Herniation Flashcards
(69 cards)
1
Q
Hernia vs Rupture?
A
Hernia =
* Abnormal protrusion of an organ or part of an organ/tissue through the wall of the cavity that contains it
* A weak part or other abnormal opening in the body wall permitting organs/tissue to bulge through
Rupture =
* Tearing or disruption of tissue
* Used interchangeably with hernia (diaphragmatic rupture/hernia)
2
Q
Classifications fo hernias?
A
- Congenital vs acquired (incisional woudnbreakdown)
- Anatomical location (unbilical, perinealn inguinal..)
- Status -> reducible, non reducible, strangulated
3
Q
Detail Reduible, non reducible and strangulated
A
Reducible
* Contents freely replaced back into cavity
Non–reducible (Incarcerated)
* Adhesions between hernia contents and surrounding structures
Strangulated
* Vascular supply to hernia contents compromised
* Direct compression
* Torsion
* Contraction of hernia ring (traumatic)
4
Q
Pathophysio of Space occupying lesion?
A
- Diaphragmatic hernia – abdominal contents prevent lung expansion
- Peritoneopericardial hernia – impair cardiac & respiratory function
5
Q
Pathophys of incarceration (not reducible)
A
- Bowel – lumen obstruction→gas/fluid accumulation→fluid/electrolyte imbalance
- Bladder (perineal hernia) – post renal uraemia/fluid retention/hyperkalaemia
- Uterus (inguinal hernia) – if pyometra or pregnancy → rupture
6
Q
Pathophys of strangulation?
A
– circulatory compromise of incarcerated hernia
* Bowel or other hollow organ
* Incarceration or torsion
* Venous & arterial occlusion →tissue death/organ rupture →septicaemia/toxaemia
Surgical emergency
7
Q
What are the parts of a true hernia?
A
➢ Hernia ring – opening
➢ Hernia sac – generally peritoneum/abdominal wall
➢ Hernial contents – generally abdominal organs
8
Q
What does this mean for potential rupture?
A
may not have a hernia ring or sac → ’False’ Hernia
➢ Traumatic hernias
➢ Incisional hernias
9
Q
Principles of Herniorrhaphy
A
- Reduce the hernia
- Check the viability of the hernia contents
- Obliterate dead space (removal of hernia sac)
- Tension-free closure of hernia defect
- Eliminate predisposing causes
- Neutering in congenital (hereditary) hernias
10
Q
List all types of hernias
A
- Abdominal Hernias ->* Umbilical * Inguinal/femoral * Traumatic abdominal ruptures * Incisional hernias
- Diaphragmatic Ruptures
- Peritoneopericardial Hernia
- Hiatal
- Perineal
11
Q
What are the most common abdo hernias?
A
Unbilical (often congenital) -> failure fo fusion of rectus abdominis and fascia
12
Q
CLS of Umbilical hernia
A
- Soft swelling at umbilical scar (herniated falciform fat)
- Reducible
-> firm if incarcerated - Risk strangulation
» if diameter of ring =/> diameter of bowel
» →acute GI signs/increase in size of hernia
13
Q
Tx for inguinal hernias
A
- **Small **hernias (2-3mm) conservative management
- Spontaneous closure up to 6 months
- Risk of strangulation should be discussed
- Neutering advised; hereditary – repair at neutering
* Large hernias – early repair if high risk of strangulation
* Large enough for bowel to exit
14
Q
How do we go about a Herniorrhaphy
A
- Fat → ligate and excise sac en bloc.
- Organ → hernia sac should be opened & contents inspected
- Enlarge the abdominal defect
- Close primarily
- Releasing incisions in rectus fascia and tension relieving sutures if large defect
- Mesh can be used
15
Q
What cls can be seen with strangulating hernia?
A
Vomiting
16
Q
What can an inguinal hernia look like?
A
Mammary tumour
17
Q
Diagnosis of inguinal hernia?
A
- examine in dorsal recumbency
- reduce contents and feel inguinal rings
- if incarceration may need rads/US/surgical
exploration
18
Q
Where do inguinal hernias come from?
A
- Abdominal hernia through inguinal ring
- Superimposition of internal and external rings
- Usually non traumati
19
Q
DESCRIBE DIRECT inguinal hernias
A
– contents pass through canal adjacent to vaginal tunic
* Not constrained by the tunic
* → less risk of strangulation
20
Q
What is an indirect inguinal hernia?
A
– abdominal contents enter vaginal tunic adjacent to spermatic cord
* Termed Scrotal Hernia in males
* More likely to strangulate (tunic constricting)
21
Q
Which type is mroe common?
A
Direct & unilateral left
Most acquired -> middle aged entire bitches ; obesity or HAC
22
Q
Surgical approach for inguinal hernia?
A
- One approach -> incision directly over inguinal ring (DIFFICULT)
- Midline approach + coeliotomy (preffered)
23
Q
Describe advantages/disad of the midline approach
A
- Avoids damage to mammary tissue.
- Allows exploration of both inguinal rings (advised).
- Allows intra-abdominal resection of devitalised bowel.
- Allows intra(or extra)abdominal repair of hernia defect.
