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
 2o
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
H2CO3
-
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 H2CO3
-
 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 8th
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
 T13, L1, and L2
 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 T13, L1, and L2 blocked at ends of
transverse processes of L1, L2, and L4 (not L3)
 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)
 11th
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 11th
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