2. ο Hernia is defined as the protrusion of the content of a
body cavity through a normal and abnormal opening in
the wall of that cavity either to lie beneath the intact skin
or to occupy another adjacent body cavity.
4. ο Ring may be formed due to
o Rupture in the abdominal wall(ventral hernia)
o Rupture of limiting wall(diaphragmatic hernia)
o Due to persistent prenatal opening(umbilical hernia)
ο Sac
o The hernial sac made of tissue that enclose the hernial content
o Wall of sac usually contains skin, muscular fibre, fibrous tissue
and parietal peritoneum
o Absent in diaphragmatic hernia
ο The content of hernia include
o Organs (a loop of bowel)
o Tissue (omentum)
5. ο On the basis of location
o External hernia- It consist of hernial ring, sac and contents
o Internal hernias-which lacks the hernial sac e.g. diaphragmatic
hernia
6. ο Passage of abdominal viscera into thoracic cavity
through a congenital or acquired opening in the
diaphragm
ο Most commonly reticulum herniates but other organs like
omasum, abomasum, loops of intestine, liver, spleen
may get involved .
7. ο Most frequently seen in she buffalo- right side with one
or multiple rings
ο In buffaloes β DH occurs in right hemidiaphragm(90%)
and rarely in the left (7%)or in the center(3%)
ο In dogs and cats β equal on both sides
8. ο Weakening of diaphragm
o TRP/ FB
o Increased intraabdominal pressure β
β’ Advanced pregnancy
β’ Tympany
β’ Straining during parturition
β’ Violent fall
o Musculotendineous junction (less tone and thickness)
o In dogs and cats DH is caused by trauma, particularly
automobile accidents
ο DH may also occur in animal with connective tissue
9. ο Congenital hernia
o Pleuroperitoneal hernia Serous lining of
pleura and peritoneum---separated by
transverse septumβwhen weaken/ trauma in
fetusesβcause rupture of these and thus
hernia
o Peritoniopericardial hernia (congenital hole in
diaphragm and pericardium, also pericardium
is fused with dia.---entry of abdominal parts in
that hole)
ο Acquired-secondary to trauma.
o Trauma is the most common cause of DH in
dogs and cats
o 77-85% cases from traumatic origin
o 5-10% cases from congenital origin
o Rest from unknown causes
10. ο Common site for rupture β
o 12-15 cm ventral to hiatus
oesophagi
o 12 cm ventral to foramen
vena cavae close to central
musculotendinous junction
ο Other sites
o Completely in the tendinous
part or in the ventral
musculature
11.
12. ο Recurrent tympany
ο Reduced reticular motility
ο Reduced milk yield
ο Scant defecation or diarrhoea with foul smell
ο Slight degree of melena
ο In advanced cases regurgitation leads to aspiration
pneumonia
ο Brisket oedema
ο Jugular pulsation may or may not be present
ο (The herniated reticulum may lie between the heart and
diaphragm)
ο Pasty faeces
15. ο Abduction of limbs may be observed
ο In rare cases chronic cough
ο In untreated cases inanition, progressive emaciation,
weakness and dehydration and ultimately death
ο dogs and cats-
o Severe dyspnoea
o Depend on the structures herniated and size of tear
o Signs of obstruction, gastric dilatation, liver problems (vomiting,
anorexia, jaundice, exercise intolerance)
o Signs of pneumothorax and lung contusion
16. ο The herniated reticulum lies in the caudal mediastinum
5-10 cm caudal to xiphisternum between the heart and
diaphragm
ο Fibrous bands frequently observed
ο Diaphragmatic abscess may be present
ο Dogs and cats β
o Pleuroperitoneal hernia- Incomplete development of
pleuroperitoneal canal during diaphragmatic development
17. o Congenital pleuroperitoneal hernias seldom diagnosed in small
animals because many affected animal die at birth or shortly
thereafter.
