Chapter 40 - Abdominal hernias Flashcards
1
Q
What is the definition of hernia?
A
Protusion of an organ through the wall of the cavity that contains that organ
2
Q
What lines the sac of a true abdominal hernia?
A
Peritoneum
3
Q
what is the term for surgical hernia repair?
A
Herniorrhaphy
4
Q
At what age do umbilical hernias typically resolve spontaneously in foals?
A
6-12 months
5
Q
Which horses are more frequently affected by congenital umbilical hernias? Males or females?
A
females
6
Q
Which two horse breeds show increased prevalence of umbilical hernias?
A
Quarter horse and THO
7
Q
Umbilical herniation is dx how?
A
Observing protuberant sac at the umbilicus palpating hernial ring and viscus within the sac
US (allows to ID concurrent abnormalities of umbilical remnants)
8
Q
What is the diameter threshold above which umbilical hernias in foals should be corrected?
A
1) 3 cm or bigger
2) not solved by 1 year
3) strangulation requires surgery
9
Q
What device is used to treat a hernia in foals less than 8 cm in diameter?
A
Elastrator rings
10
Q
A
Figure 40-2. Elastrator rings and applicator.
11
Q
What is the term for a hernia involving only the antimesenteric aspect of the intestine?
A
Richter hernia
12
Q
A
Richter or parietal hernia. Only the antimesenteric surface
of the intestine is contained within the hernial sac.
13
Q
What is the main goal of umbilical herniorrhapy?
A
- prevent intestinal incarceration and strangulation
- improve cosmetic appearance
- prevent enterocutaneous fistula
14
Q
A
Figure 40-6. Mayo mattress suture pattern (also known as “vest-over-pants” suture pattern). This pattern is no longer recommended for closing abdominal hernias.
15
Q
What is applied if a hernia is too large for suture closure?
A
Prosthetic mesh if bigger than 28 cm long by 18 cm long
16
Q
How long should a horse be confined after umbilical herniorrhaphy?
A
30 to 60 days and walked daily
The horse shoud be turned out into a small paddock for 30 days before regular exercise
17
Q
Why Mayo mattress pattern is not longer advocated?
A
Because this suture pattern places excessive tension on the sutures and compromises the blood supply to the hernial ring.
18
Q
During herniorrhaphy
dissection of subcutaneous tissue is extended about ___ cm beyond the hernial ring
A
1 cm beyound the hernial ring
19
Q
What is the purpose of delaying hernia repair in the presence of a fistula?
A
Control infection, delay hernial repair until tissue is mnore sound (AB+NSAIDS) if massive amount of intestinal fluid is lost through fistula
20
Q
The hernial ring is closed with No. 1 or 2 (USP) synthetic, absorbable suture material, using an _________ suture pattern
A
appositional suture pattern
21
Q
What type of incision is used in both open and closed umbilical herniorrhaphy?
A
Fusiform incision
22
Q
Herniorrhaphy should be performed using the open technique when?
A
When hernial contents are incarcerated
23
Q
A
Figure 40-3. (A) Incarcerated umbilical hernia accompanied by an enterocutaneous fistula. (B) Intraoperative picture showing the enterocutaneous fistula, isolated using a sterile latex glove, before performing a small intestinal resection and anastomosis. (Courtesy C. Koch and D. Rodgerson, Lexington, Kentucky.)
24
Q
There are 2 types of TOTAL dehiscence, name them
A
Acute total at recovery of the horse - go back again GA
Delayed total disruption 3 to 8 days postop
25
What should be done when total dehiscence is imminent?
the abdomen should be **supported with a bandage**, and the horse anesthetized as soon as possible so that the abdominal wall can be repaired
26
How do you start the procedure of preparing the surgery in case of total dehiscence?
**dorsal recumbency**,
**sutures are removed**, and the **ventral aspect of the abdomen is prepared for surgery**.
**Devitalized tissue is excised**, the **wound and abdomen are lavaged** with sterile isotonic saline solution, and the **wound is cultured for bacteria**. The horse should be administered broad-spectrum antimicrobial therapy before surgery.
27
What caractherizes the total delayed disruption of the ventral midline incision?
