Journal of Feline Medicine and Surgery (2014) 16, 231–239

CLINICAL REVIEW

FELINE GASTROINTESTINAL
SURGERY
Principles and essential
techniques
John Williams

Principles of GI surgery Practical relevance: Gastrointestinal

(GI) surgical procedures are performed

Good pre- and perioperative care of the patient is essential when dealing
Pre- and perioperative patient care commonly in cats in general practice for

with the gastrointestinal (GI) tract, as for any surgery.1–5 Patients

both diagnostic and treatment purposes.

presenting for GI surgery may have fluid, acid–base and/or electrolyte

It is essential that the surgeon

imbalances, all of which must be corrected preoperatively. It is also vital

understands and adheres to the principles

that the response of the patient to fluid administration is monitored

of GI surgery in order that postoperative morbidity

before, during and after surgery. This is especially important in cats, to

and mortality are kept to a minimum.

prevent overhydration with its potentially life-threatening sequelae.6

Audience: This review is aimed at feline and
general practitioners wanting to update their
core skills in GI surgery. It discusses anatomical

The routine use of antibiotics is to be discouraged in order that we

Antibiotic prophylaxis considerations and surgical principles, and aims to

minimise the risks of development of multidrug resistance. Newer

familiarise the surgeon with techniques (some well

generation antibiotics (fourth and fifth generation cephalosporins), and

established, others newer) that will help to promote

the fluoroquinolones in
surgical success.

particular,7 should be
Equipment: Standard general surgical equipment

avoided. Moreover,
is required, together with the facilities to provide

there are strong

Rational perioperative antibiotic use adequate pre-, intra- and postoperative patient
< Use antibiotics when the risk of infection is high
arguments, on both
care.

scientific and ethical

or sequelae are significant Evidence base: The author draws on clinical
< Tissue levels of the antibiotic should peak at the
grounds, that antibiotics
experience and evidence from the literature,

with restricted use in

time that the scalpel cuts the tissue where appropriate, in reviewing the guidance
< Give the right antibiotic(s)
human medicine (eg,
and techniques under discussion.
< Use the intravenous route; oral absorption is
imipenem, vancomycin)
should never be used.
unreliable

It is a well established
< Administer an additional intraoperative dose only

principle that peri-

when necessary: ie, for prolonged procedures

operative prophylactic
(>90–120 mins) or where there is high blood loss

antibiotics are warranted

< Keep postoperative doses to a minimum;
for some GI surgical
procedures (see box, left).8
generally, postoperative doses should not be

However, there is a strong

needed for GI procedures

argument for not using

antibiotics at all for gastric and small intestinal surgery when there is
no inflammation and the potential for abdominal cavity contamination
is low.8

John M Williams
MA VetMB LLB CertVR DipECVS FRCVS
Northwest Surgeons,
Delamere House, Ashville Point,
Sutton Weaver, Cheshire WA7 3FW, UK
Email: [email protected]

DOI: 10.1177/1098612X14523185
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JFMS CLINICAL PRACTICE 231
R E V I E W / Essential techniques in GI surgery

and Fusobacterium species and so is adequate

for surgery of the colon, where Gram-negative
aerobic and anaerobic bacteria predominate.
Table 1 Pathogens associated with postoperative infection

Cefuroxime has activity against Gram-positive

and Gram-negative organisms, with some
Body system/surgical site Common pathogens

activity against anaerobes. It is very effective

Skin Staphylococcus species (especially coagulase-positive

against Enterobacter species, some Proteus

S aureus)

species, E coli and Klebsiella species. For colonic

Escherichia coli and Pasteurella species (especially in
cats)

surgery a combination parenteral treatment

of cefuroxime and metronidazole (10 mg/kg
Gastric and upper intestinal Gram-positive cocci, enteric Gram-negative bacilli,

slow IV) has also been advocated.10

surgery anaerobes

Cefuroxime has a long half-life and, where

Colorectal surgery Enteric Gram-negative bacilli, anaerobes (especially

indicated, a repeat dose need only be given

Bacteroides species, Streptococcus species)

after 3–4 h. This compares with 1.5 h for

Modified from Brown9

clavulanic acid potentiated amoxicillin.

