RETROSPECTIVE STUDIES

Retrospective Study on Clinical Features and

Treatment Outcomes of Nontraumatic Inguinal
Hernias in 41 Dogs
Teruo Itoh, DVM, PhD, Atsuko Kojimoto, DVM, Kentaro Kojima, DVM, Hiroki Shii, DVM

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ABSTRACT
Several factors are suggested to be involved in the development of nontraumatic inguinal hernias (NTIHs) in dogs, but case
series studies focusing on the etiology and treatment outcomes are limited. The aim of this study was to retrospectively
evaluate the clinical characteristics and treatment outcomes of NTIHs in dogs. Medical records of 42 dogs with surgically
treated NTIHs were reviewed. Forty-one dogs were included in the study, all dogs were small breeds weighing ,10 kg, and
middle to older age (.5 yr old; 33 cases), female sex (34 cases), and miniature dachshunds (26 cases) predominated. Left-sided
occurrence was common (30 left, 9 right, 2 bilateral), and organ protrusion was seen in 22 cases (15 uteri, 9 small intestines, 1
colon). Fourteen of 15 uterine herniations (93%) were located left side. Ovariohysterectomy was performed with herniorrhaphy
in 27/30 intact bitches, two of whom also underwent resection and anastomosis of a devitalized portion of the small intestine.
Recurrence was seen in only one male dog. These results suggest that NTIHs are more likely to occur in small-breed female
dogs, and that age may increase the risk of left-sided uterine protrusion; however, the long-term results after herniorrhaphy with
ovariohysterectomy are excellent. (J Am Anim Hosp Assoc 2020; 56:301–306. DOI 10.5326/JAAHA-MS-7106)

Introduction incarcerated omentum,5,6 and herniation with a nonviable small

An inguinal hernia is defined as a protrusion of an organ or tissues
1
through the inguinal canal. Inguinal hernias in dogs are classified as
1,2 3
congenital or acquired and traumatic or nontraumatic. Acquired,
nontraumatic hernias predominate, especially in sexually intact
3,4
bitches, whereas congenital hernias are rare and tend to occur in
3
male dogs.
The omentum and fat are the most common contents of in-
guinal hernias, and unless other organs prolapse, most cases are
3
asymptomatic for a long period without treatment. Herniation of
the hollow organs is less common, and prompt surgical repair is
1,2
recommended to avoid organ strangulation. Herniated organs can
1,2
include the uterus, intestine, and bladder, but the incidence of
each organ herniation has not been demonstrated.
The negative effects or consequences of inguinal hernias also
depend on the dog’s sex; severe scrotal edema may result from
intestine is more common in young male dogs,3 whereas uterine
herniation in bitches may be asymptomatic and possibly prevent
intestinal herniation.3 However, there are sporadic reports of sur-
gically repaired uterine hernias caused by pregnancy or uterine
diseases.7–10
Anatomical, hormonal, and metabolic factors contribute to the
development of inguinal hernias; the diameter of the inguinal canal in
bitches is relatively large, estrogen weakens the inguinal ring, and
metabolic abnormalities may weaken the abdominal wall.2 Addi-
tionally, there may be other factors because inguinal hernias re-
portedly occur more often on the left than the right side,3 but the
reason for this difference has not been described.
Knowledge of the epidemiological, etiological, and clinical
features of inguinal hernias, as well as postsurgical outcomes, are
important considerations for surgical decisions. However, to our

From Aoba Animal Hospital, Miyazaki, Japan (T.I., A.K.); Nagoya Veterinary HOH (hollow organ herniation); NTIHs (nontraumatic inguinal hernias);
Consultation, Nagoya, Japan (K.K.); and Division of Animal Medical OVH (ovariohysterectomy)
Research, Hassen-kai, Miyazaki, Japan (T.I., A.K., H.S.).
Accepted for publication: June 1, 2020.
Correspondence: itohteruo@gmail.com (T.I.)

