Ch 85 Diaphragmatic hernia Flashcards

Question

peri-op care

Answer 1

- stabilisation - O2 flow - rapid induction to have control of airway - may be necessary to tilt the table to elevate the patient's head and thorax and relieve pressure on the lungs. - ab's if liver herniation

Answer 2

Avoid ventilation pressures over 20 cm H2O

Answer 3

- Traumatic hernias may have multiple rents - reduced by gentle traction - swollen or adherent > rent in the diaphragm is enlarged (avoid phrenic vessels and nerves, caudal vena cava) - Intrathoracic adhesions divided under direct observation (may require caudal median sternotomy) - adhesions <7 to 14 days = fibrin and little organized fibrovascular tissue, digital manipulation. - Mature organized adhesions are divided by precise sharp separation, electrocautery

Answer 4

- horacic cavity can be lavaged with warm saline. - organs are carefully inspected for viability - thoracostomy tube or tube can be exited through the diaphragmatic closure and out the abdomen - Reestablishment of negative pressure is not necessary after hernia repair and may be detrimental - debridement of the edges of chronic hernias to stimulate healing is controversial - Suture closure dorsal to ventral - polydioxanone or polyglyconate) in (3-0 to 0 USP) - continuous patterns are preferred over an interrupted suture pattern - near the caudal vena cava > avoid obstructing venous return - circumcostal > sutures can be anchored around the costal arch - rostral advancement of the diaphragm produces satisfactory clinical results

Answer 5

Laparoscopic stapling is inferior

Answer 6

* Omentum - too weak to provide adequate support alone (double layer of omentum, stimulates angiogenesis and promotes wound healing) * Muscle - 10% larger than the defect when developed (transverse abdominis 13th rib as base, rectus abdominis, latissimus dorsi) * Liver * Fascia * Collagenous xenographs * Polypylene mesh * Silicon rubber sheeting

Answer 7

- Some clinicians leave residual air within the thoracic cavity, removing it only if respiration is compromised - reestablish negative intrathoracic pressure is potentially dangerous - Airway pressures should not exceed 20 cm H2O pressure - Chronically atelectatic lungs should be reinflated by gradual reexpansion (rupture, reperfusion injry) - continuous maintenance of 10 cm H2O negative intrapleural pressure, these lung lobes reexpand gradually over several hours

Answer 8

A dangerous reduction in venous return due to unduly prolonged expansion of the lungs while suturing

Answer 9

Rupture of pulmonary parenchyma: - Intrapulmonary haemorrhage - Pulmonary oedema - Pneumothorax

Answer 10

- Therapeutic antibiotics are unnecessary unless the liver herniated or injured or GIT perforated. - cardiovascular and respiratory status is monitored - may develop hypoventilation, hypoxia, and respiratory acidosis from inadequate thoracic expansion - thoracostomy tube allows early detection and correction of respiratory compromise > 2-3 mL/kg/d of fluid tube pulled 1. Reexpansion Pulmonary Edema 2. Pneumothorax 3. Abdominal compartment syndrome

Answer 11

An inflammatroy response to lung expansion that causes increased capillary permeability Presumable due to expansion-related mechanical injury to alveolar capillary membrane and reperfusion injury - Treatment: hemodynamic support, oxygen, diuretics, bronchodilators. - patients may require ventilation and positive end-expiratory pressure - guarded prognosis

Answer 12

* Handling suring surgery * Damage during break down of adhesions * Reinflation injury

Answer 13

- chronic hernias may experience a loss of abdominal domain as a result of abdominal wall contraction or underdevelopment - replacement of abdominal viscera, closure may result in significant increase in intraabdominal pressure (IAP). - Aggressive pain control has made a significant difference in many patients

Answer 14

* Decreased renal function * Hypotension (decreased CO) * Hypoxia (reduced ventilation and lung compliance) * Visceral hypoperfusion * Acidosis * Increased ICP

Answer 15

Can be measures with an indwelling urinary catheter - IAP 5-10 mmHg - monitored and adequately hydrated - 11-20 mmHg - Medical treatments instituted - Over 20 - Surgical decompression

Answer 16

Medical - Analgesics (Epidural catheters, wound “soaker” catheters, CRIs, opioid) - Evacuation of intraperitoneal contents (fluid/air) - Evaculation of intraluminal contents (urine, gastric air) Surgical - Surgical mesh - Removal of spleen - Advancement of diaphragm - Relaxing incisions in external rectus sheath - Leave linea unapposed

Answer 17

Approx 15% die before arriving to hospital Survival to discharge 82-89%

Answer 18

- Poor anesthetic management and inadequate ventilation have been blamed for intraoperative deaths - Complications may be expected in up to 50% of patients - first 24 hours: death is caused by hemothorax, pneumothorax, pulmonary edema, shock, pleural effusion, and cardiac dysrhythmias - later deaths: secondary to rupture, obstruction, or strangulation of GIT or diseases unrelated to hernia - Recurrence rates 4% for dogs and 5% for cats.