- Inguinal hernia repair
24
Q
Describe steps of Herniorrhaphy of inguinal hernia
A
» Caudal midline incision
» Ligate hernia sac & amputate
» Close inguinal ring with simple interrupted sutures from cranial aspect
➢ Leave space for genitofemoral and pudendal vessels
» Spay or castrate to prevent recurrence
25
PG & complications for inguinal herniorrhaphy
Pg -> excellent if uncomplicated
Complications: pain, seroma, haematoma, recurrence, not closable
26
What increased risks for scrotal hernia (indirect inguinal) ?
* young, large breed dogs
* increased risk of strangulation
* increased risk of testicular neoplasia
27
CLS of scrotal hernia?
* Usually unilateral
* Cordlike swelling from inguinal ring to scrotum
* Usually signs of strangulation
* vomiting, painful
28
Diagnosis of scrotal hernia?
* Examine in dorsal recumbency
* Frequently non reducible
* Palpate base of scrotum
* Cordlike structure travelling towards inguinal ring
* US/Rads
29
Scroal herniorrhaphy?
* Repair URGENT; at time of diagnosis
* Castrate; prevent recurrence and neoplasia
* May be inherited
*Approach*:
* Lateral to inguinal ring if reducible
* Midline incision/celiotomy if incarcerated
30
Pg & complications fo scrotal hernia repair?
Prognosis:
➢ good if uncomplicated
➢ guarded if strangulation
Complications:
* scrotal dermatitis
* haematoma
31
Femoral hernia?
V RARE
* Swelling on the medial aspect of the thigh
* Repair similar to inguinal hernia
* Need to avoid damage to the vessels
32
Describe Traumatic abdo hernias?
» Pre-pubic hernia
* Following blunt trauma
* ↑↑intra-abdominal pressure
* →rupture/avulsion of the prepubic tendon
* Can have other life-threatening injuries. (Multi systemic trauma/pelvic fracture)
33
Diagnosis of pre-pubic hernia
Palpation & Xray caudal-abdo strip must be examined
34
Surgical repair ffor traumatic hernia?
* Stabilisation/pain relief/fluids therapy
* Dorsal recumbency, pelvic limbs pulled forward (reduces tension on pre-pubic tendon)
* Attempt to place sutures in tendons or fascia
* In small patients can anchor sutures round obturator foramen (make sure no tissue is
trapped)
* In larger patients, predrill holes in pelvic brim and suture remnants of prepubic tendon
* Synthetic mesh sometimes needed
35
Incisional hernias ?
- Midline most common
- Acute incisional hernias -> wi/in 3-5 days of surgery
- Chronic - weeks or months
36
Most common cause of abdo incisional hernia?
incorrect surgical technqiue
37
Other causes of abdo incisional hernia?
* increased intra-abdominal pressure
* entrapped fat between wound margins
* infection
* chronic steroid medication/immunosupression
* poor postoperative care
* concurrent diseases – HAC, hypoproteinaemia, anaemia, FIV/FELV
38
What to do for acute incisional hernia?
Evisceration is a surgical emergency
* Repair ensuring using external rectus sheath, appropriate
sutures and pattern
* no need to debride in most cases
* simple interrupted
39
What. todo if chronic incisional hernia?
not emergency
* adhesions
* more difficult to repair
* require debridement
* require mesh?
40
Diaphragmatic rupture (Hernia)
- Blunt trauma RTA (inc intra abdo pressure with open glottis)
- Often concurrent injuries -> ortho/spinal & other abdo injury
41
Diaphragmatic rupture - can. it be chronic?
Most acute
42
Diaphragmatic rupture anatomy?
COSTAL MUSCLE TEARS MROE FREQUENT
43
CLS of DP Rupture?
* Dyspnoea & exercise intolerance (orthopnoeic
stance)
* Muffled heart & lung sounds (gut sounds in thorax)
* Empty abdomen
* Concurrent trauma
44
Diagnosis of DP hernia?
» Radiographs
* Loss of the diaphragmatic line in lateral (66-97% of
cases)
* Abdominal viscera in the thorax = diagnostic
» Ultrasound (diagnostic in 93% of cases)
45
Timing of DP hernia surgery?
* Was thought better survival with delaying surgery (72 hrs-weeks) (Boudrieau 1987)
* Recent studiesshow no adverse effect with herniorrhaphy within 24 hours of trauma
* Current recommendation; perform surgery as soon as stabilized
46
Pre-anaesthtic care with DP hernia?
47
DH Herniorrhaphy ?
1. Cranial ventral midline incision
2. Excise falciform fat
3. Attempt reduction of contents with gentle traction
➢ Beware adhesions
➢ Enlarge tear in diaphragm if needed
4. Appositional closure of defect
➢ From dorsal to ventral
➢ Synthetic absorbable (PDS or vicryl)
➢ Simple continuous
➢ Circumcostal sutures may be used to reattach to body wall
5. Re-establish negative pressure of thoracic cavity by draining chest slowly
6. Inspect abdo contents for viability
7. Lavage, suction abdomen and close routinely
48
DH Rupture Tips and Tricks
* Transition from induction to intubation quickly
* minimize hypoxemia and hypoventilation
* Adequate premedication to minimize stress
* Adequate preoxygenation to maximize oxygenation
* Enlarge hernia if needed to allow safe reduction
* Repeat rad and thoracocentsis/thoracostomy tube drainage of pneumothorax slowly over time
* Be prepared to perform organ resection
* In chronic cases, adhesions should be anticipated
49
DH Hernia Post op ?
