Quiz 2 Flashcards
What is the most common form of diaphragmatic hernias?
What percentage of all diaphragmatic hernias do they make up?
- Aquired diaphragmatic hernias due to TRAUMA
- 93%
List the radiographic signs of a diaphragmatic hernia.
- Interupption of diaphragmatic outline
- ST density in the Thorax
- GAS filled viscera in the Thorax
- Loss of cardiac sillhouette
- Incidental finding
What time periods is mortality HIGHER when hernias are repaired after occurence?
Why?
- When repaired <24 hrs. or >1 yr. after they occurred
- Due to adhesion formation
Why should you delay diaphragmatic hernia SX till 1-2 wks after occurrence?
- Success rate improves to 90%
- Better suture holding
When must SX be performed if the STOMACH has herniated into the Thoracic cavity?
Why?
- Immediately
- Dilated stomach will cause complete & rapid collapse of the lungs
What is a possible POST-op complication w/ Diaphragmatic Hernia repair?
Reperfusion injury → Pulmonary edema
Which surgical approach for repairing a diaphragmatic hernia requires an accurate DX?
Why?
- Thoracic approach
- only allows access to one side of the body
Where do you start suturing to repair a RADIAL diaphragmatic tear?
at the most DORSAL margin
What suture patterns & suture material are recommened to repair a Diaphragmatic hernia?
- Simple continuous or simple interrupted
- 3-0 or 2-0 PDS
What must you do JUST before closing up on a traumatic diaphragmatic hernia repair?
Have the anesthestist SLOWLY EXPAND the lungs while the last suture is placed
to force air out from the pleural space
When should you place a thoracotomy tube(s) when repairing a traumatic diaphragmatic hernia?
- w/ a chronic hernia
- herniated liver
Why must you perform good post-op care/monitoring of patients recovering
from traumatic diaphragmatic hernia repair?
Due to risk of:
- Reperfusion injury (esp. lungs)
- Re-expansion Pulmonary Edema
- Hemorrhage
- Pneumothorax
What is the prognosis for traumatic diaphragmatic hernia repair?
- Guarded until patient survives 24 hrs. post-op
- Excellent after the 1st 24 hrs. → 60-90% survival rate
Cats & Dogs ALWAYS get what form of Peritoneo-Pericardial Herniation (PPH)?
Congenital form
PPH is associated w/ ______ hernia in 1 out of 3 dogs.
VENTRAL hernia
How do you surgically repair PPH?
Abdominal approach → relocate abdominal viscera → debride edges of defect → close from dorsal to ventral → DO NOT CLOSE THE PERICARDIAL SAC
What must you do if communication w/ the pleural cavity occurs during surgical repair of a PPH patient?
For 24-48 hrs. POST-op:
- Assisted ventilation
- Thoracic drainage
- ICU
What classifies a TRUE hernia?
Must contain a peritoneal lining for it to be a true hernia!!
List the 3 examples given of FALSE hernias?
- Diaphragmatic hernia
- Herniation of kidneys
- Perineal hernia
Define eventration.
Protrusion of the abdominal content through a debiltated area of abdominal wall due to a SXical or Traumatic origin w/ INTACT skin
Define evisceration!
The rupture of all structures constituent of abdominal wall w/ PROTRUSION of the visceral content through a wound or SX incision.
What is a common reason why evisceration occurs?
2° complication of an OVH
List the 2 types of Reducible hernias/eventrations.
What is the most common of the 2?
- Coercible → most common
- Incoercible
Define a (reducinle) Coercible hernia.
hernial content CAN be manually reduced & RETAINED inse the abdominal cavity
Define a (reducible) incoercible hernia/eventration.
hernial content can be manually reduced but is NOT RETAINED inside the abdominal cavity
List the 2 types of Irreducible Hernias/eventrations.
- Incarcerated
- Strangulated
Define an (irreducible) Incarcerated Hernia/Eventration.
impossible reduction of hernial content w/ intact blood supply to the content
Define (irreducible) Strangulated hernia/eventration.
impossible reduction of hernial content w/ VASCULAR COMPROMISE leading to ischemic injury of the protruded viscera
List the 4 Herniorrhaphy Priniciples.
- Return all viable content to the abdominal cavity
-
Close the hernial ring to prevent recurrences
- avoid obliterating pudenal vessels
- Obliteration of redundant tissue in the hernial sac
- Use the patient’s own tissues whenever possible
What is the TX of choice for an Umbilical hernia?
Why?
