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com

Animals with urinary tract

obstruction secondary to
73 * < _ _ perineal hernia will
deteriorate rapidly, and
require urgent treatment
a.a

~ng~en of herna n rutrs

in small animals KATHRYN PRATSCHKE

A HERNIA is a protrusion of an organ or part of an organ through a defect in the wall of the anatomical
cavity within which it normally lies. The majority of hernias in small animals involve defects in the
abdominal wall, diaphragm or perineum. These may be either congenital or acquired and can result in
appreciable morbidity and even mortality. Hernial defects may occur at normal 'openings', such as the
inguinal ring or the oesophageal hiatus of the diaphragm, they may be iatrogenic, or they may be
abnormal in nature (eg, following trauma). This article describes how hernias are classified and outlines
the principles of hernia repair (herniorrhaphy). It discusses different types of hernia and, in each case,
provides guidelines on diagnosis and management of the defect.
Kathryn Pratschke
graduated from the
Veterinary College CLASSIFICATION OF HERNIAS
of Ireland, University Aims of hernia repair
College Dublin, in
1994, after which she The termsi 'lhernia' and 'rUptUre are 11ot sy nony mous, * Return of viable hernial contents to their normal
completed a one-year
internship and a
ItlEhough for certain conditions they are sometimIIes used location without undue disruption
three-year residency interchangeably (eg. diaphragmatic herniar/-uptu-e1). A * Secure closure of the neck of the hernial sac/
in small animal hernia consists of a hernial rin, anid a hernial sac con-
surgery at University defect to prevent recurrence
College Dublin. taining the helrn-ial contenits (see box below). A ruptul-e
* Obliteration of any redundant tissue in the her-
Having spent some does not necessarily imply the presence of eithler a
time in small animal nial sac
practice in Ireland,
hernial rino or sac. Hernias are variOUsly classitied by * Wherever possible, use of a patient's own tissues
she joined the their- alnaltomilical location, \vhether they are congellital or for hernia repair
University of acquired. and by the status of the hernlial conteints.
Edinburgh in 2000
as a lecturer in small
animal surgery with ANATOMICAL LOCATION
emphasis on soft
tissue surgery. She Probably the most comimllon wvay of classifying herilias is
holds the RCVS by their anatormical location (eg. umbilical, incisional. CONGENITAL OR ACQUIRED?
certificate in small
animal surgery and a ing,uinal, diaphragmatic or1 perineal). A congenital detect is presciit fiom birtil and is usual1ly
Master of Veterinary due to embryonic failure of fusion, as is the case with
Medicine degree. She peritoneopericardical hernais and certaii1 abdomiinal her-
is a diplomate of the
European College of nias. Althoughli the defcct is present fromil birth, hernil-
Veterinary Surgeons. Parts of a hernia ti()n may not necessarily manifest until later in lite. An

* HERNIAL RING. This is the actual defect, and may acqUiired hernia is oine that oCcurs somiletimie alter birthi.
and is usually traumalitic or iatrogyenic in origin, althou1gh
vary in size from a couple of millimetres to several
degenerativ c changes may also be implicated (eg peri-
centimetres
neal hernias in dogs).
* HERNIAL SAC. This comprises the tissues which
cover the herniated contents. In the case of congen-
STATUS OF HERNIAL CONTENTS
ital hernias, a mesothelial lining is present; traumat-
Reducible or non-reducible?
ic hernias, however, may not have a true sac
A hernia is reducible when its contents are freely move-
* HERNIAL CONTENTS. These refer to whatever has
able and may be readily manipulated back into the
protruded through the hernial ring. The nature of
aniatomical cavity from \which they hav e protruded. If
the hernial contents can sometimes be predicted
her-nial cointenits cannot be replaced thieni the hernia is
from the anatomical location
said to be non-reducible.