Antibiotic prophylaxis requires that the

When performing GI tract surgery it is all too

chosen drug is effective against at least Tissue handling

easy to overlook the fundamental require-

ment for gentle handling of tissue – which
80% of probable pathogens.

pertains not only to manual disruption but

The choice of antibiotic(s) for antimicrobial also to desiccation (see box below). Ensuring
prophylaxis is based on the most likely minimal surgical trauma is one of Halsted’s
Halsted’s principles

contaminating microorganism(s) for the GI principles of surgical technique that should

of surgery
< Minimal surgical
tract and their susceptibility to the drug(s) always be adhered to.
used. Antibiotic selection is by necessity
trauma (gentle

empirical but is based on clinical experience

tissue handling)
<
combined with published data. Antibiotic
Accurate Surgical approach to the

prophylaxis requires that the chosen drug is

haemostasis abdominal cavity
<
effective against at least 80% of probable The most common and useful surgical approach
Preservation of

pathogens (Table 1). to the GI tract of the cat is via a ventral midline
an adequate blood

Clavulanic acid potentiated amoxicillin laparotomy, which provides excellent access to

supply
<
(20 mg/kg) or cefuroxime (20–50 mg/kg), all the intra-abdominal organs.
Aseptic surgical

a second generation cephalosporin, are It is important to note that, when closing the
technique
<
commonly used. Amoxicillin with clavulanate laparotomy, suturing of the peritoneum is not
No tension on

is useful in the treatment of Gram-positive needed and may, in fact, inhibit healing and
tissues
<
bacilli and cocci, as well as Gram-negative predispose to adhesion formation.11–14 The
Careful tissue

bacilli including Escherichia coli. It also has an peritoneum rapidly migrates and seals over a
approximation
<
anaerobic spectrum that includes Bacteroides defect such as a closed laparotomy incision.
Minimisation of

Closure of the external rectus sheath provides

dead space

a reliable strong closure of a laparotomy

(Figure 2).15
All fascial tissues heal slowly and, as
Avoiding tissue desiccation
extended wound support is required, it is
essential to use an appropriate type and gauge
Desiccation of peri-

of suture material.14 The choice lies between

toneal cells occurs

simple interrupted sutures of non-absorbable

very rapidly under the

monofilament nylon or polypropylene (eg,

hot lights of an

Prolene; Ethicon), or a simple continuous

operating theatre. It is

pattern (Figure 3) of a synthetic absorbable

important to protect

suture material which retains a high

these cells and the

proportion of its tensile strength at 28 days.

underlying tissues,

Examples of the latter include polydioxanone

not only to prevent

(eg, PDS II; Ethicon), which retains 50%

desiccation but also

strength, and polyglyconate (eg, Maxon;

to minimise heat loss.

Covidien), which retains 41%.16 The gauge

Figure 1 Saline-moistened laparotomy swabs (sponges)
This can be readily placed under the tines of a Baby Balfour retractor to

depends on the size of the patient; 2 metric

achieved with the use protect tissues and to minimise desiccation and heat loss

(3/0) is suitable for most cats, although 3

of large sterile swabs

metric (2/0) may be considered for some of the

(sponges) soaked in warm sterile saline and placed under the tines of self-

larger breeds.
retaining retractors (Figure 1).

While non-absorbable monofilament suture

Swabs, of any size, must be counted at the start and end of an abdominal

material (nylon or polypropylene) has been

procedure and should incorporate a radiopaque marker to allow for non-
invasive detection should the need arise.

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 R E V I E W / Essential techniques in GI surgery

Healing processes and

Linea alba
Rectus abdominis muscle implications for suturing
Though the GI tract is constantly exposed
to food, enzymes and bacteria, by virtue of
External abdominal
a oblique muscle

its rich vascular supply, healing is usually

uncomplicated and is relatively fast due to the
capacity of the epithelium to regenerate and
Falciform
Transverse fascia ligament and fat

the natural defences against leakage provided

peritoneum
Internal abdominal

by the omentum and peritoneum. The healing

Transversus
abdominis muscle oblique muscle

process itself is arbitrarily divided into three

phases, but as with all physiological events
there is overlap between these, and the
divisions are there for ease of understanding.
b

< Lag phase Begins on day 1 and continues

for 3–4 days. It is during this phase that the
fibrin clot forms; it has minimal strength
in holding wound edges together, but helps
to minimise leakage. By day 3, epithelial
migration will have occurred, sealing the
c
Ventral ligament

wound. This is the most critical phase of

of bladder

healing and dehiscence/breakdown are

most likely to occur during the first 72–96 h.
At this stage, wound strength relies entirely
Figure 2 Cross sections
of the ventral abdominal wall

on the sutures.
taken at three levels in a

< Proliferative phase Occurs from days

craniocaudal direction (a to
c). Note the lack of covering

3 and 4 through to day 14. Fibroblasts

of the deep layer caudally (c)

proliferate and produce immature collagen

and there is a rapid gain in wound-bursting
strength. Strength will be near-normal by
days 10–17 post-surgery.
< Maturation phase This phase is of little
clinical importance and continues from day
Linea alba

