Hernia Flashcards
What is a hernia?
Protrusion of a tissue/ organ through a defect in the wall of of the anatomical cavity
True vs false hernia?
True: anatomical hernial sac
False: lacks hernial sac —> traumatic hernias are initially false hernias
What makes a complicated hernia?
Strangulation
Obstruction
What is a incarcerated and strangulated hernia?
Strangulation = Blood supply compromised leading to ischemia and potentially necrosis.
—> incarceration between two tissue planes
How does loss of domain lead to hernia?
Normal location of tissues is to small to accommodate contents —> compartment syndrome
Chronic hernia, especially diaphragmatic
What are the internal hernias?
Diaphragmatic
Hiatal
Mesenteric
Intercostal
What are the external hernias?
Paracostal Ventral Inguinal Femoral Prepubic Intercostal
What are the 4 principles of herniorraphy?
Return contents to normal location
Secure ring closure
Tension free closure
Utilize patient tissues
What type of suture should you use if your patient has a recurrent hernia or has an underlying disease like diabetes or cushings?
Non-absorbable
How can true hernias be treated?
Open —> hernial sac incised and removed, freshening edges by removing the hernial ring is NOT necessary and avoided if possible
Closed —> invert sac and contents without opening the hernial sac
What are causes of abdominal hernias?
Congenital
Developmental
Traumatic
Incisional
T/F: umbilical hernias may close spontaneously up to 6 months
True
How do umbilical hernias develop?
Failure of fusion of rectus abdominis muscle at umbilicus
Breeds predisposed to umbilical hernias?
Airedales, Pekingese, basenji, pointers, Weimaraner
Clinical signs of umbilical hernias?
Soft round mass at umbilical scar
Often reducible
If viscera is entrapped, may be hard and painful (will often have GIT signs if obstructed)
How do we treat a small (<3mm) or large (>2.5cm) umbilical hernia??
Little risk of strangulation
Treat conservatively
Patient <6months may close spontaneously
Repair during elective procedures
T/F: if you have an umbilical hernial the size of a finger you can treat this conservatively and only repair surgical during elective procedures
False
— this tissue is at increased risk for strangulation, do not wait to repair
You are going to correct a umbilical hernia in a dog during a spay.. how would you do this?
Incision extended cranially over hernial (or can make elliptical incision over hernia
If incarcerated—> enlarge ring and dissect sac free and them examine contents
Dissect sac and ever into abdomen (closed) or ligate sac at next and transection (open)
DO not freshen edges —> routine closure
Breed predisposed to inguinal hernias?
Basenji Basset hound Carin terrier Cavalier King Charles Chihuahua Cocker spaniel Dachshund Maltese Pekingese Poodle Pomeranian West highland white terrier
What are the multifactorial causes of an inguinal hernia?
Genetic
Obesity
Trauma
Estrogen - estrus/pregnancy
What is a direct inguinal hernia?
Occurs through inguinal musculature
What is an indirect hernia?
Occurs through vaginal ring (scrotal hernia)
What is the surgical approach for an inguinal hernia?
Female - ventral midline (can correct both sides)
Male - inguinal approach directly over hernia
What structures must you make sure to preserve when closing inguinal rings ?
Pudendal artery and vein
Genitofemoral nerve
Major complications of inguinal hernia surgery?
Seroma/hematoma
Scrotal hernias are usually seen in what age dogs?
Young <2yrs
—> weakness of vaginal ring orifice
T/f: cryptorchidism predisposes animals to scrotal hernias
True
Presentation of scrotal hernia?
Usually unilateral
Painful swelling
Risk of strangulation
How can you surgically repair scrotal hernia?
Incision over ring
Reduce contents and closure ring
Castrate —> facilitate repair and decrease recurrence
Most common hernia associated with HBC trauma?
Abdominal hernia
Clinical signs of traumatic abdominal hernia?
Bulging mass
Asymmetric abdomen
Reducible contents
Palpable ring
Treatment of acute abdominal hernia repair?
Ventral midline
- can explore abdomen
- repair organ injury
- difficult to reconstruct
- 2/0 monofilament
- tension relieving pattern vs continuous pattern (horizontal mattress vs vertical mattress)
Treatment of chronic abdominal hernia?
Approach over hernia
- > less likely concurrent injuries
- > better anatomic closure
Can perform both approaches for exploration and better closure
Hernias at the prepubic tendons are usually associated with what pathology that can complicate repair?
Pubic/pelvic fractures
How will you position your patient when repairing a prepubic tendon hernia?
Dorsal recumbency with hindlegs in frog leg position with pelvis raised on towels
How can you surgically repair prepubic tendon hernias?
Prepubic tendon attaches rectus abdominals to pubis
Reattach the free edge of the abdominal wall to the cranial pubic ligament with a simple interrupted crutiate/mattress (non-absorbable)
Can use a mesh if large defect
What is an acute vs chronic incisional hernia?