570 In Practice * NOVEMBER/DECEMBER 2002

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Incarceration
Incarceration occurs when adhesions form between the
hernial contents and surrounding structures (eg, between
the liver and lung/pleura/pericardium in the case of
chronic diaphragmatic hernias).
Strangulation
Strangulation of a hernia occurs when the vascular sup-
ply to structures within a hernial sac is compromised.
This can be the result of direct compression (eg, gastric
obstruction in diaphragmatic hernias), torsion of a vascu-
lar pedicle, or contraction of the hernial ring (particularly
with traumatic hernias).
PRINCIPLES OF HERNIA REPAIR
REDUCE THE HERNIA
Most hernias are best approached via a direct incision
over the site, although complicated abdominal hernias
frequently require a combination of approaches using
both intra- and extra-abdominal manipulations. Adequate
surgical exposure is essential and, as a result, a hernial
defect may occasionally need to be enlarged. Tissues may
be friable, so careful handling and an atraumatic tech-
nique is important. Adhesions, where present, should
be carefully broken down using a combination of blunt
and sharp dissection. Organs that are distended by fluid
and/or air may require aspiration to allow repositioning
and to reduce the pathophysiological effects on the
animal (eg, space-occupying effect of gastric distension
within the thorax in the case of diaphragmatic hernias).
CHECK THE VIABILITY OF THE
HERNIAL CONTENTS
Strangulated hernias may require resection of part or all
of the organ in question. Vascular pedicles that are twist-
ed should not be derotated before resection. Non-viable
tissue, such as necrotic loops of bowel, should be resect-
ed before returning the herniated organs to the abdomi-
nal cavity. Such cases are surgical emergencies.
CLOSE THE HERNIAL RING OR DEFECT
Secure closure of the hernial ring or defect is best
performed by direct suture apposition of local tissues. A
good knowledge of the regional anatomy is essential to
ensure that sutures are placed in tissues with adequate
strength to provide a secure closure but without compro-
mising normal functions or vital neurovascular struc-
tures. Select a suture material with sufficient strength tion. This combination of factors promotes herniation of
and duration of tensile strength. For traumatic hernias,
an absorbable material such as polydioxanone (PDS II;
Ethicon) or glycomer 631 (Biosyn; Vetoquinol) is usual-
ly sufficient, while congenital or other acquired hernias
require non-absorbable materials such as polypropylene
(Prolene; Ethicon). It is advisable to use monofilament
rather than multifilament or braided materials as these
carry the risk of suture sinus formation or potentiation of * Constipation
infection.
OVERCOME TENSION
A secure hernia closure must be tension-free. It is some-
times possible to overcome tension through the use of
local muscle or fascial flaps (eg, an internal obturator
flap in perineal hernias or a transverse abdominal muscle
flap in diaphragmatic hernias). If such techniques are not
In Practice * NOVEMBER/DECEMBER 2002
feasible or are insufficient, prosthetic implants may be
used. Polypropylene mesh prostheses allow ingrowth of
capillaries and granulation tissue while distributing load
in two directions. They are well tolerated and do not
disintegrate with age; however, if a synthetic mesh
prosthesis is to be used, strict asepsis and the use of
non-absorbable suture materials are mandatory. Poly-
propylene mesh prostheses should only be used when
absolutely necessary and never as a first choice. Other
options for augmenting a hernia repair include the use of
omental pedicles and collagen implants.
OBLITERATE 'DEAD SPACE'
Any dead space should be obliterated when closing the
hernia. If this is not possible, consideration should be
given to the use of drains.
ELIMINATE THE PREDISPOSING CAUSE
Where possible, eliminate the predisposing cause of the
hernia. An example of this is castration of male dogs
with perineal hernias (see later).
MANAGEMENT OF CONGENITAL HERNIAS
Congenital hernias may be hereditary. Information
regarding the nature of inheritance and expression of
congenital hernias is limited; therefore, congenital her-
nias should only be repaired if the owner gives consent
for neutering or the animal is not to be bred from.
PERINEAL HERNIAS
Perineal hernias are caused by a failure of the pelvic
diaphragm muscles, although the exact aetiology of the
condition is still unknown despite investigation for over
30 years. This type of hernia typically occurs as an
insidious condition in middle-aged to older male dogs,
although it is also reported occasionally in bitches and
cats.
The pelvic diaphragm consists of the paired medial
coccygeal and levator ani muscles, which arise from the
pelvic floor and insert on the caudal vertebrae. These
muscles supply lateral support to the terminal rectum.
When the muscles of the pelvic diaphragm fail, the ter-
minal rectum loses lateral support, allowing an increase
in rectal capacity which interferes with the normal linear
passage of faeces. Tenesmus is a consistent feature of
perineal hernias, together with increased reliance on
contraction of abdominal muscles to facilitate defeca-
Typical clinical findings in cases
of perineal hernia
* Unilateral or bilateral perineal swelling ventro-
lateral, dorsolateral or ventral to the anus
* Obstipation
* Tenesmus
* Dyschezia
* ± Stranguria if the prostate and urinary bladder
are involved
* Faecal and urinary incontinence may occur in
chronic cases
573
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Contrast radiographic studies may be useful in selected

Perineal swelling ventrolateral or ventral to the anus is a cases (eg, where rectal dilation or sacculation is suspected)
common feature of perineal hernias. The case pictured here to outline the extent of involvement and position of the
has severe bilateral swelling which is typically reducible rectum in a perineal hernia

pl v ic Lad
otta(ihlominal contents hct\ cciu thi CI Of
sle
L tI raldliol0r Lppl ic Stuldies 111ia alSO lie p)Cet1o Cd ti) oLtinelC tIel
t 1lC |)CI C1\
t 1i 1|)11 -"L-
( 11 '1111(i t ]lC I-CtLt 1 11. 'I'ICIC i 1 MIl %%SSO i- I-CC tn11. niA1uilS sWith Lilt nat tract ()hstlict0ioll seco()Ldair
atioi hct\\'s ec pce-ilICall hlerntlialS aiCI Coiic'litionIS SLIuCh aIS to( a pCi 1eal hi ritla w ill deterirate rapidlN and riCCLt ireC
)r ()stat ic h ypert lhand C()itis that pred isp(se t) tc)nes ur _eClt trteCnIltctnihibjl i either catlicterisati(ol (Oit es
111LIS and o constipaption aitlii1lII cauSa) l dlt iOnllhip toCcntesits itIl con-ectionl (it electl'ol\'tc dliStUirhbaces.
has hccn dccinitclN cstablisheld. The atrtophv ot' the esva- acid hase inmhalinces andlUtIluid detici t id( to SUi teal1
tot ali musIlIeCIC SCeC in11 1manV Clinical Cases has nlot hCCe corre'lCctionI.
adCICqoatCels CX\plainCd 10iiu hal S thelC p)rp)OndleraC e' tot It has nlot bheci psossihle to identity a silnlc satisIactO-
'ii ht-SidCdl hlern'iaS iiiLiitla'ter-l C.Scas.etSs ('o)lund iII soiie 1av ctioloi'Ical C\plallatiou1 hot pei-ctneal he riliatioll .111nd
StuLdlies So tI he ilelphasis t01' llrmaallleClllClt lremi.uisMs e\VC1 mi1t1chl ouI
Diaioosis 01lpcirincal hIe-riaMS is LILsnllstraIiclitl101ss.i c StU io cal reClaitil Oh tIlCh heCrni'a and pie vC'tiOIl ot ic-liet lial-
and can he made on the hasis (it hiistorv. clinical siens and tiOln ot' ahdominal and pclv ic StlLItLutIlrCS. AnimllllS Sh1OLIdi
e-cCtal CaUxi ti nalttionl altlSOuh 0(uta o plpiNv aInd C'Iotla.Ist alw avs le scr-cened.< t'0r' Ct01utrenC1t predispo)Sillnl dlisealses.

