R e p e a t C e l i o t o m y — C u r ren t

S t a tus
David E. Freeman, MVB, PhD*, Anje G. Bauck, DVM, PhD

KEYWORDS
 Colic  Surgery  Repeat celiotomy  Complications  Postoperative reflux

KEY POINTS
 Repeat celiotomy is a life-saving procedure in horses that have developed a surgically
treatable postoperative obstruction; however, identifying the cause of obstruction can
be difficult, before and during the second surgery.
 Timing of repeat celiotomy is critical because a delay in the decision process can worsen
the prognosis and put the total cost of treatment out of reach for the owner.
 Complications of repeat celiotomy can be life threatening, including incisional complica-
tions and adhesions; however, repeat celiotomy does not seem to exacerbate postoper-
ative ileus, despite the additional surgical manipulation required.
 An important benefit of repeat celiotomy is termination of hopeless cases, thereby
reducing cost and suffering.
 Although postoperative ileus is a recognized cause of postoperative reflux, overemphasis
of its role in postoperative reflux can delay the decision for a necessary repeat celiotomy.

INTRODUCTION

Horses that require a repeat celiotomy during the same hospitalization period as the
first surgery (defined as early repeat celiotomy) can constitute 5% to 15% of all surgi-
cal colic cases, mostly in horses treated for small intestinal diseases.1–13 In this article,
the emphasis will be on early repeat celiotomy after small intestinal surgery, although
large intestinal diseases will be addressed briefly.
Surgeons can experience a considerable mental block to repeat celiotomy, largely
because of the possible perception of a surgical error,2 and such errors can account
for 33% to 57% of early repeat celiotomies.4,9 The decision for repeat celiotomy relies
on many of the same diagnostic approaches as for the first surgery but with the addi-
tional possible finding of a deviation from the expected response to that surgery.1 This
applies to signs of postoperative colic (POC), which should usually be eliminated by
the first surgery. Postoperative reflux (POR) and systemic inflammatory response syn-
drome (endotoxemia) should also be resolved by the first surgery but their persistence

University of Florida, College of Veterinary Medicine, Gainesville, FL, USA

* Corresponding author.
E-mail address: [email protected]

Vet Clin Equine 39 (2023) 325–337

https://doi.org/10.1016/j.cveq.2023.03.012 vetequine.theclinics.com
0749-0739/23/ª 2023 Elsevier Inc. All rights reserved.
326 Freeman & Bauck

can be erroneously accepted as a typical response to small intestinal surgery.10

Recognition of risk factors for repeat celiotomy could also guide the decision, such
as jejunocecostomy at the first surgery.9,11–13

INDICATIONS FOR REPEAT CELIOTOMY

The most common reasons for repeat celiotomy are POR and POC.1,6,9 Although POC
can be managed by nasogastric decompression and analgesic drugs, severe signs
can demand a more aggressive approach.1,4,7 Suspicion of a postoperative bleeder
is a tempting reason for repeat celiotomy but identification of the responsible vessel
can be difficult.14 Although POR is regarded largely as postoperative ileus (POI), a dys-
motility induced by surgical manipulation, it is more likely a multifactorial response
with possible causes that require surgical treatment.1,10 However, this presents a
unique challenge because the clinical manifestation of POR is the same, regardless
of a functional or physical cause.2 A favorable response to medical treatment is
possible in most horses with POR15 but this response neither confirms POI nor rules
out a minor technical problem or physical obstruction that resolves with time.5 The de-
gree of pain in horses with POR varies and contributes little to the distinction between
POI and a physical obstruction.2,16 Some horses with POR can initially display mild-to-
moderate signs of colic that seem to resolve after gastric decompression.
Difficulty in maintaining either a packed cell volume (PCV) less than 50% after
24 hours of fluid therapy or an increasing PCV and decreasing total plasma protein
concentration could support the decision for a repeat celiotomy.2,17 Although
increasing heart rate could indicate the need for repeat celiotomy,17,18 this can be
misleading. Attempts have been made to identify clinical features of POR that would
distinguish between POI and a physical obstruction but the efficacy of these has not
been tested.18 The volume and duration of reflux can be similar in a horse with a sur-
gical reason for POR as in horses with a presumptive medical reason.15 Postoperative
fever was associated with finding a surgical cause of POR in one study but a cause
and effect relationship between these complications could not be determined.15 How-
ever, in a potential candidate for repeat celiotomy, a persistent fever could be another
contributor to the decision process.15
Transabdominal sonographic examination can fail to distinguish between physical
obstruction and POI because both cause small intestinal distention, static hypomotile
loops of normal wall thickness, and sedimentation of contents. Sonographic examina-
tion can be used to assess the linea alba closure if it is considered the problem,6 as
related to disruption, adhesions, and entrapment or inclusion of intestine in it. Sono-
graphic examination and abdominocentesis can be used to diagnose postoperative
hemorrhage or peritonitis. Abdominal palpation per rectum is of limited value
compared with sonographic examination and could stress the abdominal closure.19
Diagnostic findings per rectum might include cecal impaction,20 small intestinal
distention, or a tight mesenteric band.9 Abdominocentesis is helpful if the horse has
severe septic peritonitis but increased peritoneal fluid neutrophils and total protein
can be expected within the first week of the initial surgery.21 A repeat celiotomy should
be regarded as an important diagnostic procedure, in the same way as the first surgery
was considered.