ª 2020 by American Animal Hospital Association JAAHA.ORG 301

knowledge, only one published case series has evaluated long-term
outcomes.3 The aim of the current retrospective study was to
evaluate the clinical characteristics and outcomes of nontraumatic
inguinal hernias (NTIHs) in dogs.
Materials and Methods
Case Selection and Medical Record Review
Medical records of 42 dogs that underwent surgery for NTIHs in our
private hospital from January 1, 2008, to December 31, 2018, were
reviewed retrospectively. Inclusion criteria were that the location and
contents of the hernia, surgical procedure, and its complication were
documented. One dog was excluded owing to insufficient medical
records. Forty-one dogs were included. The following data were
retrieved: breed, age at surgery, sex, neutering status, body weight,
preoperative history, clinical signs and their duration, affected side,
hernia contents, radiographic and ultrasonographic findings, con-
current diseases, surgical procedures of herniorrhaphy and other
surgeries performed simultaneously, postoperative complications,
and outcomes.
Classification
Dogs were classified into one of the following two groups: (1) hollow
organ herniation (HOH) group or (2) herniation of the omentum or
fat only (non-HOH) group. Onset of clinical signs was defined as
acute if the following occurred ,7 days before surgery: clinical signs
associated with hernia, hernia detection, rapid hernia expansion.
Cases that did not fit this definition were regarded as chronic.
Surgical Procedure
All surgeries were performed via a midline incision. If the herniated
contents could not be returned to the abdominal cavity, the inguinal
ring was incised in a craniomedial direction. The inguinal ring was
closed using simple interrupted or simple continuous sutures with
3-0 polyglactin 910a, leaving a caudal gap for the vessels and nerves.
In principle, ovariohysterectomy (OVH) was performed simulta-
neously in sexually intact bitches, and the abdominal wall was closed
with simple continuous sutures. To prevent postoperative seroma
formation, several walking sutures were placed to secure the ab-
dominal wall and subcutaneous tissue to the inguinal area in all
dogs. The subcutis and skin were closed with a simple interrupted
pattern using nonabsorbable suture.
Statistical Analysis
Age and body weight between the HOH and non-HOH groups were
compared using the Mann-Whitney U test, and sex and affected side
(left or right) were compared using the binomial test. Deviation of
the affected side (left or right) by the prolapsed organs, sex, onset
302 JAAHA | 56:6 Nov/Dec 2020
(acute or chronic), and age (,8 yr or $8 yr) were compared using
Fisher exact test. P , .05 was considered significant for all tests.
Results
Signalments, clinical findings, surgical procedures, and outcomes in
the HOH (n ¼ 22) and non-HOH (n ¼ 20) groups are summarized
in Table 1. Because one male dog developed HOH 2 yr after the first
hernia repair for omental herniation alone, his status (age, weight),
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surgical procedures, and complications at both surgeries were
evaluated in both groups.
All 41 dogs were small-breed dogs weighing less than 10 kg
(median, 5.0 kg), with miniature dachshunds accounting for 63%
(26/41) of all the dogs. There were significantly more bitches in both
the HOH (P , .05) and non-HOH groups (P , .01). Four spayed
bitches (age at surgery: 10–15 yr) had undergone OVH at 8–13 yr of
age. The median age at surgery was 9.0 yr (range: 0.4–13 yr), and 33
dogs (80%) were .5 yr old (Figure 1). The dogs in the non-HOH
group were significantly younger (P , .05) than the dogs in the
HOH group. All eight dogs younger than 6 yr of age were sexually
intact bitches, only one (5 yr old) of whom was in the HOH group.
The affected sides were the left in 30 (73%) dogs, right in
9 (22%) dogs, and bilateral in 2 dogs, with significantly (P , .01)
more cases on the left than on the right, for all dogs, and in the
HOH group. Regarding the onset timing, 12 dogs were classified
as acute because clinical signs associated with hernia (n ¼ 7),
hernia detection (n ¼ 3), or rapid hernia expansion (n ¼ 2)
occurred ,7 days before surgery. The remaining 29 dogs were
regarded as chronic because they were asymptomatic with long-
standing hernias (n ¼ 12: 1–24 mo of duration) or unknown disease
duration (n ¼ 17).
Nine dogs underwent herniorrhaphy alone; the other 32 dogs
underwent herniorrhaphy and other concurrent procedures. OVH
was performed in 27 of 30 intact bitches simultaneously.
Non-HOH Group
All 21 dogs in this group had herniation of the omentum and fat, of
whom only 1 dog was regarded as acute onset because of sudden
inguinal swelling within 6 days before surgery. In four dogs, including
this acute case, free liquid was detected ultrasonographically. Four
dogs underwent herniorrhaphy alone; the other 16 dogs underwent
herniorrhaphy and other concurrent procedures.
Regarding short-term postoperative complications, partial wound
dehiscence secondary to licking was noted in one bitch. Another 13 yr
old bitch with mitral regurgitation, who underwent herniorrhaphy
and bilateral regional mastectomy, died suddenly 3 days after suture
removal. A cause of death other than herniorrhaphy-related com-
plications was suspected, but an autopsy was not performed. Of the
 NTIHs in 41 Dogs