The use of the internal obturator muscle as a transposition

flap in conjunction with standard herniorrhaphy gives a
more secure repair. This picture shows suture placement
The internal obturator muscle flap may be elevated and in the internal obturator, levator ani and rectococcygeus
used for closure of perineal hernias in dogs muscles and the external anal sphincter

574 5 InPractice * No vEMBER /DECEMBER 2002

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Potential complications of
perineal hernia repair
* Rectal prolapse
* Infection
* Faecal incontinence
* Urinary complications
* Sciatic nerve entrapment
Several procedures have been described for surgical
correction of perineal hernias. The conventional or 'stan-
dard' herniorrhaphy involves reapposing the muscles of
the pelvic diaphragm with the external anal sphincter,
sometimes using the sacrotuberous ligament for addi-
tional suture purchase where severe muscle atrophy is
present. Care must be exercised to avoid entrapment of
the sciatic nerve where this technique is used. With the
standard repair, there is tendency for persistence of
a a
ventral defect which may permit recurrence rates of up
to 30 per cent. The use of the internal obturator muscle
as a transposition flap in conjunction with the standard
herniorrhaphy gives a inorc secure repair, with reported
recurrence rates in the order of 10 per cent. Other
herniorrhaphy techniques include the use of the superfi-
cial gluteal muscle or semitendinosus muscles and the
use of prosthetic mesh implants. In the case of severe
or recurrent hernias, colopexy, cystopexy and/or vas
deferensopexy may also be performed to reduce the risk
of re-herniation.
Tenesmus and pain are well recognised complications
after perineal herniorrhaphy and effective analgesia is
therefore very important. This may be provided by
parenteral administration of opioid or non -steroidal
anti-inflammatory medications, or via epidural opioid/
anaesthetic administration. Daily application of warm
compresses may also be beneficial. If rectal prolapse
occurs, this should be gently reduced following lubrica-
tion, and a purse-string suture should be placed. Proce-
dures such as colopexy are only indicated where rectal
prolapse is a persistent complication. Surgical wounds
should be checked daily for evidence of infection
although the routine use of antibiotics is not indicated
unless devitalised or necrotic tissue is identified at
surgery. Partial or complete faecal incontinence may be
a trainsient complication in some cases. Stool softeners
should be continued for one to two months after surgery.
Sciatic nerve paralysis may result following inaccurate
Typical clinical findings in cases
of diaphragmatic rupture
* Variable levels of respiratory distress (depending
on the size of the rupture, movement of the
organs, what organs are herniated and so on)
* Pleural effusion
* Cardiac dysrhythmias (present in 10 to 12 per
cent of cases)
* Gastrointestinal signs
* Exercise intolerance, depression, weight loss
* Abnormal thoracic auscultation
* 'Wasp waist' appearance (classical sign, but rare)
In Practice * NOVEMBER/DECEMBER 2002
placement of sutures during surgery. This is a rare but
serious complication, manifesting as pain and hindlimb
lameness with neurological deficits. Immediate surgical
re-exploration is indicated where sciatic nerve entrap-
ment is suspected.
In cats, information regarding perineal herniation is
limited. It seems that, as in dogs, many cases are appar-
ently idiopathic, while in others there is a predisposing
condition such as colitis or megacolon which results in
increased abdominal straining, constipation and/or tenes-
mus. Middle-aged to older male cats are more commonly
affected. Tenesmus, constipation, vomiting and partial or
complete anorexia are the most common clinical signs.
The condition has been bilateral in the majority of
reported cases. Where primary repair has been attempt-
ed, recurrence rates are comparable with those seen in
dogs.
DIAPHRAGMATIC HERNIAS/RUPTURES
Diaphragmatic hernias are relatively rare (reportedly
affecting I to 9 per cent of road traffic accident cases)
but result in significant injury associated with increased
intrai-abdominal pressure in the presence of an open glot- A ventral left-sided radial
diaphragmatic tear. The
tis. This form of hernia involves a tear in the diaphragm muscular portion of the
that allows abdominal contents to move into the thoracic diaphragm is most
commonly affected, with
cavity. The muscular portion of the diaphragm is most an approximately even
commonly affected, with even distribution between the distribution between the
right- and left-hand sides.
The hernia pictured here
was acute in nature
Typical radiographic findings in
cases of diaphragmatic rupture
* Loss of diaphragmatic outline
* Loss of cardiac silhouette
* Presence of gas-filled structures within the
thorax
* Presence of soft tissue structures within the
ventral thorax
* Atelectasis
* Displacement of abdominal organs and/or alter-
