[Audio] Surgical correction of perineal hernia in a Pomeranian was performed by Harshal S. Ramteke, a BVSc scholar at the College of Veterinary and Animal Sciences, Mannuthy.. 

Scene 1

Surgical correction of                        perineal hernia                    
in a Pomeranian

Made by : harshal .s. ramteke  19-bvm-85 Bvsc scholar  College of veterinary  and animal sciences mannuthy

[Audio] Description of the Case Signalment:
Species: Canine
Breed: Pomeranian
Age: 9 years
Sex: Male
Body weight: 7.4 kg. 

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Species                             Canine Breed  pomeranian age 9years sex male Body weight 7.4 kg

[Audio] Owner's Complaint
The owner brought the animal with a complaint that it had a swelling on its backside and had not been passing urine for the past 2 days.. 

Scene 3

Owner brought the animal with the complaint of :animal was having a swelling an back side and not passing the urine since 2 days

[Audio] During the physical examination, it was observed that the animal had a swelling on its perineal region.. 

Scene 4

Animal was having a swelling on perineal region

[Audio] On ultrasonography, urine collected from aspiration of the fluid from a tumor can show a urinary bladder that is obstructed in a hernial sac.. 

Scene 5

Urinary bladder which as  obstructed in hernial sac , can be seen






  on aspiration of fluid from tumor:  Urine was collected

[Audio] Diagnosis:
Perineal hernia with urinary obstruction
Treatment:
Surgical management has been performed.
Surgery:
The following procedures were carried out: Cystocentesis, repositioning of a retroflexed urinary bladder, and anatomical herniorrhaphy.. 

Scene 6

Diagnosis 
perineal hernia with obstruction of      urinary

Treatment : surgical management has done

 Surgery: Cystocentesis ,repositioning of retroflexed urinary bladder and  Anatomical herniorraphy has done

[Audio] Cystocentesis, repositioning of a retroflexed urinary bladder, and anatomical herniorraphy were performed. Before the surgery, preanesthetic medication was given with Xylazine at a dose of 1mg/kg body weight and ketamine at a dose of 5mg/kg body weight via intramuscular injection. The perineum was shaved and prepared in a sterile manner. Maintenance of anesthesia was achieved by administering propofol, with an initial bolus of 0.8 ml via intravenous injection, followed by subsequent boluses of 0.5 ml also via intravenous injection.. 

Scene 7

Cystocentesis ,repositioning of retroflexed urinary bladder and  Anatomical herniorraphy

Preoperative : Preanasethetics Xylazine:@1mg/kg BW ketamine@5mg/kgBW(i/m)

 Clipped and aseptically prepared the perineum for the surgery Maintainance of anaesthesia was done by administrating :  propofol as an (I/V)  first bolus as 0.8 ml as I/v   subsequent boluses as 0.5 ml as(I/V)

[Audio] The animal was positioned in ventral recumbency with the tail fixed over back ,the pelvis elevated and hindlimbs padded A linear incision is made beginning cranial to coccygeus muscle over the hernia bulge 1-2cm lateral to the anus and extending 2-3cm ventral to the pelvic floor, subcutaneous tissue and hernial sac was incised. Retroflexed Urinary bladder was noticed just beneath the hernia sac which was ruptured using hypodermic needle and cystocentesis has done. Retroflexed urinary was repositioned and the other hernial contents were repositioned to their original location Anatomical herniorraphy has done by putting simple continuous sutures by (vicryl 2-0)between external anal sphincter muscle and levator anii muscle Subcutaneous tissue was sutured by using simple continuous sutures And skin was sutured by using cross mattress sutures. 