**may happen 3 to 8 days** postoperatively and is usually **preceded by flow of peritoneal fluid** from the incision and formation of gaps in the incision through which a finger can be inserted into the abdominal cavity
28
What is the incidence of incisional herniation after midline celiotomy
8-16%
29
What are the risk factors associated with incisional herniation?
postoperative drainage
sepsis of the surgical wound
repeat celiotomy
30
What are the measures (4) to take into account to diminish the risk of incisional complications?
1. placing linea alba sutures 1.5 cm apart and 1.5 cm away from the wound’s edge
2. lavaging the closed linea alba with sterile isotonic saline solution before closing the subcutaneous tissues,
3. covering the incision with a sterile incise drape during recovery from anesthesia,
4. and applying an abdominal bandage in the postoperative period
31
How far apart are the sutures placed in case of reconstrution total dehiscence?
**far portion 5 cm** from **midline** through skin-sscut-rectus abdominis, and **NEAR portion 2.5 cm** from midline through skin-sscut-musc or only skin-sscut
CUTTING needle 18 to 22G stainless steel wire - verticaç mattress pattern - Place tube (bolsters) 2.5 cm
EXCLUDE retroperitoneal fat and peritoneum
32
What kind of suture is used in the repair of a dehisced celiotomy?
Stainless-steel wire 18 -22 G
33
How long after surgery are sutures and bolsters usually removed?
stainless steel wire removed 14 to 21 days
34
How can bolsters embedded in granulation tissue be located?
Ultrasonography
35
How long should the horse be restricted to a stall postoperatively?
60 days
36
What pattern is used for the sutures for total dehiscence?
Interrupted vertical-mattress pattern
37
Do you suture skin and subcutaneous tissue after placing the stainless steel wire with large cutting needle?
No, the skin and subcut tissue are left unsutured to facilitate drainage.
38
How do you secure the sutures in the end of the placement of stainless steel wire?
By twisting the ends of the wire and the cut ends of the wire are tucked into the tubing
39
What is the goal of placing 2.5 cm long sections of thick hard rubber or plastic?
To **distribute pressure** and **reduce the tendency of the wire** to cut through underlying tissues
40
Why should a chronic incisional hernia be repaired?
1) If inhibits athletic activities,
2) affects gestation or parturition,
3) or if the horse’s cosmetic appearance is important to the owner - there are no reports of incarceration of intestine within an incisional hernia.
When: 3 to 4 months postop
41
Can the dehiscence celiotomy be closed in layers or repaired with a mesh?
No because the wound is infected.
42
Primary closure of chronic incisional hernias without the use of prosthetic mesh decreases the risk of (advantages)
- **Infection** at the surgical site
shortens the time of sx
- **avoids additional cost of the mesh**
- **Risk of adhesions** between mesh and abdominal viscera are acoided
shorter duration of AB tx and hospi, and quicker return to use, without compromise of the cosmetic outcome, when compared to herniorrhaphy with implantation of a mesh
43
Primary closure of chronic incisional hernias without the use of prosthetic mesh disadvantages is
**leaves multiple small gaps** in the ventral midline after healing even if cosmetis is restore
44
Primary closure has been used successfully to repair chronic ventral incisional hernias up to (say dimensions)
**28 cm long or 18 cm wide**
45
what distance should the linea alba sutures be placed in chronic incisional hernias?
linea alba sutures 1.5 cm apart and 1.5 cm away from wound edge
46
A) Onlay.
47
B) Inlay.
48
C) Retrorectus sublay.
49
E) Underlay.
50
D) Preperitoneal sublay.
51
Chronic incisional hernias are evident when?
2 to 3 months later (are rarely evident at the time the horse is discharged from the hospital) . Do sx 3 to 4 months after
52
2 measures are important to prepare before chronic incisional hernia surgery
1. **Decreasing an overweight horse’s bodyweight**
2. diminishing the volume of intestinal contents prior to the surgical intervention - 50% of labeled recomendation for a week prvious to sx and **24 h fasting before sx**
53
Surgical repair of chronic incisional hernia should be postponed 3 to 4 months after the hernia has become apparent (5-7 months postop). WHY?
**Place an hernia Belt** and **allow time for local inflammation/infection to resolve** and for the hernial ring to mature, making it more apparent and more capable of retaining sutures
54
describe the closure of an incisional hernia without mesh
**DR**
**fusiform skin incision** is made over the hernia and **extended 2 to 5 cm beyond** the hernia’s cranial and caudal borders.
