessment also allows accurate identification infection, as does the use of antibiotics where indicated.
of the patient’s fluid balance/imbalance and acid-base status Soaked sterile swabs should be used to isolate those
including electrolyte derangements, eg. hypochloraemia, segments of the GIT that are to be opened, to minimise
hypokalaemia and hyponatraemia with intestinal obstruction contamination from spillage of contents (see Figure 3).
(Brown, 2012). Aseptic technique for intestinal surgery includes changing
A retrospective case series in 2003 suggested that presence gloves after the contaminated portion of the procedure is
of two or more of the following factors meant an increased complete, and using clean instruments and suture material
risk of leakage at anastomotic sites: pre-existing peritonitis, for closure of the body wall.
obstruction from intestinal foreign body (as opposed to other Atraumatic surgical instruments that are fit for purpose
causes), and serum albumin less than 2.5g/dL (Ralphs et al, should be used, for example Debakey and Adson-Brown
2003; [see Figure 2]). thumb forceps are both acceptable for use on intestinal
Studies in both people and animals have previously identified tissues, but so-called ‘smooth’ tissue forceps still found in
many other factors potentially associated with leakage of many veterinary surgical packs are not appropriate. These are
intestinal wounds, including sex (males are more likely to designed to hold swabs, not living tissue, and therefore if you
develop leakage than females in some studies), trauma, an hold intestinal tissue tight enough to stop it slipping out of
intra-abdominal abscess, concurrent infection, malignancy, the grip, it will cause patchy necrosis and damage. Babcock
preoperative use of corticosteroids, increased age, chronic forceps may be used with care, but Allis tissue forceps should

Figure 2: Foreign body obstruction of the small intestine was

identified as a potential risk factor for anastomotic leakage in
the study by Ralphs et al, 2003. This may reflect the potential Figure 3: The surgical site should be isolated from the rest
difficulty in judging intestinal viability in the region of the of the abdomen using sterile swabs to minimise the adverse
foreign body and along the dilated proximal intestine, and effects of any leakage or spillage during surgery. This
how far to take the enterectomy in order to ensure good principle can be seen in this image taken during surgery to
wound healing. resect an ileocolic tumour.

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never be used to hold intestine unless that segment is to be

removed. Artery forceps should be placed with care to avoid
causing collateral damage to neurovascular structures that
might compromise intestinal viability. Doyen forceps can be
very useful when operating single-handed, but care should
be taken not to over-tighten and cause tissue damage.

