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SAM 2 > Surgery of Hernias > Flashcards

Surgery of Hernias Flashcards

1
Q

Hernia

A

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

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2
Q

Umbilical hernias

A

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

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3
Q

Diagnosis of umbilical hernia

A

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!!

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4
Q

Treatment of Umbilical hernias

A

NEMETH ALWAYS RECOMMENDS SURGERY!!

Standard herniorrhapy

Mesh hernioplast: polyglycolic acid, polypropylene, polyester

Elisabethian collar

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5
Q

Umbilical hernial surgery description

A

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!!

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6
Q

Inguinal hernias- anatomical differences btw the male and female, starting with the female

A

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

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7
Q

Inguinal hernias male anatomy

A

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
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8
Q

Inguinal hernias- incidence

A

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

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9
Q

Direct inguinal hernias in female

A

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

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10
Q

Direct inguinal hernias in female: treatment

A
  1. Incise the hernial sac
  2. Widen hernial ring cranially to allow for reposition- examine vitality of contents
  3. Remove sac
  4. Close hernial ring but make sure not at the site of the ext pudendal vessels
  5. Layer-by-layer opposition
  6. 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!!!

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11
Q

Direct inguinal hernia in males

A

Is very RARE!!

And is usually the same as it is in females

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12
Q

Indirect inguinal hernias in males

A

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!

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13
Q

Treatment of indirect inguinal hernias in males: surgery!!

A
  1. paramedian incision over the hernia/swelling NOT midline!!
  2. Exploration of the hernia- check viability
  3. resection of intestine if needed
  4. castration- is always advised as threr is ofte compression of the intravaginal structure
  5. Closure of hernial ring- be careful of pudendoepigastric trunk
  6. Layer by layer opposition of the structues
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14
Q

Traumatic abd hernia

A

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!

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15
Q

Diagnosis of traumatic abd hernia

A

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

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16
Q

Diagnosis of traumatic abd hernia

A

X-ray

Contrast

US

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17
Q

Treatment of traumatic abd hernia: SURGERY

A
  1. stabilise resp and circ prior
  2. AB’s metronidazole- skin has decreased immunogenicity
  3. Incision on flank/ below ribs
  4. Explor hernial contents and the do ex lap!! because you don’t want to overlook e.g splenic rupture
  5. Restore viability: necrotomy, resection, splectomy, lobectomy
  6. herniorrhapy or plasty
  7. Lavage before layer by layer closure
  8. Drainage
18
Q

Perineal Hernia/ Rectal Sacculation

A

In males older than 7

Hormonal imbalance!!

  1. incr DHT: prostate enlargement because high number of DHT receptors– incr abd P- difficulty urinating, pooing
  2. Incr relaxin: weakening of perineal muscles- because high amount of relaxin receptors

Results: fossa ischiorectalis+ herniation+ rectum deviation

19
Q

Perineal Hernia/ Rectal Sacculation: notes from lecture

A

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

20
Q

Perineal Hernia/ Rectal Sacculation: diagnosis

A

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

21
Q

Perineal Hernia/ Rectal Sacculation: complications re bladder

A

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!

22
Q

Perineal Hernia/ Rectal Sacculation: treatment is SURGERY

A
  1. castration- obligatory- if you don’t there will be reoccurence or will happen on the other side
  2. 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!

  1. Pursestring on anus
  2. Herniorrhapy, rectorrhapy, hernioplasty
  3. Closing: mattress using monofilament! put in stitches loosely before tying knots
23
Q

Extra notes to consider when doing perineal hernia surgery

A

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

24
Q

Diaphragmatic hernia

A

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!

25
Q

Congenital defects causing Diaphragmatic hernias

A
  1. Pleuroperitoneal diaphragmatic hernia= hereditary- when there is NO DIAPHRAGM
  2. Peritoneopericardial hernia (PDDH)- no septum transv at xiphoid- there is comm btw pericard and peritoneum
  3. Hiatal hernia: sliding, axial/rolling, paraesophageal
26
Q

Acquired defects cauing diaphragmatic hernias

A

90-95% traumatic!

27
Q

PDDH

A

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

28
Q

Surgical treatment of PDDH

A

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

29
Q

Hiatal hernia

A
  1. Abd esoph
  2. Junction btw esophagus and stomach
  3. maybe part of the stomach

All go into the thorax!

30
Q

Sliding hiatus hernia

A

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!!!

31
Q

Rolling/ paraesophageal hernia

A

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)

32
Q

Traumatic hernias

A

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

33
Q

Pathogenesis of traumatic hernias

A

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

34
Q

Diagnosis of diaphragmatic hernia

A

General assessment

Detailed exam

Supplementary exam

Differentials

35
Q

Diagnosis of diaphragmatic hernia: general assessment

A

Weakness, apathy

Lying or sitting to alleviate resp

Cyanotic, pale mm

Prolonged CRT

Tachypnoe, dyspnoe

36
Q

Diagnosis of diaphragmatic hernia: detailed exam

A
  1. 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
  2. Ausc of Thorax
  • incr resp sounds: compressed lung, edema
  • absent sounds: PTX or organs in the way
  • Maybe can hear GI sounds?
  1. 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
  1. Palpation of abd
    * Abnormal “empty” feeling esp in cats
37
Q

Diagnosis of diaphragmatic hernia supplementary exams

A
  1. 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
  2. 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

38
Q

Diffs of diaphragmatic hernias

A

Pleural effusion without herniation: hydro, hemo, chylo, pyo thorax

Pulm edema and haem

Pneumonia

PTX

GDV

Intestinal obstruction

Cardiac disorders

39
Q

Therapy for diaphragmatic hernia

A

ALWAYS surgery- is an emergency situation

  1. Stabilize Circ and Resp: O2, diuretics, correct acid base and electrolytes, sedation (ACP, DZP), Thoracocentesis in the 7-8 ICS
  2. 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

40
Q

Surgical problems associated with a CHRONIC diaphragmatic hernia

A

the lungs have become atelectic

  1. organs have adhered and have become stable in their abnormal positions
  2. Lungs adapt to being compressed- if ofrce them to take up air air- will cause re-expansion pulm edema- extravasation of blood!
  3. 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
  4. Loss of flexibility of diaphragmatic muscle
  5. 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)

41
Q

Postop of diaphragmatic hernial surgery

A

O2

Intensive monitoring- blood gas analysis

Infusion, diuretics

Analgesia: flunixin meglumine or opiates

Mashy/pulp diet

SAM 2 (12 decks)

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