Hernias & Ruptures

Question 1

What is a hernia?

Answer 1

• A protrusion of an organ or part of an organ through a defect in the wall of the anatomical area in which it normally lies.
• Generally consists of a hernialring and sac

Question 2

What is a rupture compared to a hernia?

Answer 2

Question 3

What can be seen here?

Answer 3

Here is the rupture visualised

Question 4

What are the locations of hernias?

Answer 4

• Umbilical
• Inguinal
• Incisional
• Diaphragmatic
• Perineal
• Pericardio-peritoneal
• Hiatal

Question 5

What are the aims of hernia surgery?

Answer 5

• Return hernia content to normal location
• Secure closure of neck of sac
• Obliterate redundant tissue in the sac
• Try to use the patients own tissues for repair

Question 6

How should hernias reduced?

Answer 6

• Some are non-reducible
• Directly incise over site
• Ensure adequate exposure
• Try to use atraumatic technique
• Breakdown adhesions
• Check viability of herniated tissues especially if strangulated hernia
• Resect non viable tissue before returning to abdominal cavity

Question 8

Discuss defect closure?

Answer 8

• Direct opposition if possible
• Know anatomy to ensure holding strength
• Don’t compromise vasculature
• Use sufficiently strong suture material; e.g., polydioxanone, polypropylene, etc.
• Monofilament to avoid sinus formation Defect closure

Question 9

What structures run through the inguinal canal?

Answer 9

The structures which pass through the canals differ between males and females:

in males: the spermatic cord and its coverings + the ilioinguinal nerve.

in females: the round ligament of the uterus + the ilioinguinal nerve.

The classic description of the contents of the spermatic cords in the male are:

3 arteries: artery to vas deferens (or ductus deferens), testicular artery, cremasteric artery;

3 fascial layers: external spermatic, cremasteric, and internal spermatic fascia;

3 other structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics;

3 nerves: genital branch of the genitofemoral nerve (L1/2), sympathetic and visceral afferent fibres, ilioinguinal nerve (N.B. outside spermatic cord but travels next to it)

Note that the ilioinguinal nerve passes through the superficial ring to descend into the scrotum, but does not formally run through the canal.

Question 10

Discuss tensionless closure?

Answer 10

• Use muscle flap; e.g., internal obturator for perineal hernia
• Polypropylene mesh if necessary
• Well tolerated, allows capillary and granulation tissue in growth
• Strict asepsis
• Omentum
• Eliminate dead space, drains if necessary

Question 11

Discuss umbilical hernias?

Answer 11

• Generally young
• Usually congenital due to failed embryogenesis
• Thought to be inherited
• True hernias-lined by peritoneal sac
• Can see in association with cryptorchid dogs

Question 12

Discuss umbilical hernias further?

Answer 12

• Clinically soft, painless swelling at umbilicus
• May be vomiting/abdominal pain if strangulation of bowel
• Normally contain fat/omentum, occasionally intestine Check diaphragm and heart

Question 13

How are umbilical hernias treated?

Answer 13

• Radiography not normally necessary
• Diagnose on palpation
• Can resolve spontaneously, or be corrected at neutering (fine to wait till neutering as long as no strangulation and it isn’t huge)
• Repair by reducing, incise over hernia, excise sac and repair muscle edges
• Don’t debride margins
• Close with synthetic, absorbable, monofilament suture; e.g., polydioxanone

Question 14

What is being done here in this umbilical hernia repair?

Answer 14

Illiptical incision around hernia mass

Reason:

You don’t know what is in the sac so if you boldly cut in could do an instant enterotomy and you don’t want to leave a saggy bit of stretched skin allowing good apposition of skin.

Always resect masses with an ellipse as apposition is better and no puckering occurs.

Question 15

Discuss an incisional hernia?

Answer 15

• Surgical closure of body cavity fails
• Generally linea alba
• Normally within 7 days
• Can be chronic
• These will be your fault and it will be due to your surgery that it happens.
• This is when a closure fails.
• Day 5 is weakest point for wound healing.

Question 16

What can be seen here?

Answer 16

Incisional hernia

Question 17

What are the causes of incisional hernias?

Answer 17

• Generally surgeon to blame
• Incorrect technique
• Incorrect suture material/pattern
• Entrapped fat between wound edges
• Infection
• Steroid therapy/cushingoid patient
• Poor post op care
• Can tell owner that dog moved around too much and didn’t follow aftercare but know it is your fault and do your stitching better.

Question 18

What are signs of incisional hernias?

