Surgeon's Corner: Surgical Management of Gastric Dilatation-Volvulus (GDV)

Presentation

Three patients were presented for treatment of gastric dilatation–volvulus (GDV).

Surgery

The entire abdomen is clipped and aseptically prepared. An incision is made from the xiphoid process to the pubis to allow for adequate exploratory laparotomy and gain the proper exposure to facilitate stomach derotation. Once the abdomen is open, it is immediately clear that the omentum is draped over the ventral aspect of the stomach; this is the pathognomonic sign for GDV. The surgeon takes a quick glance at the serosal surface of the stomach to help determine if there are any nonviable areas and reaches to identify the pylorus and pull it from left to right. In this first case, the patient had a 180° volvulus that was easily reduced with this manipulation.

On occasion, patients can be much more difficult to derotate; in these cases, first exteriorizing the spleen can be helpful. If gas has reintroduced into the stomach, it may also be easier to derotate the stomach if an orogastric tube can be passed to remove the air.

In general, the spleen is extremely large in a patient with GDV; however, GDV patients rarely require splenectomy. The surgeon inspects all of the splenic vasculature to ensure that arteries are beating, that veins have flow, and that there is no evidence of venous thrombosis.

If it is difficult to examine all areas of the stomach, and if there is air remaining in the stomach, an orogastric tube can be passed and the remaining air decompressed from the stomach. This also facilitates the gastropexy procedure.

The second patient presented with the same history. Of particular interest, however, was this case’s questionable viability of the fundic portion of the stomach. The surgeon must inspect the serosal surface, looking for vessels coming into the area and assessing pulses and motility.

This gives the surgeon a reasonably good idea as to whether the stomach will survive or whether a partial gastric resection is necessary. Notice the excellent gastric motility present in this patient.

In the next case, we were unable to pass a stomach tube and decompress the stomach, which was full of food, complicating gastric derotation. Once again, we used the same motions to encourage derotation. We were finally able to overpower the stomach, and after several attempts we were able to get the stomach completely derotated. The stomach’s viability looks good, and the stomach tube is in place. It was difficult to get any food or air out of the stomach when completing this decompression. In addition, this patient’s stomach is very flaccid; notice when the surgeon touches the serosal surface, it does not seem to respond at all. Even the intestines show evidence of ileus, which is strange. The spleen in this dog was slightly enlarged, but not as enlarged as many of the spleens we have seen. Examining the vessels and making sure the spleen does not have evidence of venous thrombosis or other pathology is still highly important.

The final patient was presented with a history of GDV and was decompressed before surgery. This is the abdominal exploratory showing the pathognomonic sign of the omentum draped over the ventral aspect of the stomach. The spleen was exteriorized to facilitate derotation. The stomach was derotated to its normal position, and in this case we elected to do an incisional gastropexy. After careful evaluation of the stomach’s viability, we assessed the patient to have excellent blood supply to all areas of the stomach. Air was removed to facilitate gastropexy.

When performing an incisional gastropexy, it is important to position the incision on the antrum at a point that is equidistant between the greater curvature of the stomach and the lesser curvature of the stomach, and at the midpoint between the pylorus and the gastric incisure. If the thumb and finger are used to grasp the full-thickness stomach wall, and the thumb and finger are gently elevated, the gastric mucosa and submucosa will slip out of the surgeon’s grasp; the remaining tissue in the thumb and finger is the seromuscular layer. A pair of Metzenbaum scissors can be used to cut all of the tissue remaining in the surgeon’s grasp. The subsequent gastric incision can now be undermined and extended to a length of 4 cm. An alternate technique is to use a sharp #15 scalpel blade to cut through the serosal and muscularis layers. When the muscle fibers of the muscularis are cut, their fibers separate, thus exposing the dissection plane between the muscularis layer and serosal layer. This dissection plane is undermined and extended to allow a 4-cm antral incision.

It is important when suturing the stomach to the body wall that the diaphragm is visualized and not inadvertently cut. This video shows the radiating fibers of the diaphragm and their attachments to the costal arch. The diaphragm attaches very closely toward the abdominal cavity. Inadvertently cutting the diaphragm can result in a catastrophic outcome. It is important that the surgeon stays caudal to the diaphragm by at least 2 cm. Once the location of the gastropexy has been determined (approximately 2–3 cm caudal to the insertion of the diaphragm and approximately 3–4 cm off the midline abdominal incision), an incision of a similar length that was made in the antrum is made through the muscle fibers of the transversus abdominis muscle. The cut edges of the transversus abdominis muscle is then sutured to the cut edges of the antral muscle. The sutures are engaging a generous bite in the smooth muscle of the stomach wall. A larger bite in the stomach wall than in the body wall  is preferred because there is much more collagen in the body wall than in the stomach wall; thus, the sutures will hold a little bit better in the body wall than in the stomach wall.

A simple continuous appositional suture pattern is utilized to suture each of the incisions separately so that the incisional gastropexy results in a 2-layer closure. 3-0 synthetic absorbable suture is appropriate, and the pattern of choice is a simple continuous appositional suture pattern. Although we are using 2 packs of suture to perform the gastropexy, this is not necessary; it could easily be completed with a single pack of suture, suturing each side of the gastropexy separately. The surgeon must suture the dorsal incision first, followed by the ventral incision. Once the suturing is complete, the sutures are tied together at the end of the incisional gastropexy. No further sutures are necessary to encourage a secure closure; a scarified surface being sutured to a scarified surface will result in a mature fibrous connective tissue scar.

Outcome

All 3 patients recovered from surgery without complication.

This video was authored by Howard B. Seim III, DVM, DACVS. Other surgical videos are available through VideoVet.

Surgeon’s Corner is intended as a forum for those with specialized expertise to share their approaches to various techniques and procedures. As such, the content reflects one expert’s approach and is not subject to peer review.