Acute -> Hernia that occurs through a surgery site within 7 days of surgery
Chronic —> weeks/months/years later
What are risk factors for incisional hernias?
Inappropriate surgical technique Altered tissue strength Suture failure Patient condition Poor owner compliance
Diagnosis of incisional hernias?
Exaggerated swelling Serosanguinous discharge Reducible Radiographs US
DDX for incisional hernia?
Hematoma/seroma
Abscess
Treatment for incisional hernia?
Determine underlying factor
Approach original incision
Culture if open
Anatomic closure
Long lasting suture
Repair evicerated tissue
What hernia results from weakness and separation of the pelvic diaphragm components?
Perineal hernia
What organs could be herniated in the perinum?
Prostate, bladder, intestine
What anatomy makes up the perineal diaphragm ?
External anal sphincter/rectum
Sarcotuberous ligament
Levator ani and coccygeous m
Ischial arch/internal obturator m
Prudendal artery, vein and nerve
What are the types of perineal hernias?
- Lateral—> between coccygeus and sarcotuberous ligament
- Dorsal —> between coccygeus/levator ani
- Caudal (most common) —> between levator ani, external anal sphincter and internal obturator
- Ventral (sciatic) -> blubo/ischio muscles
Signalment for perineal hernia?
Older intact males
7-9yrs
Pekingese, boston terrier, corgi, boxer
Can be uni or bilateral
What are predisposing factors for perinal hernias?
Shorted tailed dogs -> underdeveloped levator ani and coccygeus m
Hormonal -> intact make dogs more predisposed
Females at less risk -> levator ani is larger, broader, and stronger
Relaxin -> prostatic dz or prostate located near diaphragm
Neurogenic atrophy -> straining from prostatic dz, traction on nerves of sacral plexus
Nerve damage and atrophy of levator ani and coccygeous muscles
Chronic straining —> constipation, cystitis, prostatitis
Clinical signs of perineal hernia?
Perineal mass — usually non painful and reducible
Tenesmus/Dyschezia
Constipation
Dysuria (bladder retroflexion)
What are possible contents of a perineal hernia?
Retroperitoneal fat Serous fluid Rectus Prostate Urinary bladder Small intestine
Diagnosis of a perineal hernia?
Rectal palpation -> finger pass through into rectal dilation
Radiographs —> prostate size, bladder disposition, contrast study
US-> hernial contents
When would you consider medical management for perineal hernia?
Only in patients where health status prevents general anesthesia
Stool softeners —> lactulose, psyllium
Fecal evaluation
High fiber/high moisture diet
What is treatment of choice for perineal hernias?
Surgery
Internal obturator muscle transposition (most commonly and most successful procedure)
Others: Traditional herniorraphy Superficial gluteal muscle transposition Semitendinosisus muscle transposition Various prosthetic implants
What do you do for surgical preparation in a perineal hernia case?
Prep -CBC, chem, U/A Fast the night before No enema within 24hrs of surgery (liquid fecal contamination) Perioperative antibiotics
Remove fecal material from rectum Express anal glands Hang legs over padded elevated table Secure tail Gauze in rectum Purse string suture
How will you do a traditional herniorraphy in in a perinal hernia case?
Approach over hernia lateral to anus
From tail base to ischial tuberosity
Open sac and replace contents
Reconstruct pelvic diaphragm
—> use levator ani and coccygeus (often atrophied)
—> sarcotuberous ligament (suture through)
—> preplace all sutures
Avoid rectal wall, sciatic nerve, and gluteal and pudendal (artery, vein and nerve)
How do you perform an internal obturator muscle transposition ?
Reduce tension
Adds blood supply
Incise cd/lat border
No farther than cd obturator foramen
Periosteal elevator dorsally and medially
Suture to coccygeus, EAS, and ST ligament
What pexy procedures can help minimize perinal hernial content?
Cool pexy
Cystopexy
Ductus deferopexy
Post op care for perinal hernia repair?
Perform rectal exam while under anesthesia —» assess repair, assess opposite side if unilateral repair
Pain management
Continue medial management for 4-6weeks
Common complications with perineal hernia repair?
Infection/abscess Fecal incontinence (injury to pudendal or caudal rectal nerve)
Sciatic nerve injury
Urinary dysfuntion —>. Muscle/nerve damage from bladder herniation
Tenesmus —> structures through rectal wall
What is the prognosis of perinal hernia?
Recurrence fro 0-70%
- > surgeon experiance
- > previous repair
- > suture type
- > poor local tissue strength
- > amount of tension
- > castration
Predisposition to perineal hernia in cats?
Megacolon
Perineal mass
Colitis
—> 95% are bilateral
Only 22% have perineal swelling
RARE in cat