TIMING OF REPEAT CELIOTOMY

Early repeat celiotomy is usually related in time to the first surgery,6 although the dura-
tion of signs is probably a more critical issue.1 The time element is important because
prolonged medical treatment can put a repeat celiotomy beyond the owner’s financial
 Repeat Celiotomy 327

reach, create complications from protracted treatment, including those related to fluid
therapy and delayed feeding, and favor adhesion formation. A tendency to overem-
phasize the role of POI in pathogenesis of POR can evoke the need for protracted
medical therapy and thereby delay the need for a repeat celiotomy. However, under-
estimating the importance of POI could prompt an unnecessary repeat celiotomy.15
The authors’ approach for POR that persists for the first 24 hours after it starts is to
discuss the possible need for repeat celiotomy with the owner. If POR decreases in
volume during the first 24 to 48 hours, continued medical treatment is justified; how-
ever, persistence to 48 hours and beyond should invoke a stronger consideration for
repeat celiotomy. Signs of POC, especially if difficult to control, can force an earlier
decision than POR.

TEAMWORK FOR REPEAT CELIOTOMY

Even experienced surgeons have limited experience with repeat celiotomy, and many
lesions that necessitate a second surgery can be subtle and different to what is typi-
cally encountered in colic surgery. Ideally, an experienced surgeon should be involved
in the repeat celiotomy.2 An experienced surgeon can guide the decision to reoperate
and can expedite the surgery so that the horse’s chances of survival are improved.

APPROACH AND EXPLORATION

The high incisional infection rate in the original midline incision if reused1 could justify a
paramedian approach22 (Fig. 1). If the paramedian and original ventral midline

Fig. 1. Healed paramedian incision (between arrows) used for repeat celiotomy because
midline incision was infected. Although the paramedian incision became infected, both in-
cisions healed without forming hernias. Prepuce is indicated (asterisk).
328 Freeman & Bauck

incisions both become infected,6 the abdominal wall can be weakened. However, full
recovery and return to expected use is still possible (Fig. 2).
If the original incision is used, the ventral abdomen is scrubbed and draped as for
any celiotomy, the adhesive skin drape is incised along the original incision, and
skin sutures are removed. Instruments used to that point are discarded and gloves
are changed.17 The exposed subcutaneous tissues can be rinsed with sterile physio-
logic saline and wiped gently to remove the excess solution and blood clots.17 The
subcutaneous and linea alba sutures are removed by cutting each strand below the
knots. Granulation tissue and draining tracts can be debrided as part of the surgical
approach or immediately before closure. An alternative approach is to remove the
skin sutures during the preliminary scrub, so that the linea alba edges can be
scrubbed. This approach might be preferred by some surgeons but could be irritating
to raw tissue edges.
In most cases, peritoneal surfaces are not inflamed and peritoneal fluid is sparse
and serosanguinous. The degree of small intestinal distention can be less than ex-
pected, possibly because of effective preoperative decompression through a naso-
gastric tube. The anastomosis or previously strangulated segment should be sought
by tracing from the ileocecal fold orally. The anastomosis should be exteriorized
with care to void damage to it and should be checked for a kink or excess tension
caused by an error in placement or orientation.17 A jejunocecal anastomosis can be
difficult to exteriorize, especially if it’s most aboral part was placed high on the cecal
body. Access can be improved with careful traction on the cecum and possibly exte-
riorization of the large colon. Some fibrin might be evident on the anastomosis and sur-
rounding tissues (Fig. 3) but this can resolve in time. Serositis close to or on an
anastomosis or enterotomy is not unusual and possibly not clinically important unless
associated with another finding. Peritonitis is usually evident as excess serosangui-
nous peritoneal fluid with numerous fibrin tags (Fig. 4). If accompanied by an odor,
then intestinal leakage from an anastomosis, enterotomy, or ruptured viscus should
be suspected.