14 to about day 180. During this time there is

reorganisation and remodelling of collagen.
Figure 3 Simple continuous closure of the linea alba

used for fascial closure in cats,17 it reportedly

leads to an increased risk of suture sinus
Layers of the GI tract wall
formation18 and infection,19 and thus its
use cannot be recommended. Moreover, the
external abdominal fascia is no more likely to
dehisce with a continuous suture pattern than
Serosa

when simple interrupted sutures are used.17

The security of a continuous suture is only as
Muscularis

good as the two end knots and, therefore, a

sufficient number of throws must be used
Submucosa

with this pattern. Polydioxanone requires five

throws for the start knot and seven for the end
Mucosa

knot.20 The use of a barbed knotless wound

closure device comprised of a copolymer
of glycolic acid and trimethylene carbonate
< Serosa Layer of squamous mesothelial cells firmly attached to

(V-Loc 180; Covidien), which has an extended

the underlying muscle layers

absorption profile, can also be considered for

< Muscularis
the fascia.21
Inner circular and outer longitudinal layers of smooth
muscle
< Submucosa Layer of connective tissue connecting the mucous
Anatomy of the GI tract wall membrane to the muscle layers of the GI tract. It is

A cross section at any level of the stomach

the strongest layer of the GI tract and, from a surgical

or intestines will reveal four layers: serosa,

viewpoint, is the all-important suture-holding layer
< Mucosa
muscularis, submucosa and mucosa (see box
Layer comprising epithelial lining, lamina propria (loose

on the right).
supporting connective tissue with blood vessels and
lymphatics) and muscularis mucosa

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JFMS CLINICAL PRACTICE 233
R E V I E W / Essential techniques in GI surgery

For optimal healing by first intention in

the intestines, accurate apposition of wound
Two-layer closure is usually reserved
edges is required. Proper alignment of the
submucosa ensures that there is good
for the stomach. Single-layer closure is
approximation of blood vessels which carry
the vital cells and factors needed during the
adequate for the small and large intestines,

healing process. Direct apposition promotes

and is less likely to result in stenosis.
rapid re-epithelialisation and deposition of
well vascularised collagen, and minimises the
risk of reducing the bowel lumen diameter.
The large intestine poses a particular
problem to the surgeon because healing is The suture gauge needs to be 2 metric (3/0) for
Choice of suture material

slower than for the stomach or small intestine. the stomach; 1.5 metric (4/0) is preferred for
This has implications for suturing (see below). the small intestine. A monofilament synthetic
Also, bowel preparations (oral antibiotics, absorbable suture such as poliglecaprone 25
multiple enemas) are contraindicated as (Monocryl; Ethicon) should be used. This
enemas increase the risk of peritoneal spillage material is absorbed by hydrolysis and, as a
by producing a liquid slurry within the colon, monofilament, produces minimal friction and
which then readily leaks.10 drag as it passes through tissue. It has the
added advantage of having minimal memory,
which allows snug, safe knots to be produced.
One- or two-layer appositional suturing is the The absorption data of poliglecaprone 25 show
Choice of suture pattern

most logical within the GI tract. Two-layer that at 7 days it retains 50–60% of its strength,
closure is usually reserved for the stomach; at 14 days it retains 20–30% and at day 21 it has
single layer closure is adequate for the small lost all tensile strength. This makes it ideal for
and large intestines, and is less likely to result gastric and small intestinal surgery where
in stenosis.22,23 For two-layer closure, the inner prolonged wound support is not required. By
layer is the mucosa and submucosa, while the contrast it is not appropriate for fascia or other
outer layer is the muscularis and serosa. The tissue requiring extended wound support.
selection of suture pattern is very much an Where there is intraperitoneal sepsis or severe
individual choice, the options being simple inflammation of the bowel wall, for example,
interrupted (see box below), interrupted it would be prudent to consider a suture
crushing suture or simple continuous. material providing extended support, such as
The critical step with appositional suturing polydioxanone, as the healing process may be
is to pass the suture material through the delayed.24
submucosa (Figure 4), which is the vascular Chromic catgut should never be used in
and collagen-containing layer of strength feline GI tract surgery as it usually causes a
within the intestinal tract. A swaged-on taper severe inflammatory response, which can lead
point needle is preferred. The use of eyed to severe fibrosis and marked intestinal
needles is contraindicated in GI surgery. narrowing.16,25,26

Appositional intestinal closure

a It is critical to pass the suture through the
submucosa, which is the layer of strength
within the intestinal tract.

