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Repair of Bilateral Perineal Hernia with Semitendinosus Muscle Transposition Along with Colopexy and Cystopexy in a Bitch

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Repair of Bilateral Perineal Hernia with Semitendinosus Muscle Transposition Along with Colopexy and Cystopexy in a Bitch pISSN 1598-298X J Vet Clin 30(5) : 371-375 (2013) Repair of Bilateral Perineal Hernia with Semitendinosus Muscle Transposition Along with Colopexy and Cystopexy in a Bitch Su Young Heo, Dong Bin Lee and Hae Beom Lee1 College of Veterinary Medicine, Chonbuk National University, Jeonju 561-756, Korea (Accepted: August 10, 2013) Abstract : An 11 year-old intact female Yorkshire Terrier weighing 3.5 kg was presented with the complain of having a perineal mass, fecal incontinence and tenesmus. Physical examination revealed reducible bilateral ventral perineal mass, enlarged mammary gland and vaginal discharge. Bilateral ventral perineal hernia (BVPH) and pyometra were diagnosed based on the clinical and radiographic findings. Ovariohysterectomy was performed after general anaesthesia to treat pyometra. The BVPH was repaired by herniorrhaphy with semitendinosus muscle transposition along with colopexy and cystopexy. The postoperative radiographs and CT revealed a good correction of the BVPH. The patient showed good activity after 10 days and no complications were observed during a one year follow up period. BVPH can be successfully surgically managed by herniorrhaphy with semitendinosus muscle transposition along with cystopexy and colopexy in the dog. Key words : bilateral perineal hernia, semitendinosus muscle flap, colopexy, cystopexy, dog. Introduction swelling on either side of the rectum. The swelling is usually ventrolateral to the anus (3). Other signs may include strain- Perineal hernia is one of the most common pelvic dia- ing to urinate, pain on defecation, fecal incontinence and phragm disease in the middle aged to elderly sexually intact altered tail carriage. dogs (1,11). It commonly occurs in dogs but rare in cats and Standard herniorrhaphy along with elevation of the inter- other species (17,18,21). Approximately 59% cases of the nal obturator muscle with or without severing the insertion perineal hernia are unilateral while 41% are reported to be tendon, transposition of superficial gluteal muscle, or a com- bilateral. On the unilateral cases, 66% occurs of the right bination of internal obturator muscle elevation and superfi- while 34% on the left side of the perineum (3). Most cases cial gluteal muscle transposition are the conventional surgical occur in older intact male dogs (93%) and uncommon in procedures for perineal hernia repair (8,14). Till now several female dogs. Veterinary hospital records of perineal hernia reports described standard perineal herniorrhaphy including have shown an overrepresentation of certain breeds including primary suture repair of the muscular pelvic diaphragm the Boston terrier, Boxer, Collie, Corgi, Kelpie and Kelpie (1,4,15). Recurrence of perineal hernia due to tension in the crosses, pure bred and crossbred Dachshunds, Old English ventral area of the perineal diaphragm is the most commonly Sheepdogs and Pekingese (3). encountered complication after standard herniorrhaphy (5). Perineal hernia occurs when there is separation of the pel- The internal obturator muscle transposition is reported to vic diaphragm muscles allowing caudal displacement of pel- reduce the recurrence rate (10). However, it has been thought vic or abdominal organs, or lateral deviation of the rectum that the pelvic diaphragm reconstruction can be a good sal- into the perineum (18,21). Pelvic and abdominal contents vage procedures in the recurrence cases of bilateral ventral may protrude between pelvic diaphragm and the rectum (19). perineal hernia (BVPH). The semitendinosus muscle transpo- The causes of muscular deterioration may include muscular sition is one of the recommended methods for pelvic dia- atrophy, myopathies, hormonal influence and prostatic hyper- phragm reconstruction (6). trophy (3). The rectal diseases that may play a role in The colopexy is used primarily with severe rectal dilation perineal herniation include rectal deviation, sacculation and and recurring rectal prolapse. The cystopexy is advocated for diverticulum (9). The most common signs of perineal her- treatment of bladder retroflexion leading to urinary inconti- nias are chronic constipation, straining to defecate, and a nence in perineal hernia. The colopexy and cystopexy are performed as additional procedures along with pelvic dia- phragm reconstruction in bilateral perineal hernia (3). The 1Corresponding author. common postoperative complications include perineal swell- E-mail : [email protected] ing, absence of the ventral portion of perineal diaphragm and 371 372 Su Young Heo, Dong Bin Lee and Hae Beom Lee rectal sacculation (12). The other diseases reported to