The **subcut tissue is dissected** circumferentially from the **external sheath of the rectus abdominis muscle** for **4 to 5 cm beyond the hernial ring.**
The **hernial sac is either resected** (open repair) or **inverted into the abdomen (closed repair)**, and the **herniorrhaphy** completed using No. 2 or 3 (USP) synthetic, absorbable suture material, placed in a simple-continuous or interrupted pattern (simple or cruciate).
The subcutaneous and skin incisions are closed separately
55
To what muscle's external sheath is the mesh anchored in onlay mesh placement?
Rectus abdominis
56
What is the length of the skin incision beyond the hernial ring in onlay mesh?
6 to 8 cm
57
How is the tension reduced on the sutured hernial ring?
Tightening Mayo sutures
58
How are the subcutaneous tissues closed in the onlay technique?
**Two layers**
One layer incorporating mesh every **2- 3bites** (diminish dead space and anchors mesh)
One layer normal
59
Describe onlay first steps of isolating the hernial sac to place the mesh
DR
**fusiform skin incision** that extends **6 to 8 cm** beyond the cranial and caudal margins of the hernial ring.
The skin within the fusiform incision is excised from the hernial sac, leaving the hernial sac intact.
**About 6 cm of the external sheath of the rectus abdominis muscle** adjacent to the hernial ring is exposed circumferentially by blunt and sharp dissection. The **isolated hernial sac** is **inverted into the abdomen**, and the right and left margins of the hernial ring are apposed with preplaced **inverted cruciate sutures** of **doubled No. 2 (USP) synthetic, absorbable monofilament suture** material using a blunt needle, such as a hernia or a **kidney needle**
60
After tying the preplaced sutures the synthetic mesh is apposed how?
After tying the preplaced sutures, a synthetic mesh (e.g., nylon, polypropylene, or polyester), the length of which corresponds to the length of the hernia, is folded in half and placed over the sutured ring.
The **folded edge of the mesh** is sutured to the abdominal tunic with **simple-interrupted sutures of No. 0 (USP), synthetic, absorbable monofilament** suture material swaged to a taper needle.
The **open side of the folded mesh** is sutured to the external sheath of the rectus abdominis muscle on the contralateral side of the hernia using preplaced sutures of the same material, inserted using a Mayo mattress pattern. Tightening the preplaced Mayo sutures in unison tightens the mesh, thereby reducing tension on the sutured hernial ring. The Mayo sutures are tied, and second and third staggered rows of simple-interrupted sutures are placed through the mesh and underlying rectus sheath axial to the first rows of sutures on each side of the hernial ring. Excess mesh abaxial to the sutures is trimmed, and excess skin, if any, is excised. The subcut tissues are closed in 2 layers, using No. 0 (USP) synthetic, monofilament suture material inserted in a simple-continuous pattern. The skin is apposed using staples.
61
62
63
What is used to appose the skin in the onlay technique?
Staples
64
65
Describe in what consists inlay (interposition) technique
Using the inlay (interposition) technique of repair, the mesh is placed in the hernial defect and secured circumferentially to the edges of the hernial ring.
66
Describe the surgical approach of inlay tx
DR, asepsis
Semicircular incision beyond the hernial ring
Dissectº sscut and hernial sac separated
Hernial sac incised adjacent to skin incision and reflected toward the contralat side
Folded mesh sutured to this exposed edge with nonabsorb mat interrupted horizontal mattress pattern
Peritoneum and retro fat separated from edge
Hernial sac separated from fibrous ring, Mayo sutures through the folded mesh with nonabsorb sutures --> tying preplaced sutures --> tigheten mesh accross defect
Incise edge of hernial sac attached to rectus abdominis
SScut +skin closed routinely
67
What technique combines mesh inlay with fascial overlay?
Inlay with fascial overlay
68
prosthetic mesh sublay with primary closure or with fascial overlay has two tx: retrorectus sublay and preperitoneal sublay. What is the difference?
Retrorectus sublay technique the mesh is implanted btw rectus abdominis and its internal sheath
Preperitoneal sublay technique mesh is between peritoneum and internal sheath rectus abdominis
69
What type of suture material is used for inlay with fascial overlay?
