Small Ani. Sx- Perineal Hernias 1

drraythe's version from 2016-04-29 14:19

intro and stuff

Question Answer
what should you know about what kinda hernia a perineal hernia is?FALSE hernia bc no serosal lining he said
anatomy you must know for this procedure is..external anal sphincter, levator ani mm, coccygeous mm, and internal obturator mm +sacrotuberous lig
perineal hernias happen bc of a rupture of..the PELVIC DIAPHRAGM
is there a gender predisposition with perineal hernias?93% are male
is there an age predisposition with perineal hernias?yes, adults (7-9yrs)
why does dilation of the rectum/colon happen?bc of hernia pressing strangely on rectum, or lack of wall support, there is some blockage at rectum which causes a dilation behind it
what is the difference between a real and a false diverticulum of the colon? which should you repair? REAL: seromuscularis breaks and the mucosa/submucosa bulge out. FALSE: when the whole wall kinda bubbles out. Only the REAL diverticulum should be sx repaired (bc you don't enter lumen- just push in mucosa/submucosa and repair the seromuscularis
of the sacculation/ dilatation/ diverticulation (real/false) which can be repaired sx? WHY?ONLY THE REAL DIVERTICULUM can be sx repaired, bc doesn't involve entering lumen (since just pushing mucosa back in and suturing torn muscularis over it). bc there is a lot of collagenase activity in the last part of colon/rectal area which means by the 5th-7th day there is a lot of dehissance (collagenase activity due to bacteria). So don't touch them! will repair themselves once you fix the pelvic diaphragm
what is the big problem with the bladder being in the perineal hernia?urine can't get out of bladder/ureters--> kidney problems
what kinda prolapse might be associated with his kinda hernia?not a rectal prolapse, but a prolapse of the rectal mucosa
are castrated or non-castrated more prone to perineal hernias?95% of cases are intact (non-castrated)
is it usually bilateral or unilateral and is there usually a side which gets it more?2/3 are unilateral and usu on the right side
6 breeds more predisposed to perineal hernias?GSD, collie, boxer, Pekingese, Dachshund, Mongrel
only true way to dx the perineal hernia is with..your finger! need to feel weakened pelvic diaphragm
6 possible (as in, we actually dont know why) etiologies to perineal hernias?neurogenic atrophy, senile atrophy, myopathies, endocrine disorders, prostatomegaly?, constipation and tenesmus
what are the 4 ways something can go wrong with the rectum/colon in a perineal hernia?flexure, saccule, dilatation, diverticle (real vs false- false is if it is just bubbling out)
how is the pelvic diaphragm different in the cat from the dog?no sacrotuberous ligament! both external and internal sphincters are striated
etiology of perineal hernia in cats? (rare) (3)(1) perineal urethrostomy (2) megacolon (3) perineal masses
7 clinical signs of perineal hernias?constipation, tenesmus, inflammation, edema, dysuria, anal dilatation, rectal mucosa prolapse
pre-op what are some things you should do before you start to fix the perineal hernia?for the urinary bladder, catheterization/centesis. empty anal sacs. purse string suture around anus
why do you wanna place purse string suture around anus?bc working against colon/recum, messing around with your fingers down there, so purse string to prevent feces coming down into your surgical field
what do you do with the tail when preparing for sx, and why is it this way?need to pull back and make sure it's still on the midline to avoid distortion (esp when dealing with bilateral hernias)
when you are going to fix the hernia, you should castrate to reduce chance of reoccurance. which approach should you use?since in perineal position, do a kinda perineal approach (he said its kinda more like a ca to the scrotum approach but w/e)
how should the pt be positioned for this sx?sternal recumbency with towel under their hips for a trendelemburg position (monitor carefully bc organ load towards diaphragm)
what is going on in the 1st, 2nd, and 3rd pic?First is flexure, second pic is saccule/dilation, third pic is the diverticulum