TABLE 1
Summary of the Clinical Findings, Surgical Procedures, and Outcomes in 41 Dogs Classified as the Non-HOH and HOH Groups

Non-HOH Group (n ¼ 20)* HOH Group (n ¼ 22) Total (n ¼ 41)

Age, median (range), yr 8.0 (0.4–13) 9.5 (5–13)y 9.0 (0.4–13)

Body weight, median (range), kg 4.5 (2.2–9.4) 5.0 (2.5–9.3) 5.0 (2.2–9.4)
Breed
Miniature dachshund 11* 16 26 (63%)

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Chihuahua 0 2 3 (7%)
Toy poodle 1 1 2 (5%)
Other 7 3 10 (24%)
Gender
F [SF] 17x [3] 17x [1] 34 (83%)x
M [CM] 3* 5 [3] 7 (17%)
Affected side
Left 12 18** 30 (73%)**
Right 6* 4 9 (22%)
Bilateral 2 0 2 (5%)
Onset
Acute 1 11 12 (29%)
Chronic 19* 11 29 (71%)
Surgical procedure
Herniorrhaphy alone 4 5 9 (22%)
With other procedures 15 (OVH 11, CT 3*, MT 1, PH 1, UH 1) 17 (OVH 16, ER 2, MT 2, PH 1) 32 (78%)
Follow-up
Impossible 3 (12–50 days) 1 (10 days) 4 (7%)
Possible (median, range) 17* (1723 days, 388–3119) 21 (887 days, 297–3165) 38 (93%) (1079 days, 297–3119)
Surgical complication
Short term pwd 1, sudden death 1 pwd 1 3 (7%)
Long term Recurrence of hernia 1* 0 1 (2.4%)

Values indicate the number of dogs except for age and body weight.
* One male dog in the HOH group was included in the HOH group because of recurrence of HOH after herniorrhaphy without HOH.
y
Significantly (P ¼ .043) higher in the HOH group versus the non-HOH group.
x
Significantly (P , .05) higher on the right than on the left side.
** Significantly (P , .01) higher on the right than on the left side.
CM, castrated male; CT, castration; ER, enterectomy; F, female; HOH, hollow organ herniation; M, male; MT, mastectomy; OVH, ovariohysterectomy; PH, perineal
herniorrhaphy; pwd, partial wound dehiscence; SF, spayed female; UH, umbilical herniorrhaphy.

17 dogs with long-term follow-up data, 1 male miniature dachshund
developed recurrence (small intestinal protrusion) 2 yr after her-
niorrhaphy and castration. In this case, a second herniorrhaphy using
3-0 polyglyconateb was performed; no recurrence was observed
746 days after the second surgery.
HOH Group
Of the 22 dogs in this group, 11 were classified as acute disease onset,
7 of whom showed clinical signs associated with hernia: vomiting
(n ¼ 4), anorexia (n ¼ 3), and pain (n ¼ 3). The affected side,
herniated organs, and onsets of clinical signs separated by sex are
shown in Table 2. The rate of left-sided hernias was significantly
(P , .01) higher in bitches than in male dogs.
Uterine herniation was observed in 15 bitches aged 5–13 yr
old, with pregnancy (n ¼ 2), pyometra (n ¼ 2), and endometrial
hyperplasia (n ¼ 1). Intestinal herniation was observed in five
bitches and five male dogs, and three of the bitches also had
uterine herniation. Resection and anastomosis of the small intes-
tine was required in two bitches; one had a 3 day history of loss of
appetite, and the other had a 2 day history of vomiting (concurrent

JAAHA.ORG 303
 recurrence was observed. As a short-term complication, partial
wound dehiscence was observed in one dog.

Factors Associated with the Affected Side

A significantly higher rate of left-sided involvement was detected in
the uterine-herniated cases (P ¼ .038) and in intact bitches (P ¼
.0184) compared with other cases in each group, but no significance
was identified between cases classified by onset or age (Table 3).

