pISSN 1598-298X J Vet Clin 30(5) : 371-375 (2013)

Repair of Bilateral Perineal 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 . Key words : bilateral perineal hernia, semitendinosus muscle flap, colopexy, cystopexy, dog.

Introduction swelling on either side of the . 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. (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 (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 . 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 , 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 , 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 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 in a that the dog had no constipation or fecal incontinence and no routinely manner. inappropriate defecation even in the house confinement dur- The postoperative treatment was given with cephalexin ing night. (Methilexin Inj®, Union Korea Pharm. Co. Ltd., Korea) 25 mg/kg, intravenously, every 8 hours, and Tramadol (Tama- Discussion dol inj®, Dongkwang Pharm. Co. Ltd., Seoul, Korea) 2 mg/ kg, orally every 12 hours were administered for one week. The perineal hernia usually occurs between the Lactulous (Duphalac®, JW Pharm. Co. Ltd., Seoul, Korea) 1 and coccygeus muscles and the external anal sphincter (2,16). ml/4.5 kg orally every 8 hours was administered for one The primary suture repair of the muscular pelvic diaphragm month. The wound healed without any complication. The was first reported in the 1950s, since then several reports stitches were removed 10 days after the operation. The post- have described standard perineal herniorrhaphy (1,4,12,15). operative radiographs (Fig 3) and CT (Fig 4) revealed a good The perineal herniation is reported to recur in 10 to 46% of correction of the BVPH. The patient showed good activity cases (2,5,13). The recurrence of perineal hernia usually after 10 days and no complications were observed during one occurs due to tension in the ventral area of the perineal dia- year follow up period. The dog first defecated on the second phragm. This is why the alternative techniques of perineal 374 Su Young Heo, Dong Bin Lee and Hae Beom Lee

dinosus muscle might be compensated by other muscles, such as caudal part of the cranial biceps femoris, the caudal crural abductor and semimembranous muscle (11). The ventral perineal hernia recurs, causing feces to accu- mulate in the rectal sacculation. To minimize the rectal sac- culation and reduce abnormal pressure of the abdominal contents on the pelvic diaphragm and to prevent the protru- sion of abdominal organs to the hernial sac, colopexy was performed which showed a very good prognosis in this case. Dysuria also develops that is attributed to the abnormal pel- vic diaphragm. The cystopexy performed in this case brought about good prognosis and no urinary incontinence was ob- served during the follow up period. Satisfactory results using colopexy and cystopexy as the adjunctive or sole treatment for perineal hernia have been reported (7). The dog had no constipation or fecal incontinence and no inappropriate defe- cation even in the house confinement during night reported by the owner which is in agreement with previous report (6). The midline celiotomy is recommended for colopexy or cystopexy of perineal hernia because incise of ventral abdominal wall Fig 4. Computed tomography (one month postoperative) of the might be inadvertently damaged the bladder and colon (3). pelvis revealed transposed semitendinosus muscle flap (black In this case the semitendinosus muscle flap fulfilled most asterisk) and good correction of the perineal hernia. of the major requisites for a transposition flap, including being large enough to fill sizable defects, being relatively herniorrhaphy are important. The weaker ventral area of the superficial and easily accessible, being functionally expand- perineal diaphragm seems to be better supported by transpo- able and having a consistent and simple vascular anatomy sition of different muscles; the internal obturator muscle (3), (6). However, the semitendinosus muscle flap should be con- the superficial gluteal muscle (20), both the internal obtura- sidered as an alternative in those cases where the flaps have tor muscle and the superficial gluteal muscle (14) or recon- failed, are unavailable or insufficient. The findings of this struction of perineal diaphragm by polypropylene mesh (16). study suggest that the BVPH can be successfully surgically However, these cases have not clarify been informed the managed by herniorrhaphy with semitendinosus muscle flap recurrence rate after the surgery. transposition along with cystopexy and colopexy in dogs. It has been reported that the dogs with severe clinical signs or having bilateral benefited less from surgery (3). Reference The common postoperative complications after the surgical repair of bilateral perineal hernias include perineal swelling, 1. Anderson MA, Constantinescu GM, Mann FA. Perineal hernia absence of the ventral portion of perineal diaphragm and rec- repair in the dog. In: Current Techniques in Small Animal tal sacculation (12,18). In this case, the bilateral ventral her- Surgery, 4th ed. Baltimore: Williams & Wilkins. 1998: 555- nia was repaired by semitendinosus muscle transposition that 564. was observed to bring about a good prognosis without any 2. Bellenger CR. Perineal hernia in dogs. Aust Vet J 1980; 56: 434-438. postoperative complications. This finding is in agreement with et al 3. Bellenger CR, Canfield RB. Perineal hernia. In: Textbook of the report of Vnuk . 2008, who also successfully treated Small Animal Surgery, 3rd ed.Philadelphia: WB Saunders. bilateral perineal hernia with transposition of semitendinosus 2003: 487-498. muscle in a cat (18). Transposition of the semitendinosus 4. Bojrab MJ. Perineal herniorrhaphy. Comp Cont Educ Pract muscle is particularly useful for reconstructions where the 1981; 3: 8-15. ventral aspect of the perineum is severely affected in case of 5. Burrows CF, Harvey CE. Perineal hernia in the dog. J bilateral perineal hernias (10). The semitendinosus muscle Small Anim Pract 1973; 14: 315-331. flap is chosen for the treatment of the bilateral perineal her- 6. Chamber JN, Rawlings CA. Application of semitendinosus nia because of the low success rate of bilateral perineal herni- muscle flap in two dogs. J Am Vet Med Assoc 1991; 199: orrhaphy by the standard method or by transposition of the 84-86. internal obturator muscle (18). 7. Gilley RS, Caywood DD, Lulich JP, Bowersox TS. Treatment with a combined cystopexy-colopexy for dysuria and rectal The gait examination and range of stifle joint motion were prolapse after bilateral perineal herniorrhaphy in a dog. J Am found similar in both hind limbs. This revealed that semiten- Vet Med Assoc 2003; 222: 1717-1721. dinosus muscle transposition did not induce any locomotion 8. Kolata RJ. Perineal hernia repair using the obturator muscle damage. It has been thought that the function of the semiten- flap. In: Current Techniques in Small Animal Surgery, 4th Repair of Bilateral Perineal Hernia with Semitendinosus Muscle Transposition Along with Colopexy and Cystopexy in a Bitch 375

