Following the ingestion of fishhooks, monofilament line, and fishing-line leaders used in trade fishing, loggerhead sea turtles (Caretta caretta [Linnaeus, 1758]) are quite often found stranded on the seashore or floating at the surface of the sea. When such foreign bodies lodge in the lumen of the esophagus, their removal can be easily achieved surgically by approaching the cervical portion of the esophagus from the ventral surface because of the soft and distensible nature of this part of the intestinal tract.1–4 In contrast, to remove foreign bodies that are lodged in the more distal portions of gastrointestinal tract (perhaps causing obstruction of the intestinal tract or perforation of the gastric or intestinal wall), it is necessary to make a surgical approach via the coelomic cavity.
In the limited available literature2,5,6 regarding intestinal surgery in sea turtles, it is suggested that the surgical approach to the stomach and duodenum requires plastron osteotomy. However, after undergoing plastron osteotomy, an extended recuperative period is required before the turtle can be released from captivity because plastron healing times are long.2,5,6 The purpose of the study reported here was to describe the surgical approaches to the coelomic cavity in loggerhead sea turtles via the axillary region (to remove fishhooks located in the gastroduodenal portion of the intestinal tract) and via the inguinal region (to remove fishhooks and fishing lines located in other portions of the intestines [jejunum to colon]).
Procedures
Loggerhead sea turtles that had signs of gastrointestinal foreign bodies clinically and radiographically were included in the study (Figure 1). Each turtle was premedicated with medetomidine (80 μg/kg [36.4 μg/lb], IM) and ketamine (10 to 15 mg/kg [4.5 to 6.8 mg/lb], IM). After approximately 20 minutes, the turtle was intubated with an orotracheal tube. Anesthesia was maintained with a mixture of sevoflurane and pure oxygen in a nonrebreathing circuit; each turtle was manually ventilated (1 to 2 breaths/min). Once the turtle was anesthetized, it was placed in dorsal recumbency and the surgical site was aseptically prepared.
Dorsoventral radiographic view of a loggerhead sea turtle with a large fishhook in the stomach.
Citation: Journal of the American Veterinary Medical Association 228, 6; 10.2460/javma.228.6.922
For the extraction of fishhooks located in the stomach, an approach to the coelomic cavity through the soft tissues of the left axillary region was made. Access to the stomach through this region was attempted because of the proximity of that area to the stomach and the absence of important anatomic structures between the body wall and the stomach (Figure 2). A 4- to 6-cm incision was made along the cranial margin of the plastron (at a distance of about 10 to 15 mm from the margin), coinciding with the inframarginal plates. After the incision of the thick skin layer, the fatty subcutaneous tissue was dissected to expose the pectoralis major muscle. This was laterally dissected along the fibers until the coracobrachialis magnus muscle was exposed and dissected to reveal the coelomic membrane; incision of this membrane achieved entry into the coelomic cavity. Through this incision, the stomach was readily viewed. The stomach, located dorsal to the left hepatic lobe, was easily exteriorized and isolated by use of Allis forceps and gauze laparotomy sponges (Figure 3). The gastric wall was incised (3 to 4 cm) on the ventral surface of the organ, between the small and large curvatures. After removal of the hook, the stomach wall incision was closed with 3-0 polyglactin 910 suture in a double-layer inverting seromuscular suture pattern, which also included the submucosa in the first layer.
Endoscopic appearance of the coelomic aspect of the axillary region (A), stomach (S), and liver (L) in a loggerhead sea turtle.
Citation: Journal of the American Veterinary Medical Association 228, 6; 10.2460/javma.228.6.922
Illustration depicting the axillary approach to the coelomic cavity of a loggerhead sea turtle. The stomach is exteriorized through the incision.
