HERNIAS 85, 86 Flashcards by Charlotte Doyle

name the pars of muscles that composes the diaphragm

pars lumbaris
pars sternalis
pars costal is (each side)

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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

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name the structures that passes through the aortic hiatus

aorta, azigos, hemiazigos, lumbar cistern of the thoracic duct

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what are the “foramina of Morgagni?”

also named sternocostal triangles.

situated between costal and sternal attachments of thoracic diaphragm

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what structures pass through Morgagni foramina

cranial epigastric arteries

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diaphragm blood supply

phrenic arteries, originate from phrenology-abdominal arteries.
anastomose with phrenic branches of 10-11-12 intercostal arteries

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diaphragm innervation

PHRENIC NERVES

dog: ventral branches 5-6-7 cervical nerves
cat: 4-5-6 cervical nerves

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surgical approach to diaphragmatic ernia

median celiotomy

9 intercostal toracotomy: side of the hernia!! (not peritoneo pericardial)

resection xiphoid process

celiotomy extended to sternotomy

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causes of diaphragm ernia

85% trauma

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diaphragm muscle tears orientation cats dogs

DOG: 40% radial, 40% circumferential, 20% mixed

CAT: 59% circumferential, 18% radial

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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

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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%)

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ultrasonography accuracy for diaphragm hernia

93%

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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

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closure options for large diaphragm defects

omentum
fascia
muscle
liver
Polypro mesh
silicon rubare sheating

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muscle flaps for diaphragm closure

transversus abdominins
rectus abdominis
latissimus dorsi

have to be 10% bigger than defect to close

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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

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what muscle separate pleural and peritoneal cavities dorsally

psoas muscles, by only a thin layer of fused endothoracic and transversalis fascia

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what is the “cullen sign”

ring of subcoutaneous hemorrage around the ombilicus (in same cases of hemoperitoneum or peritonitis)

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what are the vascular structures that bound the epiploic foramen?

dorsally caudal vena cava

ventrally portal vein

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what are the 3 portions of the omentum?

bursal portion, splenic portion (form gastroepipolic ligament), veil portion (left pancreas)

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normal colloid-osmotic pressure of peritoneal fluid

28 mmHg, less than 300 cell/mm3

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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

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?

diagnostic accuracy of different ABDOMINOCENTESIS techniques

43% needle paracentesis 82. 9% catheter paracentesis 94. 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

types of aseptic peritonitis

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%) ```