Synthetic, nonabsorbable
70
Describe how to creat the pocket for mesh insertion in the mesh sublay
Fusiform skin incision, hernial sac separation using blunt/sharp dissection
Pocket creation for mesh insertion
Undermining hernial ring superficial to peritoneum (preperitoneal sublay) or
Sharply incising free edge of hernial ring and creating space between rectus abdominis muscle and its internal sheath (retrorectus sublay)
71
Describe surgical tx of preperitoneal sublay
Afet the pocket a double layer of prosthetic mesh is inseted between the peritoneum and internal sheath of the rectus abdominis muscle and anchored circumferentially to the abdominal wall abaxial to the hernial ring with preplaced Mayo sutures
Apply tension to the preplaced Mayo sutures to birnt the opposing right and left margins of the hernial ring into apposition covering the mesh and these margins are then
72
What is the prognosis for preperitoneal sublay?
Guarded prognosis because complications +++ in 1 study while other talks about better
73
Describe surgical tx of retrorectus sublay
Internal sheath of rectus abdominis separated from muscle and approximated on the midline using continuous suture pattern
Mesh extending at least 5 cm beyond margins of the repair is inserted
Anchored to internal sheath or rectus abdominis with simple
External sheath of rectus abdominis closed (may require separting and releasing abdominal fascial tunics abaxial to rectus sheath)
74
Which muscle's fascia is transected in the laparoscopic procedure?
External abdominal oblique
75
How many rows of sutures are placed axially to the first rows in onlay mesh placement?
Second and third
76
What suture pattern is used for subcutaneous tissue closure in the onlay technique?
Simple-continuous pattern
77
Laparoscopic Repair With Intraperitoneal Mesh Underlay - What is the size excess for the trimmed prosthetic mesh?
5 cm circumferentially
78
Laparoscopic Repair With Intraperitoneal Mesh Underlay - What composite material is used for preventing adhesions?
Polypropylene
PTFE - polypropylene:expanded polytetrafluoroethylene prosthetic mesh
79
Laparoscopic Repair With Intraperitoneal Mesh Underlay - What tool is used to retrieve the sutures attached to the mesh?
Suture passer
80
Laparoscopic Repair With Intraperitoneal Mesh Underlay - What is the purpose of insufflating the abdomen during the procedure?
Expose hernia
81
Laparoscopic Repair With Intraperitoneal Mesh Underlay
- What pattern is used for permanent mesh fixation?
Transfascial sutures
82
Laparoscopic Repair With Intraperitoneal Mesh Underlay
- What interval is used for stab incisions along the mesh edge?
3-4 cm
83
What is the main advantage of laparoscopic hernia repair?
Reduced infection risk, but also
anchored tension-free to the abdominal wall, precise delineation of hernial margins, adhesiolysis under direct observation
84
Describe the surgical procedure of laparoscopic repair with mesh underlay
DR
Mesh trimmed to exceed size of defect by 5 cm circumferentially
Insufflation
1 laparoscopic portal, 4 instrument portals (2 each side of hernia, equidistant from each other, 12-15 cm lateral to hernial edge)
Adhesions disrupted
Retroperitoneal fat reflected 6-7 cm from hernial ring circumferentially to expose inner rectus abdominis muscle
Tightly rolled prosthetic mesh with long-tailed nylon sutures attached to midcranial, midcaudal and milateral edges introduced, unfolded
Suture passer for retrieving attached sutured.
85
What duration did the parietal pain last post-surgery?
24 to 72 hours
86
What is reflected 6-7 cm from the hernial ring during laparoscopic dissection?
Retroperitoneal fat
87
What suture material is used in Mayo mattress pattern for lateral hernia closure?
No. 2 nylon
88
How is the suture introduced into the abdomen?
introduction suture into abdomen using 18G spinal needle
gasped with kelly forceps
retrieved using suture passer
exteriorized ends of suture tied over external sehat of rectus abdominis
Closure stab incisions in 2 layers
89
What tool is used for mesh fixation in laparoscopic lateral hernia repair?
Endopath Multifeed Stapler
90
What are the cause of lateral abdominal hernia?
history of trauma
91
How long were horses confined post-lateral hernia surgery before returning to work?
