4 for the removal of foreign bodies from the esophagus.
Stomach
Foreign bodies within the stomach represent 16–50% of GI foreign bodies reported [2–4, 55]. Removal of foreign material from within the stomach is primarily achieved via either induced emesis, endoscopy, or gastrotomy. In two studies of dogs with gastric foreign bodies, administration of apomorphine resulted in successful gastric foreign body removal in 374/495, and 46/61 dogs. [56, 57] Only minor adverse effects were reported in four of the dogs. Recent ingestion, ingestion of fabric, leather or bathroom waste, and young age were associated with a successful emesis event. [56] In a study of endoscopic gastric foreign body retrieval, 10 of 36 gastric foreign bodies required surgical removal after attempts at endoscopic removal failed. The authors in that study pointed out that only foreign bodies with attempted endoscopic retrieval were included and that some types of foreign bodies would not be considered candidates for endoscopic retrieval [21].
When surgical intervention is required, it is important that the entire GI tract be evaluated via visualization and palpation, regardless of the specific location of the offending foreign body. Identification and removal of all foreign material is essential to prevent the possibility of a second obstruction. When the foreign material has been isolated to the stomach, the stomach must be packed off with saline‐moistened laparotomy sponges and stay sutures placed to minimize the risk of contamination of the abdominal cavity during foreign body retrieval (Figure 5.4). Following placement of stay sutures, an incision is made on the ventral surface of the stomach midway between the branches of the gastroepiploic and gastric vessels and along the greater curvature using a number 15 scalpel blade. In the majority of cases, the incision does not require excessive length; however, the length of the gastric incision may need to be extended with Metzenbaum scissors after the nature of the foreign material has been identified. For example, some wood glue compounds when ingested become a solid material that cannot be removed easily without an incision of adequate length of approximately the same size as the foreign body [8]. Maintenance of tension on the stay sutures is critical to prevent spillage of gastric contents. Following removal of a discrete foreign body, closure of the stomach may be achieved in any of the following ways: a simple continuous appositional pattern through all layers, a double layer, continuous pattern (gastric mucosa and submucosa in the first layer with the second layer being full thickness), a double layer, inverting pattern (the first suture line is full thickness and the second suture line incorporates only the seromuscular layers), or a simple continuous pattern in the gastric mucosa and submucosa followed by an inverting pattern in the seromuscular layer. Monofilament absorbable suture materials such as polydioxanone, polyglyconate, and glycomer 631 are most commonly used.
Figure 5.4 (a) Foreign body within the stomach. The stomach has been packed off using laparotomy sponges from the remainder of the abdomen and a foreign body is palpable within the stomach. (b) Stay sutures are utilized to prevent spillage of gastric content. Length of incision is based on the size of the foreign body being removed.
In the case of a linear foreign body, the anchored foreign material must be released from its location before attempts to remove the foreign body are made. In cats, the most common anchor site is under the tongue (Figure 5.5), while in dogs, it is at the pylorus [11]. If the material is anchored at the pylorus, a gastric incision may be made in the pyloric antrum in order to better facilitate release of the material as it extends into the duodenum. In some cases, it may be possible through combined gentle external manipulation of the duodenum and gentle traction on material in the stomach, to manipulate the material back into the stomach, forgoing the need for additional surgical incisions in the GI tract. It is ideal if the gastrotomy incision does not involve the pylorus, as outflow may be reduced by the presence of inversion or swelling at the site of closure. Contaminated instruments should be replaced with sterile instruments in the surgical field to close the gastric incision. The surgeon should also replace their gloves with a sterile pair. Following gastrotomy closure, the abdomen should be lavaged and suctioned thoroughly followed by standard closure of the abdominal cavity.
Small Intestine
Anatomy
Even though many discrete small intestinal foreign bodies are easily removed, the nature of the foreign body and the location of the obstruction can present a surgical challenge. Removal of foreign bodies within the duodenum demands knowledge of the regional anatomy including the entrance of normal anatomic structures, such as the bile and pancreatic ducts, into the proximal duodenum (Figure 5.6). The intimate association of the duodenal and pancreatic blood supply is also important to consider when incising the duodenum. In addition, the distal duodenum turns at a sharp angle at the caudal duodenal flexure. This bend is created by the duodenocolic ligament, which tethers the distal duodenum to the colon. Careful excision of this ligament allows this area of the small intestine to be exteriorized and more adequately visualized during foreign body removal.
Figure 5.5 A string foreign body under the tongue of a cat.
Minimally invasive options for exploratory laparoscopy in patients with GI obstruction recently have been evaluated. One study performed laparoscopy followed by open laparotomy in dogs to assess if laparoscopy was feasible in cases of suspected GI obstruction. The results indicated that laparoscopy was equivalent to open laparotomy in regard to ability to diagnose an obstruction, with laparoscopy having a significantly smaller incision length; however, the time for laparoscopic explore was longer than for open abdominal explore. Additionally, complete laparoscopic explore was not possible in 3 of 16 cases, and conversion to a much longer incision length would have been needed to treat the obstruction in 4 of 13 cases where laparoscopic explore was feasible [58]. In another study, dogs undergoing single incision laparoscopic‐assisted intestinal surgery (SILAIS) were retrospectively compared with dogs undergoing open laparotomy for simple intestinal foreign body removal. Three of thirteen dogs in the SILAIS group required conversion to open laparotomy, but no postoperative complications occurred in either group. No significant differences were found in recovery time, surgical time, or duration of hospitalization between the two groups [59]. The results of these studies show promise for minimally invasive options for use in simple GI obstructions; however, more research is needed to determine if these options provide a benefit to the patient over traditional open procedures for intestinal foreign body cases.
Figure 5.6 Anatomy of the stomach and duodenum including the entrance of normal anatomic structures, such as the bile and pancreatic ducts, into the proximal duodenum.
Discrete Foreign Body
When removing a discrete foreign body, the enterotomy incision should be made in the normal small intestine immediately distal (aboral) to the foreign body (Figure 5.7a). Incisions made directly over a discrete foreign body are