Citation: Journal of the American Veterinary Medical Association 228, 6; 10.2460/javma.228.6.922
For the removal of fishhooks and long fishing lines located in the intestinal tract (from the jejunum to the colon), an approach to the coelomic cavity was performed via an inguinal approach as described by Brannian7 and Gould et al.8 A 30° laparoscope (10-mm diameter) was inserted through the incision to allow a detailed view of intracoelomic organs and examination of any pathologic changes in the intestinal tract. Inspection of portions of the intestine that were distended, edematous, congested, or plicated was possible by use of this procedure. After the terminal portion of the ileum was located and exteriorized, the more proximal portion of the intestine was exteriorized until the proximal portion of the jejunum was exposed (Figure 4). When the fishing line extended from the duodenum to the rectum, the middle portion of the jejunum was isolated by means of 2 intestinal clamps. Next, a 2-cm incision was made lengthwise on the antimesenteric side and, once exteriorized, the fishing line was cut to more easily unthread the proximal segment. The fishing line was carefully extracted via the oral cavity by an assistant, or the surgeon removed it via the enterotomy site. In turtles that had ingested a fishhook that had become lodged in the intestines, the incision was made at the location of the hook to allow its removal directly.
Photograph obtained during abdominal surgery in a loggerhead sea turtle. The proximal portion of the jejunum, the ileum, and the ascending colon have been exteriorized easily via an inguinal approach to the coelomic cavity; the intestines appear congested and plicated because of a long linear foreign body (fishing line) in the intestinal tract.
Citation: Journal of the American Veterinary Medical Association 228, 6; 10.2460/javma.228.6.922
In all turtles, the end of the remaining piece of fishing line was kept steady by use of mosquito hemostatic forceps; an intestinal clamp was placed at the level of the enterotomy. The enterotomy site was isolated and wrapped by gauze laparotomy sponges soaked with warmed sterile saline (0.9% NaCl) solution. The distal portion of the intestine was exteriorized until the end of the transverse colon was exposed; depending on the length of the fishing line, multiple (from 2 to 4) enterotomies were performed at regularly spaced intervals along the exposed intestine. At each enterotomy site, the fishing line was cut, and each segment of line was extracted through the incision that was immediately proximal to the site until all of the line was removed and the plication of the intestine was completely resolved. After repeated lavages of the coelomic cavity with sterile saline solution, the intestinal incisions were closed with 3-0 polyglactin 910 suture in a continuous double-layer suture pattern. If the intestinal wall was severely damaged, a wide segment was resected; end-to-end anastomosis was performed by use of 3-0 polypropylene suture in a double-layer simple interrupted pattern.
In all turtles, regardless of the approach used, the coelomic membrane and muscle layers were closed with 2-0 polyglactin 910 suture in a simple interrupted suture pattern; the same suture material was used to close the wide layer of subcutaneous fatty tissue, whereas the skin was sutured with 1-0 polyamide monofilament in an interrupted suture pattern. Approximately 20 minutes before the end of the surgery, administration of the anesthetic agent was discontinued and the turtle was allowed to breathe 100% oxygen; at the end of surgery, atipamezole (300 μg/kg [136.4 μg/lb], IM) was administered to aid recovery from anesthesia. For rehydration, each turtle received treatment with lactated Ringer's solution, and saline solution and 5% glucose solution (20 mL/kg/d [9.1 mL/lb/d]) were administered into the coelomic cavity for 1 week. Enrofloxacin (10 mg/kg [4.5 mg/lb/], IM, q 24 h) and ranitidine (0.3 mg/kg [0.14 mg/lb, IM, q 24 h) were administered for 10 days.
Results
Nine loggerhead sea turtles that were referred to the Department of Veterinary Surgery of the University of Bari by the World Wildlife Fund (Italy) Rehabilitation Centres in Policoro (Matera) and Lampedusa (Agrigento) underwent surgical treatment. The mean weight of the turtles was 18.5 kg (40.7 lb; range, 3.1 to 42.5 kg [6.82 to 93.5 lb]), mean length was 50.7 cm (range, 30.5 to 86.0 cm), and mean width was 45.1 cm (range, 26.0 to 64.0 cm). There were 2 females, 1 male, and 6 immature turtles.
On physical examination, 4 immature turtles had heavy monofilament leader line emerging from the oral cavity and cloaca (ie, the line extended through the entire digestive tract); radiographic examinations revealed that 1 of these turtles also had a fishhook located in the stomach. Among the 5 other turtles, 3 (the male and 2 immature turtles) had a fishhook located in the stomach, and 2 females had a fishhook located in the ileum and fishing line in the ileum and colon.
