THE ABDOMINAL EXPLORATORY: FROM XIPHOID TO PUBIS DR. STEVEN MEHLER, DACVS
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ONE METHOD OF SYSTEMATIC EXPLORATION The following steps ensure consistent abdominal exploration following celiotomy: 1 Balfour retractor is placed in the cranial aspect of the incision and an assistant pulls up on the sternal spoon portion of the retractor. This action elevates the xiphoid process to create a visual pathway to the area between the liver and the diaphragm . a. Sequential retraction of the left, central, and right divisions of the
liver in a caudal direction. The entire ventral central tendon aspect of the diaphragm , the hiatus of the vena cava , aorta , and esophagus are inspected and felt. b. Palpation along each lateral and dorsolateral aspect of the diaphragm is also performed to rule out congenital or traumatic defects. 2 Next, the liver is replaced against the diaphragm and the stomach is retracted caudally.
a. The common and proper hepatic arteries , the hepatic ducts and common bile duct , and some of the distal portion of the portal vein can be seen and palpated through the filmy layers of the gastrohepatic ligament and the lesser omentum. Identification of the vascular structures and ducts is facilitated by placing a finger into the epiploic foramen, which is located between the portal vein and the vena cava. b. Express the gallbladder gently and confirm patency of the common bile duct into the duodenum. i. Many surgeons express the gall bladder to ascertain patency of the bile duct; however, expressing the gall bladder is not as easily achieved as expressing the urinary bladder and is not necessary. ii. My preference is to apply the “Pillsbury Doughboy Test”. That is, gently poke the gallbladder with your index finger. The gallbladder should indent and spring back to normal position. 1. Failure to indent = gall bladder is overly distended due to obstruction. 2. If you are truly concerned about bile duct patency, perform a duodenotomy and cannulate the duct via the major duodenal papilla after you have completed the abdominal exploration. c. Next, one hand is placed up under the stomach to immobilize it from the dorsal side. The other hand is used to palpate the gastric cavity for foreign bodies or other internal masses from the ventral aspect.
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