hernia

Why I came here

Work assigned by my colleagues

S.Thilagar

HOD.

1980

Definition

HERNIA – protrusion of an organ or a part through a defect in the wall of the anatomical cavity in which it lies.

Anatomy of the dog-Thoraco-abdomen

Anatomy of the Abdomen

Parts of Hernia

Ring… ring , opening, slit, gappingSac… Not in all typesContent-vary

Parts of Hernia-schematic

Ring

Sac

Content

Ring

Classification anatomical site congenital acquired reducible- incarcerated/

irreducible strangulated type of herniated tissue

External Vs Internal Hernia

Protrusion of an organ/part through a defect in the wall of the anatomical cavity in which it lies

External abd. hernia Internal abd.hernia

defect in the abd wall occur thro. A ring of tissue confined in the cavity

Ex-umbli ex dia hernia.hiatal

Types of hernia

I-False(no peritoneal sac) Vs True (PS)

II-Abdominal hernia Vs Thoracic III -Organ of protrusion IV -Site

Herniorrhaphy in general Opposing the weak muscle-muscle Opposing the weak muscle-adjacent muscle Overlapping technique Transposition and placement Oval hernial ring may be elongated at the corner Artificial graft materials.: as patch

Laparotomy a glance

Ventral midline incision

Cranial VML

Caudal VML

Para median

Ventral midline incision-female

Midline celiotomy in male

Ventral midline and para median incision-muscle

Median-midline:

Skin Linea alba2-4mm wide fibres of

tendinous aponeurosis of EAO,IAO,TA)

Paramedian:

Crania Middle CaudalEAO EAO EAOIAO-E IAO IAORA RA -IAO-I - -TA TA TA

- - RA Peritoneum

Laparotomy-flank approach Skin

SC tissue

EAO (carnio caudal)

IAO-(caudal-cranial and ventral)

Transverse ab

Celiotomy care-.Preservation of moisture

Covering the exposed area with moistened gauze and frequent hydration with normal saline is essential

Celiotomy.Peritoneal lavage

Lavaging the abdominal organ with sterile saline after prolonged surgery-dilutes the formed fibrin due to handling or disease-

Celiotomy. Drainage provision

Severe peritonitis case

Volume 10% of the body weight

Open drainage or tube drainage

Avoid adhesion formation

Celiotomy.Laparotomy clearing s/c tissue

a.Detatching subcutaneous fascia over a small width 0.4-1.0cm to guarantee

wall suture with only fascia not fat

Laparatomy closure

b.Simple continuous joining all layer (or)

c.Simple continuous that includes only external fascia

.Laparatomy closure

d.Another method: to close cranial third sutures anchoring full thickness and caudal third anchoring only external fascia of rec.mus

Laparatomy closure- knot

e.Security of the knot

for continuous suture

five throws for start

f-Seven throws for end knot

.Laparatomy closure

G-Simple interrupted

suture consists of four suture

Suture materials

Catgut,steel,thread, can be avoided

Absorbable poly

filaments Poly glycolic acid (Dexon,Dexonplus) Polyglactin(vicryl) and monofilaments polydioxonone(PDS,Ethicon) may be used

Round sewaged needle

Suture materials

Size2(3-0)-cats and small size dogs

Size3(2-0)- for medium size dogs

Size4(0) -for large size dogs

Size5(1) - for very large sizedogs

Role of antibiotics..

Better to administer 30-60 minutes before surgery which can prevent bacterial multiplication for up to 3 hours

Choice of antibiotic depends on the surgery-ex-G.I.trac. ampicill.amoxi.metron

Prolonged surgical procedure -repeat the dose post-operatively

Role of antibiotics in celiotomy

Antibiotics and dose(mg/kg)

Percentage of

E.coli

Susceptibility

Staphylococcus

Amoxicil(7mg)

Ampicill.(10mg)

55.0 37.0

Cephalosporin

(10mg)

90.0 99.0

Clavenic acid &amoxici(8.75)1:4

81.0 99.0

Fluroquinolone(2.25mg-morbofloxin,orbi

100.0 98.0

Repositioning of organ

Repositioning and replacing the organ is important to avoid strangulation and adhesion

Surgical method Make a curve linear incision on the perineal

bulging Identify the levator ani muscle(runs dorsal to

ventral),internal obturator(runs form the midline to laterally ).and external anal sphincter

Suture is done on the external sphincter to the LAM and IOM

Perineal Hernia

Perineal hernia

Occurs due to separation of perineal muscle allowing rectum,abdomen and pelvic contents to displace perineal skin

Synonyms-caudal hernia, sciatic hernia dorsal hernia, ventral hernia

May be unilateral or bilateral

What is a perineal hernia?

