Thursday, June 22, 2017

3089. A Maltese has a gigantic perineal hernia - synthetic mesh

June 21, 2017

"Very rarely do we get such a gigantic hernia measuring over 10 cm across," I said to the owner who came to me as the 3rd vet. The 2nd vet had quoted some $3,000 to insert a synthetic mesh to close up the big gap of the width of 2 fingers. Ordinary apposition will not be effective.  The first vet had referred her to the 2nd vet who did not want to operate as she had no mesh but had inserted a urinary catheter as the dog could not pee.  The two vets had done X-rays and advised mesh to cover the defect in the pelvic diaphragm. So, the owner searched for a vet who was more affordable. 

"Can you guarantee 100% successful outcome?" the owner asked me.
The dog was a male not neutered dog as frisky as a young puppy despite his age of over 10 years.
"I cannot guarantee 100%," I replied. "The dog needs to be crated for at least 14 days and preferably 30 days."
"He will bark and bark," the owner said. So the dog was my inpatient for the 3 days post-op.

The dog stopped breathing at an early stage and was revived with emergency adrenallin and resuscitation.  He survived the lengthy anaesthesia as the mesh surgery took over 1 hour. The next day, he was normal and would be crated for 2 days.

Excess skin to be trimmed to prevent haematoma swelling. To neuter 14 days later.
Hernia repair took over 1 hour. Not advisable to prolong anaesthesia to neuter resulting in increased anaesthetic risk of dying on operating table.


Normal except monocytosis

1. Hernia reduced.  Hernial ring dissection.
2. Check muscular weakness and size of defect. Hernia is lateral to the external anal sphincter muscle. The herniated contents are between the sphincter and the levator ani muscle. Often the levator ani is atrophied, making a big opening for abdominal contents between the anal sphincter and the coccygeus muscles.
The herniated contents include intestines, bladder, prostate and rectum are pushed into the abdomen.

3. Identify pudendal arteries, veins and nerves. Also note sciatic nerves and sacrotuberous ligament.

4. (Video in Youtube). In one big dog, a vet drill 4 holes into the caudal ischial border to insert sutures to anchor mesh to internal obturator muscles. This was not done in this case.

4.1 Mesh folded diagonally and cut.

5. Cone formed from one half.
6. Place cone over the defect and size adjusted until the base of the cone covers the hernial ring.
7. Take out mesh. Suture the ends with 3 interrupted sutures.
8. Stitch horizontal mattress sutures (muscles of anal sphincter to mesh).
9. Inside the cone, stitch mesh to muscles.
10. (Video in Youtube).  Ischial border holes - stitches tied onto ventral cone via holes attaching internal obturator muscles. This was not done in this case.

11. Trim excess cone off the top.
12. Suture subcutaneous skin.
13. Suture skin.


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