Scene 8

The animal was positioned in ventral recumbency with the tail fixed over back ,the pelvis elevated and hindlimbs padded

A linear incision is made beginning cranial to coccygeus muscle over the hernia bulge 1-2cm lateral to the anus and extending 2-3cm ventral to the pelvic floor, subcutaneous tissue and hernial sac  was incised. Retroflexed Urinary bladder was noticed just beneath the hernia sac which was ruptured using hypodermic needle and cystocentesis has done. Retroflexed urinary was repositioned and the other hernial contents were repositioned to their original location   Anatomical herniorraphy has done by putting simple continuous sutures by (vicryl 2-0)between  external anal sphincter muscle and levator anii muscle  Subcutaneous tissue was sutured by using simple continuous sutures And skin was sutured by using cross mattress sutures

[Audio] Post-operative:
injection Amoxirum forte 4.5g-1vial
take 0.7ml subcutaneously
injection Meloxicam 30ml-1vial
take 0.3ml subcutaneously
advised: Metrogyl P ointment, apply externally Sus. Cremaffin-1 bottle, take 2ml twice a day orally
Advised to continue the above injections for 4 more days.. 

Scene 9

Post operative:
inj.amoxirum forte4.5g-1vial
sig 0.7 ml as s/c
inj.meloxicam 3oml-1vial
sig0.3mlkas s/c

advised: Oint.Metrogyl P Sig for ext.application Susp. Cremaffin-1 bottle Sig 2ml B.I.D P.O. Advised to continue the abopve injection foir 4 more days

[Audio] Discussion:
Perineal hernia is a condition where the muscles in the perineal area become separated, allowing the rectum, pelvic organs, and/or abdominal contents to protrude through the perineal skin. This condition is more commonly seen in dogs than in cats.
There are different types of perineal hernia, which vary depending on their location. These include caudal hernia, sciatic hernia, dorsal hernia, and ventral hernia.. 

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Occurrence: perineal hernia occurs when the perineal muscles separate allowing rectum ,pelvic,and /or abdominbal contents top displacec perineal skin More common in dogs as compared to cats  Types: Depending on location Caudal hernia Sciatic hernia Dorsal hernia Ventral hernia

[Audio] The pelvic diaphragm is composed of several muscles, including the paired medial coccygeal muscle, levator ani muscle, and internal obturator muscles. The paired levator ani muscle starts from the base of the pelvis and the inner side of the ilium bone, spreads out around the sides of the rectum, and then narrows down before attaching to the ventral side of the seventh caudal vertebra. The paired coccygeus muscle lies next to the thin levator ani muscle and originates from the ischial spine on the pelvic floor, attaching to the ventral side of the second and fifth caudal vertebrae. The paired rectococcygeus muscle arises from the external longitudinal muscle of the rectum, and attaches to the ventral surface of the fifth to sixth caudal vertebrae, located below the levator and coccygeus muscles.. 

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Anatomy of pelvic diaphragm

pelvic diaphragm made of :
paired medial coccygeal muscle 
levator ani muscle 
internal obturator muscles 
paired levator ani muscle originates from the floor of pelvis and medial shaft of ilium,fans out around the sides of rectum and then narrows and inserts ventrally on seventh caudal vertebra 
paired coccygeus muscle lies lateral to thin levator ani musclewhich originates from ischiatic spine on pelvic floor and inserts ventrally on second and fifth caudal vertebrae 
paired rectococcygeus muscle arises from external longitudinal muscle of rectum and caudal to levator and coccygeus muscles and inserts on ventral surface of fifth to sixth caudal vertebrae

[Audio] The internal obturator muscle is a fan-shaped muscle that covers the dorsal surface of the ischium and pelvic symphysis.. 

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Internal obturator muscle –a fan shaped muscle covering doprsal surface of ischium and pelvic symphysis

Levator
ani
muscle
External anal
sphincter
Internal
obturator muscle
Coccygeus
muscle

[Audio] The occurrence of a hernia between muscles can happen in various locations, such as: Caudal hernia: between the levator ani, external anal sphincter, and internal obturator muscles Sciatic hernia: between the sacrotuberous ligament and coccygeus muscle Dorsal hernia: between the levator ani and coccygeus muscles Ventral hernia: between the ischiourethralis, bulbocavernosus, and ischiocavernosus muscles.. 

