Surgery of Hernias Flashcards
Hernia
There is skin covering
True: wehn hernial content is covered by peritoneum (i.e the peritoneal sac is protruded peritoneum)
Untrue: no sac therefore no peritoneum covering
Reponable/reducible: can push contents back into place because there are no adhesions!! however high chance of recurrence
Irreponable/ irreducible: cannot push back
Incarcerated: adherence of hernial tissue therefore irreponable
Strangulated: decr bs— necrosis
Umbilical hernias
Dogs
Strictly congenital but can be worsened by trauma because is an LMR– suffusion and swelling
Can occur with other congenital abnormalities e.g crypto
Diagnosis of umbilical hernia
non-painful fuctuant swelling in the umbilical region
usually reducible, rarely strangulated or incarcerated
Content: falciform, greater omentum, rarely SI
Usually no symptoms
ALWAYS true!!
Treatment of Umbilical hernias
NEMETH ALWAYS RECOMMENDS SURGERY!!
Standard herniorrhapy
Mesh hernioplast: polyglycolic acid, polypropylene, polyester
Elisabethian collar
Umbilical hernial surgery description
Elliptical incision- remove the bulged skin
Remove dead space to avoid hmatome or seroma formation
Excise the hernial sac/peritoneum
Examine the content and vitality- perform any necessary resection before introducing them!!
Suturing:
1st layer= rectus
2nd layer= SC with thoracic fascia
3rd layer= intradermals
4th layer= skin
coninuous or interrupted!!
Inguinal hernias- anatomical differences btw the male and female, starting with the female
Caud supf epigastric a and v
Ext pudendal a and v
Ext abd oblique muscle and ext inguinal ring
Pectineus muscle
Gastrofemoral nerve
Proc vag!! is part of the peritoneum and is the attachment of the teres uterine ligament
the ext and int inguinal rings- are not at the same level and between the 2 are many arteries and veins
Inguinal hernias male anatomy
basicall the same as the female, proc vaginalis is much smaller and does not contain the teres uterine ligament
SPERM CORD:
- testic a and v
- DD
- Tunica vaginalis
Inguinal hernias- incidence
Direct in females!!
Indirect in males- scrotal
Congenital: wide inguinal ring
Acquired: width of the ring incr with age, obesity also causes widening
Can be unilat or bilat- if bilat then not symm!!
Usually fluctuant and not painful
Direct inguinal hernias in female
Hernial contents get into the vag proc
Always true because there is time for the peritonuem to cover
Not painful, loose, fluctuant swelling
Content: major omentum, uterus because the teres lig pulls a horn into the sac, bladder-this causes the size of the hernia to change! and maybe SI
Direct inguinal hernias in female: treatment
- Incise the hernial sac
- Widen hernial ring cranially to allow for reposition- examine vitality of contents
- Remove sac
- Close hernial ring but make sure not at the site of the ext pudendal vessels
- Layer-by-layer opposition
- Suturing: interrupted btw rectus and pudendal going cranially, leave out the last stitch to leave room for the vessels and nerves
If you put the stitches too close– strang of the vein— edema!!!
Direct inguinal hernia in males
Is very RARE!!
And is usually the same as it is in females
Indirect inguinal hernias in males
into scrotum!!!
Huge incr in abd P is required to push the SI into the cavity!
Cavity content: protruded sperm cord and vaginal tunic. (small and tight)
Enlarged scrotum
Cord-like vag process
Painful swelling
Time sensitive- when palpate the base there is a huge pain reaction!
Content: SI, tumour, fluid (hydrocoele)
Strang is more freq- rapid necrosis of the SI
When not acute there is edema- infiltration of bact– swelling/discolouration of the area to black/blue!
Treatment of indirect inguinal hernias in males: surgery!!
- paramedian incision over the hernia/swelling NOT midline!!
- Exploration of the hernia- check viability
- resection of intestine if needed
- castration- is always advised as threr is ofte compression of the intravaginal structure
- Closure of hernial ring- be careful of pudendoepigastric trunk
- Layer by layer opposition of the structues
Traumatic abd hernia
ALWAYS UNTRUE!
Dogs and cats- car accidents, bites, high rise In cats- blunt traumas i.e no skin damage!
Usually accompanied by injuries of abd contents
Simulataneous weaking of the abd wall and incr in abd P– dislocation of organs– therefore emergency so cHeck Resp, CV and CNS- only proceed with treatment when stable!
Diagnosis of traumatic abd hernia
Signs are very variable! depends on severity, size of ring, damage to the wall, contents and if strangulation of contents!