Failure of the muscular pelvic diaphragm to support the rectal wall

Perineal structures…….

Signalment

Most common in the middle aged, intact male dog

Rare in female dogs Uncommon in cats Common breed : Boston Terrier,

Boxer, Collie, Kelpie and Kelpie crosses, pure bred and crossbred Dachshund and Old English Sheepdog

Predisposing causes for PH Prostatitis Cystitis Urinary tract and colorectal obstruction Rectal deviation and dilation Perianal inflammation Anal sacculitis Diarrhoea Constipation

Etiopathogenesis

Chronic constipation Hormonal imbalance Congenital predisposition Structural weakness of the pelvic

diaphragm Prostate enlargement

Clinical Signs

Bilateral/Unilateral perineal swelling Constipation Tenesmus Dyschezia Stranguria (retroflexion of the

bladder)

Diagnostics

HistoryClinical signsRectal examinationRadiographUltrasound

Surgical procedure

Herniorrhaphy- to surgically repair a hernia

Castration if applicable Colopexy or cystopexy if necessary

Organ involved

RectumColonProstate BladderMesentry

Blood – CBC, serum biochemistry, parasitology

Urine – urinalysis Radiograph – abdomen and chest perineal herniorrhapy + castration

Plan

Radiography Finding

Pre-operative treatment

Manual evacuation of feces Fed food in small quantity Prophylactic antibiotic

- Metronidazole (Stanzil) 10 mg/kg PO BID

- Clavamox 12.5mg/kg PO BID

Appearance of PH

Anaesthetic Protocol

Drug Dosage Route

Premed. Pethidine 5mg/kg SQ

Induction Thiopental 2.5%

12.5mg/kg IV

Maintenance Isoflurane Inhalation

Right Perineal Herniorrhaphy Patient was

placed in sternal recumbency with elevated hind quarter

A purse-string suture

was placed around the anus

The hernia content were identified and returned to their original location

Treatment (Post-surgery)

D1 D2 D3-D6

Metronidazole (Stanzil)10mg/kg, 2ml PO BID

√ √

Clovamox 250mg,12.5mg/kg ½ tab PO BID

√ √ √

Lactulose 5ml PO BID

√ √ √

I/D diet TID √ √ √

Papase 1 tab POantiinflammatory

√ √ √

Post-op complications

Recurrence Wound infection Fecal incontinence Tenesmus Rectal prolapse

Perineal hernia can be diagnosed by history, observation and clinical signs

Surgical intervention is the only treatment for perineal hernia

Conclusion

Abdominal Hernia generally occur secondary to trauma do not contain a hernia sac common sites for traumatic abdominal

hernias are the prepubic region and the flank

Common herniated organ…. prevalence is low….

Signs of Hernia

Swelling

Asymmetry of the abdominal contour

Pain

Diagnosis

Observation

Palpation

Radiograph

Differential Diagnoses

Hernia

Abscesses

Hematomas

Principles of Herniorrhaphy

To return the viable contents to their normal location To secure closure of the neck of the hernia,

preventing recurrence To obliterate redundant tissue in the sac To use the patient’s tissue whenever possible

Adequate surgical exposureDevitalized tissues are excisedAnatomical knowledgeUsage of mesh

BLADDER INTESTINE

TREATMENT PLAN

Debridement of the bite wounds Apply passive drainage to bite wounds. HerniorrhaphyPlace E- Collar

SURGICAL PROTOCOL

ANAESTHESIA

Induction: Tiletamine- Zolzepam, Ketamine- Xylazine 0.01 ml/kg

Maintainence: Halothane (Fluothane®) 2 % and Oxygen

SKIN PREPARATION

Dorsum and flank were clipped Routine skin preparation

5% Clorohexidine 70 % alcohol Tincture iodine

SURGERY

1. Incision was made directly over the hernia.

2. The herniated spleen was identified

Herniated spleen

3. The spleen was examined for viability

4. The hernia was reduced into the abdominal cavity

Replaced spleen

5.The torn muscle edges were sutured with Safil® green (Polyglycolic acid)3/0 using simple interrupted suture pattern.