ations in topographical anatomy (eg, altered gastric
axis)
575
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Lateral thoracic radiograph of a Jack Russell terrier with a diaphragmatic hernia. Note
the dilated stomach within the thoracic cavity - this presentation constitutes a surgical
emergency
Severe pleural effusion may develop secondarily to partial or complete organ strangulation
following diaphragmatic rupture and is a particular feature of incarceration of the liver
ii lit anld lef't sidlCs. [Th Illmost trl-Cfuliltl> iat1101tcan
ed
is the isver tfollowsedhvi small ilitestinic onilelituilml stoiil-
i
ch la and splecic Thlc phsical p1resenice ot' tbdomlial
OFLiiS \ ithin,, the tholiacic vsit\ ius-o-olkcs irespilratorv
distrCss duLIe to al sfiaIeC-iOCCUN in)g ettcCt aiCi IrCsti ictiol
Of lug Xpallnsiont. Partiall ()o Comilete
o replacenienit ot ai twisted poitioni of' lisvcr and/oi ho\ssel
orgaii SttrlaiIg l-
tloml mal leaId to CXtrasasatioSl Of)lamiod0it'icd taiilsuIdaktC iito tlhe ahbdomen.
01' CIkidatC, ss hicli c'an ti tlier iniie)CdeC 1tt14el eX.\pXlaiiOl
tl is is x tiCUIal>VtrueIo is rC inc .Cerattiol)) iA s'\ t
an> thin-iacic tiainia1. fiuliio rN tland Car-lialc conLtsiolis
mla als lIec associated .iwti di aphiragmiatic i ii as.
ID)iaphiragmatlic hernias are -creqUIltlx illiSsedCCI at thle
iiiitiall fieselitatiil - it is hlot unlllcoilillll to sce iaphirag-
matic hcbtiias after ssccks o'r evn ciitiioiitlis as some1c ca,lsec's
ate clinicalks siciut. Diagnmosis caLii otftcin le aclitevs c ithi
i)iti slUAnCi adiogliralls. hUltiLasolograp-ihN is partietlLIkIn-1I
LIsCtetl inI aimiaIls sithi a1 p1IcmLIal CtuTLsioii, ats Hlui h is an
e\cCl cIlt ImedliuLImI toi thIeCr-ansiiissioii ii sigiUials. ss1iCi-C-
576
Yorkshire terrier with a diaphragmatic rupture. There is
evidence of right lung lobe collapse, and extensive linear
gas opacities throughout the left hemithorax, consistent
with herniated viscera
.IS tLli(i o0cSiII-CS adiCOII- alliic detail. Coiiti ast ad inca a
ph> is indicated ollv w\ henl Conv\entional radio-lirapls d1ie'
1(10-C1liac!InostIC. and LItraI-sonloarapi x11I is Unav ai able.
Cint(lIosis
On'Ce tilaC is ,C,.CIachd snLr-cical inIter\ nCIti(In
is the onkl option. Diaphrliamiatic helinialS ICIUil'e lngCllt
1,tathei than,ll CImCI(1CencV sni erCN'V' .e\c\iCt ss'hic tlcr-c is her-
niation of, tie stomllach sith ca,stric dil.ation, incarcerated
or ohstl-Lntctl bosswel. oincoeln hacileniorhae or hecriniation
ot'a a., i tel nIS. ScIirsV,a I rateS are co1nsider* ah,bi highei
in animials that has\c cb stabihilised f'or 24 to 36 11honr-s
pricopcrativI
Pciiopciatisc antibaicterild tireatment is iidicatcatd in,all
cases hcaIuSe ot':
* The comprionimised sta,te of' thlc aiinial:
* The possihility tilhat snrg may take longer than (1
of' hosci Is olv ement:aLndc
* Tlic likclihood
I'or ciildotoxlii release associated w ith
* The potential
Thc nSLMI snrai0Cal apizproaIcIh is s ata milidlinC coelio-
toMiiN . AthonLabll C1li-oniC CaIses ma1>IV r-cfLlil-C coIlV elsioin to a1
stcIilotoliii I'\11-ii1ianaCemeiit of' intrathoracic adhesions. 11'
oroicans cannot be r-ednLICCCd CeasilV dnLIe to tIlh IrlatitVlC
simall si/c oft tt iaphilagIIiialtic Iptil ,C, tIlCIh thlC tCaimllaI
le exteindcd c ith a veiitrallll directedt radial iiicisioln. It is
inad isable to atteilmpt to deal \ ith intrathoracic aodheCsionMs
thinidl aiid onil> rarcly is it possiblc to managc tilciiii va
the diaphliraimatiC 1initnie. Gciiilcl> soriiief from ' the
lealst accessiblc dorsal aspect s ciitral.I uLsing si0i-t runIIs
of a1 0oiitiWiIOIs sLtml C patterili is recomimiiiended. Rapilo-1
5 In lractice * Nov EMBER D EF MBE R 2002
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absorbed suture materials (catgut, polyglactin 910, poly-
glycolic acid) should not be used. Polydioxanone, gly-
comer 631 or polypropylene are all suitable choices.
Air must be removed from the thorax prior to abdom-
inal closure. The author uses a thoracostomy tube in
preference to transdiaphragmatic methods of aspiration.
This also provides ready postoperative access for assess-
ment of pneumothorax or haemothorax. The thoracosto-
my tube can usually be removed within hours of surgery
in uncomplicated cases. It is advisable to avoid over-
inflation of the lungs during surgery, especially in cases
with chronic diaphragmatic hernias, as this increases the
risk of re-expansion pulmonary oedema.
Postoperative monitoring is crucial; after anaesthetic
induction, the first 24 hours postoperatively ranks as the
highest risk period for mortality.
HIATAL HERNIAS
The oesophageal hiatus is one of three openings in the
diaphragm. The caval foramen is located ventrally, the
oesophageal hiatus is located centrally and the aortic hia-
tus is located dorsally. The oesophagus, vagal nerves and
oesophageal vessels pass through the hiatus together.
The phrenico-oesophageal ligament surrounds the hiatus
and attaches the oesophagus to the diaphragm. The pres-
ence of an abdominal oesophagus is not consistent, nor