6 weeks
92
What device is used for provisional mesh fixation over the hernia?
EndoANCHOR
93
Permanent fixation mesh by transfacial sutures placed through stab incisions into abdo wall with ___-___ cm intervals along outer edge mesh
3 - 4cm
94
What is the common outcome of lateral hernia surgery in equids?
Excellent long-term outcome if primary closure 15-21 d postrauma
95
What is the common outcome of lateral hernia surgery in equids?
excellent outocme
96
What complication arose 4 days after an unsuccessful lateral hernia repair?
Suture tear through muscle
97
What approach is used for securing the prosthetic mesh in lateral hernia repair?
Open or laparoscopic
98
Describe open tx
Skin incision, hernial sac opened and content inspected and replaced
Defect closed in single layer number 2 Mayo mattress/cruciate pattern and overlapping freee edge of abdo wall sutured to underlying fascia + sscut + skin
99
Describe laparoscopic tx
ventrolat defect
DD trendlenburg
2 instrument portals adjacent to umbilicus - coiled mesh introduction - unfold in abdomen - periphery anchored abdo wall with endoscopic stapling device
100
What is the postop of the lateral abdominal hernia surgery
Box 2w
Paddock 4 w
101
In case of 10 days postrauma ideally the suture pattern should be which?
interlocking suture pattern - sutures torn through muscle and a 2dn sx is performed to place sutures on ployester buttos + mesh onlay repair
102
What breed is most commonly affected by prepubic tendon rupture?
aged Draft horses
103
What the muscles involved?
Rectus abdominis
Gracillis
Pectinus
104
What is palpation of the prepubic tendon rupture painful for mares?
Edematous tissue
105
How is the diagnosis of prepubic tendon rupture confirmed?
Ultrasonography
106
What condition is ruled out by confirming prepubic tendon rupture?
Hydroallantois
107
What is the primary sign of prepubic tendon rupture in mares?
Ventral abdominal edema
108
What stance is assumed by mares with prepubic tendon rupture?
Saw-horse stance
arked lordosis and elevation of the tail head and tuber ischii.
109
Diagnosis of rupture of prepubic tendon
Discontinuity of the abdominal wall cranial to the pubis, seen during transcutaneous ultrasonographic examination of the abdomen, confirms the diagnosis of rupture of the prepubic tendon and distinguishes the condition from hydroallantois, hydroamnion, and edema of late pregnancy
110
Treatment of pregnant mares for rupture of the prepubic tendon
usually conservative and determined by the stage of gestation
Preterm mares are best treated by applying a supporting abdominal bandage to transfer some of the weight of the hernia to the vertebral column
111
If the mare is term can you induce? with what dosage?
If the mare is term or near-term, parturition should be induced using 75 I iU oxytocin diluted in 1 L of isotonic saline solution administered intravenously over an hour
112
Sucessful repair of ruptured prepubic tendon has been done with prothetic mesh. Can she be rebred?
Mares that have suffered rupture of the prepubic tendon, however, should not be rebred, even if the tendon has been repaired.
113
Where are congenital diaphragmatic hernias usually found?
Left dorsal tendinous portion
Traumatic are ventral
114
What can cause congenital diaphragmatic hernia in utero?
Trauma during parturition
115
What is the name of a retrosternal hernia in horses? what age?
Morgagni hernia -Failed fusion of septum transversum and pleuroperitoneal folds
1 year old
116
Which part of the colon is consistently involved in Morgagni hernias?
Large colon
117
What other symptom, aside from abdominal pain, can be seen in diaphragmatic hernia?
Respiratory distress
118
What diagnostic methods are usually necessary to confirm diaphragmatic hernia?
Radiography or ultrasonography
119
What invasive diagnostic methods can be used for definitive diagnosis of diaphragmatic hernia?
Thoracoscopy or laparoscopy
120
What are the two surgical approach?
Ventral lesion is ventral midline celiotomy and dorsal lesion is difficul to expose with no good outcome
121
What position is used for surgical repair of retrosternal hernias?
Reverse Trendelenburg (30 degrees)
122
What tool is used to expand the celiotomy for better exposure of the diaphragm?
