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A Modified Salvage Technique in Surgical Repair of Perineal Hernia In Veterinarni Medicina, 51, 2006 (3): 111–117 Original Paper A modified salvage technique in surgical repair of perineal hernia in dogs using polypropylene mesh D. VNUK, D. MATICIC, M. KRESZINGER, B. RADISIC, J. KOS, M. LIPAR, T. BABIC Clinic of Surgery, Orthopaedics and Ophthalmology, Faculty of Veterinary Medicine, University of Zagreb, Zagreb, Croatia ABSTRACT: In 16 male dogs who suffered from perineal hernia, polypropylene mesh was used to close a defect in the pelvic diaphragm. Pelvic bone was drilled on the pelvic floor and mesh was sutured through holes by polypropylene suture. Strong pelvic diaphragm, good long-term results and time-sparing by this technique was achieved. Suture sinuses were developed in two dogs one month postoperatively. Objectives of this study were to describe a new alternative technique of perineal herniorraphy and postoperative possible complications. Weak- ness of internal obturator muscle flap is complication which can be observed during transposition of internal obturator muscle flap. This technique can be used when internal obturator muscle flap is weak like the operation of the first choice. Keywords: perineal hernia; dog; polypropilene mesh Perineal hernia results from failure of the mus- Since primary suture repair of the muscular pelvic cular pelvic diaphragm to support the rectal wall, diaphragm was first described in the 1950s, several which stretches and deviates. Pelvic and abdominal reports described this standard method of hernior- contents may protrude between pelvic diaphragm rhaphy (Orsher, 1986). Perineal herniation recurred and the rectum. The cause of the muscular deterio- in 10% (Petit, 1962), 15.4% (Bellenger, 1980) and ration could be one or combination of the following 46% (Burrows and Harvey, 1973) of cases. pathological processes: muscular atrophy, myopa- Alternative techniques of perineal herniorrhaphy thies, hormonal influence and prostatic hypertro- were described in the 1980s. Transposition of the phy (Bellenger and Canfield, 2002). internal obturator muscle reduced the recurrence Perineal hernia is diagnosed most often in rate of perineal hernia to under 10%. In one study dogs, but occasionally is observed also in the cats only 2.4% of dogs had a recurrence (Hardie et al., (Welches et al., 1992). 1983). The disease occurs commonly in males and is as- Only a few reports have described the use of sociated with constipation, obstipation, dyschesia, synthetic materials in perineal hernias in dogs. a soft perineal swelling and occasionally urinary Polyethylene sponge (Koger, 1954), plastic mesh problems. The swelling is usually ventrolateral to (Larsen, 1966), porcine dermal colagen sheet the anus (Bellenger and Canfield, 2002). (Frankland, 1986), polyester mesh (Nommensen, Rectal diseases that may play a role in perineal 1974) and polypropilene mesh (Clarke, 1989) were herniation include rectal deviation (S-shaped cur- used. vature of the rectum), sacculation (dilatation of The purpose of the presented study was to de- rectal wall), and diverticulum (mucosal protrusion scribe a new alternative technique of perineal through seromuscular layer of rectal wall) (Mann, herniorraphy and possible complications. The 1993). advantage of this technique was strong pelvic 111 Original Paper Veterinarni Medicina, 51, 2006 (3): 111–117 diaphragm and quickness. This technique can be perineal herniorrhaphy at privat clinics in 7 dogs. recomended in the case of weakness of internal Internal obturator flap was too weak and did not obturator muscle flap. hold a suture after pulling of strands in 5 dogs. Defect in perineal diaphragm was huge and ten- sion was present during suturing of ventral part MATERIAL AND METHODS of defect in 2 dogs. Owners were contacted by telephone during surgery and accepted repara- Polypropylene mesh was used to close a defect tion of perineal hernia by this method. Owners in the pelvic diaphragm in 16 dogs who suffered accepted this method as surgery of first choice from perineal hernia. Perineal hernia recured after in 2 dogs. Table 1. Signalment, duration of disease, clinical signs, side, rectal disease and hernial contents of cases Age Weight Duration Rectal Breed Clinical signs Side Hernial content (years) (kg) of disease disease perineal swelling, rectal Maltese 10 6.80 1 year tenesmus, dyschezia, bilateral retroperitoneal fat sacculation haematochezia perineal swelling, Pomeranian 14 4.10 1 year right no retroperitoneal fat tenesmus perineal swelling, Maltese 8 5.50 8 months right no retroperitoneal fat tenesmus small intestine, tenesmus, rectal prostate gland, Maltese 6.5 5.20 1.5 year bilateral haematochezia sacculation urinary blader, retroperitoneal fat tenesmus, perineal rectal Australian silky terrier 