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Occurrence of hernia in between muscles
caudal hernia: between levator ani,external anal sphincterand internal obturator

Sciatic hernia: between sacrotuberous ligament and coccygeus muscle Dorsal hernia: levator ani and coccygeus muscle Ventral hernia:ischiourethralis bulbocavernosus andischiocavernosus muscle

[Audio] Cause: When the pelvic diaphragm is unable to support the rectal wall, it can lead to rectal distension and difficulty with bowel movements. There are various reasons for weakness in the pelvic diaphragm, including male hormones, straining, and congenital or acquired weakness or atrophy of the pelvic muscles. Animals may have difficulty with bowel movements, urination, or both, along with swelling on the side of the anus, which can be on one or both sides. Clinical signs may include constipation, obstipation, difficulty defecating, tenesmus, rectal prolapse, difficulty urinating, not being able to urinate, and vomiting. During a physical exam, a weakened pelvic diaphragm may be felt during a digital rectal examination, with or without swelling in the perineal area. In cats, bilateral hernias may also cause swelling in the perineal area, and this can be felt during a ballottement exam. If the hernia is filled with a full bladder, it may feel tight and resilient instead of having a wavy texture.. 

Scene 14

Cause: pelvic diaphragm fails to support rectal wall and causes rectal dis
tension and impaired daefecation 
Various causes of pelvic diaphragm weakness:male hormones,strainingand congenitalopr acquired muscles weakness or atrophy of pelvic muscles

Animal may comes with difficuilty in daefecation ,urination  or both along with sewlling lateral to anus, which may be unilateral or bilateral   Clinical signs constipation ,obstipation ,dyschezia ,tenesmus ,rectal prolapse , stranguria , anuria and vomiting  Physical examination on digital rectal examination –wekened pelvic diaphragm can me noticed with or without perineal  swelling. Perineal swelling may be on lateral to anus unilateral or bilateral.  Cats have bilateral hernias which seldom cause  perineal sewllings       on ballotment  if hernia filled with a full bladder a tight resilient feel will be there instead of wavy feel

[Audio] If there is a suspicion of fluid, an ultrasound and perineal centesis should be performed to determine if the fluid is urine or not. In cases of hernia with rectal or rectal contents, there is often obstipated feces present. Radiography can be used to differentiate between the urinary bladder, small intestine, and prostate gland in cases of hernia. Laboratory findings show that patients with bladder retroflexion often have Azotemia, hyperkalemia, hyperphosphatemia, and neutrophilic leukocytosis. Treatment options include medical management and surgical management. The goal of medical management is to prevent constipation, dysuria, and organ strangulation. Underlying factors such as megacolon, urinary tract infections, or prostate enlargement should be addressed and corrected.. 

Scene 15

If fluid is suspected then ultrasound and perineal centesis should be done to determine whether fluid is urine or not 
 hernia with rectum or rectal contents often having obstipated faeces inside

Radiography can be done to distinguish between urinary bladder small intestine and prostate gland in hernia  Lab.findings:patients with bladder retroflexion often have Azotemia,hyperkalemia,hyperphosphatemia and neutrophilic   leukocytosis Treatment: 1)medical management                          2)surgical management MEDICAL MANAGEMENT: goal of medical management is to prevnt constipation ,dysuria , organ strangulation  Causative factors like megacolon uti or urinary tract obstruction prostatic hypertrophy should be corrected

[Audio] Normal bowel movements can be maintained by using stool softeners, making dietary changes, and periodically using enemas or manually evacuating the rectum.
To decompress the urinary bladder, either centesis or catheterization can be used.
For surgical treatment, two commonly used techniques are: 1) the traditional or anatomic repositioning, and 2) the internal obturator roll-up method. Prior to surgery, preoperative treatments such as stool softeners should be given 2-3 days in advance. Prophylactic antibiotics effective against both gram-positive and gram-negative bacteria are also recommended.
In cases of retroflexed urinary bladder, cystocentesis or urinary catheterization should be performed.. 

