Treatment of perineal hernia in the dog—a reassessment

The results of treatment of fifty-four dogs seen at the University of Pennsylvania Veterinary Hospital with perineal hernia were analysed. Conservative treatment was not satisfactory for dogs which strained to defaecate. Perineal herniorrhaphy was followed by recurrence of the hernia in 37% of the dogs; continued straining to defaecate, urinary problems and rectal prolapse were other post-herniorrhaphy sequelae. Anal splitting was performed in eight dogs; soiling of the anal area and occasional incontinence were reported in some dogs.     

Use of canine small intestinal submucosa allograft for treating perineal hernias in two dogs

Here, we describe two dogs in which canine small intestinal submucosa (SIS) was implanted as a biomaterial scaffold during perineal herniorrhaphy. Both dogs had developed severe muscle weakness, unilaterally herniated rectal protrusions, and heart problems with potential anesthetic risks. Areas affected by the perineal hernia (PH) located between the internal obturator and external anal sphincter muscles were reconstructed with naïve canine SIS sheets. In 12 months, post-operative complications such as wound infections, sciatic paralysis, rectal prolapse, or recurrence of the hernia were not observed. Symptoms of defecatory tenesmus also improved. Neither case showed any signs of rejection or specific immune responses as determined by complete and differential cell counts. Our findings demonstrate that canine SIS can be used as a biomaterial scaffold for PH repair in dogs.     

Ultrasonography and surgical management of a perineal hernia in a donkey

This case report records a unilateral perineal hernia in a 7-year-old female donkey. The donkey had a history of unilateral swelling lateral to the left vulvar lip and difficulty in defaecation. Upon palpation, the swelling was painless, soft and reducible. Ultrasonography revealed a hyperechoic hernia sac containing dilated nonmotile bowel with homogenous hypoechoic contents. Primary herniorrhaphy was performed after repositioning of the herniated bowel. The donkey made an uneventful recovery with no recurrence or complications for 6 months of available follow-up. In conclusion, perineal hernia should be considered in the differential diagnosis of perineal swellings in donkeys. Clinical examination, ultrasonography and surgical exploration are valuable for definite diagnosis of perineal hernia in donkeys. Surgical herniorrhaphy was successful in correcting the problem in this case.     

Use of laparotomy in a staged approach for resolution of bilateral or complicated perineal hernia in 41 dogs

OBJECTIVE: To evaluate the value of laparotomy as the initial step in the treatment of bilateral or complicated perineal hernia (PH) in dogs. STUDY DESIGN: Retrospective study. ANIMALS OR SAMPLE POPULATION: Forty-one dogs with PH. METHODS: Dogs with bilateral or complicated PH treated by a 2-step approach between November 1997 and December 2001 were studied. Inclusion criteria for complicated PH were: recurrence of PH, unilateral PH with a major rectal dilatation, PH with a concurrent surgical prostatic disease, and PH with retroflexed bladder. Colopexy, vas deferens pexy, cystopexy, and prostatic omentalization were performed during laparotomy as needed. Later, PH was performed by internal obturator muscle flap (IOMF) or if there was a perineal rent or weakness on the contralateral side, appositional herniorrhaphy was performed. Outcome was followed for >/=6 months. RESULTS: PH were bilateral (20 dogs) or unilateral (21). Twenty-one (51%) dogs had prostatic disease (clinical or ultrasonography diagnosis; 17 confirmed histologically) and 12 (29%) had urinary bladder retroflexion. Forty-one colopexies, 32 vas deferens pexies, 6 cystopexies, and 9 prostatic surgeries (omentalization or perineal cyst resection) were performed. PH was performed 2-20 days (median, 6 days) later: 61 IOMF transpositions, 13 appositional. Mean follow-up time was 26.6 months (range, 6-54 months, median, 27 months). PH was resolved in 37 (90%) dogs; 4 dogs had recurrence, and all occurred within 6 months. Thirty-eight (92%) dogs had an improved quality of life (good in 34 dogs, fair in 4 dogs). Wound complications occurred in 7 dogs (17%). Postoperative urine dribbling occurred in 15 dogs (37%) and was irreversible in 7 dogs (17%). Postoperative fecal straining persisted in 18 dogs (44%), and was permanent in 4 dogs (10%). Fecal incontinence did not occur. CONCLUSIONS: In bilateral or complicated PH, fixation of the urinary bladder and colon, and treatment of prostatic disease increase the chances of resolution. Emptying of the perineal space by organ pexy allows improved observation during herniorrhaphy. Despite a 90% clinical resolution, dogs with complicated PH treated by a 2-step protocol may have persistent urinary and fecal disorders. CLINICAL RELEVANCE: To improve the prognosis of bilateral or complicated PH, investigation and treatment of concomitant lesions (rectal, prostatic, bladder) should be part of a rational surgical strategy using a 2-step protocol.     