Local signs: swelling of flank area, lacerated skin- suffusion/swelling
In dogs: the bad muscle is thicker- contraction is likely to cause strang
In cats: larger hole because the skin is thin therefore more contents in the sac but less likely to be strangulation
General signs: anaemia, shock, jaundice
Diagnosis of traumatic abd hernia
X-ray
Contrast
US
Treatment of traumatic abd hernia: SURGERY
- stabilise resp and circ prior
- AB’s metronidazole- skin has decreased immunogenicity
- Incision on flank/ below ribs
- Explor hernial contents and the do ex lap!! because you don’t want to overlook e.g splenic rupture
- Restore viability: necrotomy, resection, splectomy, lobectomy
- herniorrhapy or plasty
- Lavage before layer by layer closure
- Drainage
Perineal Hernia/ Rectal Sacculation
In males older than 7
Hormonal imbalance!!
- incr DHT: prostate enlargement because high number of DHT receptors– incr abd P- difficulty urinating, pooing
- Incr relaxin: weakening of perineal muscles- because high amount of relaxin receptors
Results: fossa ischiorectalis+ herniation+ rectum deviation
Perineal Hernia/ Rectal Sacculation: notes from lecture
Detachment of perineal muscles- therefore the type of hernia depends on the muscles involved
Caudal: sphincter and levator ani- forms the fossa ischiorectalis
Dors: levator and coccyg
Lat: gluteal, int obturator and coccyg
Ventr: spincter and urogenital
*in this area you must be v careful of the large int pudendal A that is accompanied by the pudendal nerve
Perineal Hernia/ Rectal Sacculation: diagnosis
Long history as usually a chronic problem!
Trouble defecating
Perineal enlargement and rectal bulging/deviation to the affected side
RDP
X ray
US of prostate
Rectal digital palpation is compulsory- the prostate will be enlarged and painful
Dog will lose feeling in one/both muscle walls- finger imprint remains because you’re pressing into the fossa
Perineal Hernia/ Rectal Sacculation: complications re bladder
If huge abd P- stang of bladder- no urination– swelling
If puncture- will drain bloody urine- this reduces the P so you can introduce catheter! surgery now possible
If the skin is edematous- wait a few days before doing surgery!
Perineal Hernia/ Rectal Sacculation: treatment is SURGERY
- castration- obligatory- if you don’t there will be reoccurence or will happen on the other side
- Perineal approach in ventral recumbency: curved incision on perineum- not too close to ischial tubercle- extend from base of tail to the ischial arch
1st opening: ext anal sphincter- this is innervated by the pudendal nerve and is responsible for defecating
2nd opening: int anal sphincter
More lat: levator ani and then lat to this is the coccyg
Ext obturator covers the obturator foramen— all of these muscles form a tight sheet!
- Pursestring on anus
- Herniorrhapy, rectorrhapy, hernioplasty
- Closing: mattress using monofilament! put in stitches loosely before tying knots
Extra notes to consider when doing perineal hernia surgery
Levator ani muscle is usually very atrophied
Need to elevate/perform transposition of the internal obturator muscle
If muscles are very atrophied- put in surgical mesh- fibrous lamina formation
Diaphragmatic hernia
frequent locations: hiatus esophagus or aorta
Abnormal dislocation of abd organs into the thoracic cavity through congenital (e.g the hiatus) or acquired defects
The clinical consequnces are due to the compression of the thoracal organs or functional disorders of the affected abd organs therefore are v. variable!
Congenital defects causing Diaphragmatic hernias
- Pleuroperitoneal diaphragmatic hernia= hereditary- when there is NO DIAPHRAGM
- Peritoneopericardial hernia (PDDH)- no septum transv at xiphoid- there is comm btw pericard and peritoneum
- Hiatal hernia: sliding, axial/rolling, paraesophageal
Acquired defects cauing diaphragmatic hernias
90-95% traumatic!
PDDH
Opening/comm btw the peritoneum and pericard
Dislocation of abd organs to the pericard
In normal x-ray the heart seems to be filling out the chest and can’t see anything wrong with the pericard
Contrast x-ray- maybe able to see intestines right up to the pericard
Surgical treatment of PDDH
The defect has a smooth even edge because its congenital- make it bleedy! and then place continuous sutures btw it and wall following the costal arch all the way to the xiphoid cart
Because of the lack of tissue- the edge will be tense/tight
Pleural sac is not touched therefore no interference to resp therefore the risk is not as higj!!
Air in the pericardial sac will be absorbed over time
Hiatal hernia
- Abd esoph
- Junction btw esophagus and stomach
- maybe part of the stomach
All go into the thorax!
Sliding hiatus hernia
Instability btw the cardia and the defect
Cardia slips axially into the chest
Cranio-caud movement and opening of cardia
Reflux esophagitis
Chronic anorexia
Vomitting
Regurg
Normal x-ray: will see a mass just cran to the diaphragm
Cotrast x-ray: shows narrowing of the esophagela lumen
NO GAS ACC!!!
