Hernia
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Transcript of 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?