TYPICAL FINDINGS

Potential causes of postoperative obstruction that indicate a need for early repeat
celiotomy can be categorized as failure to correct the original lesion, development

Fig. 2. Horse in Fig. 1 to demonstrate absence of hernia formation and satisfactory abdom-
inal contour, despite infection in midline and paramedian incisions after repeat celiotomy
6 years previously.
 Repeat Celiotomy 329

Fig. 3. Impacted jejunojejunostomy that caused reflux in less than 12 hours after the first
surgery (before feeding) and necessitated a repeat celiotomy 38 hours postoperatively.
Note fibrin tags on intestine and mesentery (arrows).

of a new lesion, recurrence of the primary lesion, or surgery-related complication. The

most common pathologic or obstructive findings are stenosis or impaction at an anas-
tomosis (see Fig. 3), distended small intestine (as the sole finding or secondary to an
obstruction), adhesions, torsion/volvulus, flexion, intussusception, and intestinal

Fig. 4. Peritonitis with serosanguinous peritoneal fluid and fibrin can be managed in milder
cases if the cause can be eliminated.
330 Freeman & Bauck

ischemia or necrosis.1,2,4,8,9,12,16,23–25 Although focal adhesions usually cause

obstruction after hospital discharge, they can cause POR and POC during hospitaliza-
tion,24 even within 5 days after surgery.9 Although anastomotic impaction is regarded
as a risk of early feeding, it usually develops before feed is offered, probably with dry
matter already in the stomach.1,2,9,25 Consequently, this common cause of postoper-
ative obstruction should not be ruled out because of an early onset of signs, and can
develop in all anastomoses, including jejunocecostomy (Fig. 5), with a possible
greater risk with jejunoileostomy. Jejunoileostomy was associated with more repeat
celiotomies in one study than with other small intestinal anastomoses,26 which can
be related to anastomotic impaction in the author’s experience.9
Vascular complications can develop from failure to ligate a mesenteric vessel during
resection, failure to accurately identify nonviable intestine, progression of vascular
changes from the primary disease, continued ileal necrosis, coagulopathy, and
venous thrombosis in one or more sites.1,24–28 Mucosal ischemia extending orally or
aborally from an anastomosis might not be apparent on inspection of the serosal sur-
face.1 Less common lesions revealed at repeat celiotomy include anastomotic
leakage, mesenteric hematoma, blind-loop syndrome, mesenteric abscess, gastric
impaction.1–3,5,9,26

TREATMENTS AT REPEAT CELIOTOMY

Treatment of the obstruction revealed at repeat celiotomy should include the preven-
tion of recurrence whenever possible. For example, manual disruption or softening of
an impacted jejunojejunostomy by water infusion by any means could risk reimpaction
because of stenosis or a possible functional defect that interrupts transit. Conse-
quently, resection and revision of an impacted anastomosis are recommended. Con-
version to jejunocecostomy is recommended for an impacted jejunoileostomy. An
impacted jejunocecostomy is difficult to revise because opportunities for the replace-
ment on the cecum are limited. Instead, lavage through a jejunal enterotomy followed
by the extension of the oral end of the anastomosis should be effective29 (Fig. 6).
Adhesions to the anastomosis or nearby intestine usually require adhesiolysis and
even resection of the involved intestine and anastomosis.8 Extensive and mature adhe-
sions are usually beyond treatment. Anastomotic leakage is a very rare complication
in small intestine, and it can be treated by resection of the affected anastomosis.

Fig. 5. Impacted jejunocecostomy at repeat celiotomy. Manual breakdown of such impac-

tions can be traumatic (see text).
 Repeat Celiotomy 331

Fig. 6. Incisions required in jejunum and cecum (red broken lines) to extend a stoma consid-
ered too small in a horse diagnosed with impacted jejunocecostomy at repeat celiotomy.
The edges thus created are apposed from jejunum to cecum to end at the red arrow. The
impaction is resolved beforehand (see text) through an enterotomy in jejunum about 1 m
from the anastomosis, indicated by the short black line.