- Perform a Herniorrhaphy immediately
- If wait → risk of entrapment due to growth of the animal
What 2 ways can you make your incision to correct an umbilical hernia?
- Straight incision over the defect
- Elliptical incision around the defect to remove redundant tissue
What is an INDIRECT Inguinal Hernia?
Who gets it?
- hernia goes through the Vaginal process & into the scrotum → scrotal hernia
- MALES only
What is a DIRECT Inguinal hernia?
Who gets it?
- hernia goes thru the inguinal canal & CREATS a sac APART from the testicular canal
- Males & females can get
List some DDX for an Inguinal Hernia.
- Abscess
- Mammary neoplasia
- Neoplasia
- Hematoma
- Inguinal lymph node
- Fat of the round ligament
- Eventration
Which side must you leave open, when repairing an Inguinal hernia,
to prevent damage to the Pudenal vessels?
MEDIAL/Caudal side
What suture pattern should you use when closing the inguinal ring during a herniorrhaphy?
“Vest over pant”
(Mayo-Mattress suture pattern)
Post-op care for an Inguinal Hernia?
- Analgesics/NSAIDs
- Restrict exercise
- Feed soft/low residue diet
- ABXs ONLY needed if pyometra or enterectomy
Who do Perineal hernias most commonly occur in?
Where do they occur?
- INTACT male dogs → 7-9 yrs. old
- 2/3 are unilateral
- tend to appear more on the RIGHT
Animals w/ Perineal Hernias often tend to have ___________ as well.
Benign Prostatic Hyperplasia
Why are the diverticulums usually not resected in perineal hernias?
due to increased collagenase activity 5-7 d. after anastomosis →
collagen degradation exceeds collagen synthesis
What is a Perineal Hernia?
Pseudo-Hernia/False Hernia
No Serosal Lining***
What ligament is very important for anchoring during perineal hernia repair?
Sacrotuberous ligament
How do you diagnose a perineal hernia?
- CS
- Physical Exam
- Rectal - finger:
What makes a perineal hernia an emergency?
Herniation of bladder!
What do you need to remember about the anatomy of the pelvic diaphram in a Cat?
NO Sacrotuberous Ligament
What do you do PRE-op for perineal hernia patients?
- Stabalize!!!!!
- Bladder catheterization or centesis
- Empty anal sacs
- Purse string suture around anus → Don’t forget to remove!!!
- NO ENEMAS
When repairing a perineal hernia what is the most common approach?
What is your landmark?
- Perineal Approach
- ventral recumbency w/ elevated pelvis
- Sacrotuberous ligament is your landmark →place sutures THRU it not around it
- May hit the Sciatic n. if go around it
When using implants to repair perineal hernias what is best?
Patient’s own tissues b/c or rejection issues
What are the Most common POST-op complications of perineal surgery?
- Rectal prolapse → purse string w/ opening to allow defecation
- Incontinence → Pudendal n. damage
- Dehiscence → rare; avoid pulling sutures to tight
- Sciatic nerve lesion → entrapment (rare)
- fuctional recovery 2-4wks or may need corrective SX
- Recurrance → 10-46%
- Castration prevents
When correcting a Sciatic nerve entrapment what approach do you use
and which one do you never use?
Caudolateral Approach
NEVER via herniorrhaphy!
What is an alternative SX to fix perineal hernias?
What pt. does this work best in?
What order do you do the procedure?
(TQ)
- Colopexy/cystopexy/deferentopexy
- Pexy colon to the L
- Pexy bladder to the R
- Anchor deferens to the adjacent abdominal wall
- Good for pts in critical contition
- If doing both an Intra-abdominal & Perineal procedure:
- Do the intra-abdomimal procedure first (cleanest procedure)
What animal is perinal gland adenoma most common in?
What animal does it NOT occur in at all?
- Most common: intact, male dogs (rare in female)
-
Does not occur in cats!
- No perianal or circumanal glands
What is the CLOSED technique for anal sac excision?
- Make curved incision parallell to the anal sphincter
- Peel entire gland out
- careful not to damage muscle fibers
- can inject wax to make it easier to remove
What is the #1 rule about surgery of the ear?
Always use antibiotics!
(it’s a contaminated procedure!)
What are your landmarks for ear surgery?
- Anthelix
- Tragus (ventral)
- Intertragic incisure
- Tragohelicine incisure (medial & lateral boarders)
What is the only way to evaluate a dogs ear canal?
Otoscopy
When do you perform a Total Ear Canal Ablation combined with Lateral Bulla Osteotomy (TECA-LBO)?