Answer 19

Incomplete development or failure of fusion of the pleuroperitoneal membrane across the pleuroperitoneal canal Results in absense of part of left lumbar crus (1-2cm defect) or absense of both crura and part of central tendon (large defect)

Answer 20

Abnormal development of the transverse septum resulting in either a gap in the ventral diaphragm or an unusually thin ventral diaphragm which ruptures *result of dysembryogenesis, in which a connection remains between the pericardial and peritoneal cavity*

Answer 21

- herniation of abdominal viscera into the pericardial sac. - Peritoneopericardial diaphragmatic hernia is usually present at birth - liver, falciform ligament, omentum, spleen, small intestine, and rarely the stomach. - indirect pulmonary compression causes respiratory insufficiency. - Incarceration, obstruction, or strangulation of abdominal viscera - effusion in the pericardial sac or bloating of a herniated stomach produces cardiac tamponade; signs of right heart failure (reduced venous return) - hepatic cysts, gallbladder torsion and rupture

Answer 22

* Sternal defects * Cranial ventral abdominal wall hernia * Umbilical hernia * Abnormal swirling of hair in sternal region * Intracardiac defects * Pulmonary vascular disease

Answer 23

- Weimaraners and long-haired cats of varying breeds - incidental finding in 40% to 50% of affected cats,77 and 46.4% of dogs. - Clinical signs may result from pathology in the gastrointestinal, cardiovascular, and respiratory systems - muffled heart sounds RADs - cardiac silhouette is enlarged and usually rounded - Discontinuity or overlapping of the diaphragm and the caudal cardiac border - gas or feces-filled bowel within the cardiac shadow - contrast stidies - CT ultrasound - useful for confirming peritoneopericardial diaphragmatic hernia - through the right fifth intercostal space or transabdominally

Answer 24

- Cardiac tamponade from hepatic lobe effusion may require emergency pericardiocentesis - Conservative treatment may be recommended for asymptomatic animals - a midline celiotomy provides the best exposure - pericardial sac is conjoined to the borders of the diaphragmatic defect and is continuous with the peritoneum - closure can be accomplished in many without disruption of the pericardial-diaphragmatic junction (avoids pneumothorax and pleural effusion) - in some cases the diaphragm may need to be incised to allow return of viscera to the abdomen. - Once the pericardial sac is opened, so are the pleural cavities small defects - closed with an interrupted/ continuous suture pattern of monofilament absorbable material, commencing dorsally > ventrally. - Air entrapped within sac may impede pulmonary expansion and should be drained by thoracocentesis

Answer 25

Transection of the pericardium cranial to its attachement to the diaphragm and used as a flap or free graft | phrenic nerves should be identified

Answer 26

Successful in 86% Mortality rate 8.8%

Answer 27

encountered in 78% * hyperthermia (54%), * tachypnea (14%), * dyspnea, * hypoventilation, * hypoxia * refractory pneumothorax.

Answer 28

Not a true hernia Elevation of the dome of the diaphragm into the thoracic cavity. Can be congenital or acquired after phrenic nerve disease/injury

Answer 29

The ventro-central diaphragmatic defect was repaired with a pericardial flap, which subsequently failed 7 months later. The revision surgery was performed with a novel surgical technique. The defect was closed by means of incising the ventral attachments of the diaphragm either side of the defect and sliding it medially to allow a tension-free closure. The ventral aspect of the incised diaphragm was reattached with circumcostal sutures and the central defect closed. The dog recovered rapidly and without complication. An excellent outcome was reported after surgery.

Answer 30

Retrospective study. - surgically treated more likely younger, entire, have clinical signs and other congenital abnormalities - sx → 97% discharge; complications: intra- 22%, post- 41% - majority low grade - major complications: pneumothorax, apnoea, SIRS, portal hypertension - no hernia recurrence - mortality: 5/91 sx, 4/37 conservative – attributable to PPDH - MST: sx 8.2y, conservative 5y A diagnosis of PPDH can confer a good long-term prognosis for both ST and CT dogs. retrospective data set prevent us from making evidence-based conclusions about which dogs are likely to benefit from one approach vs the other

Answer 31

review, no evidence to support effect of timing of surgery on mortality rates - overall mortality rate across 10 studies 6.8-50% - highest mortality rate in paper from 1980 - other papers report 6.8-26.7% no statistically significant information available with only several retrospective studies published that are a low quality of evidence.

Answer 32

time from trauma to development of signs no effect on survival - complications: intra-op: 14/49 (28.6%) dogs, 5/48 (10.4%) cats post-op: 7/49 (14.3%) dogs, 6/48 (12.5%) cats - death: overall 14.4%; intra-op: overall 6.2%; post-op 8.2% (1h – 10d post) - surgery <48hr after diagnosis → lower risk of death

Answer 33

alternative to intracorporeal suturing → successful outcome with no complications

Ch 85 Diaphragmatic hernia Flashcards

(57 cards)