o Located in dorsolatral part of diaphragm
o Intermediate part of left lumbar muscle of the crus may be absent
o 1-2 cm in diameter
o Animal die because of respiratory insufficiency
o Peritoniopericardial hernia β faulty development or prenatal injury
of the septum transversum- teratogen, genetic defect, or prenatal
injury
o In this type of hernia organ herniated into pericardial sac
18. o Organs like liver, falciform ligament, omentum, spleen, Small
intestine and very rarely stomach
o This leads to strangulation of viscera which leads to less venous
drainage from liver
o Effusions
o Herniated stomach produce cardiac temponade
o Traumatic diaphragmatic hernia β costal muscle are more
often ruptured then the central tendons
o Parietal surface of liver covers most of diaphragm so liver is the
organ most herniated
19. o Incarceration, strangulation and obstruction are the chief effect
on the abdominal viscera
o Flow obstruction of stomach leads to tympany
o In liver hepatic venous stasis may develop
o Hydrothorax and ascites may develops
o Pleural effusion may be seen
20. ο History- history of recent parturition
ο Clinical signs
ο Auscultation β
o Intestinal sound on thoracic cage is heard
o Muffled heart sound
o Reticular sound cranial to 6th rib
21. ο Position-
o Right Lateral and supine and lateral projections are taken
ο Plain and contrast radiography can be performed
ο Plain radiograph β
o An empty reticulum appears as a air filled viscus in the thoracic
cavity
ο Contrast radiograph- for confirm diagnosis
o Barium meal is used as contrast material
27. ο Laparorumenotomy
ο Evacuate rumen 3/4th or full
ο Replace the healthy liquor
ο Off feed the animal for 48 hours after evacuation and
fluid therapy should be maintained
ο GA- Induced with thiopental sodium 5% solution @ 5
mg/kg b.wt
ο Maintained with isoflurane
ο IPPV after intubation
28. ο Sedation (xylazine @0.1 mg/kg) i/v
ο Local anaesthesia (lignocaine HCl 2%) was given at
surgical site
ο Approaches
o Transabdominal
o Transthoracic
29. ο Right cranial quadrent
/right hypochondric area
is prepared for the
surgery
ο 25-30 cm incision : 5 cm
caudal to xiphoid
cartilage :parallel to
costal arch
ο Severe the adhesions of
diaphragm and reticulum
ο Abdominal and thoracic
organs
30. ο Close the ring with
continuous suture or lock
stitch or vest over Pants
by using non absorbable
suture materials(no 2)
ο Close the abdominal
incision using absorbable
suture material with
simple continuous suture
in muscle and peritoneum
ο Close the skin incision
31.
32.
33. ο Right or left lateral
thoracotomy
ο Midway on 7th rib
to downward
toward
costochondral
junction
ο Overlaying
thoracic muscles
incised
34. ο Rib resesection β
o Periosteum incised by scalpel
o Periosteum retracted cranially and caudally with periosteal
elevator
35. ο Gigli wire is used
ο Transect
ο Rib wide and thin
ο Disarticulate rib at costochondral Jn.
36. ο Incise pleura-
herniated reticulum
seen
ο Separate the
adhesions with lungs
and pleura
ο Push in abdominal
cavity
37. ο Close the diaphragmatic rent
ο Resect indurated diaphragmatic tissue along with
reticulum if adhesions are extensive
ο If small gap then close by few suture
ο If large gap then use grafts
ο Similarly, adhesions with pulmonary lobe requires
partial/complete lobectomy
ο It may recur, if animal is pregnant at the time of surgery
after parturition so postpone surgery till parturition
38.
39.
40. ο Medicinal treatment
o If the animal is dyspnoeic, oxygen should be provided by face
mask, nasal insufflation, or an oxygen cage.
o Positioning the animal in sternal recumbency with the forelimb
elevated may help in ventilation.
o If moderate to severe pleural effusion is present, thoraco-
centesis Should be performed.
o Fluid therapy and antibiotics should be given if animal in the
shock.
41. ο Depends upon-
ο The extent of initial cardiopulmonary dysfunction.
