HERNIAS 85, 86 Flashcards
name the pars of muscles that composes the diaphragm
pars lumbaris
pars sternalis
pars costal is (each side)
descrive the origin of the right and left crus of diaphragm
origin from paired lumbar muscles of diaphragm
each gives a crus, that further divides in two.
right crus is bigger
tendon arise from 3-4 lumbar vertebra and medial to psoas minor
name the structures that passes through the aortic hiatus
aorta, azigos, hemiazigos, lumbar cistern of the thoracic duct
what are the “foramina of Morgagni?”
also named sternocostal triangles.
situated between costal and sternal attachments of thoracic diaphragm
what structures pass through Morgagni foramina
cranial epigastric arteries
diaphragm blood supply
phrenic arteries, originate from phrenology-abdominal arteries.
anastomose with phrenic branches of 10-11-12 intercostal arteries
diaphragm innervation
PHRENIC NERVES
dog: ventral branches 5-6-7 cervical nerves
cat: 4-5-6 cervical nerves
surgical approach to diaphragmatic ernia
median celiotomy
9 intercostal toracotomy: side of the hernia!! (not peritoneo pericardial)
resection xiphoid process
celiotomy extended to sternotomy
causes of diaphragm ernia
85% trauma
diaphragm muscle tears orientation cats dogs
DOG: 40% radial, 40% circumferential, 20% mixed
CAT: 59% circumferential, 18% radial
complications with diaphragm ernia
DISPNEA 38%
hepatic venous stasis
hepatic necrosis
biliary tract obstruction
jaundice
pleural effusion
ascites
hemotorax
urotorax
chylotorax
1 report cardia tamponade
radiographic signs of diaphragm hernia
LATERAL PROJECTION
loss line of diaphragm (66-97%)
viscera in torax
obscured cardiac shadow
DORSO VENTRAL
lung lobe collapse (20-31%) pleural fluid (20-31%)
radiographic signs of diaphragm hernia
LATERAL PROJECTION
loss line of diaphragm (66-97%)
viscera in torax
obscured cardiac shadow
DORSO VENTRAL
lung lobe collapse (20-31%) pleural fluid (20-31%)
ultrasonography accuracy for diaphragm hernia
93%
timing of surgery for repair of diaphragmatic hernia
as soon the patient is stable
67% within 24h
37% within 1 year
delay 1-3 weeks 93.7% (another study)
-> STABILIZE PATIENT BEFORE SURGERY
closure options for large diaphragm defects
omentum fascia muscle liver Polypro mesh silicon rubare sheating
muscle flaps for diaphragm closure
transversus abdominins
rectus abdominis
latissimus dorsi
have to be 10% bigger than defect to close
IAP: intraperitoneal pressure: values
increase pressure -> abdominal compartment syndrome
11-20 mmhg: medical treatments (analgesic therapy, evacuation intraperitoneal fluid-air or organ contents)
>20 mmhg: surgical correction; mesh to augment abdominal wall, splenectomy, advancement diaphragm
what muscle separate pleural and peritoneal cavities dorsally
psoas muscles, by only a thin layer of fused endothoracic and transversalis fascia
what is the “cullen sign”
ring of subcoutaneous hemorrage around the ombilicus (in same cases of hemoperitoneum or peritonitis)
what are the vascular structures that bound the epiploic foramen?
dorsally caudal vena cava
ventrally portal vein
what are the 3 portions of the omentum?
bursal portion, splenic portion (form gastroepipolic ligament), veil portion (left pancreas)
normal colloid-osmotic pressure of peritoneal fluid
28 mmHg, less than 300 cell/mm3
normal intrabdominal pressure dog
2 - 7,5 cm H2O
technique to prevent adhesion intraoperatively
prevent tissue dessiccation gentle handling meticolous hemostasis precise suture placement removal blood clots-debris thorough lavage
what effect has peritonal fluid volume on peritonitis?
increase in bacterial proliferation
slowed bacterial clearance
increase mortality rates
systemic manifestation of peritoneal inflammation
hypovolemia -> hypotension
hypoproteinemia
respiratory acidosis
hypoxiemia (diaph rigidity)
common findings in animals with peritonitis
MODS
DIC
paralytic ileus
poorly defineable and localizable abdominal pain
peritonitis classification
primary-secondary
acute-chronic
localized-generalized
septic-aseptic
primary peritonitis, survival and aetiology (spontaneous inflammation)
CULP et al. 2009 survival 46.7 % dogs, 44,4% cats in one study
56% dogs monoculture, 100% cats monoculture
most common form of peritonitis in dogs
secondary peritonitis most commonly from intestinal leakage-dehiscence
RALPHS et al., 2000 (85% death after int-leakage)
what is intended for chemical peritonitis. is it primary or secondary?
