hernias - scholar.cu.edu.eg classification of hernias according to the site: 1- external...
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ByBy
Prof. Dr. Ashraf Abu-Seida
2016
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Definition�Hernia is the protrusion of the viscera fromits normal cavity through an acquired orcongenital opening.congenital opening.
�The typical hernia is formed of hernial ringand hernial swelling. The hernial swelling isformed of henial sac and hernial contents.
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Structure of hernia
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Structure of hernia�Hernial ring (Hernial opening):- It my be an accidental opening in the
abdominal wall, persistent prenatal orificeabdominal wall, persistent prenatal orifice(umbilicus) or normal passage (inguinal canal).
- Its size varies fromone finger to more thanhand size.
- Its shape may be round, oval or irregular.
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Structure of hernia�Hernial swelling:- It has various sizes and shapes
- It is composedof:- It is composedof:
1- Hernial sac which is formed of skin + s/c tissues +few muscle fibers + parietal peritoneum(if notruptured).
2- Hernial content which is usually small intestine(called enterocele), omentum(epiplocele), stomach(gastrocele) and urinary bladder (vesicocele).
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Classification of hernias�According to the cause:1-Congenital hernia
- Herniapresentsatbirth, suchasumbilical hernia- Herniapresentsatbirth, suchasumbilical hernia
2- Acquired hernia
- Hernia occurs in later life, such as incisional hernia (acomplication of laparotomy) and perineal hernia
�According to the hernial content:- Such as gastrocele, enterocele, epiplocele…etc
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Classification of hernias�According to the site:1- External hernia- Protrusionof thevisceraoutsidetheabdominalcavity- Protrusionof thevisceraoutsidetheabdominalcavity
- Such as umbilical, inguinal, scrotal, abdominal hernias
2- Internal hernia- Protrusion of the viscera through a normal or
pathological opening within the abdominal cavity (nohernial sac).
- Such as diaphragmatic and hiatal hernias
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Classification of hernias�According to nature of hernia:1- Reducible hernia:- In which, the hernial content return to the- In which, the hernial content return to the
abdomen spontaneously when the animal isrecumbent or with manual pressure.
2- Irreducible hernia:- In which, the hernial content can not be returned to
the abdomen due to incarceration, strangulationand adhesions
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Causes of irreducible hernias� Incarceration- Too large hernial contents to pass through the hernial ring.
� Strangulation� Strangulation- Due to compression obstruction of the blood supply to the
incarcerated content which may be lead to gangrene of thestrangulated part.
�Adhesions- Due to local inflammation of the hernial parts which leads
to fibrinous adhesions between the hernial sac andcontents.
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Hiatal Hernia
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Diaphragmatic Hernia
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Diaphragmatic Hernia
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Umbilical Hernia
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Scrotal Hernia
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Right Perineal Hernia
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Causes of hernias�Congenital causes:- Inherited weakness of the muscles.- Congenital opening in the linea alba- Imperfectdevelopedumbilicus- Imperfectdevelopedumbilicus- Genetic disturbance� Predisposing causes:- Muscular weakness due to abscess or wounds- Increased intra-abdominal pressure due to chronic
cough, diarrhea, constipation and late pregnancy.
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Causes of hernias�Exciting causes:- Imperfect repair of the abdominal wall after
laparotomy(Incisionalhernia).laparotomy(Incisionalhernia).
- Trauma such ac kicks, blows, falling down andhorn thrust
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Clinical Symptoms�Local Symptoms:- Abdominal swelling
- Hernialring- Hernialring
- Soft homogenous (epiplocele) or tympanic(enterocele) hernial swelling
- Reducible or irreducible hernial swelling.
- Slight pain in recent hernia.
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Clinical Symptoms�General Symptoms:- In non complicated hernia, slight colic and
indigestionindigestion
- In complicated hernia, severe abdominal pain,colic, vomition and depression.
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Diagnosis�Case history
�Clinical symptoms
�Physicalexamination�Physicalexamination
�Ultrasonography
�Exploratory laparotomy
�Differential diagnosis fromother swellingssuch as abscess, hematoma, neoplasms andcysts.
