Hernias and Umbilical Remnant pathologies

Question 1

Reported complications of umbilical infections

Answer 1

• Septic arthritis/physitis/osteomyelitis
• Abdominal adhesions
• Pneumonia
• Diarrhoea
• Septic aortic aneurysm (single case report)
• Septicaemia

Question 2

Describe the standard surgical procedure for sx resection of infected umbilical remnants

(described by Oreff et al (VS 2017))

Answer 2

1. Fusiform skin incision (10 blade) around the umbilicus, continuing cranially to a point where the vein is comsidered normal on US
2. SQ dissection to expose the abdominal wall.
3. Abdomen entered 3-5cm CRANIAL to stump, through linea alba w care not to damage the vein
4. Vein located and exteriorised; double ligated (transfixing ligature w 0 PDS) and transected where visibly normal (incision continued cranially if not normal)
5. (Cranial linea can be closed at this stage to prevent large incision and exposure of intestines)
6. Incision continued caudally around the umbilicus (may need to be parapreputial in males)
7. Arteries double ligated (transfixing 2-0 PDS) where they have a normal appearance
8. Place stay sutures either side of the bladder. Can make stab incision for suction if full
9. Transect arteries and urachus at the bladder apex, removing them from sx field
10. Close the bladder in 2 layers → (Oreff used simple continuous full thickness then Cushing oversew - all 2-0 PDS. Can use vicryll or polysorb but need to not enter the lumen?)
11. Close in 3 layers; simple cont linea alba (PDS or vicryll), SQ (2-0 glycomer 631 SC) and intradermal (2-0 glycomer 631) or staples

Question 3

Outcomes following umbilical resection in foals for infected remnants (Oreff et al 2017 VS)?

What were risk factors for long term nonsurvival?

Answer 3

Overall 77% survival to DC (50/65)

66% alive 1 year PO

Risk factors for nonsurvival long term were:

• Younger age at presentation
• Concurrent synovial spesis
• Presence of multiple pathologies
• Higher creatinine level
• Higher heart rate
• Umbilical infection dx at the hospital rather than prior to referral
• Prolonged hospitalisation
• Longer period between arrival and surgery
• Development of PO complications - 45% of those with PO complications did not survive

Question 4

Generally reported outcomes following surgical resection of infected umbilical remnants

Answer 4

77-91% short term

Between 66 and 91% longer term- poorer px for vein infections with upto 50% mortality

Question 5

Short term survival following umbilical remnant resection for remnant infection and patent urachus reported by Reig Codina et al (2019 EVJ)

What were the risk factors for nonsurvival (short term) and developing PO complications?

Answer 5

STS was 89%

Risk factors for nonsurvival (2): concurrent/pre-existing septic arthritis/physitis and development of new septic arthritis and/or physitis PO - all 8 that developed new PO septic ortho dz had at least 1 site of ortho sepsis pre-op

39% PO complication rate - risk factors for PO complications (2): - FPT and long anaesthetic times

Umb vein infection was not identified as stat sig assoc w non-survival -despite the fact that 2 foals w severe umb vein infections had to be euthanased

Question 6

Definitions of Littre and Richter hernias

Answer 6

Littre hernia = incarceration of a Meckels diverticulum in an umbilical hernia (this is a remnant of the vitillointestinal duct present as an outpouching from the ileum in some horses and remains attached to the umbilical remnant providing an axis for intestinal torsion in some horses. Persists in very few of the population)

Richter hernia = (syn parietal hernia); incarceration of the anti-mesenteric portion of the intestine (usually ileum)

Question 7

Strucures originating/involved with the prepubic tendon

Answer 7

Runs transversely at cranial pelvic from 1 ileopectineal eminence to the other

Comprises linea alba & insertion of rectus abdominis

Origin or pectineus & gracilis muscles

Rupture rx in complete loss of ventrolateral support of the abdominal musculature

Question 8

Main ddx for PPT rupture & predisposing factors

Answer 8

Maain ddx is ventral/lateral body wall hernias. Can be v difficult to differentiate & both occur most commonly in late term mares

Twin pregnancies & hydrops are risk factors