Retroflexion of the urinary bladder associated with a perineal hernia in a female cat

A case of retroflexion of the urinary bladder into a bilateral perineal hernia in a female domestic shorthaired cat, three weeks postpartum, is reported. The bladder was repositioned and a cystopexy performed. A pelvic ostectomy was also carried out in order to alleviate the narrowing of the pelvic canal caused by an untreated acetabular fracture. Bilateral perineal herniorrhaphy was performed.     

The use of porcine small intestinal submucosa as a biomaterial for perineal herniorrhaphy in the dog

OBJECTIVES: To develop an in vivo perineal hernia model, to develop a technique for using small intestinal submucosa (SIS) in perineal hernia repair, to further elucidate the biological behavior of SIS, and to compare SIS herniorrhaphy with the internal obturator muscle transposition (IOT) technique. STUDY DESIGN: Prospective evaluation comparing SIS herniorrhaphy with IOT. ANIMALS: Twelve adult castrated male, large-breed dogs. METHODS: All dogs had bilateral pelvic diaphragm defects created by complete excision of the levator ani muscle. Each dog had one side repaired using SIS and the other by IOT. Pain and inflammation were subjectively scored. Dogs were killed 2 weeks (n = 4), 12 weeks (n = 4), or 16 weeks (n = 4) after surgery. Each pelvic diaphragm was biomechanically tested to failure. The pelvic diaphragms from 2 normal dogs (n = 4 sides) were also biomechanically tested. Failure site, maximum pressure, displacement at failure, and initial linear stiffness values were determined. Histologic assessment was performed. Statistical analysis was performed with significance set at P <.05 RESULTS: No significant postoperative complications were noted. There were no significant differences in maximum pressure to failure, displacement, or stiffness when comparing normal, SIS, and IOT at any time point. The SIS group had significantly less displacement (P =.004) at 2 weeks than at weeks 12 or 16. For all herniorrhaphy techniques, the failure site was central (n = 22) or at the suture line (n = 2). At 2 weeks, histologic evaluation of tissues from the IOT group showed inflammation, mineralization, and necrosis, which were not present in tissues from the SIS group. Histologic examination at 12 and 16 weeks showed no microscopic differences in cell population or tissue characteristics between the IOT and SIS groups. CONCLUSIONS: SIS herniorrhaphy was successfully performed in this in vivo model of perineal hernia in the dog. CLINICAL RELEVANCE: This study suggests that SIS can be used as a primary means of repair, as augmentation when the internal obturator muscle is thin and friable, or as a salvage procedure in cases of recurrence in dogs with perineal hernia.     

Mineralized paraprostatic cyst as a potential contributing factor in the development of perineal hernias in a dog

Perineal hernias almost exclusively affect male dogs (sexually intact or castrated). Factors that may contribute or predispose a dog to perineal hernias include tenesmus, pelvic musculature variations (male vs female), and gonadal hormone influence. In dogs with perineal hernias and tenesmus it is important to include rectal and prostatic diseases, including paraprostatic cysts, in the differential list of potential underlying causes. Surgical correction of the perineal hernia with a perineal herniorrhaphy is indicated. Successful treatment depends on the degree of preexisting neurologic alterations, meticulous surgical technique, and identification and correction of underlying contributing factors. Paraprostatic cysts develop predominantly in sexually intact medium to large breed dogs. These cysts are thin-walled structures often attached to the prostatic dorsal midline. Osseous metaplasia of paraprostatic cysts may occur. Clinical signs of tenesmus often result from compression on adjacent structures (urinary bladder and colon), and tenesmus may contribute to the development of perineal hernias. Preferred treatment of a paraprostatic cyst is surgical removal and castration. This report describes a dog with bilateral perineal hernias and a large mineralized paraprostatic cyst that was identified as a possible contributing factor to the hernias.     