ο The presence and absence of organ entrapment
ο The degree of compromised pulmonary function
ο Whether or not animals condition is improving , stable, or
detoriarating.
ο Diaphragmatic herniorrhaphy may require immediate
surgery if aggressive supportive care can not stabilize
respiratory function
42. ο Acute dilatation of a herniated stomach or strangulated
bowel are examples of situations where emergency
surgery may be indicated.
43. ο Prophylactic antibiotics in animals with hepatic
herniation.
ο Massive release of toxins into the circulation may occur
with hepatic strangulation or vascular compromise.
premedication such patients with steroids may be
beneficial.
ο An ECG should be performed on all trauma patients
before surgery.
44. ο Supplementing oxygen before induction improves
myocardial oxygenation
ο Drugs with minimal respiratory depressant effect.
ο Injectable anaesthetics allowing rapid intubation are
preferred.
ο Inhalation anaesthetics should be used for maintenance
of anaesthesia
45. ο Intermittent positive pressure ventilation should be
performed and high inspiratory pressure should be
avoided to help to prevent re expansion pulmonary
oedema.
ο Methyleprednisolone may be beneficial to prevent
reeexpansion pulmonary oedema
46. ο Midline abdominal celiotomy is the easiest and most
versatile approach
ο Position the animal head towards the top of the table and
tilting the table at a 30-40 Μ angle will facilitate gravitation
of abdominal viscera out of the thorax.
ο Rarely is it necessary to extend the incision into the
thorax via a median sternotomy .
47. ο Incision is made from xiphoid to point caudal to
umbilicus.
ο Open the peritoneal cavity, diaphragm is exposed now.
ο Herniated content are replaced in their proper position
and inspected for damage.
ο If adhesions exist, they should be broken down using
blunt dissection
ο Using large sponges or laparotomy pads moistened with
warm saline, the liver and bowel are retracted caudally.
48. ο All thoracic fluids should be aspirated
ο The lung should be expanded to remove atelectasis and
to inspect and persistent tear of collapse
ο Edges of the tear should be debrided
ο Recommended to suture the hernia from dorsal to
ventral
ο Hernia is closed with single layer, simple continuous
pattern using synthetic absorbable suture material
(dexon is preferred, vicryl) (3-0 to 1 )or non absorbable
49. ο If the diaphragm is avulsed from the ribs, incorporate a
rib in the continuous suture for added strength
50. ο Median sternotomy-
o Sternotomy of caudal 2-3 sternebrae
o Rarely performed alone
o May be necessary in irreducible hernia
ο Lateral thoracotomy-
o 9th intercostal approach
o It allows inspection of convex part of diaphragm
ο Transsternal thoracotomy- 7th-8th rib provide good
exposure
51. ο Antibiotics should be given for 5-7 days
ο Fluid therapy should be given
ο Analgesics should be given
52. ο Causes of diaphragmatic hernia in horses
ο Congenital
o This may occur as a secondary condition to pulmonary
hypoplasia.
o In incomplete hernias, such as diaphragmatic diverticulum, the
abdominal contents enter the thorax, however, are covered by a
thin membrane
ο Acquired diaphragmatic hernia (ADH)
o trauma
o Internal pressure like in advanced pregnancy
53. ο The most common symptom seen is signs of severe
abdominal pain.
ο Respiratory distress such as difficulty with breathing
ο Rapid breathing
ο Blue mucous membranes
ο Signs due to complications such as pneumothorax (fluid in the
thoracic cavity)
ο Muffled heart and lung sounds
56. ο This will be done under general anesthesia
ο Xylazine β 1.1 mg/kg b. wt. i/v
ο Diazepam β 0.05 mg /kg b.wt i/v
ο Ketamine -2.2 mg /kg
ο Anesthesia maintained with either isoflurane or
sevoflurane via an endotracheal tube
57. ο Ventral abdominal midline approach
ο Carefully reduce the incarcerated intestine into the
abdominal cavity.
ο Repair the herniated rent with the non absorbable suture
(no 2)
ο If rent is large then polypropylene mash is used to close
it
ο Close the incision