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General Treatment� Small congenital hernia (5<cm), spontaneous healing
usually occurs at 6 months of age.
� Conservative treatment:- Trass: A beltwith apadto supportthehernia.- Trass: A beltwith apadto supportthehernia.
- Skewers: A too long pin to hold the ruptured muscles.
- Hernial clamp: After reduction of the hernial contents, aplastic or wooden clamp is applied to induce strangulationand necrosis of the hernial sac within 10-21 days and thewound heals by secondary intention.
- Injection of irritant material around the hernial ring toinduce fibrosis
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General Treatment� Surgical treatment:
� Indications:- Persistent congenital hernia
- Largehernia(>10cm)- Largehernia(>10cm)
- Irreducible hernia
� Principle lines of treatment- Reduction of the hernial contents
- Closure of the hernial ring (herniorrhaphy) by eithersutures (Suture herniorrhaphy) or prosthetic mesh(prosthetic herniorrhaphy)
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General Treatment�Surgical herniorrhaphy:�Anesthesia:- Generalanesthesia- Generalanesthesia
- Tranquilizer + local infiltration ring block
�Control:- Dorsal recumbency
�Preoperative technique: As usual
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General Treatment�Surgical technique:- Elliptical incision to open the hernial swelling.
- Reduction of the hernial content intra-- Reduction of the hernial content intra-abdominally.
- Widening of the hernial ring in incarceratedhernia
- Careful manipulation of the strangulated boweland excision of the necrosed parts.
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General Treatment- Cutting of adhesions and if not possible,
reduction of the adhered parts together.
- Excisionof theadheredpartof theomentum(if- Excisionof theadheredpartof theomentum(ifpresent).
- Refreshment of the hernial ring
- Closure of the hernial ring by one of thefollowing:
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General Treatment�Suture Herniorrhaphy:- In case of small hernial ring(Easly co-optation)
- By using horizontal mattress, simple- By using horizontal mattress, simpleinterrupted or purse string sutures
- Using synthetic absorbable (As Vicryl®) ornon absorbable suture materials (As nylon orprolyene).
-
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General Treatment�Prosthetic Herniorrhaphy (By using
prosthetic mesh):� Indications:- Attenuated muscles- Too large hernial ring- Hernia presents nearby bony attachment (as
costal arch and pubis).- Long standing recurrent hernia.
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General Treatment�Characters of a good prosthetic mesh:- Simple material
- Durable- Durable
- Elastic
- Have graining texture
- Easily sterilized
- Induce rapid fibroplastic response
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General Treatment�Aim of use the mesh:- To bridge the tissue gap that can not be sutured.- To support the newly developedgranulation- To support the newly developedgranulation
tissues and blood capillaries.�Techniques of prosthetic herniorrhaphy:- Retroperitoneal Technique- Intraperitoneal Technique- Double Sandwich Technique
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General Treatment�Retroperitoneal Technique:The prosthetic mesh is implanted eitherbetween the internal rectal sheath andperitoneum OR between fascia transversalisperitoneum OR between fascia transversalisand peritoneum� Intraperitoneal Technique:The prosthetic mesh is implanted in theperitoneal cavity with or withoutomentalization (Poor results due to adhesion).
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General Treatment�Double Sandwich Technique:
Double layers of meshes are implanted, onebetween the internal rectal sheath andperitoneumand the secondover the externalperitoneumand the secondover the externalrectal sheath.
- The prosthetic mesh is fixed in position withnon absorbable suture materials as prolene ornylon using simple interrupted or horizontalmattress sutures.
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General Treatment
- Closure of s/c tissues with absorbable suturematerials as Vicryl using simple continuouspattern.pattern.
- Closure of the skin with non absorbable suturematerials as silk, nylon or prolene using simpleinterrupted or horizontal mattress patterns.
