Hernias and ruptures

Question 1

What is the difference between a hernia, a prolapse and a rupture?

Answer 1

Hernia consists of a hernial ring and sac
Rupture normally has no ring or sac
A prolapse doesn’t pass through a deficit in the body wall

Question 2

What are the aims of hernia surgery? What are the steps of a hernia reduction?

Answer 2

Aims
* Return hernia content to normal location
* Secure closure of neck of sac
* Obliterate redundant tissue in the sac
* Try to use the patient’s own tissues for repair

Steps
* Some are non-reducible
* Directly incise over site
* Ensure adequate exposure
* Try to use atraumatic technique
* Breakdown adhesions
* Check viability of herniated tissues especially if strangulated hernia
* Resect non viable tissue before returning to abdominal cavity
* Defect closure
* Direct opposition if possible
* Know anatomy to ensure holding strength
* Don’t compromise vasculature
* Use sufficiently strong suture material; e.g., polydioxanone, polypropylene, etc.
* Monofilament to avoid sinus formation
- Tensionless closure
- Use muscle flap; e.g., internal obturator for perineal hernia
* Polypropylene mesh if necessary
* Well tolerated, allows capillary and granulation tissue in growth
* Strict asepsis
* Omentum
* Eliminate dead space, drains if necessary

Question 3

When are umbilical hernias often diagnosed? What do they normally contain? How are they repaired?

Answer 3

• Generally young
• Usually congenital due to failed embryogenesis

Normally contain fat/omentum, occasionally intestine

Diagnose on palpation

Repair
* Can resolve spontaneously, or be corrected at neutering
* Repair by reducing, incise over hernia, excise sac and repair muscle edges
* Don’t debride margins
* Close with synthetic, absorbable, monofilament suture; e.g., polydioxanone

Question 4

What is an incisional hernia? What can cause it? How are they treated?

Answer 4

• Surgical closure of body cavity fails
• Generally linea alba
• Normally within 7 days
• Can be chronic

Cause
* Generally surgeon to blame
* Incorrect technique
* Incorrect suture material/pattern
* Entrapped fat between wound edges
* Infection
* Steroid therapy/cushingoid patient
* Poor post op care

Repair
* Repair asap
* Evisceration is an acute abdominal emergency
* Lavage and resect nonviable tissues/anastomose bowel if necessary
* Re-open and repair entire wound
* Only debride edges if infection or are non viable
* Suture EXTERNAL SHEATH OF RECTUS ABDOMINIS (strongest holding layer)
* Ensure monofilament suture, long lasting and appropriate size
* Chronic hernias often more difficult due to adhesions

Question 5

What needs to be taken into account with contaminated traumatic abdominal ruptures? How are they repaired?

Answer 5

e.g. bites, lots of lavage and avoid mesh
- same hernia repair principles
- Identify free edge of abdominal wall and reattach to cranial pelvic brim if prepubic tendon rupture

Question 6

What causes inguinal hernias? What can they contain?

Answer 6

Cause
* Due to congenital inguinal ring abnormality or trauma
* Can be associated with obesity/pregnancy
* Thought to probably be inherited => recommend neutering
* scrotal hernias can be traumatic or occur post castration in small mammals with large inguinal rings and open methods

Intestine, bladder or uterus can enter subcutaneous space. Omentum is most common content

Question 7

When are diaphragmatic ruptures mostly seen? What clinical signs are associated? How are they diagnosed? What treatment is available?

Answer 7

Common presentation following RTAs but can be congenital
Can also be a chronic injury with resp/GI clinical signs

Clinical signs
* Normally present shortly after trauma shocked
* Pale/cyanotic
* Tachypnoeic/dyspnoeic
* Tachycardic
* Occasional cardiac arrythmias
* Hydrothorax

Diagnosis
* Radiography
* Loss of diaphragmatic line
* Loss of cardiac silhouette
* Presence of gas filled structure in thorax
* Atelectasis
* Displaced abdominal organs
* Water soluble contrast into abdomen
* Ultrasonography, esp. in chronic case

Treatment
* OXYGEN
* IVFT and warm up
* Higher mortality if surgery performed less than 24 hr following injury (also greater than 1-year-old)
* Acute gastric distension, need to operate a.s.a.p.
* Prophylactic antibiotics due to toxin release from organ strangulation
* ECG

Question 8

Which breeds are predisposed to hiatal hernias? What is it caused by? What clinical signs are associated? How is it diagnosed? How is it treated?

Answer 8

Brachycephalic breeds (English bulldog, French bulldog, pug, etc.), Shar pei

Congenital defect

Clinically very similar to oesophagitis
* Regurgitation
* Hypersalivation
* Visceral discomfort

Diagnosis
* Radiography - soft tissue opacity in dorso-caudal thorax adjacent to diaphragm
* Fluoroscopy
* Endoscopy

Treatment
Tx oesophagitis
* Antacid
* Sucralfate
* Prokinetic
* Antibiotic (if aspiration)

Surgery
* ventral midline coeliotomy
* reduce hernia at oesophageal hiatus and close
* pexy oesophagus to diaphragm
* pexy stomach to body wall

Question 9

What is a peritoneopericardial diaphragmatic hernia? What signs are associated? Which breeds are predisposed? How is it diagnosed? How is it treated?

Answer 9

Congenital communication between pericardial sac and abdomen
Faulty development of septum transversum
Often cardiac/sternal deformity in association

Clinical signs
Can be asymptomatic
GI or respiratory signs e.g. v+/d+, anorexia, weight loss, wheezing, dyspnoea

Breeds
Weimaraner, Cocker spaniel

Diagnosis
* Radiography
* enlarged cardiac silhouette
* dorsally displaced trachea
* gas opacities in pericardial sac
* Ultrasound
* Contrast radiography

Surgery
* Ventral midline coeliotomy
* Incise sternum if necessary
* Reduce viscera
* Suture diaphragm
* no need to separately close pericardium