Serosa

Muscularis
Submucosa

Mucosa

Figure 4 (a,b) Appositional intestinal closure showing a simple interrupted suture passing through the submucosal layer
of the intestine

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 R E V I E W / Essential techniques in GI surgery

Omentalisation Serosal patching

Omentum has historically been regarded Serosal patching is a
as being of immense value in abdominal technique of particular value
visceral surgery as it is readily available where leakage is anticipated
and will help to seal off any potential leaks and/or there are multiple
from wounds. wounds in the intestinal tract
The effectiveness of omentalisation has (eg, after a ballistic injury).29
been questioned in recent years,10 and Patching can also be used
reports suggest that cats are far less like- to close significant defects
ly than dogs to suffer from post-intestinal in viscera (eg, following
wound closure leakage.3,28 Nonetheless, perforation or necrosis). The
the author still advocates its use as a technique involves suturing a
means of potentially reinforcing intestinal portion of jejunal serosa over Figure 5 Serosal patching: jejunum being sutured over
wounds and filling defects in the a wound or defect, thus a previously dehisced cystotomy wound

mesentery when necessary. Suturing of allowing serosa-to-serosa

omentum to wounds should be performed contact (Figure 5).30 Serosal patching appears to work, initially, because of the
with extreme care so as not to entrap reinforcing effects of the seromuscular and submucosal layers, which provide
blood vessels and thus compromise its resistance to intraluminal pressure. With time strong adhesions form to create a
function. permanent seal.

It has been established that initially the wound

Special considerations in the colon a

strength at the surgical site within the colon is

weak (around 30% of normal strength after
48 h),27 and that this weakness will last for a
minimum of 3–4 days. Subsequently, the
wound is at increased risk of dehiscence due
to collagen degradation by matrix metallo-
proteinases. Return of wound strength is
slower in the colon compared with the small
intestine, with around 75% of normal strength
regained at 4 months post-surgery27 versus
100% at 3 weeks, respectively. Care must be
taken in apposing the tissue and a suture such
b

as 1.5–2 metric polydioxanone is preferred, as

it provides extended wound support. Vascular
supply to the area can be augmented by
overlying the wound with omentum (see box,
above left).
An alternative technique that is extremely
useful in reinforcing and sealing intestinal
wounds where leakage is anticipated is
serosal patching (see box, above right).
Figure 6 Intestine isolated
from the abdominal cavity
with moist swabs

Enterotomy

An enterotomy is an incision
Figure 7 (a,b) A longitudinal incision is made with a number

through the intestinal wall

15 scalpel blade in the antimesenteric portion of the intestine

and is usually used to remove

foreign bodies, to carry out
full thickness biopsy or, of the abdominal cavity with saline-soaked
occasionally, to access the swabs (sponges) (Figure 6). Prior to
common bile duct via enterotomy, the intestinal contents should be
duodenotomy.31,32 milked away, cranially and caudally, from the
When performing an proposed incision site. If a foreign body is to be
intestinal procedure, it is removed, the incision is ideally made distal to
best practice to exteriorise the the obstruction in a healthy part of the bowel.
bowel to be incised and to A longitudinal incision is made with a number
pack it off from the remainder 15 scalpel blade in the antimesenteric portion

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JFMS CLINICAL PRACTICE 235
R E V I E W / Essential techniques in GI surgery

Figure 9 Mucosa ballooning out from the incised wound in a very inflamed jejunum

experience, transverse closure is always

required in cats following elliptical biopsy.33
The defect is closed with a simple interrupted
or simple continuous pattern of 1.5 metric
Figure 8 For full thickness biopsy an elliptical incision is

monofilament absorbable suture (Figure 10b,c).