Finochetto rib retractor
123
Describe the surgical approach in ventral lesion
Reverse Trendlenbrug and incision caudal to xiphoid
Finochetto rib retractor to expose the lesion diaphragm
isolate intestines with soaked abdo compress
Closure of diaphragm depends on size: small sutured or staple mesh over it
if LARGE mesh secured with laparo stapling device
124
Describe surgical approach for dorsal lesion
difficult to expose - leave the defect open has recurrence and not good outcome
1. Ventral midline celiotomy with securing mesh blindly
2. Ventral mdline celiotomy to reduce the hernia + thoracotomy with rib resection in LR to expose defect and corret with prosthetic mesh
3. Staged repair by ventral celiotomy to reduce and the defect of the diaphragm is corrected 7 weeks later (GA in LR with hand assisted thoracoscopy)
4. Standing thoracosccopy by 10th IC sace and pneumothorax was induced to collapse the ipsilateral lung
125
Figure 40-13. Lateral thoracic radiographic view of a Morgagni hernia. The black arrows mark the intact dorsal border of the diaphragm, and the small white arrows identify the dorsal margin of the hernial sac. White arrowheads mark sacculations and haustra of the large colon contained within the diaphragmatic hernia.
126
Figure 40-12. Diaphragmatic hernia (arrows) at the musculotendinous junction of the ventral aspect of the diaphragm.
127
General anesthesia of horses with a diaphragmatic hernia is often complicated, why?
because of decreased thoracic compliance and pulmonary dysfunction
128
What are the factors negatively associated with survival in diaphragmatic hernias?
50% SI
Age of the horse - older than 2 years
Dorsal location of the herna
defect greater than 10 cm in diameter
129
What abdominal organ often herniates through the vaginal ring in an inguinal hernia?
* Small intestine
130
What term is used if hernia contents extend into the scrotum?
Scrotal hernia
131
18. What are signs of a ruptured inguinal hernia in foals?
* Colic or swelling
132
What is the recommended treatment for a congenital inguinal hernia in foals?
* Herniorrhaphy
133
At what age does spontaneous resolution of congenital inguinal hernias usually occur in foals?
* 6 months
134
Inguinal rupture and ruptured inguinal hernia definition
Intestine protrudes through the vaginal ring and passes through a rent in the parietal tunic and scrotal fascia so that it lies subcutaneously in the inguinal or scrotal region
135
Inguinal rupture. Intestine protrudes through a rent in the peritoneum and transverse fascia outside the vaginal sac but adjacent to the vaginal ring. The testis lies within the vaginal cavity.
136
The superficial inguinal ring is a slit-like opening in the aponeurosis of the (name the muscle)
external abdominal oblique muscle
137
The deep inguinal ring is bordered cranially by the caudal edge of the _______ cranially by the _____ ventromedial border is formed by___________ and ______ and is caudolateral border is the _________________
The deep inguinal ring is bordered cranially by the caudal edge of the internal abdominal oblique muscle, its ventromedial border is formed by the **rectus abdominis muscle*** and the **prepubic tendon**, and its caudolateral border is the **inguinal ligament.**
138
Two conservative tx until the foal is 6 months old
- Truss with 2 rolls of gauze anchored over the superficial inguinal ringwithin the abdomen
- manual reduction by the owner
139
Herniorrhaphy is also indicated when?