Abdominal lavage might be required if obvious septic peritonitis has developed. A focal
leak in a jejunocecostomy could be repaired with interrupted sutures without resection
if the margins are viable17 and the lumen can be preserved because revision and relo-
cation to another site on the cecum is difficult.
If a jejunocecostomy needs revision at early repeat celiotomy, the jejunum is de-
tached from the cecum and resected as needed and the remaining opening in the
cecum can be used for the revised handsewn side-to-side or end-to-side anasto-
mosis. Any excess in the cecal opening is closed separately to meet the new anasto-
mosis. Placing the new anastomosis further distally or laterally on the cecum (between
the dorsal and lateral cecal bands) or even bypass of the cecum with a jejunocolos-
tomy might be considered in some cases.
In horses that have had a small intestinal strangulation, the large colon can acquire a
“vacuum-packed” appearance (Fig. 7), presumably the consequence of correcting
systemic dehydration by intense water absorption from the large intestine.30
Response to colotomy for the removal of dehydrated contents can be favorable,
even when this is the only procedure performed at repeat celiotomy following a pri-
mary small intestinal disease.1 This response can be explained by the observation
332 Freeman & Bauck

Fig. 7. Vacuum-packed ventral colon at repeat celiotomy with deep crenellations (arrows on
examples) caused by dehydration and contraction of contents. Removal of such contents by
colotomy could contribute to resolution of reflux.

that such impactions can be slow to resolve, which could delay cecal emptying and
thereby cause downstream resistance to small intestinal transit.

EXPECTED RESPONSE TO REPEAT CELIOTOMY

In most cases, early repeat celiotomy saves horses that might otherwise die but it can
also terminate a hopeless case at a reasonable cost and with reduced suffering.1 Most
horses should demonstrate an immediate favorable response to a repeat celiotomy,
evident as improved attitude and interest in food shortly after recovery from anes-
thesia. After a repeat celiotomy, horses can be fed according to a typical postopera-
tive schedule,9 thereby deriving full benefits from early postoperative feeding. Early
feeding and voluntary water consumption can be beneficial through reducing IV fluid
therapy and hospital stay.
Finding “nothing abnormal” at the second surgery and only decompressing dis-
tended small intestine might lead to a favorable outcome. It might also indicate that
a lesion was missed. This could be attributed to the rarity of some complications
and their subtle manifestation, such as an anastomosis that does not function normally
despite normal physical appearance. The intestine is usually distended proximal to the
anastomosis in such cases. Repeat celiotomy would seem counterintuitive as a treat-
ment of POR because of the risk of exacerbating POI through intestinal manipula-
tion.31 However, one study on small intestinal strangulation reported that manual
decompression resolved POR in 3 of 4 horses,8 possibly by eliminating some of the
adverse effects of persistent intestinal distention.32,33 In a more recent study on stran-
gulating diseases in the jejunum, repeat celiotomy (1 or 2) completely eliminated POR
in 81% of horses with this complication and eliminated POC in all horses1 (Fig. 8).
Apparently, tissue handling associated with the second surgery, possibly as much
or more than at the first surgery, does not increase the risk of POR1 (see Fig. 8).

COMPLICATIONS AND SURVIVAL RATES

Short-term postoperative complications following repeat celiotomy include incisional

complications and adhesions. If the original ventral midline incision is reused, the risk
of postoperative incisional infection and hernia formation is approximately 4-fold
higher compared with a single celiotomy in the same hospitals.1,4,6,9,34 This suggests
 Repeat Celiotomy 333

Fig. 8. Response to repeat celiotomy in 19 horses recovered from surgery to treat POR only,
POR and POC, and POC only. Repeat surgery resolved POC in all horses, and 1 or 2 repeated
surgeries resolved POR in all but 3 with this complication. (Data from Ref.1)

a deep infection with profound adverse effects on wound healing.6 The high rate of
incisional complications after repeat celiotomy can reduce client satisfaction and re-
turn to athletic activity, and increase cost of treatment. Consequently, this risk must
be included in the decision process, balanced against the life-saving benefits.
Repeat celiotomy has earned a negative reputation, largely based on highly variable
short-term survival rates compared with a single surgery (27% to 86% survival for repeat
celiotomy).1–4,6–9,23,26,27,35 Long-term studies suggest a decline in survival rates,3,4,6–9,27
possibly because of a greater risk of adhesion formation than after a single surgery.2,4,36
Horses that had multiple celiotomies in one study were almost 3 times less likely to start a
race compared with horses that had only one colic surgery.37 However, some horses can
survive to the ends of their expected life spans after repeat celiotomy.1,38
Intraoperative euthanasia has been identified as the most common cause of death
for horses that had a repeat celiotomy2–4,35 at 21% to 30%, probably because of
financial constraints, irreparable lesions,7 and a poor prognosis.35 Findings that lead
to euthanasia during repeat celiotomy include severe peritonitis with extensive fibrin
deposition and adhesions (Fig. 4), intestinal rupture or necrosis, or uncontrollable
intra-abdominal bleeding.2 Reasons for euthanasia after repeat celiotomy are perito-
nitis, ischemic intestinal necrosis, ruptured viscus, anastomotic leakage, obstructive
adhesions, POR, POC, severe endotoxemic shock, and colitis.3,4,39
A favorable prognosis for survival7 and a positive response to a second surgery
have been associated with POC as the clinical indicator for repeat celiotomy1 (see
Fig. 8). Possibly uncontrollable pain pushes the surgeon and owner to a repeat surgery
promptly, whereas other complications, including POR and peritonitis, can have a
more insidious course and induce a lower sense of urgency. A favorable outcome
could also be expected in a horse with distended small intestine at the second sur-
gery,1,7 possibly because this finding is associated with a lesion that is amenable to
correction. Increased PCV at 24 hours after the first surgery, peritonitis as the reason
for repeat celiotomy, and adhesions as the major findings at the second surgery yield a
poor prognosis for recovery.7