made with a blade or fine scissors

The suture line can then be reinforced by

of the intestine (Figure 7). When a full wrapping omentum around the wound and
thickness biopsy is required this can be intestine; this should be tacked to the serosa
modified to an elliptical incision with a blade with 1.5 metric suture material.
or fine scissors (Figure 8). An alterative to creating an elliptical incision
Prior to closure of the site any mucosa for biopsy is to use a 4 or 6 mm skin punch
ballooning out from the wound (Figure 9) is biopsy instrument, which is ‘pushed’ through
trimmed away either with a scalpel or fine from the serosa to the lumen (Figure 11). The
Metzenbaum scissors. If routine longitudinal resulting defect is closed, either longitudinally
closure is likely to lead to significant narrowing or transversely (depending on the width of the
of the intestinal lumen, a transverse closure intestine), with simple interrupted 1.5 metric
is preferred (Figure 10a). In the author’s sutures.34

Figure 10 (a–c) Transverse

closure of the intestine
(using I.5 metric
monofilament absorbable
suture material) is always
required following elliptical
biopsy

b c

Figure 11 A 4 mm skin punch biopsy instrument being

‘pushed’ through from serosa to lumen

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 R E V I E W / Essential techniques in GI surgery

If there is a large lumen disparity – for

example, after ileocolostomy or if the pylorus is
Enterectomy

Enterectomy (intestinal resection and resected during a gastroduodenostomy (Bilroth

anastomosis) is usually necessary as a result of a I) procedure – the larger lumen (distal colon
foreign body impaction or intussusception that or gastric antrum) can be partially closed with a
has resulted in ischaemia and necrosis, or for simple continuous suture pattern until its
resection of intramural tumours. Transection diameter matches that of the remaining colon
should be carried out with a scalpel and resected or proximal duodenum (Figure 13).
tissue submitted for histological examination.
If there is lumen disparity, this can most
readily be addressed by spatulating the smaller
Alternatives to suturing for

lumen (Figure 12a). Simple interrupted sutures

anastomosis

of 2 or 1.5 metric (3/0 or 4/0) absorbable

monofilament suture should be placed at the Stapling devices are increasing in popularity
Stapling devices

mesenteric and antimesenteric borders initially in veterinary surgery and can be used either
(Figure 12b). The ends should be left long to to form an anastomosis or to close a bowel
allow their use as stay sutures; tension can be wound. GI anastomosis (GIA) instruments
maintained on the wound edges by gentle create a functional rather than a true end-to-
traction on the stays. The intestine is then end anastomosis (EEA). The technique also
sutured using an appositional interrupted or requires the cut ends of the bowel to be closed
continuous pattern on one side. Once either by hand suturing or by use of a suitably
closed, the intestines are rotated and the sized thoracoabdominal stapler.35
opposite side is closed. The author prefers to The main described advantage of stapling
use simple interrupted sutures in the cat as is the ease in which intestine of different
there is less risk of creating a ‘purse string’ diameters can be anastomosed – for example,
narrowing effect, compared with a continuous when the oral portion is dilated after intestinal
pattern. obstruction or when anastomosing small

Correction of lumen disparity

a b

Figure 12 (a) Lumen disparity is most readily addressed by spatulating the smaller lumen at its antimesenteric border.
(b) Simple interrupted sutures of 2 or 1.5 metric (3/0 or 4/0) absorbable monofilament material are placed at the mesenteric
and antimesenteric borders initially. The ends are left long to allow their use as stay sutures; tension can be maintained on
the wound edges by gentle traction on the stays

Figure 13 Where there is a big lumen

disparity, the larger lumen (eg, distal
colon) can be partially closed with a
simple continuous suture pattern until
it matches that of the remaining colon
or proximal duodenum

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JFMS CLINICAL PRACTICE 237
R E V I E W / Essential techniques in GI surgery

intestine to colon. There is less tissue introduced transcaecally into the colon; the
manipulation, and no difference in wound- intestinal ends are eased over the cartridge and
bursting strength or absolute strength during anvil and the purse string sutures are tied.
the healing process compared with sutured The bowel segments are then pushed together
anastomosis.36 Disadvantages are similar to and the EEA stapler is closed to fire the staples.
those of sutured anastomosis, with leakage, The stapler is then opened slightly and rotated
abscess formation and late foreign body to ease it around the staple line so that it can
obstruction at the stapled site having been be removed.
described. In addition, mucosal ulceration The stapled anastomosis should be inspected
has been described as a not uncommon for gross leakage and/or haemorrhage and
complication of stapling.36 the caecal wound closed with either an
It is essential to note that use of a GIA linear appositional suture pattern or thoraco-
stapler is not appropriate in cats (and restricted abdominal stapler.25
to larger dogs), as the forks need to enter the
intestinal lumen. The smaller endoscopic linear
cutting stapler can be used in cats, but it is The biofragmentable anastomosis ring (BAR
Biofragmentable anastomosis ring