perineal approach/ lateral approach

Question Answer
what are the two approaches?perineal (classic approch) or lateral (bottom pic is lateral)
is the omentum serosa/peritoneum? is just part of the peritoneal cavity
how and where should you make your incision to begin the procedure?curved lineal incision about 1-2 fingers from external anal sphincter (curved to follow curvature of area and also curvature of the bulging)
after you dissect the SQ, what is underneath it, and why is it important?perineal fascia, very important layer for closure! often overlooked. Will reinforce suture line with the pt.
how do you preserve the perineal fascia when you are making your incision?pick up skin and bluntly dissect skin and SQ from it to preserve it. Then you will have a defined sac that is still intact.
why do you want to be 1-3 fingers away from the anal sphincter in your incision?bc you want to have enough skin to reflect over the anus to protect sx site from any loose feces. So take this flap an with towel clamps fix it on the opposite side.
there might be fat in the hernia sac. It might be lobular and kinda look like a bunch of grapes. the fat's color might also vary- why?depends on how much pressure was being exerted on it from the hernia- if necrotic, must remove.
where is the internal obturator mm?on the floor of the pelvis
what is the mm that fans out (looks like a big fan)?internal obturator mm (on floor of pelvis)
what are the benefits of the lateral approach?Rarely used, however, better for older a's w/ resp or cardiac problems- can also access scrotum if need to do castration, so can do a pre-scrotal approach. purse string around anus-tightly.
describe the perineal approach (run through)1-2 fingers from anus- incision in curved fashion- bc following curve of area and bulging its producing. --> SQ is thin bc of pressure of viscera against hernial sac. below sq is perineal fascia. make sure preserve this fascia- bluntly dissect it from skin and SQ- so sac is still defined and intact- then can make incision to separate as diff layers --> make sure have enough skin to reflect over anus and move toward opposite side- and move over and maintain in place with towel clamps- will isolate anus and shit will go into this tubular structure and not into sx site. --> fascia is important as reinforcement to incision line. once there will see contents- fat, omentum, lobules or grapes- color varies depending on pressure a manually. reduce. he is talking about suturing the diff mm together (See other card)--> preserve pudendal aa and n. have to palpate sacrotuberous ligament when placing ligatures- can go through this- but not around bc can pick up sciatic nerve.--> preplace stitches in mm- then tie them tight enough but dont ischemia mm. tie from dorsal to ventral. then use perineal fascia- stretch- bite is in and out on one side and then in and out on the other side- tension and inverted- makes sutre line stronger and will adhere to mm. sutures will be overlapped. then do sub q and then skin. simple interrupted or simple continuous
use what to reinforce suture lines?fascial layer
careful of what aa/vv/nn in this area?pudendals
when placing sutures, what should you know about how to deal with the sacrotuberous ligament? palpate sacrotuberous lig...with finger can guide needle to go through sacrotuberous lig (DONT GO AROUND OR WILL HURT SCIATIC NERVE- GO THROUGH). *since you are guiding needle with your fingers, might pierce glove, so double-glove for this procedure
what should you know about the lateral approach technique?same as perineal, just the dog is lying on its side
If you can't keep the viscera in when you are trying to preplace sutures and such, what can you do?use gauze to stuff it in and hold it there (just don't forget to remove before you've completely tied all your sutures together)
how do you place stitches for closure of the hernia/pelvic diaphragm (mm)?grab levator ani and external anal sphincter, 2-4 stitches preplaced there, then preplacing 2-3 stitches between internal obturator mm and anal sphincter, and then crossing over from levator ani to internal obturator mm. Then it's a matter of tying your preplaced sutures- and tying them tight (without strangulating mm). Tie dorsal to ventral in order of levator ani to external sphincter--> external sphincter to obturator--> then later aspect between levator ani and internal obturator mm.
Once you have closed the pelvic diaphragm (muscles) how do you finish suturing closed? (perineal fascia-- in what pattern? and why?)for perineal fascia, suture in and out on one side, cross over, and then suture in and out on the other side-- this will INVERT THE TISSUE to put tension on the perineal fascia, to make suture line stronger, but also inverted portion will adhere to site where you placed sutures in the mm. (creates a stronger, fibrous scar after the wound heals). Then suture SQ, then skin. If redundant skin, can remove. Then suture (simple interrupted or simple continuous-- he says better to do simple interrupted or interrupted cruciate than continuous)
pic of lateral view (diagram) of pelvic diaphragm
trick to strong sutures- your stitches should not go into flesh of internal obturator mm...where should they go?drag your needle against the pubic bone to catch the CT attachment (stronger). pull and make sure it doesnt give (if it gives, too much flesh in bite)
what is going in an internal obturator transposition?peel off origin of internal obturator (can use periosteal elevator), it's lifted up, and used as a patch. to reinforce the herniated area.
often the muscles have atrophied from being herniated. So when you are preplacing your sutures what should you do?pull on them and make sure they dont' give
pic of preplaced sutures
relation of sacrotuberous lig and sciatic nn (pic)*this is why you go through instead of around the lig- or you can catch the sciatic nerve! (sciatic is yellow)
examples of implants you can use to reinforce the sx(he's not a fan, higher chance of reoccurance, prefers you just know anatomy) polypropylene mesh or swine intestinal submucosa, etc..
once you have finished, what things should you do?REMOVE PURSE STRING, palpate rectum for sutures which might have been inadvertantly placed through rectal wall (recto-cutaneous fistula), and watch pt until they can ambulate in their cage. ***rectal prolapse can occur!
if there is a rectal mucosal prolapse, or a rectal prolapse after sx, what can you do to help reduce this?you can place a purse string but make sure to leave enough room to defecate
5 possible post-op complications?rectal prolapse, incontinence, dehisence, recurrence (10-46%! :( )
why might there be post-op incontinence?if bladder had been retroflexed into hernia, or manipulated it in a rough manner
how will a sciatic nerve lesion present, why does this occur?due to entrapment in sutures, they will knuckle over, they will scream in pain
If there is a sciatic nerve lesion, how do you approach it to repair it?don't go through 1* incision! do a caudodorsal approach to the femur. Dissect right behind the femur and there it is. If you go through perineal approach you wont be able to see which suture is hurting the nerve so this approach is essential.