Good evening, everybody, whoever you are around the globe. Anthony, thank you very much for inviting me to this conference, to this virtual conference 2021. For the next one hour, I will talk about renal hernias, and I will give you, I'll try to give you my tips on how to fix it safely.

This is the outline of the webinar today. We're going to talk about the key features and diagnosis. A few things about the medical management, mostly about surgical treatment in a step by step condition, postoperative management, complications, prevention and prognosis, and finally some tips.

Before saying goodbye. Some key features to begin with, what is the perineal hernia? This is a defect of the muscles making up the pelvic diaphragm.

When it happens, when these muscles fail to support the lateral rectal wall, and the pelvic diaphragm consists of three muscles the external sphincter muscle, the lever muscle, and the coccygeous muscles, and you will, as you will see here. In the diagram. The external sphincter muscle in purple, with green, the lever and, and in yellow, the coccygus muscle.

Aetiology is mostly unknown, although many theories have been investigated. Constipation, inflammatory bowel disease, prostatic disease, neuropathy of the pelvic dia from muscles, or myopathy of these muscles. The relaxing receptors have been found in increased numbers in the pelvic diaphragm of those with perineal hernia.

Some or key feature species, dogs are mostly, encourage this problem, this peroneal hernia, very rare in cats and tar male dogs at most, middle aged around 7 to 9 years old, mostly, usually unilateral with a right side, predominance or bilateral, breeds, collies, boxers, German shepherds, Yorkies, garos. And there is also a theory about the breeds with sore tails which may be predisposed to peroneal hernia. Clinical signs, mostly constipation and peroneal swelling at presentation, and 20% of cases with urinary bladder retroflexion.

Cases are those with problems to urinate during the initial presentation. How we diagnose the peroneal hernia is very simple. It's the hook sign, you can, you will see here the video.

How my finger works in this rectum. This is the loss of the lateral support. Of the muscles to the pelvic diaphragm.

This is not should be happening. Whenever you see the hook sign, you have a peroneal hernia. Imaging may be rewarding from time to time.

You see here faeces accumulated in the perineal swelling. We can also find some disorder in the abdominal cavity like or prostatic cyst, for example. And before surgery and until surgery, we have to treat our patients medically by giving them some high fibre diets and treating concurrent disorders like constipation.

We can help them by digitally evacuating the faeces from the rectum and for those cases that are presented to us with urinary retroflexion, we may catheterize those patients if catheterization is not. Possible, we can do cystocentesis to alleviate signs and have no problems so with the kidneys. Surgery is the mainstay of treatment and what we do at surgery, the first thing we have to do is to reconstruct the pelvic diaphragm and castrate our patient.

Castration can be done with a pre-scrotal or scrotal approach depending on the preference of the surgeon. And for those of you who have read the literature and seen some additional procedures performed like coopexy, cystopexy, or vasopexy, these are very rarely indicated and usually, we do those kinds of additional procedures in complicated cases. Preoperatively, we are giving our patient prophylactic IV antibiotics against gram-negative bacteria and arobes.

Multimodal analgesia is very important. We express the anal sacs, we evacuated through the rectum. We are placing, our patient in stellar recumbency in the perineal position with its hind legs off the table, and we support the abdomen with this spotted, support here, as you see, in the slide.

In order to avoid damage to femoral, or peroneal nerves, we do a white clip, we place a poor swing suture in the orifice and we are ready to begin our surgery. Remember that enemas are not good. We don't want enemas, to help those patients before surgery or even preoperatively because enemas will provide us with liquid faeces and liquid faeces may contribute to wound infection, during surgery or even after.

So no one Amos. Before entering the OR, any surgeon has to review the anatomy, and this is the pelvic diaphragm anatomy. You see here the external sphincter muscle in yellow, the coccyous muscle in green, the levator an eye muscle, and in blue, the internal obulator muscle.

One more structure that we will talk about is the sacred tuberous ligament. This ligament connects the circum, vertebrae with the is tuberosity and may be used to enforce our, earn a repair. We have 4 perreal hernia types.

