Umbilical hernia Flashcards
what passes through the umbilical opening
- Umbilical opening: Passage for urachus, umbilical arteries, and umbilical vein
umbilical hernia contents
- perietal peritoneum outpouching through hole in muscle, contains:
- Peritoneal fluid
- Greater omentum
- Small intestine (horses)
- Abomasum
origin of umbilical hernial ring
Defect in Linea Alba
Occurrence & Etiology
- species
congenital: pigs > horses > cattle
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a. In foals, often regress
b. In pigs & calves, often enlarge
umbilical hernia variable characteristics
- Size? > smaller is better
- Inflammatory (heat, pain, redness, discharge) or non-inflammatory? > simple, uncomplicated usually not inflammed
- Contents? (Ultrasound often beneficial)
- Reducible or non-reducible?
non-reducible hernia - why it is like this? complications?
Etiology
* Incarceration
* Adhesions
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Complications
* Obstruction
* Inflammation
* Strangulation
when can we use non-surgical treatments for an umbilical hernia?
- what are examples of these treatments?
reducible and uncomplicated hernias only
- abdominal pressure bandage
- hernia clamp > necrosis and sloughing, then fibrosis across defect
- inject hernial ring with inflammatory agent > foals, small hernias, may close ring
surgical treatment for umbilical hernias, indications
- No spontaneous recovery
- Size increasing
- Non-reducible
contraindications for surgical treatment of umbilical hernias? why?
Animal < 4 wk old, unless non- reducible
* More susceptible to stress of anesthesia
* Give time for spontaneous improvement
* If umbilical infection present, ± treat local infection before surgery
restraint and anesthesia for surgical umbilical hernia repair, options:
- preanesthetic protocol: fast ruminants, but not simple stomach (including calves)
- dorsal recumbecy
- Sedation (xylazine) & local anesthesia: Possible restraint problem compared to general anesthesia (kicking & potential contamination of surgical site)
- General anesthesia:
> injectable (e.g. xylazine (± diazepam) & ketamine)
or
> Inhalation anesthesia preferred (most common method for foals)
umbilical hernia surgical repair incision and dissection methods
- fusiform skin incision
- “Sharp/Blunt” Dissection
umbilical hernia surgical repair techniques - open vs closed, when we use them and why
- Internal Hernial Sac: Excision or Replacement, open vs closed techniques
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Closed technique: - reducible hernias only
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Open technique: - reducible and non-reducible hernias
- usually faster method… good
- +/- better incision healing… good
- enters abdonimal cavity… good or bad
hernia repair surgical technique - closure
Closure of Hernial Ring (Abdominal Wall)
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* Small defect → Mild ↑ tension on suture line
* Primary choice = Simple interrupted sutures.
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Larger defect → ↑↑ Tension
* Usually horizontal or vertical mattress
alternative method for umbilical hernia surgery closure - prosthetic mesh
- types of mesh
- propylene
- nylon
- stainless steel
surgical hernia repair closure of SQ tissue and skin
- Suture pattern(s) & materials appropriate for amount of tension on suture line and other factors + other factors…
> pattern options for SQ and skin
Subcutaneous tissue
* Simple continuous ?
* Simple continuous in multiple segments ?
* Simple interrupted ?
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Skin
* Simple continuous ?
* Simple continuous in multiple segments ?
* Simple interrupted ?
* Tension suture patterns ?
* Staples ?
surgical repair aftercare? complications?
A. Perioperative medication
1. Systemic antibiotics?
2. Analgesic/anti-inflammatory medication (NSAIDs)
3. Tetanus prophylaxis
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B. Confine to stall for several wk (longer for larger hernias)
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C. Abdominal bandage may reduce edema formation (easier in females)
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main complications are edema and recurrence
OMPHALITIS (umbilical infection) Clinical Signs
- size
- inflammation
- contents? drainage tracts? diagnostics?