Answer 18

• Oedema, inflammation and serosanguinous fluid often pre-empt
• Soft painless swelling
• Palpable defect
• Exposed viscera

Question 19

Discuss incsional hernia investigations?

Answer 19

• Commonly obvious but in some cases ultrasound might be useful
• Similar with x-rays and advanced imaging

Question 20

Discuss incisional hernia treatment?

Answer 20

• Repair asap
• Evisceration is an acute abdominal emergency
• Lavage and resect nonviable tissues/anastomose bowel if necessary
• Re-open and repair entire wound
• Only debride edges if infection or are non viable
• Suture EXTERNAL SHEATH OF RECTUS ABDOMINIS (strongest holding layer)
• Ensure monofilament suture, long lasting and appropriate size
• Chronic hernias often more difficult due to adhesions
• Peritonitis risk is sky high
• If owner rings and says bowel is hanging out say put water on it wrap with a towel and bring animal in straight away.
• Don’t use braided filament in the skin.

Question 21

Discuss traumatic abdominal rupture?

Answer 21

• Caused by blunt trauma/bite/kick
• Flank
• Prepubic
• Prepubictendons can rupture associated with pelvic fracture
• Can be easy to miss

Question 22

How should traumatic abdominal rupture be managed?

Answer 22

• Use same hernia repair principles
• Contaminated wounds e.g. bites, lots of lavage and avoid mesh (the solution to pollution is dilution)
• Identify free edge of abdominal wall and reattach to cranial pelvic brim if prepubic tendon rupture
• Prognosis relates to organs involved

Question 23

Discuss inguinal hernias?

Answer 23

• Due to congenital inguinal ring abnormality or trauma
• Intestine, bladder or uterus can enter subcutaneous space
• Can be associated with obesity/pregnancy
• Thought to probably be inherited => recommend neutering

Question 24

Discuss inguinal hernia in small mammals?

Answer 24

• Scrotal hernia is rare form (can be traumatic) or post castration in small mammals with large inguinal rings and open methods
• Do closed castration in small furries due to this more open inguinal ring.

Question 25

What is signalment for inguinal hernias?

Answer 25

* Non traumatic inguinal hernias mainly seen in intact female middle aged dogs or under 2-year-old male dogs * Small breeds e.g. Cairn/WHWT * Non-painful inguinal swelling * Painful if incarcerated contents * Omentumis most common content

Question 26

What's going on her with this inguinal hernia repair?

Answer 26

Sac being exteriorised and muscle being closed \*Scrotal hernia you should castrate at same time and make sure inguinal canal is closed properly

Question 27

Discuss diaphragmatic ruptures?

Answer 27

* Relatively common presentation following RTAs * Can be congenital (hernia) * Results from including abdominal pressure with open glottis * Tear in diaphragm allows abdominal content to move into thorax * Muscular portion of diaphragm most commonly affected as weakest point * Radial or circumferential tears * When tear happens instantly have a connection between chest and abdomen

Question 28

What holes naturally occur in the diaphragm?

Answer 28

Holes in diaphragm naturally: * caval foramen * oesophageal hiatus * aortic hiatus

Question 29

What has happened here in this diaphragmatic hernia?

Answer 29

Omentum and bits of liver can go right through into the chest these cases are pretty dyspnoeic when they present. Gently draw contents back into abdomen then can see hole you need to close.

Question 30

What are the clinical signs of diaphragmatic rupture?

Answer 30

* Normally present shortly after trauma shocked Pale/cyanotic * Tachypnoeic/dyspnoeic * Tachycardic * Occasional cardiac arrythmias ( as pericardium being irritated by trauma) * Hydrothorax * Can be chronic injury with respiratory/GI clinical signs * exercise intolerance * dyspnoea * vomiting * weight loss * etc. * Occasionally incidental finding

Question 31

How can diaphragmatic ruptures be investigated?

Answer 31

Radiography * Loss of diaphragmatic line * Loss of cardiac silhouette * Presence of gas filled structure in thorax * Atelectasis * Displaced abdominal organs Water soluble contrast into abdomen Ultrasonography, esp. in chronic case

Question 32

What is diaphragmatic hernia rupture treatment?

Answer 32

* This is an emergency. Get them stabilised then get them to surgery. It is open thoracic surgery so moment you open the abdomen the animal needs to have IPPV. * OXYGEN * IVFT and warm up * Higher mortality if surgery performed less than 24 hr following injury (also greater than 1-year-old) * Acute gastric distension, need to operate a.s.a.p. * Prophylactic antibiotics due to toxin release from organ strangulation * ECG

Question 33

Discuss perineal hernias?