Sciatic perineal hernia in two dogs

A sexually intact, male Chihuahua and a spayed female poodle were presented with left perineal masses. The masses were identified as perineal hernias by rectal palpation. Surgical exploration of the perineal region in each dog revealed retroperitoneal fat protruding between the sacrotuberous ligament and the coccygeus muscle (sciatic perineal hernia). The hernias were repaired using modifications of the standard or internal obturator flap herniorrhaphies. The levator ani muscle was grossly and histologically normal in the Chihuahua and grossly normal in the poodle. No short- or long-term complications were reported in either case. The management of sciatic perineal hernia is similar to the more common caudal perineal hernia.     

Treatment with a combined cystopexy-colopexy for dysuria and rectal prolapse after bilateral perineal herniorrhaphy in a dog

A 9-year-old castrated male Yorkshire Terrier was evaluated for dysuria and rectal prolapse 2 weeks after bilateral perineal herniorrhaphy. Dysuria was secondary to caudal displacement of the bladder, rather than retroflexion of the bladder. Dysuria and rectal prolapse were associated with disruption of supporting ligaments of the urinary bladder and colon, which may have been caused by tenesmus. Combined cystopexy and colopexy were used successfully to treat the dysuria and rectal prolapse.     

Perineal hernia with bladder retroflexion in a female cocker spaniel

Perineal herniation in the bitch is rare and its complication by bladder retroflexion in the bitch has not been previously reported in the literature. This case report describes a multigravid, five-year-old female cocker spaniel with bilateral perineal hernias, complicated by marked rectal sacculation and ventral bladder retroflexion. The case was managed initially by cystopexy and colopexy, followed seven days later by bilateral perineal herniorrhaphy. There was no recurrence of the problem by 12 months postsurgery.     

Transplanting the superficial gluteal muscle in the treatment of perineal hernia and flexure of the rectum in the dog

The authors distinguish between perineal hernia and flexure of the rectum. They describe in detail an operative procedure to treat these conditions using a transplanted superficial gluteal muscle to reinforce the ischio rectal fossa.     

Surgical treatment of perineal hernia in the dog

In a nine-year period 101 dogs which were available for subsequent follow-up studies, were subjected to perineal hernia surgery. In thirty-six dogs the hernia was bilateral and, therefore, 137 hernias were initially operated. In 111 operations the standard perineal technique was adopted. In twenty-six operations the superficial gluteal muscle was reflected and sutured into the hernial defect (‘gluteal flap’). Later, following recurrence of hernia or new development on the second side, a further sixteen operations were done, including three anal splitting procedures. In all cases the deep sutures were of monofilament nylon. A post-operative follow-up was carried out for a minimum period of 12 (average 39) months. The operative and post-operative complications included superficial and deep wound infection, partial or complete sciatic paralysis, rectal prolapse and recurrence of the hernia following breakdown of the repair, as well as occurrence of the hernia on the opposite side. The success rate (75 per cent excluding six immediate post-operative fatalities) judged by remission of signs and lack of recurrence was higher in the standard technique (81 per cent) than the gluteal flap method (64 per cent). Anal splitting was unsuccessful and resulted in faecal incontinence. The standard technique was slow, sometimes gave limited exposure but was rarely associated with wound breakdown (13 per cent of operations), though sciatic paralysis was only noted in this procedure. The gluteal flap method was longer, gave excellent exposure with no risk of sciatic nerve damage, but was often associated with wound breakdown (58 per cent). Both techniques led sometimes to rectal prolapse. Castration with hernial repair resulted in a lower recurrence rate (13 per cent v. 20 per cent). Castration should be carried out in all cases of perineal hernia.     