ed. Baltimore: Williams & Wilkins. 1998: 572-574. 15. Robertson JJ. Perineal hernia repair in dogs. Mod Vet Pract 9. Mann FA. Perineal herniation. In: Disease Mechanism in 1984; 65: 365-368. Small Animal Surgery, 2nd ed., Philadelphia: Lea & Febiger. 16. Rochat MC, Mann FA. Sciatic perineal hernia in two dogs. 1993: 92-97. J Small Anim Pract 1998; 39: 240-243. 10. Mann FA, Constantinescu GM. Salvage techniques for failed 17. Vnuk D, Babic T, Stejskal M, Capak D, Pirkic B. Appli- perineal herniorrhaphy. In: Current Techniques in Small cation of a semitendinosus muscle flap in the treatment of Animal Surgery, 4th ed. Baltimore: Williams & Wilkins. perineal hernia in a cat. Vet Rec 2005; 156: 182-184. 1998: 564-570. 18. Vnuk D, Lipar M, Maticic D, Smolec O, Pecin M, Brkic A. 11. Mortari1 AC, Rahal1 SC, Resende LAL, Dal-pai-silva M, Comparison of standard perineal herniorrhaphy and transpo- Mamprim MJ, Correa1 MA, Antunes SHS. Electromyo- sition of the internal obturator muscle for perineal hernia graphical, ultrasonographical and morphological modifications repair in the dog. Veterinarski Arhiv 2008; 78: 197-207. in semitendinosus muscle after transposition as ventral 19. Vnuk D, Maticic D, Kreszinger M, Radisc B, Kos J, Lipar perineal muscle flap. J Vet Med A Physiol Pathol Clin M, Babic T. A modified salvage technique in surgical repair Med 2005; 52: 359-365. of perineal hernia in dogs using polypropylene mesh. Vet 12. Orsher RJ. Clinical and surgical parameters in dogs with Med-Czech 2006; 51: 11-117. perineal hernia: Analysis of results of internal obturator 20. Weaver AD, Omamegbe JO. Surgical treatment of perineal transposition. Vet Surg 1986; 15: 253-258. hernia in the dog. J Small Anim Pract 1981; 12: 749-758. 13. Petit GD. Perineal hernia in the dog. Cornell Vet 1962; 52: 21. Welchesd CD, Scavelli TD, Aronsohn MG, Matthiesen DT. 261-279. Perineal hernia in the cat: a retrospective study of 40 cases. 14. Raffan PJ. A new surgical technique for repair of perineal J Am Anim Hosp Assoc 1992; 28: 431-438. hernias in the dog. J Small Anim Pract 1993; 34: 13-19.

암컷 개 의 양측 회음 허니아에서 결장 고정술과 방광 고정술 후 반힘줄 근육 전위술의 이용

허수영·이동빈·이해범1 전북대학교 수의과대학

요약: 체중 3.5 kg 11년령 요크셔 테리어가 대변실금, 뒤무직(이급후증), 회음부의 종괴를 동반하는 증상으로 내원하 였다. 신체 검사상 비대 유선, 질 분비물과 정복이 가능한 회음부의 종괴가 발견되었다. 임상증상과 방사선검사를 바 탕으로 배쪽 양측 회음 허니아와 자궁축농증으로 진단하였다. 자궁난소 적출술 후 양측 회음 허니아는 결장 고정술과 방광 고정술 후 반힘즐 근육 전위술을 이용하여 정복하였다. 수술 후 방사선과 컴퓨터 단층 촬영 검사상에 배쪽 양측 회음 허니아의 정복을 확인할 수 있었다. 술 후 10일째 정상적인 활동을 보였고 1년 동안에 검사상 수술과 관련된 부 작용은 관찰되지 않았다. 배쪽 양측 회음 허니아는 결장 고정술과 방광 고정술 후 반힘즐 근육 전위술을 이용하여 성 공적으로 치료 되었다. 주요어 : 양측 회음 허니아, 반힘즐 근육 전위술, 결장고정숭,방광 고정술, 개