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Date:   09 January, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

Toa Payoh Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures

PERINEAL HERNIAS IN A PEKINESE X POM 
Written by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS 
First written: Feb 12, 2008. Updated: Jan 10, 2010

I hope that Daniel, a 2nd year vet student from Murdoch University in 2008 learnt some anatomy from observation of this surgery and find his study of anatomy of the back area of the dog more alive and interesting.


PATIENT. Pekinese X Pomeranian, Male, 10-13 years old. 
The dog was being cared for by the mother. The married daughter in her late thirties did not live with her mum but took the time to bring the dog in for a second opinion. She waited patiently and did not show an angry face. A soft spoken and gentle serene looking woman.

I had 2 long cases. A French lady with her ear scratching Golden Retriever needing its ear flushed. This took some time. Then another man who needed time to decide about putting to sleep his old Cocker Spaniel with a swollen ascites abdomen.


COMPLAINT.
Constipation. The first vet treated the dog for constipation some 19 days ago, yet the mother still complained about the dog having constipation. This dog had a full coat and the backside swelling was not obvious. I put the dog on the table and with my left hand, pressed the abdomen between my thumb and fingers. This procedure is called palpation. There was no hard stool lumps inside the abdomen. I declared: "Your dog is not constipated."

"My mum says that the Pomeranian had great difficulty in pooping for some time," the daughter said. "The dog eats well but he takes a long time to pass stools."

So, something must be wrong. What could this be? A tumour inside the rectum? Cancer of the large intestine as the dog is old? But this dog was not losing weight and has no diarrhoea.

After palpation, I took the dog's rectal temperature. Taking the rectal temperature must be done as a routine even though the dog had an excellent appetite. As I inserted the thermometer, the dog "yelped" as if he had been injured by the rectal thermometer. His back end erupted with a loud crack of gas when I expressed his anal glands to examine the glands. Farting when the anal glands are expressed is not a normal outcome. So there was something strange. 

"Please clip the anal region," I said to my groomer. "The dog has a luxuriant coat and clipping would permit me to check for wounds. If the anal glands were infected or inflamed, the dog would have great pain. Therefore, he would have difficulty pooping when pain waves came in during defaecation.

Perineal hernia. Rectum diverted. Packed with stools. Sero-sanguineous fluid in hernia sac. Toa Payoh Vets The groomer clipped and what happened? This dog had a huge right perineal swelling! There was also a small left perineal hernia! I palpated the right backside swelling. Many hard faecal lumps of over 2 cm in diameter in the rectum resisted my hand pressure. A fluid wave came from the bladder trapped inside this hernia. 

To confirm that this was a perineal hernia, I pushed the swelling inwards while the dog was standing. The swelling disappeared and this impressed looked like magic. One time the swelling was there. The next second, it disappeared. Another few seconds, it appeared. 

"You have the diagnosis of what's wrong with your dog," I said to the serene lady. "The rectum has gone into this back area from inside the abdomen. Parts of the bladder with urine and abdominal fat had also been diverted into this big rounded swelling called a perineal hernia. So the dog had difficulty in pooping as he had to strain hard to get the obstructed stools out of the twisted rectum into the anus. . He probably had some problems peeing if the full bladder got trapped inside this perineal hernia."

The sole complaint was constipation.

"What do " the lady asked as I told her that the dog also had heart disease and might die on the operating table as the heart failed. It would be a long operation lasting more than 45 minutes.

"You have to take the anaesthetic risk," I said. "If the dog can't poop, he will also die a painful death as the stools piled up inside the large intestines and release toxins into the body."

The lady decided on surgery the next day. It would be Chinese New Year's eve. I had asked this vet student to come in the afternoon at around 3 p.m as I wanted to show him the real thing. The backside anatomy he would never see in a live dog. He had a dead dog in the University shared by 4 students to study anatomy. Nothing makes veterinary anatomy as alive as seeing the rippling muscles, the pudendal blood vessels and the nerve. 
 
Intact Male PekX, constipation. Rectum with stools diverted. Perineal hernias.Toa Payoh Vets Heart disease. Old dog. Perineal hernia. Owner has to accept the anaesthetic risk. Toa Payoh Vets
Is the active old dog constipated? Yes! Stools are  trapped inside the right perineal hernia (Y)! The swelling has fluid and faecal lumps inside the rectum. Was there a bladder inside the hernia?  During surgery, the orange yellow fluid was exudate from the omental fat and other strangulated fat tissues. It was produced over several years of herniation. No bladder was found in the hernia.

On Chinese New Year's eve of 2008, a Golden Retriever with diarrhoea came in at 3 pm. The owner could not locate the Surgery although she was supposed to be in before 2.30 pm as I need to start the perineal hernia operation at 3 pm. I had the reunion dinner to attend at 6.30 pm and I did not want to be late. The culture was such that there was the "mixing of raw fish and vegetables" for good luck at the start of the dinner and every member of the family must be present to do it.

Perineal hernia repair needed. But will old dog die on the operating table? Toa Payoh Vets The dog was operated past 4 p.m. The two sides of the skin cut were retracted by forceps and the student saw a lot of blood tinged fluid and gel and some pieces of yellow fat on exposure. This yellowish fluid was drained.