For the male turtle and 3 immature turtles that had a large fishhook lodged in the stomach, the approach to the coelomic cavity was made via the soft tissue of the left axillary region. In 3 turtles, the fishhook was easily removed from the stomach together with any attached fishing line; in 1 immature turtle, it was necessary to perform a second procedure to cut the fishing line that extended through the entire digestive tract because it could not be withdrawn in 1 piece.
A right inguinal approach to the coelomic cavity was performed in 6 turtles; these included the 2 female turtles with a hook in the ileum and fishing line in the ileum and colon and 4 immature turtles with fishing line extending through the entire gastrointestinal tract. In the female turtles, the fishing line and hook were removed via the right inguinal approach; in the 1 immature turtle from which the hook lodged in the stomach was removed via the left axillary region, the fishing line was removed by use of the right inguinal approach. In one of the females, splanchnoscopic inspection revealed turbid intracoelomic liquid and many intestinal tears along the mesenteric aspect of the ileum; an enterectomy was performed in this animal.
During the 24 hours following surgery, each turtle was kept wrapped with damp cloths in a few centimeters of warm water. By the second day, the sea turtles could easily swim when dipped into a tank containing water at a controlled temperature (always ≥ 24°C). During the week following surgery, the Head of the Rehabilitation Centre of Lampedusa reported by telephone that the condition of the sea turtle that had undergone enterectomy had progressively worsened and it had subsequently died.
Beginning 7 to 10 days after surgery, the remaining 8 sea turtles were fed small quantities of homogenized food by means of a gastric probe once per week. Force-feeding was beneficial for those sea turtles weakened by a long period of anorexia and those that did not begin to eat during the weeks following the surgery.
Within 3 to 5 weeks, dissected soft tissues had healed and the skin sutures were removed. After 3 to 6 weeks, all 8 sea turtles began to eat fish and shellfish unaided, and gastrointestinal function appeared to have normalized. After approximately 8 weeks, the turtles were well enough to be released from captivity.
Discussion
At present, plastron osteotomy is considered the principal surgical approach to the intracoelomic portion of the digestive tract in tortoises and terrapins5,9–11 or sea turtles.2,5,6 However, this technique has considerable drawbacks, including the long time required for complete healing of the shell2,5,9–11 and the difficulty of keeping wild marine reptiles in captivity.2,5
In sea turtles, fishhooks are often localized in the stomach and cranial portion of the duodenum. These sites cannot be accessed via an inguinal approach because they are located near the liver in the cranial aspect of the coelomic cavity. The possibility of accessing the stomach via the left axillary region was suggested because of the proximity of that area to the greater curvature of the stomach and the absence of important anatomic structures between the body wall and the stomach. These anatomic conditions had been confirmed by our previous splanchnoscopic experiences in sea turtles. In small-sized sea turtles, the available space in which to perform an axillary approach is quite narrow because of the scapulohumeral articulation medially, the presence of marginal plates, and the well-developed pectoral muscles. Placement of turtles in dorsal recumbency widens the space between the stomach and the site of the skin incision, and even in small-sized turtles, the stomach can be readily and completely exteriorized via this approach. Because of the elasticity of the soft tissues and the absence of organs or important vessels and nerves at the incision sites, both the axillary and inguinal approaches were easy to perform.
Compared with plastron osteotomy, the durations of anesthesia and surgery associated with the axillary approach to the coelomic cavity were shorter. The inguinal approach has been described in terrapins and tortoises for treatment of intestinal obstruction,8 surgical procedures involving reproductive organs, and inspection of intracoelomic organs.7 In our experience, the inguinal approach allows exteriorization and surgical treatment of most of the intestinal tract, from the distal aspect of the duodenum to the terminal portion of the colon. This was a determining factor in selection of this approach for the surgical removal of linear foreign bodies that extended through those parts of the intestinal tract. The choice of a right-sided inguinal approach was based on findings of our previous experience involving cadaveric turtles, which indicated that the right-sided approach allowed more of the intestinal tract to be exteriorized than the left-sided approach. In the turtle that had a fishhook in the stomach and fishing line extending through the entire digestive tract, the 2 surgical approaches could be carried out at the same time because they are not major surgical procedures. Moreover, the rapid wound healing of dissected soft tissues (3 to 5 weeks, compared with 12 to 18 months required following incision of the shell) resulted in shorter rehabilitation times and an early return to the wild.
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