Answer 33

* Not uncommon * Can be spectacular * Bulging perineal area * Faecal tenesmus/dysuria * Normally entire older male * Occasionally in bitch/cat * d/dx: adenomacarcinoma * Used to be more prevelant when dogs were tailed docked.

Question 34

What is the cause of the perineal hernia?

Answer 34

Cause * progressive weakening of pelvic diaphragm * hormonal influence (Pelvic diaphragm is set of muscles that hold anus in postion and under presence of testosterone they start to atrophy and they don’t hold pelvic structures within anus anymore) * tenesmus * congenital/acquired weakness * colitis/prostatomegaly (could it be secondary to these)

Question 35

Discuss disruption of pelvic diaphragm?

Answer 35

* Levator ani, coccygeus and external anal sphincter muscles provide lateral support to the anus * Disruption to this causes rectal enlargement, faecal impaction and tenesmus * Can be bilateral * Pelvic fat, peritoneal fat, prostate and bladder can herniate

Question 37

Discuss perineal hernia diagnosis?

Answer 37

* Reducible perineal swelling * On rectal, absence of pelvic diaphragm * Always check for bilateral disease * Assess sphincter tone -chronic case can remain incontinent * Ultrasound hernia/contrast urethrography will highlight bladder ( can help you decide wher e the bladder is and whether it is retroflexed. If it is then this is an emergency as it cannot empty its bladder)

Question 38

What are the consequences of bladder retroflecion in a perineal hernia?

Answer 38

Bladder retroflexion * emergency * stranguria * hyperkalaemia (Need to lower this before operate) * azotaemia * avascular necrosis

Question 39

What is perineal hernia treatment?

Answer 39

* Cystocentesis through perineum if bladder retroflexed and cannot pass urethral catheter * IVFT (check K + levels if urinary obstruction) * Herniorrhaphy

Question 40

Discuss Herniorrhaphy, colopexy& castration?

Answer 40

* Always neuter and castrate at same time of hernia surgery. * Key points: the 3 muscle groups involed. External anal sphincter, levator ani and coccygeal are involved and need to be stitched back together to keep contents in. * When muscles are so atrophied have nothing to suture together can use external obturater muscles as a support

Question 41

What are some complications of Herniorrhaphy, colopexy& castration?

Answer 41

* Faecal incontinence * suture placement * duration of problem * Urinary problems * Infection * Rectal prolapse * Sciatic nerve entrapment (which is near the pre-pubic tendon and we sometimes anchor to this and that may trap the sciatic nerve) * Recurrence * Some patients will strain after surgery so often LA blocks after surgery to prevent it happening again after surgery.

Question 42

Discuss hiatal hernias?

Answer 42

* Brachycephalic breeds (English bulldog, French bulldog, pug, etc.), Sharpei * Congenital defect * Clinically very similar to oesophagitis * Regurgitation * Hypersalivation * Visceral discomfort * Normally thin

Question 43

How are hiatal hernias diagnosed?

Answer 43

* Radiography * soft tissue opacity in dorso- caudal thorax adjacent to diaphragm * Fluoroscopy * Endoscopy

Question 44

What is hiatal hernia treatment?

Answer 44

Tx oesophagitis * Antacid * Sucralfate * Prokinetic * Antibiotic (if aspiration) Surgery * ventral midline coeliotomy * reduce hernia at oesophageal hiatus and close * pexyoesophagus to diaphragm * pexystomach to body wall

Question 45

Discuss peritoneopericardial diaphragmatic hernia (PPDH)?

Answer 45

* Congenital communication between pericardial sac and abdomen * Faulty development of septum transversum * Often cardiac/sternal deformity in association * Can be asymptomatic * GI or respiratory signs e.g. v+/d+, anorexia weight loss, wheezing, dyspnoea * Weimaraner, Cocker spaniel

Question 46

How is PPHD investigated?

Answer 46

Radiography * enlarged cardiac silhouette * dorsally displaced trachea * gas opacities in pericardial sac Ultrasound * Contrast radiography Don’t present acute and seen in young patients as congenital.

Question 47

Discuss PPHD surgery?

Answer 47

* There is a hole in the pericardium the intestine has gotten into. To fix pull the intestines back through diaphragm and close the hole in the diaphragm you don’t need to worry about closing the hole in the pericardium * Ventral midline coeliotomy * Incise sternum if necessary * Reduce viscera * Suture diaphragm * no need to separately close pericardium