When you have a dog w/ stenotic canal(s), chronic ear infection(s) & fluid in the Bulla!
(When you KNOW there is something in the Bulla!!)
What is an iatrogenic cause of Horner’s Syndrome?
What is Horner’s Syndrome?
- Pulling to hard on the Facial n.
-
Horner’s Syndrome:
- Miosis
- 3rd eyelid protrusion
- Ptosis (upper lid)
- Enophthalmos
What is the difference between dogs’ & cats’ 3rd eyelid?
- Dogs→ 100% passive
- Cats→ BOTH passive & non-passive movement
Otitis media in Dogs vs. Cats?
- Dogs → 2° to Otitis externa
- Cats → 1° condition w/o Otitis externa
- Nasopharyngeal polyp!
What is important to remember when removing nasopharyngeal polyps?
- Polyp stalks must be removed or they will regrow!!
- If polyp is resected in pharynx or Ext. Ear Canal→Pull stalk into Bulla & remove stalk w/ epithelium via a Ventral Bulla Osteotomy
What is laryngeal paralysis?
Failure of laryngeal cartilages to abduct on inspiration due too:
- degeneration of Recurrent Laryngeal n. &/o
- Paralysis of CAD muscle
What is the etiology of laryngeal paralysis?
Who does it most commonly affect?
- Wallerian Degeneration of Recurrent Laryngeal nerve (idiopathic)
- Most often occurs in Medium & Large breed dogs
- Associated w/ hypothyroidism in labradors
- so if diagnosed, always run a thyroid test.
What is the typical HX of a dog with laryngeal paralysis?
-
Inspiratory Dyspnea
- Elbows abducted
- Retracted commisure
- Thick saliva
- Stridor
- Change in voice
- Cyanosis
- Hot weather exacerbates!
What are the surgical treatments of laryngeal paralysis?
- Choking & unable to intubate patient → Tracheotomy!
- Partial Arytenoidectomy (ventriculo-cordectomy)
- Aretenoid Cartilage Lateralization “tie back” (Aretenopexy)→ most common
- Laryngoplasty
What are the two approaches used during an Exploratory Rhinotomy?
What will you see with each?
-
Dorsal Approach
- Rostral Nasal Cavity & Sinuses
-
Ventral Approach
- Entire Nasal Passage, including area caudal to the Ethmoid turbinates
How do you perform the folded flap palatoplasty on an elongated soft palate?
- Remove a partial thicknes flap (1/2-2/3) of soft palate to create a thin soft palate
- Take a piece of buccal side of mucosa & fold the free edge to an appropriate length then suture to denuded portion of soft palate
What are the surgeries available for Brachycephalic Syndrome dogs?
- AlaPLASTY
- removal of redundant protion of nose most effective Sx for stenotic nares
- AlaPEXY
- enlarging nares by tacking them to skin lateral to nose better for not severely stenotic nares
- Partial palatectomy/Partial soft palate resection
- full thickness removal of a portion of the soft palate
- Folded Flap PalatoPLASTY
- best option to correct elogated soft pallate
- Permanent Tracheostomy
- treatment of choice for laryngeal collapse (not paralysis)
When would you perform an Exploratory Rhinotomy?
- Treatment of Nasal Adenocarcinoma (followed by radiation therapy)
- Establish Drainage or remove FB
- Obtain biopsy/culture specimens
How do you perform an OPEN anal sac excision?
- Incise along the length of the gland
- Open gland up
- Peel it off up to the nexk of opening at the anal sphincter
- Remove gland
******Careful not to damage the External anal sphicter mm.*******
What are the complications associated w/ Tie Back SX?
- Aspiration pneumonia
- Failure to correct condition
- inadequate lateralization
- failure to TX Hypothyroidism
- MisDX of the cause of dyspnea
What are the characteristics of 1° Brachycephalic Airway Syndrome?
- Stenotic nares
- Elongated soft palate
- Hypo-plastic trachea
What are the characteristics of 2° Brachycephalic Airway Syndrome?
- Everted laryngeal saccules
- Laryngeal collapse
What is the most effective SX for treating Stenotic nares?
AlaPLASTY
(removes redundant tissue)
When would you want to use AlaPEXY?
To surgically correct nares that are NOT severely stenotic
When is it okay to extubate your patient following a Partial PalatecTOMY
(Partial Soft Palate Resection)?
When they are chewing on the tube!!
What is the treatment of choise for Laryngeal Collapse?
What must the owners be warned about?