- Re-expansion pulm oedema -inflamamtory response to lung expansion
- Inflation and expansion lungs -> reduction in venous return
- Overinflation can cause lung damage and re-expansion pulm oedema
- Abdo compartement syndrome )> reduction of hernia contents -< in intraABDO pressure
50
DH repair patients are at risk of ..?
- Hypoventilation
- Hypercapnia
- Respiratory acidosis
- Hypoxaemia
51
Peritoneopericardial Hernia - PPDH (Congenital Diaphragmati hernia)
* Gap in ventral diaphragm or abnormally thin diaphragm that ruptures
* Abdominal organs herniate into pericardial sac
➢ Do not directly enter pleural cavity
* May occur with other defects
52
CLS of PPDH?
Large number are asymptomatic
Cardiorespiratory or Gastrointestinal signs
* Muffled heartsounds
* Murmurs
* GIT soundsin thorax
* Pleural effusions
* Concurrent ventral body wall defects
53
Dx of PPDH Hernia
- **Radiography**
* Enlarged cardiac silhouette and dorsal displacement of the trachea
* Discontinuity of the caudal cardiac border and diaphragm
* Presence of abdominal viscera within the pericardial sac = diagnostic
* Ultrasound reliable to confirm diagnosis
54
Tx for PPDH hernia
* As traumatic diaphragmatic rupture (may not need IPPV)
* Prognosis good
55
Hiatal hernia can be ... or ....
Congenital or Acquired
56
Hiatal Congenital?
➢ Sliding most common
➢ Shar Pei & English Bulldog predisposed
57
Hiatal Acquired?
➢ upper airway obstruction/BOAS
➢ trauma
➢ increased intra-abdominal pressure
➢ diaphragmatic hernia repair
58
CLS of hiatal hernia?
due to gastro-oesophageal reflux/oesophagitis:
*Retching
*Regurgitation
*Ptyalism
*Vomiting
*Weight loss
* Risk of aspiration pneumonia
* Secondary megaoesophagus
* Type2 -dyspnoea if gastric dilatation
59
Hiatal hernia types? (1-4)
» Type 1: Sliding or axial
* Gastro-oesophageal junction, cardia and stomach through
hiatus
* 90% of cases
» Type 2: Rolling or paraoesophageal
* Fundus rolls through hiatus alongside oesophagus
» Type 3: Combination of types 1 and 2
* Rare
» Type 4: Type 3 with herniation of other organs
* Rare/not reported
60
Diagnostic options for hiatal hernia?
- Plain Radiograph
- Contrast Radiograh
- Fluoroscopy
- Oesophagosopy
61
What migth we see with plain Radiograph
* Displacement of the stomach into the thorax
* Soft tissue density above the caudal vena cava
* Absence of right crus of diaphragm
* Megaoesophagus
* Aspiration pneumonia
62
What can be seen on Contrast Xray?
* Gastro-oesophageal junction within the thorax → apple-core sign
63
Fluoro and oesophagoscopy?
» Fluoroscopy useful for sliding hiatal hernias
» Oesophagoscopy – signs of reflux oesophagitis,, strictures, reflux
64
If asymptomatic do we treat hiatal hernia?
NO
65
How do we medically treat hiatal hernia cases by managing reflux oesophagitis?
## Footnote
(also treat underlying BOAD etc)
* Antacids – neutralise gastric acid
* H2 blockers – reduce gastric acid
* Prokinetics – Increase sphincter pressure and rate of
gastric emptying
* Little and often, low fat diet
* Antibioticsif infection
* Mucosal protectants
66
Surgical tx for hiatal hernia?
* Moderate to severe clinical signs
* Fail to respond to medical management
* All type 2 –paraoeophageal
➢ Current recommended treatment;
➢ Phrenicoplasty,
➢ Oesophagopexy
➢ Gastropexy
67
Hiatal Hernia repair involves what ?
* **Phrenicoplasty** – decrease size of hiatus
* Transect left triangular ligament to retract liver
* Reduce hernia
* Close oesophageal hiatus dorsally and ventrally
* Preserve dorsal and ventral vagal nerves
* **Oesophagopexy** – fix in place
* Anchor oesophagus to diaphragm
* **Gastropexy** – fix in place
* Left sided incisional pexy
| ALL OF THESE
68
What to place before losing on hiatal hernia repair?
Thoracocentesis or thoracostomy tube
69
Management of oesophagitis and megaO post op?
* Antacids – neutralise gastric acid
* H2 blockers – reduce gastric acid
* Prokinetics – Increase sphincter pressure and rate of gastric empytying
* Antibioitcs if infection
* Mucosal protectants