3. PROPHYLACTIC ANTIBIOTICS
Antibiotic prophylaxis is the idea of giving pre-emptive
antibiotics to prevent an anticipated infection, as opposed
to therapeutic antibiotics where the drugs are being used to
treat a confirmed infection.
A general rule of thumb is that prophylactic antibiotics should
be used if there is a significant risk of contamination during
surgery, or if a post-operative infection would be potentially
catastrophic. As mentioned previously, the small intestine
contains both gram-positive and gram-negative organisms;
if the mucous membrane barrier of the intestine is disrupted
for any reason then bacteria may move into surrounding
tissues and lead to infection. This factor makes prophylactic Figure 4: Serosal patching can be used to provide physical
antibiotics appealing for intestinal surgery, although the true support to an enterotomy or enterectomy site. This technique
is only required occasionally, but there are situations where it
need for antibiotic prophylaxis in every intestinal procedure is
can be invaluable in bolstering a surgical site.
still debated (Brown, 2012).
If prophylactic antibiotics are going to be used, then the best result with best histological restoration and least
they must be effective against the bacteria likely to be fibrosis; the crushing version induced more inflammation
encountered (eg. proximal versus distal small intestine, and necrosis, and problems with two-layer closure were as
small intestine versus colon). Also, the antibiotic must be in previously documented.
the tissues at the time of surgery, which means that giving Single-layer closure provides consistently better results and is
antibiotics subcutaneously or intramuscularly around the time the recommended option in small animals, with the choice of
of surgery is both inappropriate and ineffective. Prophylactic interrupted versus continuous sutures being largely dictated
antibiotics, by definition, should be given intravenously, by personal preference.
typically one to two doses, but no more unless there is a Everting suture patterns are generally not recommended,
compelling reason to continue therapeutic antibiotics (Brown, as they offer no benefit over appositional closure, but they
2012). do increase contamination and inflammation at the serosal
surface that can delay healing and increase the risk of
4. SUTURE PATTERN adhesions (Bellenger, 1982). Inversion causes compression
Two-layer closure of intestinal incisions was popular through of the blood supply in the inverted cuff; in smaller veterinary
much of the 19th and early 20th century, as most surgeons patients in particular this can predispose to reduced luminal
believed this gave greater security against leakage and would diameter and stenosis (Bennett and Zydeck, 1970; Bellenger,
best restore anatomy. However, this belief was convincingly 1982). Approximating patterns should avoid these potential
disproved in the mid-20th century, with several experimental complications.
studies showing that two-layer intestinal closure in fact gives
significantly greater inflammation, more tissue necrosis, 5. SUTURE MATERIAL
tissue microabscesses and reduced tensile strength; as such The suture of choice for intestinal closure is monofilament
it is associated with a far higher risk of stenosis (Sako and synthetic absorbable, such as polydioxanone (PDS) or
Wangensteen, 1951; Ballantyne, 1984). It also gives poorer polyglyconate (Maxon), although there are some situations
submucosal apposition, which is the crucial factor for primary where non-absorbable materials such as polypropylene
intestinal wound healing (Brown, 2012). might be considered.
Although there have been many studies of intestinal surgery Shorter-acting monofilament suture such as poliglecaprone
that have utilised animals, few studies exist that address the and glycomer 631 can also be used for intestinal surgery.
question of what is best for outcome in dogs and cats, as They have similar handling properties to PDS but are
opposed to what is going to be best in humans but can be degraded more quickly so there may be situations where they
tested for safety on dogs, cats and other animals. One of the are better avoided, eg. where delayed wound healing may be
few studies to directly evaluate the specifics of suture patterns encountered.
in veterinary patients was published in 2003 (Kirpensteijn et The newer ‘plus’ versions of suture material are impregnated
al, 2003). These authors compared single-layer appositional with the antibacterial agent triclosan, which is suggested
with single-layer crushing and two-layer closure. This study to reduce infection in skin and body-wall wounds; this may
identified that the single-layer appositional closure gave encourage use in intestinal surgery, although there is no