- Permanent tracheoSTOMY
- Bark may change or cease to exist
- NO SWIMMING!!!!
What additional salivary gland do CATS have?
Molar Salivary Gland
What are the secretions like for each of the Salivary Glands?
- Parotid gland → serous
- ALL OTHERS → sero-mucous
How can you DX a disease of the salivary gland?
Needle aspirate of the swelling→ get THICK saliva
(“honey cyst” if in the cervical region)
Which glands must you remove in order to TX a Sialocele?
- Sublingual salivary gland
- Mandibular salivary gland
What is the most common dz. of the Salivary system in the Dog & Cat?
Which duct is most often affected?
- Salivary mucocele
- Sublingual salivary duct
Which type of mucocele can cause respiratory distress & be life-threatening?
a Pharyngeal mucocele
How can you determine which side a Cervical Sialocele is on?
- place in DORSAL recumbency → will move to the appropriate side
- Can also use contrast radiography
How can you differeniate a pharyngeal mucocele from neoplasia?
Aspirate it!! → honey mucocele is DXstic
Where do you disect when performing a Sialaodenectomy?
-
BELOW the Digastricus mm. to the Lingual n.
- Lingual n. is the boundary!!!!
Which salivary gland is associated w/:
- Sialoliths?
- Sialoadenitits?
- Sialocele?
- K9 Necrotizing Sialometaplasia?
- Parotid
- Zygomatic
- Sublingual
- Mandibular
What side of the body is the Pancreas located on?
RIGHT side
What is the major excretory duct in CATS?
Ventral (Pancreatic) duct
What is the primary excretory duct in DOGS?
Dorsal (Accessory) Duct
What 3 things supply the LEFT lobe of the pancreas w/ blood?
- Hepatic a.
- Splenic a.
- Gastoduodenal a.
What supplies the RIGHT lobe of the pancreas w/ blood?
Why does this matter?
- Pancreatic-duodenal a.
- When resecting the RIGHT lobe → ONLY ligate the pancreatic vessels
- NOT the duodenal ones
How much of the pancrease can be removed
w/o causing Endo-/Exocrine Pancreatic Insufficiency?
up to 80%
When is it OKAY to use absorbable monofilament suture material when performing duct ligation during pancreatic SX?
in the case of Sepsis
(otherwise want a non-absorbable like polypropylene or nylon)
Etiology of an Insulinoma?
adenocarcinoma of the BETA cells
Etiology of a Gastrinoma?
Adenocarcinoma of the NON-BETA cells
What is the most common pancreatic neoplasia?
Exocrine Pancreatic Adenocarcinoma
What is pathognomic for an Insulinoma?
WHIPPLE’S TRIAD
- Neuro signs
- Hypoglycemia
- Neuro signs resolve following feeding or parenteral admin of glucose
- C/S improve when pt. is fed.
How often should you monitor BG when surigically treating an Insulinoma?
Every 5 min!
What DXstic tool is most helpful in IDing SXical pancreatic dz?
Abdominal U/S
Which side of the liver is more difficult to operate on?
Why?
Right side b/c it is less fissured
What are the 2 afferent blood supplies to the liver?
-
Portal System
- Low pressure
- Supplies 4/5 of the blood that enters the liver
- Provies 50% of the O2
-
Arterial System
- High pressure
- 2-5 branches from the Hepatic a.
- Cystic a. supplies the gallbladder
- Provides 50% of the O2
What % of liver neoplasia are primary tumors?
1% → most mestastasis from other locations
What is an important PRE-surgical consideration before performing Liver SX?
-
Do a coagulogram!!
- want to be sure the animal can clot!
- Avoid drugs metabolized by the liver → i.e. Thiopental
-
Give wide-spectrum ABXs
- Flouroquinolones + Clavamox
- Flouroquinolones + Clindamycin
- Ampicillin + Metronidazole + Cephalosporins
Surgical approach for Liver SX?
- Clip WIDE → sternum to pelvis to sides of thorax
- R lobe is harder to access than the L lobe (due to the vena cava)
- Use Balfour retractors to hold abdomen open
- Place Lap sponges btwn. diaphragm & liver
- Use stay sutures to retract the stomach caudally
What does the Pringle Maneuver do?
How long can it be SAFELLY performed?
- Occuldes the Portal Triad to prevent hemorrhage:
- Portal vein
- Hepatic a.
- (Common) bile duct
- for up to 20 min.
What is the main cause of extrahepatic biliary obstruction?
Pancreatic pathology
List the 3 pathognomonic signs of Cholecystitis.
