Small Animal Surgical Emergencies. Группа авторов

and gastrocolopexy [45,57–63]. Other techniques are described for prophylactic gastropexy including endoscopy assisted and laparoscopic, although these are not useful in the emergency situation [64, 65].

      Evidence to support recommending one technique over another is weak, with few studies objectively comparing techniques in a clinical setting. In a study comparing the tensile strength of a number of techniques, circumcostal gastropexy had the greatest strength to failure [66]. The strength necessary to prevent recurrence of GDV is unknown. Studies have shown that incisional, belt‐loop, circumcostal and tube gastropexy all form permanent adhesions as assessed at postmortem or using laparoscopy or ultrasound [60–62, 65,67–69]. In most circumstances, the authors recommend an incisional or belt‐loop gastropexy, as these techniques are easy to perform and create a permanent adhesion.

      Gastropexy Techniques

      Gastropexy should be performed with the stomach decompressed and in a normal position. Suturing of the gastropexy may be facilitated by removing the abdominal retractors, thus allowing the pylorus and body wall to be easily apposed.

      Incisional Gastropexy

Incisional gastropexy is performed as follows(Figure 8.9):

      1 The pyloric antrum is identified (Figure 8.9a).

      2 A 5‐cm seromuscular incision is made longitudinally in the pyloric antrum (Figure 8.9b). The incision should penetrate the serosa and muscle layers, leaving the submucosa intact. If the submucosa is inadvertently incised, it should be closed with a simple interrupted or continuous suture pattern before continuing with the gastropexy.

      3 A corresponding incision is made through the peritoneum and transverse abdominal muscle on the right body wall (Figure 8.9c). The incision is made in a ventrodorsal direction approximately 3–4 cm caudal to the last rib. The incision should be approximately one‐third of the distance from the ventral to dorsal midline to allow the pylorus to sit in a normal position once the gastropexy has been performed and the abdomen has been closed. The pylorus should be manually opposed to the body wall, prior to making the incision, to gauge the appropriate site.

      4 The edges of the gastric wall incision are sutured to the edges of the body wall incision with two simple continuous sutures using an appropriate synthetic absorbable suture material (e.g., 2‐0 polydioxanone). The first suture is started dorsally at the cranial borders of the gastric wall and body wall incisions (Figure 8.9d), and these borders are then apposed (Figure 8.9e). A second suture is started dorsally at the caudal border of the gastric wall and body wall incisions (Figure 8.9f), and these borders are then apposed, completing the gastropexy (Figure 8.9g).

Although recurrence has been reported following incisional gastropexy, the rate has been generally considered to be minimal [68, 70]. Two more recent studies found a 0% recurrence rate of GDV following incisional gastropexy in cohorts of 34 and 40 dogs [71, 72]. However, subsequent gastric dilatation occurred in 5.0% and 8.8%, respectively. A variation on the incisional gastropexy technique is described in 20 dogs, using a GIA™ (Covidien) stapler [73]. A seromucosal tunnel is made in the pyloric antrum and stapled to a corresponding tunnel in the body wall. This technique is quick to perform, although there is an increased cost associated with the stapler. This technique was associated with 0% recurrence in this study [73].

Figure 8.9 Series of intraoperative images showing the technique for incisional gastropexy. (a) Position of gastric incision in the pyloric antrum noted by DeBakey forceps. (b) Seromuscular incision in the pyloric antrum. (c) Incision in the body wall through the peritoneum and transverse abdominal muscle. (d) Placement of the first suture dorsally on the cranial border of the incisions. (e) Simple continuous suture apposing the cranial borders of both incisions. (f) Another suture has been placed dorsally at the caudal border of the incisions. (g) The finished gastropexy. Ca, caudal; Cr, cranial.

      Belt‐Loop Gastropexy

Belt‐loop gastropexy is performed as follows (Figure 8.10):

      1 The pyloric antrum is identified.

      2 A seromuscular flap is raised in the pyloric region, based on the serosal blood vessels (branches of the gastroepiploic artery) along the greater curvature of the stomach. A U‐shaped incision is made in the seromuscular layer, resulting in a tongue‐shaped flap approximately 4 cm long and 3 cm wide (Figure 8.10a). The flap is undermined, taking care not to penetrate the submucosa. If the submucosa is inadvertently incised, it should be closed with a simple interrupted or continuous suture pattern before continuing with the gastropexy. A stay suture placed in the tip of the flap aids manipulation (Figure 8.10b).

      3 Two parallel incisions are made through the peritoneum and transverse abdominal muscle on the right body wall (Figure 8.10c). The incisions are made in a ventrodorsal direction, approximately 3–4 cm caudal to the last rib. The incisions should be 4–5 cm long and 3 cm apart. The incisions should be approximately one‐third of the distance from the ventral to dorsal midline to allow the pylorus to sit in a normal position once the gastropexy has been performed and the abdomen has been closed. The pylorus should be manually opposed to the body wall, prior to making the incision, to gauge the appropriate site. The tissue between the incisions is undermined to create a tunnel, the “loop.”

      4 The gastric flap is passed from caudal to cranial through the tunnel in the body wall. The flap is then sutured back into its original position with simple continuous or interrupted sutures using an appropriate synthetic absorbable suture material (e.g., 2–0 polydioxanone; Figure 8.10d).

      In one study, belt‐loop gastropexy had a recurrence rate of 0% in 20 dogs [62]. A modification of this technique has been described in cadavers using a skin stapler rather than sutures to secure the gastric flap [74]. The staple technique was significantly faster than using sutures although there was no difference in the tensile strength. One prospective study reported the results of a modified belt‐loop gastropexy using a seromuscular fold of the stomach rather than a flap in 100 dogs with GDV [75]. There was no recurrence of GDV in 78 dogs with follow‐up at a median of 850 days (range 450–1200 days). The authors recommended this technique as there was no risk of inadvertently entering the gastric lumen.

      Tube Gastropexy

Tube gastropexy is performed as follows (Figure 8.11):

      1 A large (24‐ or 26‐gauge) Foley catheter or de Pezzer mushroom tipped catheter is used for the tube. The authors prefer the mushroom tipped catheter in most instances.

      2 A stab incision is made in the body wall approximately 3–4 cm lateral to the ventral midline and 3–4 cm caudal to the last rib on the right‐hand side (