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proof of efficacy for intestinal incisions and opinion remains for general enterotomy or intestinal anastomosis (Saile et
divided on the subject of impact on surgical-site infection al, 2010). There is still only one in vivo veterinary study in the
rate (Sandini et al, 2016). English language veterinary journals that evaluated saline
Multifilament sutures in general cause more tissue drag leak testing for biopsy sites. This study used 38 experimental
and in the presence of contamination they can potentiate use hounds, ie. with no underlying intestinal abnormality,
infection. They also tend to produce a greater inflammatory which automatically introduces a difference compared to
reaction in the tissues than monofilament sutures, and this clinical cases (Saile et al, 2010). The authors’ conclusion from
can prolong the lag phase of wound healing, which in turns this study was as follows: “For canine jejunum, saline volumes
delays the return of strength (Brown, 2012). of 16.3-19ml (digital occlusion) and 12.1-14.8ml (Doyen
Chromic gut is not suitable for enteric incisions as proteolytic occlusion) can be used to achieve intraluminal pressures of
enzymes found in GIT secretions degrade it, and it will 34cm water during leak testing of a 10cm segment containing
stimulate a marked inflammatory reaction during dissolution a closed biopsy site.”
(Ballantyne, 1984). This is very specific in terms of what was being tested, and
whether the data can be generalised for use on all intestinal
6. OMENTALISATION AND SEROSAL PATCHING surgical sites in clinical patients of all sizes and species is far
The omentum has an extensive vascular and lymphatic from clear. There are many anecdotal reports of apparently
supply, and provides angiogenic and immunogenic stimuli ‘good’ leak tests that developed septic peritonitis from
that are beneficial in intestinal wound healing. leakage shortly following surgery, and it seems prudent not to
Once omentum is wrapped around an intestinal surgical site, rely too heavily on this single method of assessment.
it is often not necessary to physically suture it in place other
than perhaps one or two strategic anchoring sutures. SUTURES OR STAPLES?
It’s important to remember that the omentum does not This is an interesting question, and not one that necessarily
provide physical support, so if this is required, eg. to has a quick and simple answer. Stapled anastomoses have
reinforce an intestinal repair where the strength of the wall is comparable safety to hand sewn (where the surgeon is
questionable, then serosal patching may be preferable (see experienced in intestinal surgery) with similar leakage rates,
Figure 4 [Jones et al, 1972; Crowe, 1984]). but staples have the advantage of greater speed (Toyomasu
et al, 2010; Jardel et al, 2011).
ASSESSMENT OF INTESTINAL VIABILITY In hand-sewn anastomoses, work in the human surgical
This may be difficult but is clearly very important in terms of field confirms a higher complication rate in those with less
identifying situations that increase the risk of dehiscence, experience, and in those doing fewer than 15 anastomoses
whether through tissue necrosis or suture pull-out from per annum (Byrne et al, 2006). Where a surgeon is relatively
weakened tissue. The standard clinical criteria used to assess inexperienced but is trained specifically in how to use
viability are colour, visible pulsation in the mesenteric vessels, stapling equipment to perform functional end-to-end
and active, ordered peristalsis. These are all subjective criteria anastomosis, a study from 2011 showed that the outcome
that require familiarity with what is normal to assess whether can be good, although all the inexperienced surgeons in this
abnormality is present. particular study were working under direct supervision of a
Subjective criteria always carry the potential to either senior surgeon rather than on their own, which may skew the
over or underestimate viability, the key concern being results (Jardel et al, 2011).
underestimating how much of a compromised intestine There are some situations where surgical stapling devices
needs to be resected. However, these are the only realistic can be very useful, and can reduce surgical time, but in the
criteria available for general use in practice. Surface oximetry author’s opinion veterinary surgeons should not use staplers
has been suggested for assessment of perfusion, but this as a shortcut to doing a procedure that they would not be
requires a specialised surface oxygen tension electrode, and able to do if working by hand. If the staple cartridge misfires,
only a few millimetres of intestine can be checked at a time. the stapler breaks, something gets dropped, or the tissues
Fluorescein-dye infusion has been recommended in many are too oedematous to holds staples securely – you need to
surgical textbooks, combined with Woods lamp illumination, be able to complete the procedure by hand.
but in dogs this assesses predominantly mucosal viability, not The stapled version of small intestinal anastomosis –
the full thickness of the wall. The other complicating factor is functional end-to-end anastomosis – somewhat counter-
that fluorescein only tells you that there are vessels physically intuitively does not actually mean joining the intestinal
there or not; the important question is whether there is active segments end-to-end in line with each other, as is familiar
efficient perfusion through those vessels. from hand-sewn anastomosis. The intestinal segments are
laid side by side, and a GIA stapler used to create what is
LEAK-TESTING INTESTINAL INCISIONS technically a side-to-side anastomosis, and this means cutting
This is a surprisingly popular way of testing intestinal suture through the circular muscle layer (Brown, 2012).
lines, frequently taught at undergraduate level, despite the This translates into reduced inter-digestive migratory muscle
limited information regarding reliability. Saline-leak testing as contractions for up to four weeks after surgery compared to
a concept comes from human surgery, but there it is almost hand-sewn end-to-end anastomosis, although the clinical
exclusively used to evaluate colorectal anastomotic sites, not impact of this in patients has not been specifically reported

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(Toyomsau et al, 2010). being a quick and reasonably cheap option, the use of skin
The other issue with stapling equipment is of course staples for intestinal closure has not become routine in
the added expense; three packets of suture material veterinary practice.
are significantly cheaper than investing in either single-
use staplers or reusable stainless steel hand pieces with SUMMARY
individual-use staple cartridges. The cost to the client will As with any surgical procedure, it is important to take the
potentially be several hundred euro different, depending on time to properly assess the patient prior to surgery, to identify
what is required. any risk factors that may be corrected, but also to be aware of
The use of a cheaper option, namely a skin stapler, for both risk factors that cannot be corrected in advance. Knowledge
enterotomy incisions and intestinal anastomoses has been of surgical anatomy, and adhering to good basic principles of
reported (Coolman et al, 2000a and b) but these reports intestinal surgery is key to avoiding complications, together
evaluated only a single type of skin stapler, and anyone who with making informed choices about the most appropriate
has ever used skin staplers will be aware that not all skin suture patterns and types, or surgical stapling equipment
staplers are created equal. This may explain why, despite where appropriate.

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