A. Localized (umbilical) swelling
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1. Size? Extremely variable due to variations in extent & severity of infection
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2. Usually inflammatory (heat, pain, redness, discharge) & Usually nonreducible, BUT
a. Sometimes inflammation not obvious & sometimes swelling reducible
(1) Infected area of the umbilicus may be inside the abdominal wall
(2) Umbilical hernia may also be present
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3. Contents / Structures involved?
a. Draining tract (discharge) may be present
b. Determine umbilical structures involved & direction/extent of any draining tract
(1) Usually caudodorsal, toward bladder (septic urachus &/or umbilical arteries)
(2) Sometimes cranial, toward liver (septic umbilical vein)
(3) Palpation, flexible probe &/or ultrasound
(a) Ultrasound often beneficial due to above variations in clinical findings
omphalitis clinical signs othat than umbilical swelling
- ± Walk with arched back.
- ± Frequent low-volume urination.
- ± Signs of infection elsewhere (e.g. lameness &/or joint distension)
<><> - Umbilical infection may be:
> Primary – Source of infection that moves through body
> Secondary – From infection elsewhere
omphalitis surgical treatment:
- prior to surgery, prep:
A. Sometimes treat local infection prior to surgery
1. Systemic antibiotics
2. Drain & lavage umbilical abscess: Be sure that you are not lancing a hernia
3. May decrease size of mass
a. Decreased size of incision needed at surgery
b. Decreased risk of accidentally entering an abscess during surgery
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B. Restraint, anesthesia/analgesia & aftercare: Similar to umbilical hernia. Differences?
omphalitis surgical technique and considerations
- what structures might the infection involve?
- approach and incision?
A. Incision/dissection similar to that for umbilical hernia, except:
1. Be careful to stay extracapsular to the umbilical mass to avoid contamination.
2. Site on the linea alba to enter the abdominal cavity depends on the structures involved, which you want to avoid
a. Infection usually involves urachus &/or umbilical arteries: Extends caudally
b. Infection sometimes involves umbilical vein: Extends cranially
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B. Extend incision cranially or caudally on linea alba, depending on the involved structures
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* Usually ligate & transect proximal to enlarged region
* 3-Carmalt ligation technique (modified as needed)
* Remove enlarged region with attached umbilical mass
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1. Umbilical artery
a. Ligate & transect the involved artery proximal to the enlarged region (3-Carmalt ligation method, modified as needed)
b. Remove the enlarged region of the artery with the attached umbilical mass
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2. Urachus
a. If enlargement does not extend to the bladder: Ligate the urachus & remove the enlarged region, similar to the umbilical artery described above
b. If enlargement extends to or into the apex of the bladder:
(1) Remove (resect) the bladder apex with the attached urachus & umbilical mass
(2) Close the bladder incision
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3. Umbilical vein
a. If enlargement does not extend to the liver: Ligate the vein & remove the enlarged region, similar to the umbilical artery described above
b. If enlargement extends into the liver:
(1) Unfavorable prognosis
(2) Can marsupialize the umbilical vein through the skin to establish ventral drainage
patent urachus
- work up, clinical signs
- Urachus remains open postpartum → urine present at the umbilicus
1. Wet hair &/or intermittent dribbling of urine
2. If ultrasound &/or probe the draining tract, it extends caudodorsally toward the bladder
C. More common in foals than calves
1. Calves: Usually associated with omphalitis or hernia
2. Foals: Usually no associated omphalitis or hernia → often little umbilical swelling
D. Check for signs of infection elsewhere, especially lameness &/or joint distension
patent urachus treatment
- nonsurgical options, considerations and issues
- Spontaneous closure (i.e. no treatment): Common in foals
<><> - Chemical cauterization of urachus to produce swelling & closure
1. Usually with povidone iodine or silver nitrate
2. Cauterize several cm into the urachal tract, once or twice daily for several days
3. Calves: Often unsuccessful since patent urachus usually associated with omphalitis or hernia
4. Foals: Commonly used, BUT cauterization may result in omphalitis
patent urachus surgical treatment options
- indications, technique
A. Indications
1. No spontaneous closure
2. Chemical cauterization not successful
3. Associated infection/abscessation or hernia. Therefore, surgery usually indicated in calves
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B. Technique: Similar to that for omphalitis involving the urachus > ligate urachus