be lumbosacral space for epidural anesthesia. associated with BVPH are usually megacolon, perineal The Patient was placed on dorsal recumbency and the cau- masses (adenocarcinoma of the apocrine glands and chronic dal abdominal, inguinal and perineal regions were prepared fibrosing colitis) (21). with 7.5% povidone-iodine surgical scrub. Through a prepu- This case report describes the surgical correction of a bilat- bic caudal midline ceiliotomy incision the abdomen was eral ventral perineal hernia (BVPH) with semitendinosus entered. The right uterine horn was located by means of ova- muscle transposition for reconstruction and strengthen the pel- rihysterectomy hook and index finger. A clamp was placed vic diaphragm along with colopexy and cystopexy in an intact on the proper ligament and was used to retract the ovary female dog. while the suspensory ligament was stretched or broken with index finger. The ovarian pedicle was triple clamped and sev- Case ered between the clamp closest to the ovary and the middle clamp. The clamp most distant to the ovary was removed and An 11 year-old intact female Yorkshire Terrier weighing the pedicle ligature was placed in its groove. The pedicle was 3.5 kg was presented with the complain of having a perineal gently placed into the abdomen. The procedure was repeated mass, fecal incontinence and tenesmus. The dog had a his- on the opposite ovarian pedicle. Then the broad ligament was tory of hind limb fracture due to automobile accident six isolated, ligated and severed. Three clamps were placed on years ago. Physical examination revealed reducible bilateral the uterine body just cranial to the cervix. The uterine body ventral perineal mass, enlarged mammary gland and puru- was severed between the proximal and middle clamps. The lent vaginal discharge. Bilateral ventral perineal hernia uterine arteries were ligated. The caudal clamp was removed (BVPH) and pyometra were diagnosed based on the clinical and the uterus was ligated on its groove and it was gently and radiographic findings (Fig 1). It was decided to perform replaced into the abdomen. ovarihysterectomy for the treatment of pyometra. The BVPH The incision was extended cranially and the colon and uri- was repaired by herniorrhaphy with semitendinosus muscle nary bladder was exposed by packing other abdominal organs flap transposition followed by colopexy and cystopexy to with moist laparotomy sponge. The descending colon was iso- prevent the protrution of abdominal and pelvic organs. lated, the antimesenteric surface, a few cm cranial from the The patient was premedicated with atropine (Atropine Sul- pubis was scrapped. It was pulled cranially to minimize rec- fate Daewon®; Dae Won Pharm. Co. Ltd., Korea) 0.02 mg/kg tal sacculation and prolapse, sutured with the left ventrolat- subcutaneously and butorphanol (Butophan Inj®; Myung eral abdominal wall correspoding to it with 3-0 monofilament Moon Pharm. Co. Ltd., Korea) 0.3 mg/kg intramuscularly. polydioxanone after scraping. The ventral two third of the The anesthesia was induced using propofol (Anepol Inj®; Ha urinary bladder was secured to right ventral abdominal wall Na Pharm. Co Ltd., Seoul, Korea) 6 mg/kg intravenously and three cm away from the middle incision. The skin was closed was maintained with isoflurane and oxygen delivered through in a routinely manner. a cuffed endotracheal tube. Cephalexin (Methilexin Inj®, Patient was then positioned on ventral recumbency with Union Korea Pharm. Co Ltd., Korea) 22 mg/kg intravenously slight (20 degree) elevation of pelvis. The skin incision was every 12 hours was also given at the time of induction. Two made from the popliteal area to ischiatic tuberosity. The percent lidocaine (Lidocaine Hcl Dalhan Inj®, Dai Han semitendinosus muscle was isolated from the surrounding Pharm. Co. Ltd., Korea) 1 ml/4.5 kg was administered to the structure and transected as distally as possible near the stifle. Fig 1. Ventrodorsal (A) and lateral (B) preoperative radiographs showing ventral perineal swelling. Repair of Bilateral Perineal Hernia with Semitendinosus Muscle Transposition Along with Colopexy and Cystopexy in a Bitch 373 Fig 2. Intraoperative photograph showing isolation (A) and transposition of semitendinosus muscle flap (B). Fig 3. Ventrodorsal (A) and lateral (B) postoperative radiographs showing good correction of ventral perineal hernia. The transected semitendinosus muscle was sutured dorsally day after surgery; defecation appeared to be painless, with to the external anal sphincter muscle, laterally to the sacrotu- minimal straining. There were no problems with gait or uri- berous ligament and coccygeus muscle, and ventrally to the nation. The gait examination and range of stifle joint motion internal obturator muscle, the ischiourethralis muscle and the were found similar in both hind limbs. The owner reported ischial periosteum (Fig 2). The skin suture was closed
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