is the location of the lower oesophageal sphincter rela-
tive to the diaphragm.
A hiatal hernia may be defined as a protrusion or
transposition of any abdominal structure through the
oesophageal hiatus of the diaphragm into the thoracic
cavity. Both congenital and acquired forms of the condi-
tion have been reported but it is relatively rare in dogs
and cats. In humans, an incidence of 40 per cent has
been reported, of which many cases are subclinical. Four
types of hiatal hernia are described in the literature (see
box, above right).
Clinical signs associated with hiatal herniation range
in severity. The most commonly reported signs include
hypersalivation, regurgitation, vomiting, chronic weight
loss and dyspnoea. Other, less frequently reported signs
include haematemesis, anorexia, dysphagia, orthopnoea
and exercise intolerance. Veterinary research to date on
hiatal herniation has, by and large, placed considerable
emphasis on associated factors thought to be important
in the human population, including upper respiratory
tract pathology, gastro-oesophageal reflux, oesophagitis,
gastric acidity and lower oesophageal sphincter incom-
petence. In dogs, there appears to be a link with respira-
tory tract disease, such as intranasal neoplasia, laryngeal
paralysis, brachycephalic airway disease and chronic
diaphragmatic hernia. Where there is increased respirato-
ry effort for any reason, an abnormally low intrathoracic
negative pressure may be induced. Even in the presence
of normal intra-abdominal pressure this reduced intra-
thoracic pressure may be sufficient to induce a hiatal
hernia, frequently with associated gastro-oesophageal
reflux disease. The weight of clinical evidence suggests
that in veterinary patients gastro-oesophageal reflux dis-
ease almost invariably develops secondarily to another
condition. Primary dysfunction of the lower oesophageal
sphincter per se has not been clarified in veterinary
patients, although two cats have been reported with
suspected lower oesophageal sphincter insufficiency.
In Practice X NOVEMBER/DECEMBER 2002
Types of hiatal hernia
Type I
A type 1, sliding or axial hiatal hernia involves cranial displacement of the
abdominal oesophagus, oesophagogastric junction and frequently a portion of
the gastric cardia such that these structures lie within the thoracic cavity. This is
the most commonly reported type of hernia in domestic animals.
Type 2
A type 2, paraoesophageal or rolling hiatal hernia involves the oesophagogastric
junction and abdominal oesophagus remaining in the same position but a por-
tion of the stomach displaces cranially to lie adjacent to the thoracic oesophagus.
This is a more unusual type of hernia in dogs and has not been reported in cats.
Type 3
A type 3 hiatal hernia is essentially a combination of types 1 and 2. It has only
rarely been reported in small animals.
Type 4
In type 4 herniation, the colon, spleen, pancreas or small intestine herniates into
the paraoesophageal sac..This type of hernia has not been reported in the veteri-
nary literature.
Much of the symptomatology associated with hiatal
hernias probably relates to this concurrent development
of gastro-oesophageal reflux. The normal anti-reflux bar-
rier is multifactorial, dependent on a concerted interac-
tion of both intrinsic (lower oesophageal sphincter) and
extrinsic (anatomical) mechanisms.
Megaoesophagus is commonly seen with hiatal her-
nias in dogs, particularly in the Shar pei breed. Typically,
the megaoesophagus resolves spontaneously with treat-
ment of the hiatal hernia.
Diagnosis of hiatal hernias is usually based on:
* CLINICAL SIGNS AND SIGNALMENT;
* HISTORY;
* PLAIN AND CONTRAST RADIOGRAPHY. Hiatal hernias
are often visible as a soft tissue opacity in the dorso-
caudal thorax adjacent to the diaphragmatic outline.
However, with sliding hernias and small hernias, several
Lateral thoracic radiograph
views may be necessary to 'catch' the presence of this of a labrador retriever
soft tissue mass, as it can be intermittent. The presence showing a semicircular soft
of a gas opacity within the herniated portion aids identi- tissue/fluid thorax. This
dorsocaudal
opacity in the
fication, and may sometimes highlight rugal folds con- was a herniating stomach
in a type 1 (sliding or axial)
hiatal hernia
,.XI
577
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Medcal heapy fo gatro-
oesophageai refisx disease
* Antacids to neutralise gastric acidity and increase
lower oesophageal sphincter pressure
* H2-receptor antagonists to reduce gastric acid
secretion
* Prokinetic agents to increase lower oesophageal
sphincter pressure and increase the rate of gastric
emptying
* Antibiotics where secondary infection exists
firming the presence of the stomach within the hernia.
Varying degrees of megaoesophagus and aspiration
pneumonia may be identified. Definitive diagnosis will
often require contrast studies and/or fluoroscopy.
* ENDOSCOPY will confirm the presence of oesophagi-
tis, laxity of the gastro-oesophageal sphincter, gastric
reflux and strictures.