Scene 16

Normal daefecation can be maintained y using stool oftners ,dietary changes and periodic enemas and manual rectal evacuation 
urinary bladder can be decompressed by centesis or catheterization

Surgical treatment: two commonly used techniques 1)The traditional or anatomic reapposistion  2)Internal obturator roll-up Preoperative treatment: Stool softners  should be given 2-3 days before surgery  Prophylactic antibiotics effective against gram posistive and gram negative bacteria  In retroflexed urinary bladder :cystocentesis or urinary catheterization should be done

[Audio] Operative: To perform surgery on the perineal region, first ensure that the area is properly clipped and prepared. Then, position the animal in ventral recumbency. The approach involves creating a curvilinear incision cranial to the coccygeus muscle, curving over the hernia bulge and 1-2 cm lateral to the anus, and extending 2-3 cm ventrally to the pelvic floor. Cut through the subcutaneous tissue and hernial sac. Next, identify and reduce the hernial contents by dissecting any subcutaneous and fibrous attachments. Repair the hernia using herniorrhaphy, and transition to herniorrhaphy by placing simple interrupted 0 or 2-0 monofilament sutures using a curved round-bodied needle. Begin the suture placement between the external anal sphincter and levator ani muscles, as well as the coccygeus muscle. As the placement progresses ventrally and laterally, direct the sutures between the external anal sphincter and internal obturator muscle, being mindful of the pudendal vessels and nerves to prevent injury. Tie the sutures starting dorsally and progressing ventrally.. 

Scene 17

operative:
positioning properly clipped and prepared the perineal region for surgery 
and  positioned the animal in ventral recumbency 
approach make a curvilinear incision cranial to coccygeus muscle,curving over the hernia bulge and 1-2 cm lateral to the anus and extending 2-3cm ventreal to pelvic floor.

Incise the s/c tissue and hernial sac . Identify and reduce the hernial contents by dissecting subcutaneous and fibrous attachments  Repair the hernia with herniorraphy  Transitional herniorraphy preplace  sutures simple interrupted      0 or 2-0 monofilament sutures using curved round bodied needle     begin suture placement between external anal sphincters and levator ani , coccygeus both muscles .as placement progresses ventrally and laterally Direct ventral sutures between external anal sphincter and internal obturator muscle be cognizant of pudendal vessels and nerves to prevent them from getting injuredtie sutures beginning dorsally and progressing ventrally

[Audio] Cleanse the area and then close the underlying tissue using either a interrupted or continuous method with a 3-0 to 4-0 absorbable monofilament suture. Next, close the skin using an interrupted method with a non-absorbable suture. For an internal obturator transposition herniorraphy: cut through the fascia and periosteum along the bottom edge of the ischium and the origin of the internal obturator muscle. Use a periosteal elevator to lift the periosteum and internal obturator muscle away from the ischium. Move the muscle dorsomedially or roll it up to cover the defect and allow for proper alignment between the coccygeus, levator ani, and external anal sphincter muscles. Place simple interrupted sutures as you would with a traditional technique, starting by aligning the levator ani and coccygeus muscles with the external anal sphincter muscle dorsally. Then, use sutures to connect the internal obturator muscle with the external anal sphincter muscle medially and the levator ani and coccygeus muscles laterally.. 

Scene 18

Lavage the area
close the subcutaneous tissue with interrupted or continuous appositional  pattern with 3-0 to 4-0 monofilament absorbable suture 
and close the skin in appositional interrupted pattern with non absorbable suture pattern

Internal obturator transposition herniorraphy:  incise the fascia and periosteum along the caudal borderof ischium and origin of internal obturator muscle. Elevate the periosteum and internal obturator muscle from ischium using  periosteal elevator Transp[ose dorsomedially or rollup the muscle into defect to allow apposition between coccygeus ,levator ani and external anal sphincter. Preplace simple interrupted sutures as with traditional technique Begin by apposing combined levator aniand coccygeus muscles with external anal sphincter  dorsally. Then place suture between internal obturator and eternal anal sphincter medially and levator ani and coccygeus muscles laterally

Surgical correction of                        perineal hernia                    
in a Pomeranian 


Surgical correction of perineal hernia in a Pomeranian was performed by Harshal S. Ramteke, a BVSc scholar at the College of Veterinary and Animal Sciences, Mannuthy.

avatar


Description of the Case

Signalment:
Species: Canine
Breed: Pomeranian
Age: 9 years
Sex: Male
Body weight: 7.4 kg


Owner's Complaint
The owner brought the animal with a complaint that it had a swelling on its backside and had not been passing urine for the past 2 days.