expensive to use. Costs may be offset by device, Valtrac; Covidien) is introduced after
reduced surgical times, especially where there colonic resection, which is carried out using
is luminal disparity. the same technique of Furniss purse string
Tubular EEA stapling can be carried out suture placement that is used for an EEA
transcaecally25 or transrectally37 in cats. In 15 stapler. Once the colon is resected the BAR
cats that underwent the ‘single surgical field’ device is passed into the orad lumen of the
transcaecal approach there were no long-term colon using a holding device, and the purse
complications.25 With a ‘dual surgical field’ string suture is then tied securely against the
transrectal approach, 2/10 cases developed internal barrel of a 25 mm BAR ring (with a 1.5
strictures at the anastomosis site. Further mm gap width). Once secured the BAR ring is
prospective clinical evaluation of these placed in the aboral colonic segment and the
techniques is warranted, with current data purse string suture tied. The BAR ring is
suggesting that a ‘single surgical field’ snapped shut by applying digital pressure on
approach should be adopted in cats.10 its caps through the colonic wall. This creates
For the transcaecal approach the caecum and an inverting serosa-to-serosa anastomosis. The
colon are exteriorised and packed off with wound is checked for leakage and
moistened swabs. Vasa recta are ligated and haemorrhage before an omentum wrap is
divided as necessary and colonic contents are placed over the site.38
massaged away from the transection sites. The major disadvantages of the EEA and
Doyen intestinal forceps are placed proximal BAR devices are cost and size. It is clear that
and distal to these planned sites. A Furniss they are not suitable for all cats.
purse string instrument is placed at the
proximal and distal limits of the colectomy site,
some 2 cm distal to the caecum and 2 cm
proximal to the pelvic brim. This allows a
purse string suture to be placed at both sites
using 2 metric (3/0) monofilament suture KEY POINTS
material on a straight needle. It is essential
that this is placed accurately to allow even
< Perioperative antibiotics should only be used if they are absolutely
inclusion of the intestine in the stapling device.
necessary. They are not a substitute for poor surgical technique.
The colon is transected with a scalpel blade, < Abdominal exposure should be achieved via a ventral midline
using the Furniss purse string instrument as a
cutting guide.
approach. Only closure of the skin, subcutaneous tissues and

After removal of the purse string instrument,

fascia is required; muscle and peritoneum should not be sutured.

a 3 cm incision is made on the antimesenteric

< Anatomical realignment of the intestinal wall allows for optimal

surface of the caecum, and an ovoid sizer

healing, with simple appositional sutures being preferred.

lubricated with sterile water-soluble gel is < Small gauge suture materials are favoured, with 1.5 or 2 metric
introduced through the caecal incision and
advanced normograde to the proximal colonic
sizes being ideal in cats.
< Synthetic absorbable sutures cause less reaction than
margin. Ovoid sizers are essential to allow
measurement of bowel diameter so that an
non-absorbable sutures. Catgut should never be used in

appropriately sized staple cartridge is chosen

intestinal surgery, due to the reaction it induces.

and that the colon is dilated sufficiently to

< In general, feline intestines heal well and the
facilitate introduction of the EEA instrument.
reported risks of dehiscence are low.

For most cats, either a 25 mm or 21 mm

cartridge is appropriate.25,37 The EEA stapler is

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 R E V I E W / Essential techniques in GI surgery

18 Hosgood G and Pechman RD. Suture sinus in the linea alba of

two dogs. J Small Anim Pract 1992; 33: 258–288.
Funding

The author received no specific grant from any funding agency in 19 Krukowski ZH, Cusick EL, Engeset J and Matheson NA.
the public, commercial or not-for-profit sectors for the preparation Polydioxanone or polypropylene for closure of midline
of this article. abdominal incisions: a prospective comparative clinical trial.
Brit J Surg 1987; 74: 828–830.
20 Rosin E and Robinson GM. Knot security of suture materials.
Vet Surg 1989; 18: 269–273.
Conflict of interest

The author does not have any potential conflicts of interest to 21 Patri P, Beran C, Stjepanovic J, Sandberg S, Tuchmann A and
declare. Christian H. V-Loc, a new wound closure device for peritoneal
closure – is it safe? A comparative study of different peritoneal
closure systems. Surg Innov 2009; 16: 237–242.
22 Coolman BR. Historical perspective of intestinal anastomosis in
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