I showed Daniel  the backside muscles but I doubted he could see them or name them. We had gone through the anatomy of the backside before the surgery. He had an excellent memory. But it is difficult to motivate a 2nd year student to appreciate the backside anatomy of the dog. Veterinary Anatomy can be a dull subject with so many names to be memorised.

I pushed back the hernia sac into a big gap of over 10 cm long and 1.5 cm wide. "Pelvic diaphragm" I pointed to the muscle defect. I doubted he understood. There is a diaphragm (muscle) between the chest and abdomen. But what is a pelvic diaphragm?

He could see the anal sphincter muscle. The coccygeal and internal obturator muscles were atrophied unlike the beautiful illustrations in the Vet Surgery book. I closed the muscle defect by suturing with 2 layers of 2/0 absorbable sutures.

It would be some years before he will see another perineal hernia repair as this is not a common surgery. The dog was able to poop without problems the next 3 days and sent home to save on veterinary boarding expenses.

I reminded the owner to keep the Elizabethan collar on as the dog was discharged without the collar. Small omissions from my staff do make me angry as the dog may lick and open up the big wound. Somehow my assistant overlooked the need to apply an e-collar on discharge of the dog. I empahsized to the lady that the dog had to be confined for at least 7 days. No jumping around.

A 2nd-year Vet Student from Murdoch University sees the repair of a perineal hernia. Toa Payoh VetsNow, there was the left perineal hernia which seems to swell and disappear now and then. The owner had been informed.

I advised neutering the dog some time later as the male hormone seem to be a cause of the hernia formation according to some veterinary surgery books. I don't know whether she would remember as she does not live with the dog. I did not neuter the dog at the same time as I wanted to shorten the anaesthetic time so as to be successful in bringing out a live dog at the end of surgery. The perineal surgery took more than 45 minutes. The dog was given 8% halothane gas and then maintained at 2%. For a short while there was some movement and he was given 2.5%. Other than that anaesthesia was surprising smooth flowing as if the dog had a nice nap. Without tranquilisers given as I did not want the heart to be affected. No pain killers were given after surgery for the same reason. This dog recovered the next day.

It is extremely kind of the daughter to take the time to bring the dog to the vet before it was too late. Before the dog collapsed from intestinal blood vessel strangulation and become toxic and so sickly that the anaesthetic risk increased from the 40% to zero percentage of survival on the operating table! A gentle client is always much appreciated by any veterinarian who usually has some nasty litigious pushy ones who think that "the customer and their cash is the king".

No vet can have all gentle clients all the time! But this case was a pleasant and happy case and the dog lived to go back to a happy aged mother whom I will never meet! I did make it to the reunion dinner on time.

P.S.
UPDATE: As at Jan 9, 2010, the daughter had not contacted me since the surgery in Feb 2008. I presumed that my right perineal hernia repair was a success and that the left perineal hernia did not expand and caused "constipation."

Dogs are very close to aged parents as they are substitute children. I mean, the children have had flown the coop and it will be the dogs who keep the aged parents company at home. It will be good if  the children takes time to help their parents to get the sick dogs treated early.   

Nearly 2 years had passed. Chinese New Year's Eve of 2010 would be on Feb 14, 2010 (Valentine's Day). Alice, a 3rd year vet student going to the 4th year in 2010 applied to see practice with me for 3 weeks in January 2010. Another old dog, a Shetland X with a large perineal hernia was presented. What a coincidence.

NOTES ON SEEING PRACTICE
All vet interns who see practice at Toa Payoh Vets are required to be serious and be keen to learn and excel in veterinary medicine and surgery.

It seems that vet interns take "seeing practice" literally. They just see what the vets do and are not proactive. This is just not on for interns at Toa Payoh Vets.

Vet Interns at Toa Payoh Vets must write case reports so as to maximise their learning. Seeing practice by standing around and looking at the vet handling a case is NOT acceptable if vet interns want to see practice and are accepted at Toa Payoh Vets. I know young people of Singapore dislike writing and this may be a worldwide attitude of the internet generation. By writing, the interns understand the case much more.  

Alice had a small note book in her pocket. She would sometimes take it out to write the points I mentioned during my case handling. Many times I had to remind her to write notes so that she would review them during her 4th year veterinary surgery and medicine studies in 2010. I had to explain to my clients that Alice was seeing practice and some  would nod their heads in amazement as if vet interns are rare birds. Some asked me if she was my daughter. I must be ancient.

Be proactive. Written records of seeing practice would bring veterinary surgery alive as her lecturer drones on about perineal hernia repairs via lecture notes. So boring. I don't know whether the lecturers show videos or not.

But definitely not during my undergraduate years in the late 1960s.  I used to scribble notes on drugs used and treatment when I saw practice in the U.K but I guess this is not a normal practice of vet interns.  

I had one ex-intern who will be studying vet medicine in the first year in 2010 producing a video for me to bring veterinary surgery alive to 4th and 5th year undergraduates. See:

As for Alice, after some nagging, she produced one case report after 4 days of seeing practice!  It is much treasured. Readers may click:  Perineal Hernia in a 12-year-old Shetland X

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