Clinical and Surgical Parameters in Dogs with Perineal Hernia Analysis of Results of Internal Obturator Transposition

The results of treatment of 31 dogs with perineal hernia by internal obturator muscle transposition were evaluated by comparing the clinical signs reported by the owner before surgery with those reported 11 or more months following surgery. The severity and frequency of pre- and postoperative clinical signs were categorized numerically, and composite scores were obtained for each dog. In addition, the dogs were examined 11 or more months following surgery. The presence or absence of an externally obvious perineal swelling was noted, and rectal examination was performed to detect rectal sacculation and the integrity of the pelvic diaphragm dorsal and ventral to a line drawn between the center of the anus and the ischiatic tuberosity. These results were correlated with the postoperative composite scores. Postoperative complications included wound infection (2), wound seroma (2), rectal prolapse (4), urinary incontinence (2), and flatus as a new postoperative problem (11). The postoperative composite score was significantly lower (improved function) following surgery. Dogs with worse signs preoperatively or bilateral perineal hernia benefited less from surgery. More dogs showed improvement when the operation was performed by experienced surgeons. Factors detected at follow-up examination that correlated with more severe postoperative clinical signs were perineal swelling, absence of the ventral portion of the pelvic diaphragm, and rectal sacculation. The presence or absence of reformation of the dorsal aspect of the pelvic diaphragm did not correlate with postoperative clinical signs.     

Perineal hernia in 3 cats

Cases of perineal hernias in three cats are described. All the cats were male (2 castrated, 1 intact). The hernias were situated between the external anal sphincter and the levator ani muscle. The hernial sac contained a dilated rectum filled with fecal content (2 cats) as well as a small amount of retroperitoneal fatty tissue (2 cats) and urinary bladder (1 cat). A standard perineal herniorrhaphy in two cats, and herniorrhaphy via elevation of the internal obturator muscle in one cat were performed. No recurrence of the problem was observed in two cats during 9 months following the surgery. In one case, mild stretching of the pelvic diaphragm was noted with sporadic mild defecation problems observed after a 12-month period.     

Bladder retroflexion in the dog

In a series of 61 dogs examined for perineal hernia 12, (20 per cent) were found to have bladder retroflexion. Associated urinary signs were seen in only five dogs including one case with bladder rupture. Radiology was found to be the most consistently accurate means of diagnosis. Bladders were drained by catheterization, or by percutaneous or surgical cystocentesis before manipulative or surgical reduction. Conventional herniorrhaphy and castration were performed in all cases. Cystopexy was performed in only one case although recurrence of the retroflexion was not encountered in any dogs. Three dogs remained urinary incontinent after treatment.     

Use of autogenous fascia lata graft for perineal herniorrhaphy in dogs

OBJECTIVE: To evaluate the effectiveness of a herniorrhaphy technique, using an autogenous fascia lata graft (FLG) for perineal hernia (PH) repair in dogs. STUDY DESIGN: Prospective clinical study. ANIMALS: Twelve dogs with PH. METHOD: PHs were repaired with FLG harvested from the dog's ipsilateral thigh and sutured directly into the perineal defect. Correction of associated conditions, and castration were performed. Surgical time, pain, inflammation, pattern of defecation, lameness, hospitalization time, postoperative complications, and owner satisfaction were recorded. Histopathologic examination was performed in 1 dog euthanatized 10 months after repair. RESULTS: Hernia did not recur (mean follow-up, 5.8 months). Lameness was the most frequent minor complication, and was resolved within a few days. Transient rectal prolapse occurred in 2 dogs with bilateral PH. The mean (+/-SD) hospitalization was 1.8+/-0.9 days, and the surgical time was 76.5+/-9.8 minutes. Histopathologic examination in 1 dog revealed perfect integration of FLG into adjacent tissues without substantial tissue reaction. CONCLUSIONS: FLG reconstruction of PH is a simple, effective method of treatment. CLINICAL RELEVANCE: FLG can be used without major complications for primary repair of PH, as an augmentation procedure when the internal obturator muscle is thin or friable, or when herniation has recurred after another repair technique.     

Comparison of herniorrhaphy versus clamping of umbilical hernias in horses: a retrospective study of 93 cases (1982-1994).