Dorsal hernias between the coccygu muscle and the leveron muscle. Caudal area between the external sphincter, the elevator or muscle and the internal retor muscle. Less frequently we have ventral hernias between this urethralis musclescanosis muscle and bogo fungys muscle, and even less frequently, if this is the sacred tuberous ligament, we have the sciatic hernia between the coccyguous muscle and the sacred tubular ligaments.

So do remember dorsal hernias and caudal hernias are 95% of the perineal hernias that you will see in small annual practise. Now, how do we reconstruct the pelvic diaphragm? Option number one, just reoppose the muscles.

This is one thing that we did in the past. It's not good. Due to the fact that it does not provide good support to the eventual defects.

So we try to do something more to help this rear position with muscle augmentation, and that is why we choose the internal of the rear muscle to create a flap that can augment the ventral part of our peroneal hernias. Reinforcement techniques using, polypropylene messages, for example, can be used, but not, very, often used in if you have good muscles to reoppose and close the hernias. Real position, as you can see here in this diagram from Fossum.

This is a traditional tech at the left of your screen. You can see how the sutures are replaced from dorsal to ventral, and this is how we can raise up our flap in the right side, the yellow of the. Sorry, the green side, the green slide to elevate the internal obdure muscle and create this nice lap that we can suture to the coccyguous muscle, to the vein muscle, and the external sphincter muscle in order to close this perineal hernia.

This is the best thing we can do and works perfectly in almost 95% of our cases. Using the semitendinosis muscle may be needed. It will have ventral hernias, as you can probably see here.

This is a nice paper from 2015 Journal of Small Animal practise. You can refer to that and see more about this kind of surgery very rarely needed to be done in a small animal practise, most usually in referral hospitals. Back in 2004, some colleagues of ours had this paper where they suggested that some perineal hernias should be considered as complicated cases.

And treated in a staged approach in two surgical episodes. What our colleagues said is that we should go on a step one, do a laparotomy, and deal with the condition that we have in the abdominal cavity like the purposes that sit, for example, and then go back after a couple of weeks to address the perineal hernia because in this way, a reduction of perineal hernia and repair of the hernia is technically easier. These colleagues suggest that bilateral hernias, unilateral perineal hernias with large rectal deviation, perineal hernias with concurrent surgical prostatic disease like a cyst or an abscess, and cases where we have urinary bladder retroflexion should be considered as complicated cases and treated in a staged approach.

There is some debate, of course, in this because Yes, the purpose of cyst, for example, may be considered as a cause of perineal hernia, but urinary bladder retroflection is not a cause, it's an effect. The defect is already, is already there and the bladder gets in that defect. So cases that can be treated in a staged approach are those that can be causes and not cases that are effects.

If you have a urinary bladder that's In, which is in the peroneal hernia, you should treat the peroneal hernia. In one episode. Regarding bilateral perineal hernias, most surgeons prefer to wait 4 to 6 weeks before performing the second hernia, but believe me, if you have a stable patient and you can address adequately the postoperative pain, but lateral repair may be also considered as I did in this, Rottweiler.

With this bilateral perineal hernia and in this Rottweiler, at the left side was the urinary bladder, popping in the contins. This is our patient before surgery, see how we are securing its tail with tape in the table, and we are getting ready for surgery. These are the instruments we're going to use.

Colour is very useful. We need periosteal elevators in order to raise our flaps. This is very important to have a couple of those in our, soft tissue pack.

And this is a technique that we are going to talk about, and this is the internal operator muscle elevation technique. You see on the right of your screen, the muscles and the anatomy of the area in the cadaver, the internal obduator muscle, the external anal sphincter, the levator and I muscle. The SL is the sacred tubular ligament and the H is the hernia.

You can see on the left side the way we're raising their flap. Some people like to do the tinotomy, some people don't. It depends on the case.

If you have a friable internal ob. Muscle, it's a good idea to do your tinotomy because you will have additional place to put a couple of more sutures taking the tendon into the repair. So if you have a friable IOM, you can do your tinotomy.

I definitely agree with that. Anatomy, anatomy, anatomy, this is a real case. You can see the hernia.