Rolling/ paraesophageal hernia
carida is fixed to a wider hiatus allowing the fundus which is filled with gas to enter the chest
Gas acc in the chest– compresses the lungs— dyspnoea
Surgery: to ID the greater curv of the fundus look for the gastroepiploic foramen!
Must narrow the hiatus: place 2/3 interrupted sutures
Perform esophagopexy- attaching the seromusc layer of the esoph to the hiatus
Perform gastropexy- to the midline or lat abd wall- so that the stomach does not dislocate again (this always done with GDV)
Traumatic hernias
Comprise 90-95% of the acquired hernias
Unilat: L or R sided or bilat
Direction of trauma/laceration:
- Circular: follows costal arch
- Radial: from centre of diaphragm towards periphery
- Combined hernial gate
Cat: high rise, dogs: car accident
Abd is suddenly compressed by this blunt trauma- there is a huge incr in abd P. If larynx is open at this point- rupture of diaphrgam instead of lungs
if larynx is closed- rupture of lung lobes, diaphragm intact
Pathogenesis of traumatic hernias
Depends on:
time since incident! threshold is 2 weeks
Size of hernial gate: if large more organs get out but there is less chance of strangulation/incarceration
Dislocated orgasn: ometum, liver etc
Status of lungs- if they have become atelectic
Systemic alterations as a reuslt! therefore always treat as emergency!– shock, ARDS
Intrathoracal alteration: when there has been thoracic contusion- pulm edema/haem or PTX or haemothorax
*liver can easily get into chest if diaphragm ruptures- blood in thorx/abd
*spleen rarely ruptes
Abd: hepatic- contusion, congestion, rupture
Diagnosis of diaphragmatic hernia
General assessment
Detailed exam
Supplementary exam
Differentials
Diagnosis of diaphragmatic hernia: general assessment
Weakness, apathy
Lying or sitting to alleviate resp
Cyanotic, pale mm
Prolonged CRT
Tachypnoe, dyspnoe
Diagnosis of diaphragmatic hernia: detailed exam
- Circ: look for signs of shock!
* tachycard, dislocation/lack of heart sounds- this can occur when e.g lung lobe/spleen btw the wall and the heart - Ausc of Thorax
- incr resp sounds: compressed lung, edema
- absent sounds: PTX or organs in the way
- Maybe can hear GI sounds?
- Percuss of thorax
- dislocated diaphragmatic line and horizontal fluid line (haemothorax)
- decr resonance: liver, spleen omentum covering (non-luminal organs)
- incr resonance:PTX or stomach/ intestines in the way
- Palpation of abd
* Abnormal “empty” feeling esp in cats
Diagnosis of diaphragmatic hernia supplementary exams
- X-ray: what to look for: line of diaphragm (will be too cranial) position of intrathoracal organs, lung patterns to show signs of edema, haem or contusion, fluid or gas, position of the liver and stomach
- US: line of diaphragm, position of abd organs
*pathognomic- when the liver is too close to the heart- congestion and free fluid in the pleural cavity and peritoneum
Diffs of diaphragmatic hernias
Pleural effusion without herniation: hydro, hemo, chylo, pyo thorax
Pulm edema and haem
Pneumonia
PTX
GDV
Intestinal obstruction
Cardiac disorders
Therapy for diaphragmatic hernia
ALWAYS surgery- is an emergency situation
- Stabilize Circ and Resp: O2, diuretics, correct acid base and electrolytes, sedation (ACP, DZP), Thoracocentesis in the 7-8 ICS
- The surgery itself: inhal anesth, ventr midline lap from the xiphoid to the umbilicis. Can do in combo with partial sternotomy (rare because the lung lobes are not usually ruptured)
Check viability- remove necrotic by lobectomy or resection. Restore diaphragm in one or 2 layers- interrupted or continuous, abd or non abs
Chest drain only if there was an issue with intrathoracic organs
Surgical problems associated with a CHRONIC diaphragmatic hernia
the lungs have become atelectic
- organs have adhered and have become stable in their abnormal positions
- Lungs adapt to being compressed- if ofrce them to take up air air- will cause re-expansion pulm edema- extravasation of blood!
- Contraction of the abd wall since its not as full with organs- this contraction of the wall pushes the organs up to the diaphragm which could damage the suture line
- Loss of flexibility of diaphragmatic muscle
- Must refresh the tense edges by making them bloody
If normal resp towards the end of surgery- good prognosis
*before last suture, ask for large inhale so there is minimal air in the thorax therefore lowering the risk of PTX
*if defect is dorsal- be careful of the v.cava
*continuous>interrupted because this turns in the diaphragm- less chance of air escaping (but either mono or polyfilament)
Postop of diaphragmatic hernial surgery
O2
Intensive monitoring- blood gas analysis
Infusion, diuretics
Analgesia: flunixin meglumine or opiates
Mashy/pulp diet
