Hernias Flashcards
abnormal protrusion of an organ or tissue through the normal or abnormal opening in the abdominal muscles or the diaphragm
Hernia
What are the types of hernias
1) Reducible
2) Non-reducible
3) Strangulated
What locations can hernias occur
Umbilical
Abdominal Wall
Incisional
Inguinal
Femoral
Scrotal
Perineal
Diaphragmatic
What are the types of congenial diaphragmatic hernias
1) Peritoneopericardial diaphragmatic hernia (PPDH)
2) Hiatal
T/F: hiatal hernias can be congenital or acquired
True - bulldogs might have acquired hiatal hernia (seen in cases of upperairway disease)
a hernia that occurs between the pleural sac and pericardium (pleural space is not included)
Peritoneopericardial diaphragmatic hernia (PPDH)
What causes a pleuroperitoneal diaphragmatic hernia
blunt trauma to the abdomen
What causes a peritoneo-pericardial (PPDH) hernia
congenital
Hiatal hernias are considered congenital but how might one be acquired
Upper airway disease
how does blunt trauma cause a pleuroperitoneal diaphragmatic hernia
1) When the trauma happens there is rise in intra-abdominal pressure
2) Forceful blow with glottis open
3) Tears in the areas least protected by viscera
What is the consequence of a pleuroperitoneal diaphragmatic hernia
1) Loss of mechanical function
2) Space occupying effects of abdominal organs - atelectasis
3) Pulmonary contusions
4) Other chest wall trauma
all of this leads to hypoxia
What are clinical findings of animals with a pleuroperitoneal diaphragmatic hernia
+/- trauma history
-Tachypneic/dyspneic
-Dull heart and lung sounds
-Borborygmi in thoracic cavity
-empty abdomen
-cardiac arrhyhtmias (12%)
How does Peritoneopericardial diaphragmatic hernia (PPDH)
Congenital
1) Abnormal development of the midline septum
2) Gap or thin tissue that ruptures in the ventral portion of the diaphragm
present at birth
can be asymptomatic for months to year
T/F: Animals with Peritoneopericardial diaphragmatic hernia (PPDH) are symptomatic since birth
False- can be asymptomatic for months to years
most are asymptomatic
_____% of Peritoneopericardial diaphragmatic hernia (PPDH) are incidental
30% are incidental
57% of dogs and 23% of cats with Peritoneopericardial diaphragmatic hernia (PPDH) have concurrent congenital defects. What else should you look for
1) Cleft palate
2) ASD, VSD
3) Umbilical hernia
4) Cranial abdominal wall hernia
On imaging, what does Peritoneopericardial diaphragmatic hernia (PPDH) look like
1) Loss of diaphragmatic silhouette
2) Stomach or bowel gas pattern in thorax
3) Pleural effusion (actually liver)
With diaphragmatic hernias, what organs are often displaced
Liver (67%)
Small intestine (56%)
Stomach: 48%
Gallbladder: 6%
Pancreas: 4%
For traumatic diaphgramatic hernias, what is the best time to go to surgery *
DO NOT recommend that every animal with DH be stabilized for 24 hr or more prior to surgery
-Depends on the case
actually timing
1) Once stable for anesthesia
2) be more proactive if the stomach is pherniated into the thorax
you should be more proactive to take an animal with a diaphragmatic hernia to surgery if
the stomach is herniated into the thorax
T/F: PPDH is generally less critical than DH
true- they are less critical and commonly an incidental finding but can decompensate at any time
survival is often higher for those treated surgically as well
For animals with a diaphragmatic hernia, what anesthetic considerations should you have
1) Hyperoxygenate - saturate alveoli with oxygen
2) Rapid Induction - control airway
3) Ventilate the patient
4) gastrothorax - consider orogastric tube or trocharization
What are the 3 openings in the diaphragm that you need to make sure are still there for surgery
1) Caval formaen (caudal vena cava)
2) Esophageal Hiatus
3) Aorta
For diaphragmatic hernia repair, how should you suture
Interrupted sutures to reappose
suture from dorsal to ventral
dont compress the vena cava
use ribs if needed
Why should you be prepared during diaphragmatic hernia repair
Can rapidly decompensate
Assistant scrub and setup table
open abdomen = open thorax
once you in the abdomen, youre also in the thorax
How big should your incision be for diaphragmatic hernia repair
xiphoid to pubis
if male go around prepuce
How do you remove adhesions during surgery
Q-tips
Electorocautery
Scissors
VSD
When doing diaphragm hernia reduction, which direction is it okay to reduce the hernia
Ventrally
T/F: you might need to remove organs when doing diaphragmatic hernia sx
true- might need to do liverlobectomy or cholecystectomy
What direction should you suture the diaphragm in