5 6.1 6 months right no swelling sacculation Dobermann pinscher 4 45 2 weeks perineal swelling right no no tenesmus, perineal rectal retroperitoneal fat, Cocker spaniel 9.5 18 1 years bilateral swelling, obstipation sacculation prostate gland tenesmus, rectal Maltese 12.5 5.20 1 years right retroperitoneal fat obstipation flexure perineal swelling, rectal Pekingese 9 4.90 3 months right prostate gland dyschezia diverticulum perineal swelling, rectal Mixed breed 7 23 9 months anuria, dilated right urinary bladder sacculation abdomen, vomiting perineal swelling, rectal Mixed breed 8.5 28 6 months right retroperitoneal fat tenesmus diverticulum perineal swelling, Pekingese 8.5 5.20 10 months left no retroperitoneal fat tenesmus perineal swelling, rectal Poodle 11.5 10.20 4 months right no dyschezia sacculation perineal swelling, Mixed breed 6 12 3 months left no urinary bladder tenesmus, anuria perineal swelling, rectal Yorkshire terrier 8 6.10 5 months left retroperitoneal fat dyschezia sacculation perineal swelling, rectal retroperitoneal fat, Boxer 9.5 30.20 1 month bilateral dyschezia, tenesmus sacculation prostate gland 112 Veterinarni Medicina, 51, 2006 (3): 111–117 Original Paper 12 patients were treated at privat clinics because All these surgery were done by the same surgeon. of problems caused by perineal hernia. Treatment The laterally curved, dorso-ventral skin incision at privat clinics consisted of perineal herniorrhaphy was done over the hernia, extending from the spot by standard herniorrhaphy or transposition of in- just lateral to the tail base to the medial angle of ternal obturator muscle in 7 dogs. Castration as ischial tuberosity. Hemorrhage was controlled by single operation was performed in 1 dog and in electrocautery. The hernial sac was opened by blunt 3 dogs during perineal herniorrhaphy. All dogs had dissection. Retroperitoneal fat was ligated and medical treatment (lubricants) and diet (fiber rich excised. Rectum was examined because of rectal diet). diseases. Rectal diseases were resolved by plica- The owners accepted a new surgery technique tion. Plication was done by placement of one to in repairing of perineal hernia in their dogs using three layers of Cushing suture (PDS 3-0) paralell polypropylene mesh. The case records of operated to rectal direction. Layers of the Cushing suture dogs were examined and the owners were surveyed were placed to the moment when the diameter of by telephone. The follow-up period after the last rectum cranial to the rectal sacculation/divertic- surgery procedure to the time of survey was be- ula was the same as diameter at the place of rectal tween 15 and 42 months. sacculation diverticula. Hernial contents was re- The diagnosis was made by rectal palpation. The turned to their original location. After reduction palpation of perineal diaphragm and rectal wall of the hernia, anatomical structures were exposed. was done. When a patient had a clinical signs of a One dog had lipoma incorporated in external anal urinary tract disturbances, caudal abdominal radi- sphincter, lipoma was excised before preplacement ography was performed. of prolene sutures. Premedication before surgery was acetylpro- Pelvic plate was drilled on the caudal brim with mazine (Vetranquil 1%, Ceva). In old dogs premedi- drill of 1.5 mm in diameter. Three holes were cation was diazepam 0.3 mg/kg i.v. (Apaurin, Krka, made between the ischial tuberosity and midline. Slovenia). Amoxicillin with clavulanate (Klavocin, All sutures were preplaced before they are tied. Pliva, Croatia) at the dose of 20 mg/kg was ad- First, polypropylene sutures (2-0 or 0 USP-Prolene ministered intravenously before and after surgery. Ethicon, UK) were preplaced through drilled holes The Ringer’s solution infusion was administered with ½-circle tapercut needle. 2-0 USP Prolene was at the rate 10 ml/kg/h. The rate was controlled by used in dogs weighed under 10 kilograms and 0 USP infusion pump (BIOF 3000, Biotron CO, South Prolene was used in dogs weighed above 10 kilo- Korea). Induction of anaesthesia was propofol grams. Then three sutures were preplaced laterally 4 mg/kg i.v. (Propofol, Abbott, UK). Endotracheal through sacrotuberous ligament, coccygeus muscle intubation was done. Fentanyl citrate (Fentanyl- and levator ani-muscle. Finally, three sutures were Jannsen, Jannsen Pharmaceutica, Belgium) was done medially through external anal sphincter. administered in bolus 10 µg/kg i.v. and afterwards Polypropylene mesh (Prolene Mesh, Ethicon, UK) continuos rate infusion 0.2 µg/kg/min i.v. by syringe was in shape of triangle. The mesh was sutured pump (SEP 11S, Ascor, Poland). Mixture of oxygen by single interrupted suture first at ventral, then and isoflurane (Forane, Abbott, UK) maintained lateral and finally at medial position. Any protrud-
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