During the physical examination, it was observed that the animal had a swelling on its perineal region.

On ultrasonography, urine collected from aspiration of the fluid from a tumor can show a urinary bladder that is obstructed in a hernial sac.


Diagnosis:
Perineal hernia with urinary obstruction
Treatment:
Surgical management has been performed.
Surgery:
The following procedures were carried out: Cystocentesis, repositioning of a retroflexed urinary bladder, and anatomical herniorrhaphy.


Cystocentesis, repositioning of a retroflexed urinary bladder, and anatomical herniorraphy were performed. Before the surgery, preanesthetic medication was given with Xylazine at a dose of 1mg/kg body weight and ketamine at a dose of 5mg/kg body weight via intramuscular injection. The perineum was shaved and prepared in a sterile manner. Maintenance of anesthesia was achieved by administering propofol, with an initial bolus of 0.8 ml via intravenous injection, followed by subsequent boluses of 0.5 ml also via intravenous injection.

The animal was positioned in ventral recumbency with the tail fixed over back ,the pelvis elevated and hindlimbs padded
 A linear incision is made beginning cranial to coccygeus muscle over the hernia bulge 1-2cm lateral to the anus and extending 2-3cm ventral to the pelvic floor, subcutaneous tissue and hernial sac  was incised. Retroflexed Urinary bladder was noticed just beneath the hernia sac which was ruptured using hypodermic needle and cystocentesis has done. Retroflexed urinary was repositioned and the other hernial contents were repositioned to their original location   Anatomical herniorraphy has done by putting simple continuous sutures by (vicryl 2-0)between  external anal sphincter muscle and levator anii muscle  Subcutaneous tissue was sutured by using simple continuous sutures And skin was sutured by using cross mattress sutures


Post-operative:
injection Amoxirum forte 4.5g-1vial
take 0.7ml subcutaneously
injection Meloxicam 30ml-1vial
take 0.3ml subcutaneously
advised: Metrogyl P ointment, apply externally Sus. Cremaffin-1 bottle, take 2ml twice a day orally
Advised to continue the above injections for 4 more days.


Discussion:
Perineal hernia is a condition where the muscles in the perineal area become separated, allowing the rectum, pelvic organs, and/or abdominal contents to protrude through the perineal skin. This condition is more commonly seen in dogs than in cats.
There are different types of perineal hernia, which vary depending on their location. These include caudal hernia, sciatic hernia, dorsal hernia, and ventral hernia.


The pelvic diaphragm is composed of several muscles, including the paired medial coccygeal muscle, levator ani muscle, and internal obturator muscles. The paired levator ani muscle starts from the base of the pelvis and the inner side of the ilium bone, spreads out around the sides of the rectum, and then narrows down before attaching to the ventral side of the seventh caudal vertebra. The paired coccygeus muscle lies next to the thin levator ani muscle and originates from the ischial spine on the pelvic floor, attaching to the ventral side of the second and fifth caudal vertebrae. The paired rectococcygeus muscle arises from the external longitudinal muscle of the rectum, and attaches to the ventral surface of the fifth to sixth caudal vertebrae, located below the levator and coccygeus muscles.


The internal obturator muscle is a fan-shaped muscle that covers the dorsal surface of the ischium and pelvic symphysis.


The occurrence of a hernia between muscles can happen in various locations, such as:

 Caudal hernia: between the levator ani, external anal sphincter, and internal obturator muscles
 Sciatic hernia: between the sacrotuberous ligament and coccygeus muscle
 Dorsal hernia: between the levator ani and coccygeus muscles
 Ventral hernia: between the ischiourethralis, bulbocavernosus, and ischiocavernosus muscles.