Incarcerated intestine (unreducible)
Foal bigger 6 months
If enlarges
140
The 2 surgical corrections or henia are
Laparoscopic
Open approach
141
Describe laparoscopically hernia correction
GA - DR in a ~25-ºTrendelenburg position. 2-3 cm lateral to umbilicus the laparoscope and 2 portals are made 5 cm lateral to it and other 2 portas are made 4 cm caudal and 10 cm lateral
vaginal ring on the affected side is observed. Herniated intestine often reduces spontaneously when the foal is placed in dorsal recumbency, but if it fails to reduce, the herniated intestine is replaced into the abdominal cavity by exerting traction on it with atraumatic endoscopic forceps (i.e., Dorsey or Babcock forceps). The ipsilateral testis can be excised during the same procedure by retracting it into the abdominal cavity and transecting its spermatic cord and ligament of the tail of the epididymis with a vessel-sealing device. The testis is then removed from the abdominal cavity. To prevent the hernia from recurring, the vaginal or deep inguinal ring is closed using a stapling device or with simple-interrupted sutures placed intracorporeally.56,57 Closing the deep inguinal ring using unidirectional barbed suture has also been
described.58
142
Describe the open surgical approach to correct congenital or acquired inguinal hernia
incising the skin overlying the su**perficial inguinal ring**. The vaginal process (i.e., parietal tunic) enveloping the herniated segment of intestine and testis is identified and isolated by carefully dissecting overlying subcutaneous tissue and fascia. The vaginal process is incised to expose the herniated intestine, which is examined for viability before it is reduced into the abdomen through the vaginal ring. If the horse has suffered a rare inguinal rupture, the herniated intestine is found outside of the vaginal process and is reduced into the abdomen through the rent in the abdominal wall adjacent to the vaginal ring. To **facilitate reduction of herniated intestine**, the vaginal ring can be incised, with a bistoury, at its cranial aspect. The ring is incised in** craniolateral direction** to avoid injuring the **caudal epigastric vessels**. The affected testis is excised after the hernia has been reduced, and the superficial inguinal ring is sutured to prevent the hernia from recurring. The authors suture the ring with heavy absorbable sutures on a kidney needle or hernia needle, using a simple-continuous or cruciate suture pattern. nonviable intestine is resected, and intestinal anastomosis performed through a ventral midline celiotomy.
143
Why hernia needle or kidney needle?
Because they are less likely to break or perforate a viscus or the surgeons finger
144
Acquired is typical to be
Left side
145
Acquired inguinal herniation is typical of which breeds?
Andalusian Standardbred draught horses
146
Clinical signs ina horse with acquired inguinal hernia are
enlargment of the scrotum and signs of abdominal pain, crepitus
147
how do you perform diagnsosi of inguinal herniation?
by identifying intestine entering the vaginal ring while palpating the inguinal region
per rectum.
Ultrasonographic detection of edematous small intestine within the inguinal canal or scrotum corroborates the diagnosis.
148
An acquired, nonincarcerated inguinal hernia can sometimes be reduced, with the horse standing, how?
by applying manual traction per rectum to the intestinal segments oral and aboral to the site of incarceration. horse should be sedated, and epidural anesthesia or an anticholinergic drug (e.g., N-butylscopolammonium bromide) administered before attempting to reduce the hernia in this manner, to decrease the risk of injuring the rectum. Manual reduction of the hernial contents with the horse anesthetized and in DR has also been described
149
How do you manually reduce under DR?
Traction is placed on the testis and spermatic cord with one hand while the other hand massages the neck of the scrotum and pushes intestine toward the vaginal ring. Extending the limbs further and using two hands to massage the herniated intestine, while an assistant places traction on the testis, may facilitate reduction.
150
For how much time do you try the manual reduction?
If the hernia cannot be reduced manually within 15 minutes, the hernia should be reduced using an open surgical approach.
151
Describe the laparoscopic procedure for closure of vaginal rings
Each vaginal ring is identified, and spermatic vessels and ductus deferens are displaced into the caudomedial aspect of the vaginal ring using laparoscopic Babcock forceps inserted through an instrument portal. The vaginal process is grasped on its craniolateral aspect 2 cm distal to the vaginal ring with a second pair of laparoscopic Babcock forceps, inserted through a second instrument portal to prevent the cyanoacrylate from diffusing distally. About 2 mL of cyanoacrylate is injected into the craniolateral aspect of the vaginal ring using a polyethylene tube inserted through a third instrument portal. The craniolateral aspect of the vaginal ring is subsequently compressed by grasping it with the second pair of Babcock forceps.
152
Durign the closure if you realize that the horse has exceptionally large vaginal rings?
the glued closure may be reinforced with sutures, which are most easily placed using the Endostitch laparoscopic suturing device (Endo Stitch Automatic Endoscopic Suturing Device).66 Another method used to partially obliterate the inguinal canal while sparing the testis entails inserting 8- × 6-cm polypropylene mesh rolled into a cylinder through the vaginal ring into the vaginal process with the sedated horse in standing position.67 The mesh is retained in its position by securing it to the wall of the vaginal process
with staples. Hernioplasty using a peritoneal flap is another technique used to prevent inguinal herniation while preserving testicular function
153
In what consists the tx of herniplasty using peritoneal flap?