WHEN TO STOP

Horses can undergo repeat celiotomy 2 or more times during the same hospitalization,
and survive to hospital discharge.1,3–5,9,24 If repeat celiotomy reveals an untreatable
334 Freeman & Bauck

problem, such as extensive adhesions, peritonitis from a nontreatable source (see

Fig. 4), and hemorrhage from an inaccessible vessel, euthanasia spares the horse
from further suffering and the owner from the expense of protracted and ineffective
medical treatment.

SUMMARY—SMALL INTESTINAL SURGERY

 No single guideline should be interpreted in isolation as an indicator of repeat cel-
iotomy, with the possible exception of uncontrollable POC.
 Delays in repeat celiotomy consume the owner’s finances to the point that a
repeat celiotomy is beyond his/her financial reach and might adversely affect
the outcome.
 Owners should be informed of the need for a second surgery shortly after the
relevant complications develop.
 Overemphasis on POI and its treatment can delay the decision process for a
repeat celiotomy.
 If in doubt about an anastomosis at repeat celiotomy, it should be resected,
especially if it was impacted.
 Future studies should focus on ways to reduce incisional complications after
repeat celiotomy.
 A critical goal of repeat celiotomy is to learn why the first surgery failed and then
to take that information to subsequent cases.

LARGE INTESTINE

The prevalence of POR is low after surgery for large colon diseases, and hence, a
repeat celiotomy is rarely indicated after this surgery. However, large colon displace-
ments are common causes of colic in horses and many of them, especially right dorsal
displacement of the colon, nephrosplenic entrapment (NSE), and large colon volvulus
(LCV) can recur.40 However, recurrence of these diseases is usually, but not always,
later in the postoperative course, within weeks to months after hospital discharge.
Consequently, when these horses are presented with a recurrent episode, their
abdominal incision has healed and they are in favorable systemic and cardiovascular
states. However, a preventive procedure might need to be considered by owner and
surgeon for these cases, such as colopexy or colon resection, or, in the case of NSE,
nephrosplenic space ablation.
Horses treated for impaction of the small colon at the first surgery could be at some
risk of reimpaction, especially in a small equid or foal. However, this is rare. A pelvic
flexure enterotomy can be performed at the first surgery to remove colon bulk and
thereby decrease this risk. A rare indication for repeat celiotomy in the large colon
is severe melena caused by a bleeding vessel in a colotomy.41 Recurrence of a cecal
impaction is always a concern after the first surgical treatment of this disease,20,42
especially if a jejunocolostomy is not performed or if a predisposing orthopedic dis-
ease persists.20,42 Recurrent cecal impaction can be late in the postoperative period
but can also develop within a few days after the first surgery. Colon resection can
cause POC but this is usually managed medically rather than by repeat celiotomy,
and usually resolves within 24 hours after onset. Repeat celiotomy because of poor
postoperative progress after large colon resection is usually unsuccessful, presum-
ably because of the greater bacterial and endotoxin loads from the colon and limited
access for further resection. A repeat celiotomy after correction of an LCV, without
resection, is rarely successful, even if the colon is resected at the second surgery. Ex-
amples of large intestinal diseases that can be missed at the first surgery and cause
 Repeat Celiotomy 335

persistent POC are small colon strangulation by lipoma,4 a small colon enterolith,43 or
impaction in the cecal cupola.44

DISCLOSURE

The authors have no relationship with a commercial company that has a direct finan-
cial interest in subject matter or materials discussed in this article. The authors did not
receive any financial support for any part of this study.

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