Many uncomplicated umbilical hernias have been managed successfully in foals by the application of a hernia clamp. Isolated reports of complications following clamp application have led some authors to suggest that it is an unsuitable method of treatment. Little information has been published comparing the complication rates associated with the use of hernia clamps and herniorrhaphy in the treatment of umbilical hernias. The purpose of this retrospective study was to report the characteristics of clinical cases of umbilical hernia and to compare the complication rates following these 2 treatment approaches. Information was collected from records or from owners to identify the occurrence of complications and owner satisfaction following treatment. Of 93 cases, 10 complicated and 18 uncomplicated hernias were treated by herniorrhaphy, 40 uncomplicated hernias were treated by clamping, 1 originally uncomplicated hernia was treated by both techniques, and 24 cases were untreated. Nineteen percent of uncomplicated hernias treated by herniorrhaphy, and 19% of those clamped developed minor complications. This study demonstrates that although minor complications may be associated with either technique, they generally do not result in significant morbidity.     

PERINEAL HERNIA IN DOGS

SUMMARY Thirty-five male dogs with perineal hernia were seen at Sydney University Veterinary Hospital and Clinic over a five-year period from 1975 to 1979. The Corgi breed was most commonly affected, but Kelpies and Boxers were also over-presented when compared to the general clinic population. The mean age of affected dogs was 9.4 years and the mean body weight 16 kg. There were 11 bilateral and 24 unilateral herniae. Thirty-two dogs underwent herniorrhaphy. A recurrence rate of 15.4% was found in 26 dogs followed up for more than six months, this rate comparing favourably with a number of other reported series. The major post-operative complication was wound infection or breakdown, seen in 28.6% of dogs.     

Congenital retrosternal (Morgagni) diaphragmatic hernias in three horses

CASE DESCRIPTION: 3 Horses were examined and treated because of sudden onset of signs of abdominal pain. CLINICAL FINDINGS: All horses had a retrosternal (Morgagni) hernia involving the right side of the diaphragm. In each horse, the large colon was incarcerated in a right muscular defect in the diaphragm with a large hernial sac. TREATMENT AND OUTCOME: Definitive surgical repair of the hernia was not performed during the initial celiotomy. The hernia was repaired with mesh herniorrhaphy, but without resection of the hernia sac in 2 horses. For 1 horse, conservative management was applied. In the 2 horses treated with surgical correction, no major postoperative complications developed, and all 3 horses have been free of signs of abdominal pain. CLINICAL RELEVANCE: Horses with retrosternal hernias involving the diaphragm can develop clinical signs of intermittent obstruction of the large colon and chronic colic. In horses, retrosternal diaphragmatic hernias appear to develop exclusively in the right ventral aspect of the diaphragm and could represent an embryologic defect of diaphragm formation. Affected horses can be successfully treated with mesh herniorrhaphy or, in some instances, with conservative management.     

Traumatic diaphragmatic hernia in cats: 34 cases (1991-2001)

OBJECTIVE: To determine whether signalment, duration of hernia, clinical signs, contents of hernia, CBC and serum biochemical abnormalities, concurrent injuries, perioperative treatment and administration of analgesics, results of intraoperative anesthetic monitoring data, or level of training of the veterinarian performing the herniorrhaphy was associated with mortality rate after surgical repair of traumatic diaphragmatic hernia in cats. DESIGN: Retrospective study. ANIMALS: 34 cats. PROCEDURE: Review of medical records and a telephone follow-up with owners and referring veterinarians were performed. RESULTS: Mean age of affected cats was 3.6 years; cats that survived to the time of discharge were significantly younger than cats that died or were euthanatized. Tachypnee was the most common clinical sign at hospital admission; cats that survived to the time of discharge had significantly higher respiratory rates than cats that died or were euthanatized after surgery. Postoperative complications developed in 50% of cats; tachypnea and dyspnea were most common. Mortality rate was not associated with duration of hernia or results of preoperative CBC and serum biochemical analyses, but was significantly associated with concurrent injuries. Mortality rate was not associated with hernia contents, intraoperative use of positive inotropes or corticosteroids, episodes of hypotension or severe hypoxia during anesthesia, or level of training of the veterinarian performing the surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Cats that are older or have low to mildly increased respiratory rates and concurrent injuries are more likely to die after surgical repair of traumatic diaphragmatic hernia.