Cause: When the pelvic diaphragm is unable to support the rectal wall, it can lead to rectal distension and difficulty with bowel movements. There are various reasons for weakness in the pelvic diaphragm, including male hormones, straining, and congenital or acquired weakness or atrophy of the pelvic muscles.

Animals may have difficulty with bowel movements, urination, or both, along with swelling on the side of the anus, which can be on one or both sides. Clinical signs may include constipation, obstipation, difficulty defecating, tenesmus, rectal prolapse, difficulty urinating, not being able to urinate, and vomiting. During a physical exam, a weakened pelvic diaphragm may be felt during a digital rectal examination, with or without swelling in the perineal area. In cats, bilateral hernias may also cause swelling in the perineal area, and this can be felt during a ballottement exam. If the hernia is filled with a full bladder, it may feel tight and resilient instead of having a wavy texture.


If there is a suspicion of fluid, an ultrasound and perineal centesis should be performed to determine if the fluid is urine or not. In cases of hernia with rectal or rectal contents, there is often obstipated feces present. Radiography can be used to differentiate between the urinary bladder, small intestine, and prostate gland in cases of hernia. Laboratory findings show that patients with bladder retroflexion often have Azotemia, hyperkalemia, hyperphosphatemia, and neutrophilic leukocytosis. Treatment options include medical management and surgical management. The goal of medical management is to prevent constipation, dysuria, and organ strangulation. Underlying factors such as megacolon, urinary tract infections, or prostate enlargement should be addressed and corrected.


Normal bowel movements can be maintained by using stool softeners, making dietary changes, and periodically using enemas or manually evacuating the rectum.
To decompress the urinary bladder, either centesis or catheterization can be used.
For surgical treatment, two commonly used techniques are: 1) the traditional or anatomic repositioning, and 2) the internal obturator roll-up method. 
Prior to surgery, preoperative treatments such as stool softeners should be given 2-3 days in advance. Prophylactic antibiotics effective against both gram-positive and gram-negative bacteria are also recommended.
In cases of retroflexed urinary bladder, cystocentesis or urinary catheterization should be performed. 


Operative:

To perform surgery on the perineal region, first ensure that the area is properly clipped and prepared. Then, position the animal in ventral recumbency. The approach involves creating a curvilinear incision cranial to the coccygeus muscle, curving over the hernia bulge and 1-2 cm lateral to the anus, and extending 2-3 cm ventrally to the pelvic floor. Cut through the subcutaneous tissue and hernial sac. Next, identify and reduce the hernial contents by dissecting any subcutaneous and fibrous attachments. Repair the hernia using herniorrhaphy, and transition to herniorrhaphy by placing simple interrupted 0 or 2-0 monofilament sutures using a curved round-bodied needle. Begin the suture placement between the external anal sphincter and levator ani muscles, as well as the coccygeus muscle. As the placement progresses ventrally and laterally, direct the sutures between the external anal sphincter and internal obturator muscle, being mindful of the pudendal vessels and nerves to prevent injury. Tie the sutures starting dorsally and progressing ventrally.


Cleanse the area and then close the underlying tissue using either a interrupted or continuous method with a 3-0 to 4-0 absorbable monofilament suture. Next, close the skin using an interrupted method with a non-absorbable suture.

For an internal obturator transposition herniorraphy: cut through the fascia and periosteum along the bottom edge of the ischium and the origin of the internal obturator muscle. Use a periosteal elevator to lift the periosteum and internal obturator muscle away from the ischium. Move the muscle dorsomedially or roll it up to cover the defect and allow for proper alignment between the coccygeus, levator ani, and external anal sphincter muscles. Place simple interrupted sutures as you would with a traditional technique, starting by aligning the levator ani and coccygeus muscles with the external anal sphincter muscle dorsally. Then, use sutures to connect the internal obturator muscle with the external anal sphincter muscle medially and the levator ani and coccygeus muscles laterally.