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FIGURE 1
Case distribution by age at the time of surgery. *One male dog un-
derwent two surgeries at 7 (non-HOH) and 9 (HOH, recurrence) yr of
age. HOH, hollow organ herniation.
herniated uterus case). Protruded organs were identified by ultra-
sonography in all dogs, but one case of colonic herniation on the
left side required radiography for confirmation. One male minia-
ture dachshund had a recurrent inguinal hernia that had been
operated with castration at another hospital 2 yr earlier, and this
dog also had bilateral perineal hernias. Because a fistula in the
recurrent area suggested suture-reactive inflammation, the wound
was repaired with short-term absorbable suture (3-0 polyglactin
910), and no recurrence was observed for 570 days.
Of the 22 dogs in the HOH group, 21 were followed for a
median of 887 days (range: 297–3165), during which time no
Differences in the rates of left-sided herniation were not significant
between the HOH and non-HOH groups (P ¼ .1551) or between
bitches and male dogs (P ¼ .058).
Discussion
All dogs in this study were small breeds, and 80% were .5 yr of age.
We encountered no traumatic inguinal hernias during the study
period. The case composition suggested that acquired NTIH is more
likely to occur in small breeds. In the present study, 63% of all dogs
were miniature dachshunds, which is obviously higher than the
percentage of this breed among the total dog population (16%, 455/
2781 dogs) admitted to our hospital during the study period, sug-
gesting the higher risk of this breed.
The predominance of female dogs was consistent with previ-
ous reports.3,4 Anatomically, the inguinal canal in bitches is larger
than that in male dogs.2 Additionally, estrogen-induced weakening
of the inguinal ring may contribute to inguinal herniation, which is
supported by the higher percentage of intact than spayed bitches in
this study (88%, 30/34) and in a previous report (68%, 13/19).3

TABLE 2
Number of Dogs in the HOH Group Separated by Sex and Clinical Findings

F M

Intact (n ¼ 16) SF (n ¼ 1) Total (n ¼ 17) Intact (n ¼ 2) CM (n ¼ 3) Total (n ¼ 5) Total (n ¼ 22)

Affected side
Left 15* 1 16* 2 0 2 18*
Right 1 0 1 0 3 3 4
Herniated organ
Uterine 15 — 15 — — — 15
y
Small intestine 3 (2) 1 4 2 3 5 9
Colon 1 (1)y 0 1 0 0 0 1
Onset
Acute 9 (6)x 1 10 1 (1)x 0 1 11
Chronic 7 0 7 1 3 4 11

* Significantly (P , .01) higher on the left than on the right side.

y
Value in parentheses is the number of dogs with uterine herniation.
x
Value in parentheses is the number of dogs with gastrointestinal signs.
—, not applicable; CM, castrated male; F, female; HOH, hollow organ herniation; M, male; SF, spayed female.

