Abomasal displacements and volvulus

Abomasal Displacments and Volvulus

1. Abomasal Displacments and Volvulus
Dr. Satyajeet Singh

2. 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

3. 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

4. Normal Anatomy – Left Flank

5. Normal Anatomy – Right Flank

6. Normal Anatomy - Ventral

7. 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%

8. 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

9. 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

10. LDA Clinical Signs
Anorexia
 fecal output
 rumen motility
 milk production
2
o
ketosis
Sunken left paralumbar fossa

11. LDA Clinical Signs
Percussion left paralumber fossa
Above/below line from point of
elbow to tuber coxae
Ping over gas filled portion of
abomasum

12. LDA Differential Diagnosis
Rumen tympany
Peritonitis
Pneumoperitoneum
Physometra

13. 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

14. Normal Transit
Simple LDA cases
normal serum electrolyte
levels
Normal acid/base balance
Anion Gap
H
2
CO
3
-
Cl
-
K
+
Na
+

15. Normal Transit
Not a complete obstruction
Chloride secreted in abomasum
Absorbed in small intestine
+ Mild hypochloremia
+ Mild metabolic alkalosis

16. LDA – Right Flank

17. LDA – Left Flank

18. LDA - Ventral

19. 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 omentopexy
Left paralumbar fossa abomasopexy
Right paramedian abomasopexy
Percutaneous abomasopexy

20. 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

21. 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

22. RDA Diagnosis
Clinical signs
Precussion
Ping under last 5 ribs in dorsal abdomen
Rectal palpation

23. Slow Transit
Potential for sequestration of HCl in
abomasum
Hyochloremia (loss of anions)
Obstruction
Reabsorption of Cl
-
by small intestine

24. Slow Transit
Metabolic alkalosis
Compensate for loss of Cl
-
kidney produces H
2
CO
3
-
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
+

25. RDA – Right Flank

26. 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

27. 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

28. AV Differential Diagnosis
Cecal dilitation or volvulus
Gas in spiral colon
Small intestinal obstruction or volvulus
Torsion about root of mesentery
Right abomasal displacement

29. AV Diagnosis
Clinical signs
Precussion
Ping
Extends from 8
th
rib to middle of right paralumbar fossa
Ventral border is horizontal
Fluid in abomasum
Ballottement
Rectal palpation

30. AV Clinical Pathology
Similar to RDA but more severe
Hypochloremia
Hypohalemia
Metabolic alkalosis  Metabolic acidosis
More chronic cases
Dehydration
Poor peripheral perfusion
Shock

31. AV – Right Flank
Typical orientation
Counterclockwise viewed from right flank

32. AV - Ventral

33. AV - Cranial
Typical orientation
Clockwise viewed from cranial

34. RDA Treatment
Surgical Emergency
Preoperative
IV fluids with KCl
Hypertonic saline
Normasol
0.9% NaCl
NSAIDs
Broad spectrum antibiotics

35. RDA Treatment
Surgical techniques
Right paralumbar fossa omentopexy
Best choice
Integrity of abomasum often compromised
Abomasopexy procedures do not work well
Progniosis
Depends on degree of damage to abomasal mucosa
Vagal indigestion syndrome common

36. Proximal Paravertebral Nerve Block
T
13
, L
1
, and L
2
Sensory and motor to
Skin
Fascia
Muscle
Peritoneum

37. Proximal Paravertebral Nerve Block
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

38. Proximal Paravertebral Nerve Block
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

39. Distal Paravertebral Nerve Block
Branches of T
13
, L
1
, and L
2
blocked at ends of
transverse processes of L
1
, L
2
, and L
4
(not L
3
)
Technique
25 ml 2% lidocaine hydrochloride per site
18-ga needle inserted under each transverse process
10 ml 2% lidocaine hydrochloride

40. Distal Paravertebral Nerve Block
Technique
Withdrawn short distance and redirected craniad and
caudad
2% lidocaine hydrochloride
Infiltration of ventral branches

41. Distal Paravertebral Nerve Block
Technique
Needle redirected dorsal and caudal to transverse
process
2% lidocaine hydrochloride
Infiltration of dorsolateral branches
No deviation of spine
No lumbar muscle paralysis

42. Inverted L Nerve Block
Vertical line passes caudal to last rib
Horizontal line passes ventral to transverse
processes
100 ml 2% lidocaine hydrochloride

43. Right Paralumbar Fossa Omentopexy
Vertical incision in middle of paralumbar fossa
3 – 5 cm ventral to transverse processes
20 – 25 cm long
Skin
SQ

44. Right Paralumbar Fossa Omentopexy
External abdominal oblique muscle
Internal abdominal oblique muscle
Aponeurosis of transverse abdominal muscle
Peritoneum