6. The subcutaneous closed with Safil® green 3/0 using Modified Cushings suture pattern.

7. Skin closure was done with Nylon 2/0 using Cruciate suture pattern.

WOUND DEBRIDEMENT & DRAINAGE

The edges of the bite wound were cut A Metzenbaum scissors was used to assess the extend of

the wound under the skin. A stab incision was created in a position such that it

would allow maximum flow by gravity. An IV tube was secured to the skin at each end.

POST OPERATIVE CARE E- Collar Enrofloxacin (Baytril® 5 %) 10 mg/kg 1 ml IM post operative Ketoprofen (Ketoprofen® 1 %) 2mg/kg 1 ml SQ post operative Enrofloxacin (Baytril®) 10 mg/kg 1 tab X 50mg SID for 7 days starting

day 2 Metronidazole (Metrogyl 200®) 20 mg/kg 1/2 tab X 200 mg BID for 7

days starting on day 2. Serratiopeptidase (Serrazyme®) 1mg/kg 1 tab X 5 mg SID for 5 days

starting on day 4. Gentamicin cream (Dermogen®) was applied on the wound starting day 4 Cage rested Wound assessment

Common Complications

Recurrence Extreme tension Incorrect suture material Inappropriate tissue layer Increased intra- abdominal pressure

Infection

CONCLUSSION Signs of Hernia is swelling, asymmetry of the

abdominal contour and pain Diagnosis is based on observation, palpation and

radiograph Herniorrhaphy should be done as soon as possible Determining the amount of contamination, the extent

of the tissue trauma and defect and whether loss of tissue has occurred is important in planning closure.

Secondary bacterial infection that could occur due to the bite wounds should be controlled.

Good post operative care is vital to prevent recurrence.

Abdominal Hernia

Causes of abdominal hernia

Congenital - very rare - peritoneopericardial diphragmatic hernia

Acquired - Secondary to blunt trauma - Automobile accident - Fighting - Reoccur after surgical treatment

Clinical signs

A lump or swelling at the abdominal area

Abdominal discomfort

Pain at the swollen area

Treatment

Herniorrhaphy – surgical procedure

Open surgery i) Open ‘tension’ repair ii) Open ‘tension-free’ repair

Differential diagnosis

Lateral abdominal hernia Ventral abdominal hernia Inguinal hernia

Preliminary plans

Abdominal X-ray - Lateral - DV view

Blood test - CBC - ALT - Urea & creatinine - Total protein - Albumin - Globulin

Radiology findings..

Lateral view Dorso-ventral view

Hematology result

Parameter Result Normal range

Erythrocyte (RBC) x 1012/L 4.78 5-10

MCV f/L 56 39-55

Eosinophils x 109/L 1.55 0.1-1.5

Thrombocytes x 109/L 47 300-700

Biochemistry resultParameter

Result Normal range

Urea mmol/L 9.4 3.0-10.0

Creatinine µmol/L

104 60-193

ALT U/L 301.9 10-90

Total protein (serum) g/L 70.4 55-75

Albumin g/L 37.2 25-40

Globulin g/L 33.2 25-45

Treatment

Treatment Day 1 Day 2 Day 3 Day 4 Day 5

Lactated Ringer’s solution, intravenously

Clavamox 12.5 mg/kg, 1 tab, BID, orally

Papase 1tab, BID, orally

Vitamin B complex, 1 tab, BID, orally

Stanzil 10 mg/kg, 1 ml, BID, orally

Metronidazole 10mg/kg, 7.2ml,BID, intravenously

Anaesthetic protocol

Premedication: - Tramadol 4 mg/kg, SQ - Atropine 0.5 mg/kg, IM - Acepromazine 0.05mg/kg, IM Induction: - Thiopental 12.5mg/kg, IV Maintenance: - Halothane

Skin incision (8cm)

MID VENTRAL APPROACH

Subcutaneous & abdominal muscles layer were dissected

Part of intestine was pulled to find hernia

Tearing of the abdominal muscle

Suturing the hernia defect (8cm)

Replacing the organs

Suturing of abdominal muscles layer

Complications

Post-operation - suture breakdown - mesh rejection

Untreated lateral abdominal hernia Wound infection

Conclusion Abdominal hernia is a protrusion of

abdominal organs through weakness or tearing of the abdominal wall (anywhere other than the umbilicus, inguinal ring, femoral canal or scrotum).

Conclusion (cont’)

Most of abdominal hernia are acquired.