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Postoperative Care�Using abdominal bandage
�Daily dressing of the wound with antisepticsolutionsolution
� Injection of systemic antibiotics
� Injection of antitetanic serumin equine
�Reduction of the animal, s food for a week
�Removal of the stitches after 10 days of theoperation
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Umbilical Hernia (Omphalocele)� It is common of foals, calves and less in kids,
lambs, puppies and kitten.� It is common in Friesian calves.� It is morecommonin femalesthanmales� It is morecommonin femalesthanmales� It is common in animals less than months old�Spontaneous recovery usually occurs in small
umbilical hernias� The common hernial contents are omentum,
abomasumand intestines.
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Umbilical Hernia (Omphalocele)� Causes:� Congenital causes:- Developmental defect in the umbilical opening
- Geneticfactors- Geneticfactors
� Acquired causes:- Chronic omphalitis
- Weakness of abdominal muscles.
- Mechanical failure for natural closure of umbilicus
- Severe straining - Trauma
- Excessive traction of umbilicus during birth.
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Umbilical Hernia (Omphalocele)
Umbilical Hernia in a 5-month-old Buffalo calf
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Umbilical Hernia (Omphalocele)� Clinical symptoms:- General signs of hernia- It may be alone or with omphalitis.� Diagnosis:� Diagnosis:- Case history -Clinical signs -Physical examination- Ultrasonography to differential between omphalocele
and omphalitis.- Exploratory laparotomy- Differential diagnosis fromomphalitis, cysts, hematoma
and tumors.� Treatment: As mentioned before.
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Inguinal/ Scrotal Hernia� It is the protrusion of viscera through the
inguinal canal into the inguinal region(Inguinal hernia) or into the scrotum(scrotalhernia).hernia).�The hernial ring is the inguinal ring�The hernial sac is the tunica vaginalis.�The Hernial contents are usually loop of small
intestine or omentum(rarely large intestine andurinary bladder).
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Inguinal/ Scrotal Hernia�Causes:- Hereditary defects in lambs and foals- Congenital defect results in too large inguinal
ring.ring.- Abdominal trauma- Hard work- Increased intra-abdominal pressure during
exercise, severe straining, chronic cough orbreeding.
- Hind limb slipping around and backward
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Inguinal/ Scrotal Hernia�Clinical Symptoms:- Abdominal pain and colic- Enlarged firm testicle in acute cases- The hernia may reach the ground- In chronic cases, the testicle suffers from pressure
atrophy.- The hernial contents can be palpated at the
anteroexternal aspect of spermatic cord.- Abducted lameness (mechanical lameness).
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Inguinal/ Scrotal Hernia�Diagnosis:- Case history
- Clinical signs- Clinical signs
- Physical examination
- Ultrasonography to differentiate scrotal herniafrom hydrocele, hematocele, testicular tumors,cysts, orchitis and scirrihous cord.
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Inguinal/ Scrotal Hernia�Treatment:- In congenital hernia, daily manual reduction of
the hernia may lead to recovery by time.the hernia may lead to recovery by time.
- Surgical treatment including reduction of thehernial contents, castration and closure of theinguinal ring.
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Perineal Hernia� It is a protrusion of retroperitoneal fat,
abdominal or pelvic viscera (UB, prostateand/or intestines) through the pelvic diaphragminto theischio-rectalfossa.into theischio-rectalfossa.�Pelvic diaphragmis composed of the levator
ani and coccyggeus muscles medially, thesacrotuberous ligament laterally and theinternal obturator and external anal sphinctermuscles caudomedialy…
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Perineal Hernia
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Perineal Hernia
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Perineal Hernia� Incidence:- It is common in old dogs (6-14 years)- It is common in sexually intact dogs (97% of the
cases).cases).- It is not common in females due to strong levator
ani muscle and good adhesion to the rectal wallover a long distance
- It may be unilateral (2/3 of the cases) or bilateral(1/3 of the cases)
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Perineal Hernia�Causes:- Congenital weakness of pelvic diaphragmin some
breeds as Boxer and Pekingese- Testosteroneimbalance- Testosteroneimbalance- Prostatic enlargement- Chronic constipation- Muscle atrophy especially levator ani muscle- Concurrent rectal diseases as rectal deviation and
dilatation.
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Perineal Hernia
�Symptoms:- Ventro-lateral, to the anus, painless swelling
betweenthe levator ani muscle and externalbetweenthe levator ani muscle and externalanal sphincter.