304 JAAHA | 56:6 Nov/Dec 2020


TABLE 3
Forty-One Dogs Separated by the Affected Side and Clinical
Findings
Herniated Organ Gender Onset
Affected
Side Uterine Others IF SF/M Acute Chronic ,8
Left 14 18 (15)* 27 5 (2)y 10 22
Right 1 10 (5)* 5 6 (2)y
2 9
Rate of 93** 64 (75)* 84yy 45 (50)y 83 71
left, %
Two bilateral female cases are included in both the left- and right-sided cases.
* Value in parentheses is the number of bitches.
y
Value in parentheses is the number of spayed bitches.
x term postoperative results are excellent, as reported in a previous
One recurrent case was included in both values.
** Significantly (P ¼ .038) higher versus others.
yy
Significantly (P ¼ .0184) higher than SF/M.
IF, intact female; M, male; SF, spayed female.
Metabolic abnormalities such as obesity, hyperadrenocorticism, or
diabetes mellitus are also presumed to contribute to NTIHs in both
sexes,11 but these were not noted in our study.
The most frequently protruded hollow organ was the uterus
(68%), followed by the small intestine (41%) and the colon (5%),
suggesting that the uterus tends to protrude before the intestine.
Waters et al.3 suggested that the herniated uterus prevented further
protrusion of the intestine because no simultaneous intestinal
protrusion was observed in 12 herniated uterus cases (8 cases were
reported in other studies12–19). However, in the present study, three
dogs had simultaneous protrusion of both the uterus and the in-
testine, one of whom required an intestinal resection. Concomitant
uterine conditions, namely, pregnancy, pyometra, and endometrial
hyperplasia, were seen in five bitches in the present study, and
7–10
these conditions have been reported sporadically.
the other 10 intact bitches were also sufficiently large to identify
ultrasonographically, which indicates possible concurrent disease or
estrus.1 An enlarged uterus may widen the inguinal ring further and
may even result in simultaneous intestinal prolapse. Therefore, early
herniorrhaphy with OVH may be preferable in intact bitches with
NTIHs.
A left-sided bias of unilateral hernias was reported previously
3
(69%, 20/29), and the rate was even higher in the present study
(77%, 30/39), particularly in the intact bitches (84%) and in uterine
herniated cases (91%). The reason for the left-side bias cannot be
explained by the anatomy of the inguinal canal or by systemic
factors. The most likely reason may be a mechanical factor in which
the descending colon pushes the left uterine horn ventrolaterally,
which may be supported by the left-sided colonic herniation in one
dog in our study. Physiological or pathological enlargement of the
NTIHs in 41 Dogs
uterine horns pushed by the colon may result in greater pressure on
the left inguinal ring. This partly explains the left-sided bias we saw
in bitches but not in male dogs. However, seven of nine unilateral
hernias in male dogs in the literature3–6,11,20,21 were on the left side,
Age, yr so further study is needed to derive firm conclusions.
‡8 Ultrasonography was useful in identifying the prolapsed organ,
8x 24x but bowel viability could be assessed only by intraoperative obser-
3 9 vation. Vomiting for 2–6 days is a reported predictor of nonviable
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73 73 small intestine.3 In this study, only one of the four vomiting dogs
had a nonviable small intestine, probably because surgery was
performed earlier.
Complications of inguinal herniorrhaphy are rare, and long-
study.3 No seroma formation was observed and we did not use
surgical drains in our study, which indicates the usefulness of
walking sutures. When closing the hernia ring, monofilament pro-
longed absorbable or nonabsorbable suture is described.2 We used
short-duration absorbable multifilament polyglactin suture and
experienced no recurrence, except for one male dog. These positive
results may have been partly because of decreased risk factors related
to OVH.
One male dog presented with a recurrent inguinal hernia with
bilateral perineal hernias. The rate of simultaneous occurrence of
both inguinal and perineal hernias in .3 yr old male dogs was 29%
(2/7 male dogs) in the present study and 25–100% in previous re-
ports.3,4,11 Weakening of the muscles or ligaments is thought to be
caused by estrogen from the aged testis and relaxin from the hy-
pertrophic prostate.11 In aged intact male dogs with inguinal hernia,
greater attention may be needed regarding herniorrhaphy, and in
severe cases, flaps from the cranial sartorius muscle2 or tunica
vaginalis20 may be required.
The uteri in There are several limitations in this retrospective study. First,
our results reflect surgical cases only and do not reflect epidemio-
logical features, namely, mild cases not treated surgically. Second, the
possibility that factors specific to miniature dachshunds affected the
overall results should also be considered. Third, the exact duration of
each hernia was unknown in most cases, so small or asymptomatic
hernias may have been present longer in cases classified as having an
acute onset. However, because the acute cases were operated
within ,7 days after diagnosis, these were clinically regarded as
having acute disease. Finally, the results of the statistical analysis
should be interpreted while considering the small sample size, and
larger-scale studies are needed to confirm our results.
Conclusion
NTIHs are more likely to occur in middle- to older-aged, female,
small-breed dogs, and miniature dachshunds may be predisposed.
JAAHA.ORG 305
The most frequently protruded hollow organ in our study was the
uterus, which tends to protrude on the left side, and intestinal
herniation may occur concurrently. Physiological or pathological
enlargement of the uterus associated with aging and sex hormones
appears to increase the risk of uterine herniation, but the long-term
prognosis of herniorrhaphy combined with OVH is excellent.
Therefore, even in asymptomatic NTIHs, early herniorrhaphy and
OVH are recommended. The etiology and treatment for NTIHs in
older male dogs may require further investigation.
We thank Jane Charbonneau, DVM, from Edanz Group (www.e-
danzediting.com/ac) for editing a draft of this manuscript.
FOOTNOTES
a 13. Frost C. Strangulated inguinal hernia in the bitch. Vet Rec 1948;60:186–7.
Vicryl; Johnson & Johnson Medical Pty Ltd, North Ryde, New South
Wales, Australia
b
Maxon; Covidien LLC, Mansfield, Massachusetts
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