A 4th lactation dairy cow, 35 days in milk (DIM), was referred to the Clinic for Ruminants and Swine, University of Leipzig, because of a poor response to “blind-stitch” fixation of LDA (timeline in Table 1). The cow originated from a 500-cow dairy herd and was transported more than 104 km to our clinic, which took approximately 2.5 h. The herd manager reported that the cow had a current milk production of 16 kg per day and had undergone the “blind-stitch” method for correction of LDA 2 days earlier. The cow had been treated in the 10 previous days with dexamethasone (three consecutive days 15 mL of Dexamethason-Injektionslösung ad us. vet. 2 mg/mL, Serumwerk Bernburg AG, Bernburg, Germany) and menbutone (50 mL on 5 of 10 days of 100 mg/mL, Menbutil, aniMedica GmbH, Senden-Bösensell, Germany), ketoprofen (20 mL on two of 10 days of Romefen^® PR 10%, Ceva Tiergesundheit GmbH, Düsseldorf, Germany), calcium (100 mL of Calcitat S50, Livisto/ animedica GmbH, Senden-Bösensell, Germany), oral propylene glycol (250 mL on 6 of 10 days, product label unknown), phosphorous and cyanocobalamin (30 mL on 5 of 10 days of Veyxol B-Phos, Veyx-Pharma GmbH, Schwarenborn, Germany), and rumen stimulans (300 g on 5 of 10 days of Pansenreaktiv, alfavet Tierarzneimittel GmbH, Neumünster).

Clinical examination revealed that the cow was acutely ill and had a slightly depressed demeanor and a body condition score of 2.25 (31). The vital signs were unremarkable; the rectal temperature was 38.9°C, the respiratory rate was 30 breaths per min, and the heart rate was 64 beats per min. Auscultation of the lungs and heart revealed no abnormal findings. The eyes were mildly sunken, and the skin turgor was slightly decreased. Rumen motility was absent, and rumen fill was poor, and stratification was absent. A ping sound could not be elicited on the right side of the abdomen but was prominent on the left, accompanied by splashing sounds over a wide area of the rib-supported part of the abdominal wall up to the height of the scapula. The density of the right abdominal wall was slightly increased. The manure was olive green in color and of medium consistency with some undigested long fibers. Suture material was palpable in the left paramedian area of the abdomen, approximately 5 cm cranial to the navel and 10 cm from the midline. The suture was in the center of a painful edematous swelling that was approximately 20 × 20 cm (Figure 1). Based on the severely abnormal demeanor of the cow, absent gastrointestinal motility, and moderate localized inflammation at the suture site, an acute severe complication of unsuccessful “blind-stitch” fixation was suspected.

Collection of a blood sample from a jugular vein for hematologic and biochemical analyses and a free-flow urine sample was done immediately after the physical examination (Table 2). The results showed an acute inflammatory process and tissue damage based on a high total leukocyte count and increased serum aspartate aminotransferase. In addition, decreases in dry matter intake and intestinal passage rate were reflected by lower than normal concentrations of serum magnesium, potassium, and urea, higher than normal serum bilirubin concentration, and a low urine chloride concentration (32). Ultrasonography revealed that the abomasum was located to the left of the median and extended dorsally between the rumen and abdominal wall. Echogenic structures indicative of fibrinous deposits were seen around the suture material, wound, and abomasum within the abdominal cavity (33).

Left displaced abomasum, acute moderate inflammation of the fixation site, and severe acute localized peritonitis were diagnosed. The fixation site was thought to be at an unsuitable location other than the intendent part of the abomasum.

After the initial clinical examination, the cow received an intravenous infusion of 5 L isotonic saline solution and 500 mL 40% glucose (both Serumwerk Bernburg AG). The cow was premedicated with an antibiotic (60 mL Trimethosel; 200 mg/mL sulfamidine and 40 mg/mL trimethoprim, administered intravenously; Selectavet, Dr. Otto Fischer GmbH, München, Germany) and a non-steroidal anti-inflammatory drug (15 mL Metacam; 20 mg/mL meloxicam, Boehringer Ingelheim Vetmedica GmbH, Ingelheim am Rhein, Germany). Distal paravertebral anesthesia and infiltration of the incision site with 200 mL isocaine (20 mg/mL procaine hydrochloride and 0.025 mg/mL epinephrine, Selectavet) were done. Right flank laparotomy was carried out to assess the extent of inflammation and the position of the abomasum and to perform an omentopexy (34).

The external skin surrounding the “blind-stitch” suture was cleaned and disinfected to facilitate subsequent removal of the suture material. The laparotomy showed that the pyloric part of the abomasum, approximately 10 cm cranial to the pylorus, was fixed to the ventral abdominal wall. The abomasum was displaced to the left but only slightly distended. The pexy was characterized by severe local fibrinous peritonitis corresponding to an extra-abdominal site of fixation. The liver was enlarged with blunted borders, indicating moderate to severe fatty infiltration attributable to lipomobilization (35, 36). The adhesions were carefully broken down, and the “blind-stitch” suture was cut externally and removed under careful visual monitoring to prevent further injury to the abomasum. The abomasum was then moved to its normal position, palpated, and inspected for ruptures or other lesions (Figure 2). It was cleaned using a 0.5% povidone-iodine solution (diluted Vet-Sept Lösung 10%, aniMedica GmbH, Senden-Bösensell, Germany). The lesion was repaired using inverted sutures, and an omentopexy was carried out (34). A total of 3.5 L of 0.5% povidone-iodine solution was placed in the peritoneal cavity before the incision was routinely closed.

The cow received infusion therapy consisting of 1.5 L of 40% glucose and 20 L of isotonic saline solution on the day of surgery and then approximately 1.5 L of 40% glucose and 10 L of isotonic saline solution per day for 3 days and 1 L of 40% glucose and 5 L of isotonic saline solution per day for the following 4 days. The cow showed signs of pain immediately after surgery and therefore received 50 mL of metamizole-sodium (500 mg/mL, Metapyrin, Serumwerk Bernburg AG) administered intramuscularly. On day 1 postoperatively, 30 L of warm water containing 250 mL propylene glycol and glycerin (Tirsana, H. Wilhelm Schaumann GmbH, Pinneberg, Germany), 250 g cooked linseed, 180 g NaCl, and 3 L of rumen fluid from a fistulated cow at the clinic were administered as a drench. On day 2 postoperatively, 60 mL sulfadimidine and trimethoprim (Trimethosel) was administered intravenously and continued once daily for 10 days. The cow also received 15 mL of meloxicam every other day for 10 days. An antiseptic solution (Vet-Sept) was administered intraperitoneally on day 1 (1 L) and on day 3 (2 L) postoperatively. Daily treatments with 250 mL propylene glycol and glycerin (Tirsana) were continued for 10 days.

The health of the cow improved gradually after surgery. The results of hematologic and serum biochemical analyses 1 day after surgery reflected localized inflammation and tissue damage; the results were similar to those on the day of admission but with a left shift and increased creatine kinase activity (Table 2). Decreased total protein and albumin concentrations and increased glutamate dehydrogenase activity confirmed hepatic injury. The normokalaemia indicated a resolution of the abomasal reflux. The rectal temperature was normal. An ultrasound examination done 3 days postoperatively showed that the peritoneal lesion was approximately 5 × 5 cm with a small amount of free hypoechogenic fluid in the xyphoid region. A second scan done 13 days postoperatively showed a reduction in the size of the inflammatory lesion with no free fluid in the abdomen and normal bi-phasic reticular contractions. The cow was discharged from the clinic 2 weeks after admission.