The indications for medical versus surgical manage-
ment of hiatal hernias in animals are still poorly defined.
Medical treatment is often beneficial from the point of
view of managing oesophagitis and gastro-oesophageal
reflux (see box above), but definitive management in
symptomatic animals is surgical.
Early reports of surgical management in veterinary
cases employed sphincter enhancing procedures adapted
from the human surgical literature, such as Nissens
abdominal and Belsey transthoracic fundoplications. The
morbidity and mortality associated with these techniques
is however unacceptably high in dogs, with complica-
tions including gastric tympany, vomiting, gastric wall
necrosis, aspiration pneumonia, dyspnoea and oesophagi-
tis. Better results have been obtained using a combination
of diaphragmatic hiatal reduction and plication, 360°
oesophagopexy and left fundic gastropexy. It is still
suggested by some surgeons that fundoplication should
be performed where there is clinical evidence of gastro-
oesophageal reflux disease. In the author's opinion
fundoplication techniques are never warranted, and very
good clinical results can be obtained using the 'combina-
tion' technique mentioned above.
PERITONEOPERICARDIAL
DIAPHRAGMATIC HERNIAS
Peritoneopericardial diaphragmatic hernias (PPDHs)
occur where there is a congenital communication
between the pericardial sac and the abdomen. The condi-
tion is due to either faulty development of, or prenatal
injury to, the septum transversum in combination with
incomplete fusion of the caudal pleuropericardial mem-
TVPkd dickal _# 0
i Ascites
* Muffled heart sounds
* Cardiac murmurs
* Pleural effusion
* Concurrent ventral body wall defects
578
branes. Other defects such as cranial abdominal wall
hernias and cardiac anomalies frequently accompany
PPDHs. Clinical signs are variable, and may involve the
gastrointestinal, respiratory or cardiac systems, although
PPDHs may also be clinically silent.
Survey radiographs typically show enlargement of
the cardiac silhouette, dorsal displacement of the trachea
and/or interruption of the diaphragmatic outline. Intesti-
nal gas opacities within the pericardial sac are pathogno-
monic. In cats, a distinct curvilinear radiopaque line has
been consistently identified between the cardiac silhou-
ette and the diaphragm. This has been termed the dorsal
peritoneopericardial remnant. Ultrasound is a non-inva-
sive and very useful method of demonstrating a PPDH,
with the added benefit that, unlike radiography, it is pos-
sible to distinguish between fluid and soft tissue masses
within the pericardial sac. The most commonly herniated
organ in PPDHs is the liver.
Indications for perioperative administration of anti-
biotics are as for diaphragmatic hernias (see earlier).
Surgical correction of PPDHs is via a ventral midline
coeliotomy, with extension through the sternum if nec-
essary. After the viscera have been reduced, the edges of
the diaphragm are sutured, as for diaphragmatic hernia
repair. The author does not routinely recommend separat-
ing the pericardium from the diaphragm and closing both
individually, as this increases the risk of entering the
pleural cavity.
Postoperative management is as for diaphragmatic
hernias. In general, if complications are not encountered
in the first 24 hours, the prognosis is good to excellent.
CAUDAL ABDOMINAL HERNIAS
An abdominal hernia may involve any defect in the exter-
nal abdominal wall. Abdominal wall defects with anatom-
ically defined hernial rings (eg, inguinal, umbilical) are
true hernias. The majority of abdominal hernias are con-
genital and will typically have a peritoneal lining. Many
animals will have other concurrent congenital defects, and
those with cranioventral body wall defects may have
coexisting diaphragmatic and pericardial abnormalities.
Investigation of abominal hernias
* As with any case, take a full clinical history and
perform a routine clinical examination including
careful palpation of the hernia
* If a scrotal hernia is suspected then palpation of
the base of the scrotum with the animal in dorsal
recumbency may be helpful
* Reduction of the hernia and palpation of the
hernial ring confirms the diagnosis and gives infor-
mation about the status of the hernial contents
(always check bilaterally even if the hernia is only
obvious on one side)
* Diagnostic imaging - take plain and contrast
radiographs and perform ultrasonography
* Fine needle aspiration is not advisable due to the
risk of trauma to the hernial contents, and does not
contribute much extra information
* Surgical exploration
* Always check for related congenital defects
In Practice * NOVEMBER/DECEMBER 2002
 Downloaded from inpractice.bmj.com on September 9, 2014 - Published by group.bmj.com
Typical clinical findings in cases
of caudal abdominal hernia
* Painless, doughy, soft swelling in the inguinal
region
A cord-like swelling, which may be painful, pal-
pable at the base of the scrotum with the animal in
dorsal recumbency