secondary
endogenous contaminant (gastric-intestinal, bile, pancreatic enzymes, urine)
types of aseptic peritonitis
mechanical-foreign body (sterile)
starch granulomatous (glove powder)
chemical peritonitis
sclerosing encapsulating peritonitis (abdominal organ encapsulated in thick layer of connective tissue
parasitic-protozoal (toxocara, toxoplasma, mesocestoides, angiostrongylus costaricensis
types of aseptic peritonitis
mechanical-foreign body (sterile)
starch granulomatous (glove powder)
chemical peritonitis
sclerosing encapsulating peritonitis (abdominal organ encapsulated in thick layer of connective tissue
parasitic-protozoal (toxocara, toxoplasma, mesocestoides, angiostrongylus costaricensis
risk factors for developing septic peritonitis after celiotomy
preoperative septic peritonitis
hypoprotinemia
hypoalbuminemia
intraoperative hypotension
foreign body protective against development!!
can peritonitis being associated with uroabdomen?
rarely, unless urine already infected before trauma-rupture
bile peritonitis, survival rates
LUDWIG ET AL 1997 survival 100% nonseptic. 27% septic
MEHLER ET AL 2004 survival 55% septic, 13% nonseptic
CREWS ET AL 2009 survival 82% gallb infection and rupture
most common bacterium in bowel perforation septic peritonitis
e. coli
bacterioides fragilis
what toxin is believed to facilitate patogenicity of e.coli in peritoneum?
alpha-hemolysin (common exotoxin of e.coli)
decrease intraperitoneal ph
lyses intrap. erytrocites
reduces recoverable viable lymphocites
SIRS criteria
T: >39.7 (39.2) or < 37.8 (38.1) DOG (CAT)
FC: >225 (120) <140 DOG (CAT)
FR: >40 (20) DOG (CAT)
WBC: >19500 (18000) <5000 (5000) DOG (CAT)
BAND NEUTROPHILS >5% DOG
wuat volume of free peritoneal fluid can be detected with ballottement exam?
> 10 ml/kg
can you use absolute or differential cell count to distinguish beetween normal “postsurgical” response or post-op infection?
NO
diagnostic accuracy of different ABDOMINOCENTESIS techniques
43% needle paracentesis
- 9% catheter paracentesis
- 6% peritoneal lavage (20-22 ml7kg warmed sterile isotonic saline)
blood glucose VS abdominal fluid glucose
first study reported >20 mg/dl difference high specificity and sensibility.
KOENIG 2015 reported better result with cutoff >38 mg/dl difference
- > dog anemia: false high blood glucose
- > dog hemoconcentration: false low blood glucose
accuracy of citology exam for peritoneal fluid
LEVIN 2004 87% or less
fluid lactate sensitivity and specificity
DOG >2.5 mmol/L 100% sensitive 91% specific
CAT 67% sensitive 67% specific
is triple drug therapy better than monotherapy for septic peritonitis?
MOSDELL 1991 no big difference in mono-bi-triple therapy
fluid volume for peritoneal cavbity lavage
200-300 ml/kg
is i useful to add antibiotics to fluid lavage?
no, can be toxic
is laparoscopic treatement for septic peritonitis a good choice?
no, it increase mortality. appears to be related to peritoneal damage due to insufflation
most common post-op complication with closed peritoneal drainage
anemia and hypoproteinemia
Open peritoneal drainage versus primary closure for the treatment of septic peritonitis in dogs and cats
STAATZ 2002: no big differences, overall survival 71%
LANZ 2001: 54% survival with primary celiotomy closure
use primary closure when
there is not an ICU plasma and colloids not available monobacterial infection localized inflammation, that has beem removed no foreign material no gastrointestinal spillage
most common bacteria in dog and cat bite
pasteurella multocida
most common bacteria isolated cat dog gunshot wounds
staphylococcus spp. clostridium spp.
diagnosis of uroperitoneum
abdominal fluid creatinine and potassium higher than plasmatic
urea is not useful: urea concentrations quickly equilibrates with serum ones
most common anaerobic bacteria in intraabdominal abscess formation
bacterioides fragilis
