Management of commonly-occurring hernias Flashcards
1
Q
How are umbilical hernias diagnosed?
A
- Usually obvious on clinical examination
- Palpation of ring - easier with patient in dorsal recumbency
- Check for other congenital defects
- Abdominal imaging if multiple defects, incarceration or strangulation present -
- Radiography
- Ultrasonography
2
Q
How are umbilical hernias treated?
A
- <2-3mm hernias may close spontaneously up to 6mo old
- Neuter animal
- Repair all hernias with or at risk of incarceration or strangulation - Approx. 10mm diameter, inelastic ring
3
Q
What is surgical Tx of umbilical hernias?
A
- Incise skin around base of hernia
- Dissect sac free - Ligate and amputate if only contains fat
- Enlarge ring if required to aid reduction
- Release adhesions
- Resect / repair damaged contents, reduce, excise sac
- Debride ring and suture closed
4
Q
How are inguinal hernias diagnosed?
A
- Inguinal swelling
- Place animal in dorsal recumbency - Manually reduce hernia and palpate ring, Check both sides as often bilateral
- History may suggest contents =
- Vomiting / pain / depression = intestine
- Vaginal discharge / bleeding = uterus
- Imaging =
-Plain / contrast radiography or CT - Ultrasonography
5
Q
How are inguinal hernias treated?
A
- ASAP after diagnosis
2 approaches = - Uncomplicated hernias via incision over hernia parallel to flank fold
- Complicated hernias via midline incision +/- coelitomy if required
- Incarcerated / strangulated contents, herniated uterus, significant trauma, bilateral hernia
- Allows exploration of both inguinal rings, repair of viscera and repair of bilateral hernias
6
Q
How would you reinforce hernia repair?
A
- Polyethylene mesh
- Sartorius muscle flap
- Restrict patient to lead exercise until suture removal
7
Q
What are complications of inguinal hernias?
A
- Infection
- Haematoma / seroma - Prevent with dressings / drains
- Pain / reluctance to walk
- Compression of vessels / nerves
8
Q
How are traumatic hernias diagnosed?
A
- Palpation - Reducible hernia contents, Ring, Herniated viscera under skin
- Imaging to distinguish incarcerated / ill-defined hernias from other masses
- Plain / contrast radiography or CT
- Ultrasonography
- Assess patient for other injuries
9
Q
What is treatment of traumatic hernias? Emergency surgery?
A
- Stabilise patient =
- Deal with other life-threatening injuries
- Support hernia with bandages if possible
- Delay surgery for a few days if possible =
- Improve blood supply
- Reduce oedema
- Resolve haemorrhage
- Excessive delay can risk adhesions / incarceration / fibrosis
- Emergency surgery if =
- Patient cannot be stabilised
- Patient deteriorates despite treatment
- Penetrating abdominal wound present
- Strangulation present
10
Q
What is surgical Tx of traumatic hernias?
A
- Approach hernia =
- Ventral midline coeliotomy for acute hernias
- Incision over ring for chronic hernias - prepare large area
- Debride devascularised / necrotic tissue
- Repair muscle layers individually =
- Appositional synthetic monofilament absorbable sutures
- Include enough fascia / ligament / bone
- Place closed suction drain if required
- Restrict exercise for 2-4 weeks
11
Q
What are complications of traumatic hernias?
A
- Seroma / haematoma
- Infection
- Recurrence is uncommon
12
Q
How are incisional hernias diagnosed?
A
- Palpation of deep sutures to detect defects
- Manipulate skin suture line laterally to allow this
- Imaging if in doubt = Radiography / CT / Ultrasonography
- Surgical exploration as a last resort - Some contents e.g. omentum can be very hard to identify on imaging
13
Q
How would you treat acute incisional hernias?
A
- Hospitalise animal and support wound with bandages
- Try to identify cause of herniation
*Reopen original incision for uncomplicated hernias, ventral midline coeliotomy for complicated - Resuture whole wound if technical error suspected
- Debride devitalised fat / tissue between wound edges then close primarily
14
Q
How would you treat chronic incisional hernias?
A
- Less risk of evisceration
- Conservative management if asymptomatic, no incarceration, owner can closely monitor
- Surgical repair =
- Approach over original incision
- Identify ring & excise edge
- Close defect primarily / as for chronic traumatic hernias
15
Q
How would you treat evisceration? (gut out of body)
A
- Protect viscera = Sterile dressing, Elizabethan collar
- Stabilise patient with fluids, antibacterials
*Once stable, repair = - Explore abdomen, pack off and repair / resect damaged viscera
- Samples for culture / sensitivity
- Lavage & close abdomen +/- drainage
16
Q
How is Peritoneopericardial diaphragmatic hernias diagnosed?
A
- Other defects often present
- Reduced amplitude / alternans on ECG
- Thoracic radiography =
- Enlarged / rounded cardiac silhouette
- Overlapping diaphragm / cardiac silhouette
- Abnormal ST / fat density in pericardium
- Ultrasonography
- CT
17
Q
How is Peritoneopericardial diaphragmatic
hernias treated?
A
- Conservative in asymptomatic patients
- Surgical repair via ventral midline coeliotomy
- Reduce viscera +/- extending defect
- Repair / resect as required
- Close defect with continuous monofilament absorbable suture
- Drain air from pericardial sac
18
Q
How are traumatic diaphragmatic hernias diagonsed?
A
- Physical exam
- Tucked up abdomen
- Reduced / abnormally-positioned heart sounds
- Borborygmi in thorax
- Displaced apex beat
- Ultrasonography
19
Q
How are traumatic diaphragmatic hernias treated?
A
- Surgical repair as soon as patient stable
- Assess and repair abdominal trauma at same surgery
- Complex surgery & aftercare, consider referral
20
Q
How are perineal hernias diagnosed?
A
- Rectal examination
- Radiography
- Ultrasonography
- Colonic / rectal biopsy
21
Q
How are perineal hernias repaired?
A
- Investigate for intercurrent disease
- Internal obturator transposition
- Complications occur in 19-49% of cases - Wound infection most common
22
Q
A