- May be reducible or irreducible
- May be unilateral or bilateral.
- Change in tail carriage.
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Perineal Hernia- In chronic cases, overlying skin necrosis may
be seen.
- Frequentstrainingto defecatewith little of no- Frequentstrainingto defecatewith little of nofeces.
- Dysuria or anuria if the urinary bladder isherniated
- Abdominal pain
- Lethargy and depression
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Perineal Hernia
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Perineal Hernia�Diagnosis:- Case history- Clinical signs- Clinical signs- Physical examination- Rectal examination >>>To detect the impacted
rectum& to assess the hernial ring.- Ultrasonography >>>To image the hernial
contents
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Perineal Hernia- Radiographic examination:
- Plain Radiography >>>To detect the rectaldilatationandhernialcontentsdilatationandhernialcontents
- Contrast Radiography of either rectum>>> todiscover rectal deviation or rectal diverteculumOR urinary bladder (Cystography) >>>todiscover the herniated UB.
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Perineal Hernia
Plain Radiography of Bilateral Perineal Hernia in a dog
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Perineal Hernia
Herniated UB in aperineal hernia in
Contrast Radiography of Perineal Hernia in Dogs
Herniated rectum in a perineal hernia in a dog
perineal hernia ina dog
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Perineal Hernia�Treatment�Conservative treatment:- Usinglaxatives.- Usinglaxatives.- Periodic rectal enemas- Fibers rich diets.- Urinary catheterization to decompress the
urinary bladder.- Digital removal of the impacted feces.
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Perineal Hernia� Surgical treatment:- Castration >>> decrease testosterone >>> decrease the size of prostates
- Suture herniorrhaphy(in small herinalring) - Suture herniorrhaphy(in small herinalring) - OR- Prosthetic herniorrhaphy (in large hernial ring or
very weak muscles) - OR- Muscle transposition perineal hernioplasty (in
severe or bilateral hernias and to avoid recurrence)
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Perineal Hernia�Conventionalor suture herniorrhaphy:- Fasting of the animal for 24 hours- Rectal enema- Purse string suture around the anus or inserting a
piece of gauze inside the anus to avoid defecationduring surgery.
- Sternal recumbency with tying the tail over theback
- Elevation of the hind quarter
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Perineal Hernia- Aseptic preparation of the perineum.- General anesthesia + Epidural analgesia- Openingthehernialswelling- Openingthehernialswelling- Exposure of the hernial contents- Reduction of the hernial contents
intraabdominally.- Colopexy may be done to fix the colon and
rectumto the left abdominal wall
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Perineal Hernia- Cystopexymaybe done tofix the urinary
bladder tothe right abdominal wall
- Ductusdeferensopexycanbe doneto fix- Ductusdeferensopexycanbe doneto fixthe prostates tothe abdominal wall.
Closure of the herinal ringwith 4 layers ofhorizontal mattress or simple interruptedsutures usingsynthetic absorbable suturematerial as follow:
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Perineal Hernia1- First layer sutures the coccygeus muscle and
external anal sphincter muscle.2-Second layer sutures the levator ani muscle
andexternalanalsphinctermuscle.andexternalanalsphinctermuscle.3-Third layer sutures the internal obturator
muscle to the external anal sphincter and to thelevator ani and coccygeus muscles to finishclosing the hernia defect
4- Fourth layer sutures the subcutaneous tissueand external anal sphincter muscle.
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Perineal Hernia
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Perineal Hernia
- Suturing S/C tissue with synthetic suturematerial and simple continuous pattern
- Suturingof theskin with nonabsorbablesuture- Suturingof theskin with nonabsorbablesuturematerial and simple interrupted pattern.
- Removal of purse string suture or gauze fromthe anus.
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Perineal Hernia�Post operative care:- Reduce diet for 3 days post operative- Soft easily digested food for 7 days post- Soft easily digested food for 7 days post
operative.- Daily dressing of the wound with antiseptic
solution- Systemic antibiotics- Removal of the stitches after 7-10 days
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