of the greater curvature; note the extensive white/gray and black areas of the stomach wall.
Open Resection
Intact blood vessels supplying the area to be resected are ligated and the affected portion of the stomach is sharply excised using a scalpel blade. The resection is continued until the cut edges are actively bleeding. This will ensure removal of all non‐viable tissue and allow normal healing. The stomach is then closed in two layers using an appropriately sized synthetic absorbable suture material (e.g. 2‐0 or 3‐0 polydioxanone). The mucosa and submucosa are closed with a simple continuous pattern and then the seromuscular layers are closed with a continuous or interrupted pattern, which may be appositional or inverting. The closure can be reinforced by over‐sewing a third layer with a continuous inverting pattern such as Cushing's or Lembert.
Stapled Resection
Partial gastrectomy can also be performed using surgical stapling devices. This technique is quicker and technically less demanding [53]. The additional expense of the stapler may be offset by the reduced operating time. Another advantage is that the resection can be performed without entering the gastric lumen and hence there is no risk of leakage and contamination as with an open resection. A linear stapler or linear cutter stapler can be used for this purpose. The size of stapler will vary on the amount of tissue to be resected and the size of the staple will depend on the thickness of the tissue. The staple line should be reinforced by oversewing with a continuous inverting suture pattern (Cushing's or Lembert).
Gastric Invagination
An alternative approach to gastric resection is to invaginate the affected portion of the stomach [54]. Simply, the affected area is folded inwards and healthy tissue is sutured together over it. The tissue should be sutured with two layers of a simple continuous or inverting suture pattern using synthetic absorbable material (e.g., polydioxanone). With time, the affected portion of the stomach undergoes further necrosis, is sloughed into the gastric lumen and is digested. The potential advantage of this technique is that it is technically easier and quicker than a partial gastrectomy and the technique does not enter the gastric lumen. In an experimental study of eight dogs with devitalization of a portion of gastric wall treated with invagination, 50% suffered gastric hemorrhage and melena [54]. These complications were also reported in a clinical patient with GDV and gastric necrosis that was treated with invagination [55]. This dog suffered significant hemorrhage 21 days following the procedure. For this reason, the authors would recommend partial gastrectomy over invagination in all instances. However, invagination may be a useful technique for inexperienced surgeons or when there are significant time limitations due to instability of the dog under anesthesia.
Splenectomy
The spleen is closely associated with the greater curvature of the stomach and, as a result, splenic torsion is common in dogs with GDV. Once repositioned, the spleen should be assessed for compromise of its vascular supply, specifically avulsion or obvious thrombi. If thrombi are present, the vessels should be ligated, and the spleen removed to prevent the release of thrombi into the circulation. Otherwise, the spleen should be allowed 5–10 minutes to reperfuse following untwisting prior to further assessment. Black areas of the spleen indicate infarction and a partial or complete splenectomy should be performed. In practice, a total splenectomy is preferred as it is technically easier to perform. If the spleen has undergone a complete torsion (i.e., twisted around its pedicle) or is obviously non‐viable, it is preferable to perform a splenectomy prior to untwisting to prevent the release of thrombi and myocardial depressant factors. This may not be possible until the stomach has been repositioned. Studies suggest that splenectomy is required in 10.2–22.6% of dogs treated for GDV [7, 9, 12, 13, 23, 52]. Splenectomy has been identified as a risk factor for mortality, particularly when associated with gastric resection [7, 9, 12, 52].
Gastropexy
An appropriate gastropexy is a vital part of treatment for GDV, forming a permanent adhesion between the stomach and the body wall to prevent recurrence. Since the pylorus is the most mobile part of the stomach, the gastropexy should be between the pylorus and the right body wall.
In a prospective study, the median survival time was significantly greater for dogs treated with surgical decompression and gastropexy compared to those treated with surgical decompression without gastropexy, with a recurrence rate of 4.3% compared with 54.5% [51]. In the same study, the mortality rate for dogs that did not have a gastropexy performed and suffered recurrence was 83.3%. In another study, dogs treated with surgical decompression without gastropexy had a 50% recurrence rate at six months, which was significantly greater than the 0% recurrence rate for dogs treated with surgical decompression and circumcostal gastropexy [56]. The mortality rate within the first year was also significantly greater for the dogs that did not receive a gastropexy.
Gastropexy techniques include incisional, belt‐loop, circumcostal, tube, incorporating 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