DORSAL TO VENTRAL
What suture should you use for diaphragm repair
-Monofilament suture
-Absorbable or Non
-Simple continuous and interrupted
-Knots on abdominal side
Single layer
-Dorsal to ventral closure
When repairing the diaphragm, which way should you place you knots
on the abdominal side
What might occur when closing the diaphragm to the vena cava
compression
make sure not to compress
For diaphragmatic hernia repair, what complication do you see in cats specifically
Re-expansion pulmonary edema - only with chronic hernias
caused by sudden re-expansion of the lungs and barotrauma
Re-expansion pulmonary edema in cats typically happens after
diaphragmatic hernia repair of CHRONIC HERNIAS
With diaphragmatic hernia repair, what are some complications
1) Re-expansion Pulmonary Edema (cats)
2) Recurrence
3) Cardiac arrest
4) Pneumothorax
5) Pleural effusion
What is the prognosis of diaphragmatic hernias
1) Traumatic DH -> 79-89% survival
2) PPDH -> 92-05% survival
protrusion of abdominal content through the esophageal hiatus
hiatal hernia
with hiatal hernia, what organs typically go through the esophageal hiatus
Stomach most common
(also can see liver or omentum)
What are the two types of hiatal hernias
1) Sliding (dynamic)
2) Paraesophageal
What breeds are at higher risk of hiatal hernias
shar peis with megaesophagus
also
What are the clinical findings or hiatal hernias
1) Regurgitation
2) Hypersalivation
3) Vomiting
4) Dysphagia
5) Respiratory distress
6) Anorexia
7) Weight loss
+/- upper airways obstruction
How do you diagnose hiatal hernias
-thoracic rads (dynamic so might be able to catch)
-fluoroscopy
-endoscopy (with insufflation)
What might increase your liklihood of diagnosing a hiatal hernia
Valsalva maneuver - pressure applied to abdomen -> mimics the negative pressure seen in BOAS dogs
this might cause false positives???
What are the goals of medical management for BOAS dogs
1) Reduce gastric acid secretion
2) Protect esophageal mucosa
3) Increase the rate of gastric emptying while augmenting LES tone
For hiatal hernia cases, it is important to reduce gastric acid secretion how might you achieve this
Antacids
-Famotidine
-Ranitidine
-Omeprazole
For hiatal hernia cases, it is important to protect esophageal mucosa, how might you do this
Sucralfate
For hiatal hernia cases, it is important to increase the rate of gastric emptying while augmenting LES tone, how might you do this
Prokinetics: Cisapride, metoclopramide
Low fat diets
Elevated feedings ,especialyl for those with megaesophagus
How can you medically manage patients with hiatal hernias
1) Antacids: Famotidine, Ranitidine, Omeprazole
2) Sucralfate
3) Cisapride, Metoclopramide
4) Low fat diets
5) Elevated feedings especially for those with megaesophagus
Surgical treatment for hiatal hernias is recommended when
the patient is symptomatic and not responding to medical management
What are the aims of surgical treatment for hiatal hernias
Reestablish normal anatomy
-Lower esophageal sphincter with positive pressure
What are the goals of surgical correction of hiatal hernia
1) Decrease the size of the esophageal hiatus
2) Esophagopexy
3) Left sided gastropexy (+/- G-tube)
4) Avoid iatrogenic trauma to the vagus
T/F: a gastropexy for a hiatal hernia prevents GDV
False- for hiatal hernia you do a L sided gastropexy. This does not prevent a GDV
For hiatal hernia sx, how do you open the esophageal hiatus
VENTRALLY
use 2-0 or 3-0 non-absorbable suture
Plication should be snug, but allow for room around the orogastric tube
What pexy is done for hiatal hernia
L sided gastropexy
-Body or fundus of stomach is pexied to the left body wall
gastrostomy tube can be placed in lieu of a pexy to bypass oral feedings in dogs with severe esophagitis
What can be placed in lieu of a pexy to bypass oral feedings in dogs with severe esophagitis from hiatal hernia
Gastrostomy tube
What are common complications of hiatal hernia repair
1) Esophagitis - continue medical treatment for at least 2 weeks
2) Esopheageal stricture (reported up to 10 months post-op)
3) Megaesophagus (damage to vagal nerve)
4) Failure to improve/resolve GER
How might megaesophagus develop after hiatal hernia repair
damage to the vagal nerve
What might cause a perineal hernia
1) Unknown
2) Multifactorial
3) Breed predisposition - small dogs like boston terriers
4) Older intact male dogs predisposed - hormone relaxin or prostatic disease
5) Anything that causes increased intra-abdominal pressure
what factors predispose to perineal hernias
multiple factors- primarily older intact male (relaxin)?