45. LDA Decompression
14 gauge needle attached to sterile suction hose

46. LDA Decompression
14 gauge needle attached to sterile suction hose

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

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

49. 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

50. Right Paralumbar Fossa Omentopexy
#2 or #3 chromic gut
Incorporate omentum in peritoneum and
transversus abdominal muscle closure

51. 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)

52. AV Decompression
14 gauge needle attached to sterile suction hose

53. AV Manipulation
Typical orientation
Counterclockwise
Viewed from right flank
Viewed from rear

54. 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

55. Left Paralumbar Fossa Abomasopexy
Identify abomasum

56. 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

57. 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

58. Left Paralumbar Fossa Abomasopexy
Reduction of abomasum
Each suture is placed through a sponge before
being tied

59. 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

60. Percutaneous Abomasopexy
Toggle
5 cm long plastic rod
30 cm long nylon suture
Trocar with stylet
Used to place toggle in the abomasum

61. Percutaneous Abomasopexy
Abomasum repositioned
Position of abomasum identified

62. Percutaneous Abomasopexy
Trocar with stylet inserted into abomasum
Stylet removed
Abomasal odor confirmed
First toggle passed through cannula to abomasum

63. Percutaneous Abomasopexy
Trocar with stylet inserted into abomasum
Stylet removed
Abomasal odor confirmed
Second toggle passed through cannula to
abomasum

64. Percutaneous Abomasopexy
Ends of suture tied around a sponge

65. 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

66. Laparascopic Assisted Abomasopexy
Minimally invasive technique for surgical correction of LDA
Developed to reduce incidence of complications
Traditional laparotomy
Percutaneous toggle placement

67. 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

68. Laparascopic Assisted Abomasopexy
Two-step technique
Toggle placement – standing
Suture retrieval – dorsal recumbency
One-step technique
Dorsal resumbency
One-step technique
Standing

69. 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

70. 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)
11
th
intercostal space
20 cm ventral to spinous process
II
I

71. Two-Step Technique: Step 1 - Standing
Pneumoperitoneum
Left paralumbar fossa
Position I
Veress needle with silicon tubing
Insufflation pump

72. Two-Step Technique: Step 1 - Standing
Trocar-cannula assembly inserted in left paralumbar fossa (I) through stab
incision
Laparascope inserted into cannula
Abdominal exploratory

73. Two-Step Technique: Step 1 - Standing
Endoscopic picture of LDA

74. Two-Step Technique: Step 1 - Standing
Trocar-cannula assembly inserted in 11
th
ICS (II) through stab incision
Instrument portal

75. Two-Step Technique: Step 1 - Standing
Toggle trocar passed through instrument portal
and inserted into abomasum
Toggle bar passed through trocar into abomasal
lumen

76. Two-Step Technique: Step 1 - Standing
Abomasum decompressed
Excess toggle suture fully
inserted into abdomen
Toggle trocar & laparascope
removed
Skin incisions closed
Single interrupted suture

77. 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

78. Two-Step Technique: Step 2 – Dorsal Recumbency
Laparascope and grasping forceps inserted
through portals

79. Two-Step Technique: Step 2 – Dorsal Recumbency
Abomasum and suture material identified
Suture retrieved using grasping forceps

80. Two-Step Technique: Step 2 – Dorsal Recumbency
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

81. Two-Step Technique: Step 2 – Dorsal Recumbency
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

82. 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

83. One-Step Technique - Dorsal Recumbency
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

84. One-Step Technique - Dorsal Recumbency
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

85. One-Step Technique - Dorsal Recumbency
I
II
III
IV

86. One-Step Technique - Dorsal Recumbency
Grasping forceps used to locate abomasum
Grasp abomasum in middle of greater
curvature
2 – 3 cm from greater omentum attachment
Fixation site

87. One-Step Technique - Dorsal Recumbency
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

88. One-Step Technique - Dorsal Recumbency
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

89. One-Step Technique - Dorsal Recumbency
18 G needle inserted through abdominal wall
Used as guide to exteriorize needle and suture
Suture pulled out of abdominal cavity

90. One-Step Technique - Dorsal Recumbency
3 other sutures are placed in similar fashion
Correct positioning of abomasum verified by
pulling gently on sutures to approximate
abomasum to body wall

91. One-Step Technique - Dorsal Recumbency
Sutures are knotted
Cutaneous incisions closed

92. One-Step Technique - Dorsal Recumbency
Adhesions 3 months post-operatively

93. One-Step Technique - Dorsal Recumbency
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

94. 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

95. 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

96. 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

97. Right Paramedian Abomasopexy
Closure
External rectus sheath
Horizontal mattress pattern
#3 chromic gut
Skin
Ford interlocking pattern
#3 polymerized caprolactam (Vetafil)

98. 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