* External appearance of the swelling depends on
the status and type of the hernial contents (gravid
uterus, omentum, jejunum, etc)
* Vomiting is predictive of non-viable small
intestines where intestine is involved in the hernia
So-called false hernias allow protrusion of organs through
an opening that would not normally exist. They do not
typically have a peritoneal lining although chronic cases
may demonstrate 'peritonealisation'. Traumatic hernias
and incisional hernias are examples of false abdominal
hernias.
Hernias of the caudal abdominal wall (inguinal and
scrotal) may be either indirect or direct. In indirect her-
nias, hernial contents pass through the hernial ring to lie
within the cavity of the vaginal tunic. These hernias tend
to be small. Indirect inguinal hernias (scrotal hernias) in
male dogs are particularly associated with incarceration,
strangulation and organ dysfunction because of compres-
sion. Direct hernias exist where the hernial contents pass
through the hernial ring and lie adjacent to the cavity of
the vaginal tunic, and are therefore not constrained by it.
These hernias tend to be large and are less prone to
incarceration and strangulation.
Although inguinal hernias may occur sporadically in
both male and female dogs and cats, acquired inguinal
hernias are most common in intact middle-aged bitches.
The most common hernial contents are fat and omentum.
Congenital inguinal hernias are rare and frequently coex-
ist with umbilical hernias. Certain breed predispositions
exist, with Basenjis, basset hounds, Pekinese, Cairn terri-
ers and West Highland white terriers being particularly
susceptible to the condition.
Scrotal hernias result from a defect in the vaginal
ring, allowing abdominal structures to herniate within
the vaginal process beside spermatic cord contents. The
hernia may not necessarily extend all the way to the
scrotum. The condition is usually unilateral, and young
chondrodysplastic dogs appear to be predisposed.
Strangulation may occur due to compression at the her-
nial neck and early repair is therefore advised. Castration
is recommended at the time of repair for the following
reasons:
* Recurrence is common if animals are not castrated;
* The condition may be inherited;
* An increased incidence of testicular neoplasia has
been noted with scrotal hernias.
Umbilical hernias are usually congenital and are due
to failed fusion of the lateral folds (mainly the rectus
and fascia) after the sixth
abdominis muscle
gestation. Animals with umbilical hernias frequently have
other congenital abnormalities such as cryptorchidism,
incomplete caudal sternal fusion and diaphragmatic
defects, so careful evaluation is recommended.
Surgical repair is usually undertaken using either a
direct approach over the inguinal ring itself for uncom-
In Practice * NOVEMBER/DECEMBER 2002
A 16-year-old female
Jack Russell terrier with a
vaginal leiomyoma and left-
sided inguinal hernia. These
swellings are typically
painless, soft and doughy
plicated unilateral hernias, or midline coeliotomy plus
inguinal exposure for complicated cases (ie, where
there is incarceration, strangulation or concurrent intra-
abdominal trauma in acquired traumatic hernias).
INCISIONAL HERNIAS
An incisional hernia may occur when surgical closure of
any body cavity fails or disrupts. However, the following
discussion pertains to abdominal incisional hernias only.
Abdominal incisional hernias are more likely with
gravity-dependent midline or paramedian coeliotomies
rather than a flank laparotomy. Acute incisional hernias
generally occur within seven days of surgery, although
chronic hernias may be seen weeks or months later. The
incidence of incisional hernias is reported variously as
between 1 and 11 per cent in humans, and more than 16
per cent in large animals. Although the incidence of inci-
sional hernias has not been recorded in dogs and cats, the
condition may be associated with severe morbidity or
mortality, particularly in cases of acute total abdominal
wound dehiscence (evisceration).
The most common cause of acute incisional hernia
is incorrect surgical technique or carelessness, although
increased intra-abdominal pain due to pressure, entrapped
fat between wound margins or hernia edges, infection,
chronic steroid medication and poor postoperative care
have all been implicated. The presence of concurrent dis-
eases such as hyperadrenocorticism may also be involved
in the development of incisional hernias.
Typical clinical findings in
cases of incisional hernia
* Wound oedema, inflammation and serosan-
guineous drainage from the surgical site are warn-
ing signs of an impending incisional hernia
* Swellings may be soft and painless if neither
vascular compromise nor organ dysfunction has
week of
occurred
* A defect may be palpable within the surgical site
* If viscera are exposed (evisceration), organ
mutilation is common, happens rapidly and results
in high morbidity and mortality, as well as severe
owner distress
579
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J,~ ~~~'