but primarily anything that causes increased intra-abdominal pressure
Although etiology not well understood, what is the classic signalment of perineal hernias
old intact male dog
defect in the pelvic diaphragm (musculature support for the rectum)
perineal hernia
What 3 muscles make up the pelvic diaphragm
1) External anal sphincter
2) Levator ani muscle
3) Coccygeus muscle
these muscles are laterally when doing the rectal
How do you diagnose perineal hernias
Rectal exam
What is the most common place for perineal hernia
Caudal hernia: between the levator ani and the external anal sphincter muscles
What structure near the pelvic diaghragm does the cat not have
sacral tuberous ligament - can be helpful as a landmark
What muscle is commonly used to repair perineal hernias
Internal obturator muscle in the floor of pevlic
What is the typical history for perineal hernias
-Tenesmus
-Waxing and waning fectal ball
-Urinary obstruction
-Incidental (found on rectal exam)
How do you diagonse perineal hernias
-Diagnosis on rectal exam
-Radiographs
-Ultrasound
+/- perineal swelling
+/- enlarged prostate
-evidence of urinary obstruction?
What can you do for medical management of perineal hernias
1) Stool softeners
2) Low residue diet
3) Digital evacuation
What is the best surgical option for perineal hernias
Internal obturator flap
Recommend surgical management for perineal hernias if
symptomatic
Why is herniorrhaphy not a good option for perineal hernia repair
because in most cases the levator ani is gone and there is too much tension to do closure of the pelvic diaphragm (herniorrhaphy)
Internal obturator flap is the best method for perineal hernia repair. What are other options
1) Herniorrhaphy (closure of pelvic diaphragm- not good)
2) Tunica vaginalis
3) Semiteninosus muscle - ventral hernia
4) Superficial gluteal muscle transposition
5) Mesh
6) Porcine small intestine submucosa (PSIS)
What are some common complications of perineal hernia repair
20-45%
-Incisional complications
-Tenesmus
-Rectal Prolpase
-Sciatic Nerve entrapment
-Fecal incontinence (bilateral nerve damage <15%)
-Urinary abnormalities
What is the prognosis of perineal hernia repair
27% recurrence at 1 year
post-operative straining will predipose them at failure
some report 0% recurrence rate at 27 months
straining to defecate increases risk
With perineal hernias, you do medical management for what patients
1) Less severe
2) Bridge to surgery
Medical management = Stool softeners, low residue diet, digital evacuation
What is the best surgical option for perineal hernia
Internal obturator flap - elevate muscle off pubis/ischium and flap up medially with other muscles
Why is herniorrhaphy not an ideal method for closing a perineal hernia
because you close the muscles of pelvic diaphragm and since it is a degenerative disease there is too much tension as the levator ani is gone
The tunica vaginalis is a tough fascia that can be used to close a perineal hernia if:
the patient is intact
Complications of internal obturator flap occur 20-45% of the time. What are the complications
1) Incisional complications
2) Tenesmus
3) Rectal prolapse
4) Sciatic nerve entrapment
5) Fecal incontinence (bilateral nerve damage <15%)
6) Urinary abnormalities