Repaired by herniorrhaphy; - Open surgery.

Paracostal Hernia

Paracostal hernia

Separation of costal attachments and the organs pass through the hernia –subcutaneous site

Umbilical hernia Extend the hernial ring

and replace the organ and suture the layer

Debride the border of the hernial ring and oppose

Biomaterial that growth fibrous tissue Can also be used ex: chitin

Umblical hernia and cranial abdominal hernia

Hereditary and traumatic Always examine for other organs Hernial opening is closed either as it is

overlapping method

Cranioventra abdominal ventral hernia

Usually associated with pleuro peritoneal diap..hernia due to congenital problem

Inguinal hernia complicated

Organs enter through the inguinal ring and occupy the inguinal site or even extend to the thigh region

Inguinal hernia-femoral hernia-ventral hernia

Seen at the inguinal region ,femoral and at the ventral abdomen region prepubic

Hernial opening ring is reduced by suturing

Ventral hernia the pre-pubic tendon is sutured with along with rectus to the bone itself

Caudal ventral hernia

Ventral hernia (herniated organ –bladder) due to the damage to the prepubic structures

Reoccurrence will be problem

Lateral abdomen

Hernia at the unusual site not at ventral midline

Hernia occurred due to kitten ?

Hernia was between the EAO and IAO insertion point

Diaphragmatic Hernia

Introduction

Diaphragmatic hernia

The continuity of the diaphragm is disrupted such that abdominal organs can migrate into the thoracic cavity

Preliminary Problems

Dry and slightly pale mucus membrane

Inappetance Res.Dyspnoea

Differential Diagnoses

Feline Infectious Anaemia (FIA) Haemobartonellosis

Feline Leukemia Virus (FeLV) Infection

Feline Immunodeficiency Virus (FIV) Infection

Plan

Blood to Clinicopathology lab. Minimum database

CBC, reticulo, BUN, serum creatinine, ALT, TP, Albumin, Globulin

Blood to Parasitology lab. No blood parasite

IV fluid 0.9% NaCl

Treatment

Fluid therapy ( LR + Duphalyte) 4 days

Vitamin B complex,1 tab, BID, PO Ornipural Solution, 3ml, SID, IV Clavamox, 12.5 mg/kg, 1 tab, BID, PO Bomazeal, 5 tabs, PO Coaxed feed i/d Diet

Radiograph - lateral view

Loss of diaphragmatic lineLoss of cardiac silhoutteDorsal displacement of the lung lobeHerniation of the abdominal organs into

thoracic cavityPleural effusion

Diaphragmatic Herniorrhaphy

Premedication Acepromazine, 0.05mg/kg, 0.17ml, IM Pethidine, 5mg/kg, 0.35ml IM

Induction Thiopental 2.5%, 1.75ml, IV

Maintenance Isoflurane

Surgical Procedure

Ventral midline incision xiphoid to umbilicus

Diaphragmatic defect found

Right FL Left FL

sternum

Defect

Surgical Procedure cont…

Partial liver lobectomy several overlapping

guillotine sutures were placed proximal to the excision line and excised

Excision line

Guillotine suture

Left lateral liver lobe

Surgical Procedure cont….. Abdominal lavage with 0.9% NaCl and all

the fluid from flushing was aspirated Linear alba

3/0 Vicryl, simple continuous Subcutaneous

3/0 Vicryl, modified Cushing Skin

3/0 Vicryl, intradermal

Radiograph - lateral view

Post-operative Care

Fasted for 3 days + Fluid therapy Antibiotic

Clavamox 12.5mg/kg, 1 tab, BID, PO Metronidazole 10mg/kg, 7ml, BID, IV

Metacam 0.06mg/kg, 0.21ml SID, IV Supplement – Methylcobal, Ornipural

solution

Post-operative Care cont.

Monitor breathing pattern Monitor body temperature Check incision site Thoracocenthesis – pneumothorax, pleural

effusion

Radiograph - lateral view

Discussion

How diaphragmatic hernia happen? Traumatic injury

Hit by motor vehicles

Fall down from a high place

Discussion cont.

Post surgical complication Recurrence of diaphragmatic hernia

Pleural effusion

Abdominal effusion

Leakage from site of colotomyPeritonitis

Conclusion

Diaphragmatic hernia may occurred sub-clinically Without obvious clinical signs

Diaphragmatic herniorrhaphy can end up with complication even with good post-op care Herniated organs Duration of herniation

Any questions?