Abdominal incisional hernias are more commonly seen following ventral

midline coeliotomy than after flank laparotomy. If there is no vascular
compromise or organ incarceration, the swelling may be soft, painless
and easily reducible. Acute total abdominal wall dehiscence, resulting A defect may be palpable within the surgical site where an incisional hernia
in exteriorisation of viscera, is a surgical emergency without evisceration has occurred

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- _ \ . W J: :-=e_
(left) Extensive abdominal bruising may accompany a ventral traumatic hernia. (right) Intraoperative view demonstrating the site of the rupture in the
muscular abdominal wall. The margins of the torn muscle are elevated with a pair of atraumatic Babcock's forceps

580 5 In I'ractice * No vEMBER/DECEMBER 2002

 Downloaded from inpractice.bmj.com on September 9, 2014 - Published by group.bmj.com

and immediately life-threatening injuries. Prepubic ten-

don ruptures are often difficult to identify on initial
clinical examination due to the combination of tissue
swelling and pain.
General principles of hernia repair may be applied
to traumatic abdominal hernias. Hernias which occur
secondarily to dog bites will frequently be contaminated,
and prosthetic mesh implants should not be used. Con-
current abdominal exploration is advisable after such
injuries to evaluate abdominal pathology (eg, bladder
rupture or gastrointestinal tract perforation).
With prepubic tendon ruptures, it is also important to
evaluate the inguinal rings and vascular lacunae as these
may be involved in the hernia. The free edge of the
abdominal wall is identified and reattached to the cranial
pelvic brim - this may be facilitated by placing drill
holes in the pubic bone to anchor sutures. Abdominal Intra-abdominal trauma may accompany ventral
muscle aponeuroses should be carefully sutured to the hernias, necessitating intensive postoperative care.
In this case, a cystostomy tube and gastrostomy tube
fascia over the medial proximal femoral area, taking care have been placed in addition to a closed suction
not to compromise vital neurovascular structures in the drain at the hernia site
process. If trauma to the prepubic tendon is so severe
as to preclude suture placement, the repair may be aug-
mented with either a mesh cuff or double layer mesh PRATSCHKE, K. M., HUGHES, J. M. L., SKELLY, C. & BELLENGER, C. R.
(1998) Hiatal herniation as a complication of chronic diaphragmatic
technique. Repair of prepubic tendon ruptures can be herniation. Journal of Small Animal Practice 39, 33-38
very challenging. READ, R. A. & BELLENGER, C. R. (1993) Hernias. In Textbook of Small
Animal Surgery, 2nd edn. Philadelphia, W. B. Saunders. pp 431-433
The prognosis for animals with traumatic abdominal SMEAK, D. D. (1993) Abdominal hernias. In Textbook of Small
hernias is related more to the organs involved than to the Animal Surgery, 2nd edn. Philadelphia, W. B. Saunders. pp 433-454
herniorrhaphy itself. WALDRON D. R., HEDLUND, C. S. & PECHMAN, R. (1986) Abdominal
hernias in dogs and cats: a review of 24 cases. Journal of the
American Animal Hospital Association 22, 817-823
WATERS, D. J., ROY, R. G. & STONE, E. A. (1993) A retrospective
study of inguinal hernia in 35 dogs. Veterinary Surgery 22, 44-49
SUMMARY

Hernias present the small animal surgeon with a wide

variety of interesting and challenging clinical problems
to manage. Careful preoperative assessment and plan-
ning combined with atraumatic surgery ftacilitate optimal
results. However, it is important to be aware of potential
complications in even the most apparently straightfor-
wavrd cases. Until the nature and character of inheritance
of congenital hernias is better understood in companion
animals, it is recommended that affected animals are
neutered or, at least, not used for breeding purposes.
4E '~~~
Further reading
BRAY, J. (2001) Surgical management of perineal disease in the
dog. In Practice 23, 82-97
BELLENGER, C. R. (1993) Abdominal wall. In Textbook of Small
Animal Surgery, 2nd edn. Philadelphia, W. B. Saunders. pp 399-406
BELLENGER, C. R. (1995) The treatment of hernias. Veterinary
Quarterly 17, S2-S4
BELLENGER, C. R. (1996) Inguinal and scrotal herniation in 61 dogs.
Australian Veterinary Practitioner 26, 58-59
BELLENGER, C. S. & CANFIELD, R. B. (1993) Perineal hernia.
In Textbook of Small Animal Surgery, 2nd edn. Philadelphia,
W. B. Saunders. pp 471-482
FREEDOM COMES
BOUDRIEAU, R. J. & MUIR, W. W. (1987) Pathophysiology of
traumatic diaphragmatic hernia in dogs. Compendium on
Continuing Education for the Practicing Veterinarian: Small
Animals 9, 379-386 Ultra modern, lightweight yet strong. These fully
FOSSUM, T. W. (1997) Surgery of the abdominal cavity. In Small
Animal Surgery. St Louis, Mosby. pp 179-199 supportive carts can be used single handed even at
FOSSUM, T. W. (1997) Surgery of the lower respiratory system: GSD size. With years of experience and owning all
lungs and diaphragm. In Small Animal Surgery. St Louis, Mosby.
pp 675-686
HOSGOOD, G. (1996) Diagnosis and management of diseases of
the other manufacturers carts I collaborated with
the diaphragm. Waltham Focus 6, 2-9 Eddie's Wheels to make these available here in the
HOSGOOD, G., HEDLUND, C. S., PECHMAN, R. D. & DEAN, P. W.
(1995) Perineal herniorrhaphy: perioperative data from 100 dogs. UK for I believe them to be the best available.
Journal of the American Animal Hospital Association 31, 331-342
HUBER, D. J., SEIM, H. B. & GORING, S. L. (1997) Cystopexy and For further info and a video contact
colopexy for the management of large or recurrent perineal hernias
in the dog: 9 cases (1994-1996). Veterinary Surgery 26, 253-254
Jim Colla on 020 8964 4057.
JOHNSON, K. A. (1993) Diaphragmatic, pericardial and hiatal E-mail jim.colla@lineone.net or visit
hernia. In Textbook of Small Animal Surgery, 2nd edn. Eddie's site at http://www.eddieswheels.com
Philadelphia, W. B. Saunders. pp 455-470

In Practice * NOVEMBER/DECEMBER 2002 581

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Management of hernias and ruptures in

small animals
Kathryn Pratschke

In Practice 2002 24: 570-581

doi: 10.1136/inpract.24.10.570

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