- Jaundice
- Abdominal pain
- Fever
What is the pathognomonic sign of a gallbladder mucocele?
“Kiwi sign” on U/S
What is the smallest size the stoma can be?
No smaller than 2.5-3 cm long!
What is the most common form of Congenital PSS?
Extrahepatic PSS
(EHPSS)
What is the most useful tool to DX INTRAhepatic PSS?
U/S
What is the best way to DX a PSS?
CT/MR Angiography
(CT shows you where the shunt originates & terminates)
What is the TX of choice for PSS?
Surgical attenuation/ligation
How should you attenuate vessels when attenuating a PSS?
Gradually!!
(aggressive ligation has a poorer outcome for the pt.)
An Ameroid Ring Constrictor works better on which type of Congenital PSS?
EHPSS >>>> IHPSS
Cellophane banding can be used to TX which type(s) of congential PSS?
BOTH TYPES
What is the most critical time for PSS patients?
Immediately post-op!
What are the fxns of the Spleen?
- Blood filtration & phagocytosis
- Immune activity against blood borne Ags.
- Blood reservoir
- Stores Fe
- Hematopoiesis
Where should you ligate splenic vessels?
Ligate vessels as close to the parenchyma of the spleen as possible
What is the most common Splenic neoplasia seen in DOGS?
What else should you be looking for?
- Hemangiosarcoma
- Cardiac hemangiosarcoma → 25% of dogs w/ splenic hemangiosarc will also have cardiac type.
When can you reposition the Spleen after Splenic torsion has occured?
ONLY if NO thrombosis is seen!
What artery & it’s branches are important to know when performing a Pancreatectomy?
Why?
- Celiac artery & branches
- Primary blood supply to the pancreas
What are the 4 endocrine hormones produced by the pancreas?
- Insulin
- Glucagon
- Somatostatin
- Gastrin
If pancreatic neoplasia is suspected, what other 2 organs should you evaluate/biopsy?
Regional LN
Liver
Blunt dissection & ligation is indicated for lesions located where in the pancreas?
Anywhere
Suture, Fracture technique is indicated for lesions located where on the pancreas?
focal lesions on the margin
If you have diffuse pancreatic dz, where should you BX?
caudal aspect of the RIGHT lobe.
If you have focal dz. pancreatic dz in the parenchyma, how should you BX?
Tru-Cut technique
How can you avoid causing iatrogenic pancreatitis when performing SX?
maintain good perfusion of the pancreas throughout SX
What is the prognosis for Exocrine Pancreatic Adenocarcinoma?
Extremely poor
(widespread metastasis is common)
What stain can be injected IV & used to help delineate insulinomas?
What is a side effect if use too much?
- Methylene blue
- Hemolytic anemia
What is Zollinger-Ellison Syndrome?
Gastrinoma in the pancreas secretes high levels of gastrin, which go into the blood
How do you perform a CholecysTOTOMY?
- Place stay suture on GB
- Make opening
- Aspirate bile & remove what is needed (i.e. stones)
- Close w/ an Inverting pattern
What is the most commonly used technique for removing GB stones?
How’s it done?
- CholecysTECTOMY
- Ligate Cystic a. (prevents bleeding)
- Bluntly dissect GB from liver lobe
- Ligate & remove GB
How does the Ameroid Ring Constrictor work?
- Gradually attenuates shunt over 4-5 wks due to Casein swelling
- Constriction is more due to an inflammatory ST rxn causing it to close
Describe Post-Op management for a PSS patient.
- Watch for portal hypertension
- Watch for seizure activity
- Ascites is common → don’t have to remove constricting device
- Repeat liver fxn tests 30-60 d. post-op
- If improved wean off: ABXs, Lactulose, Low protein diet
- Some may have to be on low protein diets for life
List the 5 Liver Fxn Tests.
- Cholesterol
- BUN
- Albumin
- Glucose
- Bile acids
Indications for a Total Splenectomy?
- 1° neoplasm of spleen
- Splenic torsion w/ vascular thrombosis
- Severe trauma
- Disseminated Feline mastocytoma
- Uncontrollable IMHA
What are the consequences of a Total Splenectomy?
- Increased Howell-Jolly bodies & nucleated RBCs
- Increased PLT count
- Increased chances of IDing sub-clinically infected animals w/ vector-borne dz.
- OPSI (overwhelming post-splenectomy infection)
- Decreased physical activity tolerance
When should you NEVER perform a Partial Splenectomy?
In cases of Neoplasm