This procedure can be performed laparoscopically with the horse anesthetized, or standing and sedated.61,70 A 10- × 6-cm, ventrally based inverted, U-shaped peritoneal flap is created at the craniolateral aspect of the vaginal ring using laparoscopic scissors. The dissected flap is folded caudally over the vaginal ring, spermatic vessels and ductus deferens, using laparoscopic grasping forceps. The flap is then secured to the peritoneum over the caudal, mid, and cranial aspect of the vaginal ring using Endohernia staples (Endohernia 65, 4.8 mm).61 Covering the caudal-most aspect of the ring is reported to be critical to prevent herniation.
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Is the sperm affected?
No, long-term studies performed on horses undergoing this method of hernioplasty have demonstrated that sperm production remains unaffected, despite subtle but significant alterations in the testicular blood flow detected after
the surgery.
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Khairoun and Kai 2020 EVJ Treatment of donkeys for herniation of the abdomen What was the conservative treatment method used for equids with hernias of less than 2 months' duration?
a) Antibiotic therapy
b) Compressive abdominal bandaging
c) Dietary restriction
d) Physical therapy
b) Compressive abdominal bandaging
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Khairoun and Kai 2020 EVJ Treatment of donkeys for herniation of the abdomen Why was surgical repair not possible in some cases of hernia in the equids?
a) Poor health of the animals
b) Owner refusal of surgery
c) Large size of the defect, location, and lack of prosthetic mesh
d) High risk of infection
c) Large size of the defect, location, and lack of prosthetic mesh
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Khairoun and Kai 2020 EVJ Treatment of donkeys for herniation of the abdomen What was the long-term outcome for the 11 equids treated for abdominal hernia?
a) Recurrence of hernia in 50% of cases
b) No recurrence of hernia post-treatment
c) Partial recurrence of the hernia
d) Long-term follow-up was not available
b) No recurrence of hernia post-treatment
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Fig 1: Latero-lateral radiograph of the caudo-ventral thoracicand cranio-ventral abdominal areas. The large granular structure(white arrows) causing border effacement of the diaphragmaticcrus and cardiac silhouette (red arrowheads) is the herniatedcolon
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Fig 2: Intraoperative view (after removal of the large intestine) ofthe large diaphragmatic defect with round margins (arrows),which allowed the partial migration of liver and the sternal anddiaphragmatic flexures of the ascending colon from theabdomen into the thorax. Note the presence of the migratedlobe of the liver (white*). 1: Large colon. 2: Hernial sac. 3: Band ofhernial sac covering the oesophagus. 4: Fluid accumulated intothe hernial sac.Fig 3: Intraoperative view of the surgical repair of the Morgagnihernia. Mesh herniorrhaphy was performed with a polyester meshcovered by the greater omentum.© 2020 EVJ José
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Fig 3: Intraoperative view of the surgical repair of the Morgagnihernia. Mesh herniorrhaphy was performed with a polyester meshcovered by the greater omentum.© 2020 EVJ LtdJ. M. Arevalo-Rodrıguez et al. e93
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What is the name of the glue used to close the large vaginal rings?
* N-butyl-2-cyanoacrylate glue
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36. How much cyanoacrylate is injected into the craniolateral aspect of the vaginal ring?
2 mL
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Which aspect of the vaginal ring is critical to cover in hernioplasty?
Caudal-most aspect
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Fig 2: En bloc resection of an umbilical hernia including an
enterocutaneous fistula from the ventral abdominal wall. An
incision of the aponeurosis has been made close to the hernia
ring (arrows) 2019 EVJ Sommerfeld
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Fig 3: Isolation of the ileum with Doyen intestinal forceps after en
bloc resection of the umbilical hernia including the
enterocutaneous fistula. 2019 EVJ Sommerfeld
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Fig 5: Closure of the ileal wall with a continuous Lembert suture
transverse to the long axis of the intestine (modified Heineke-
Mikulicz technique) after placing opposing stay sutures bisecting
the longitudinal extension of the wound margins 2019 EVJ Sommerfeld
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surgical approach for inguinal ring closure
Laparoscopic assisted standing
Laparoscopic assisteded under general anesthesia