This is the coccyous muscle, the superficial gluteal muscle, the internal obator muscle here, and let's see the structures we need to preserve. First of all, the internal pudental artery and vein as shown here, along with the puddental nerve, they both run as a bundle, and you need, we must preserve those. To structures called the rectal, artery vein and nerve also at this point, and, this is the caudal luteal artery vein and nerve.

All these structures need to be preserved and we will talk about that the complications by the end of the lectures why we need to preserve these structures. This is Anita melococcus angle, 13 years old. This is how we start our incision from the base of the tail to the is tuberosity, can be straight incision, can be curved incision, no matter what we got.

The skin and the subcutaneous tissues and The next thing we see is the annual sac. We open the sac and what we will find in richer peroneal fat, the prostate, possibly the urinary bladder, less frequently small intestines or the rectum. We do what we have to do either a pose or excise, and then we review our anatomy.

We are elevating our flap. We are replacing the sutures, and I will give you a couple of tips about the external anal sphincter muscle and the sacrotubrous ligament muscle. When you're incorporating your external anal sphincter muscle in the repair.

Be careful to go wide with your needle holder, not deep. If you go deep, you may penetrate the rectal lumen echo, and that will cause a fistula to be formated. We don't want that to happen.

We don't want a fistula to be formated postoperatively. So take wide bites and incorporate as many much fibres of the external and sphincter as as you can. For the sacred tuberous ligament, keep in mind that just natural to this ligament.

You will see the sciatic nerve and that means that if you want to incorporate this ligament to your repair, you should go through its fibres and not around. If you go around, you may damage the sciatic nerve. So for the external anspectator go wide for the sacro tubular ligament, if you use it, go through.

So we need to preserve the sciatic nerve, we need to preserve the internal puddental artery and vein. We need to preserve the puddenal nerve. So this is our patient.

We have already raised our internal operator muscle flap as shown here. And if everything is done correctly, this is the tendon of insertion of IOM to the is, and if everything is done correctly, you will see a reverse Y to be formed when you tighten your sutures. That means that your repair has been done in the right way.

One more trick I'd like to use is to drape. to put a drape, I like to t drape as you can probably see the medical skin incision, and the reason I'm doing that is because I want to isolate my surgical field from the anus. And the reason I want to do this is because if my suture, the post suture that I've placed in the annals fails.

I don't want the, anything from the anus, faeces or anything else to to, to make any infection, in my surgical wound. It's a nice way to react to isolate, your, surgical site and prevent wound infection. This is another case you can also see here the reverse Y being formed.

That means that you have done a nice repair to the diaphragm. One more case here, German shepherd, 11 year old intact male. The structure that is popping from this perineal hernia is the prostate and periprostatic fat.

The prostate should be returned to the abdominal cavity. The periprostatic fat can be cut with cutlery and get away from there. One more case, a German shepherd dog intact male, 7 years old, right side perineal hernia.

And this is how we are raising our flap with our periosteal elevator after incising dorsolaerally the internal obulator muscle. You can also use your finger, your index finger, and go as much cranially as you can, but you should stop at the point that you will see the caudal border of the obulator foramen. This is where you should stop.

This is the flap that's been created. The sutures have been preplaced from dorsal to ventral. It's the easiest way to put your sutures, and these are the anatomy.

The coccygeous muscle, the elevator on a muscle, the external anal sphincter muscle, and the internal obvator muscle. And the final repair is here. This is our patient in day 2 after surgery, day 10 after surgery made an uneventful recovery.

This is the worst I've ever done. This is a 9 year old male poodle, very fat. Fat is not our friend.

It was very difficult for the team to identify the muscles and do the sing the right way. We were very lucky. Our patient had an uneventful, surgical repair and an uneventful recovery.

You will probably ask me what kind of sutures are we using? We can use non-absorbable sutures like polypropylene or we can use slowly absorbable seizures like polydioxinone or polygluconate. But believe me, you want to use only monofilament sutures, no use of multi-filament sutures, for perineal hernia repair.

What size, or 2 or 3 are depending on the size, of your patient and always on a taper needle because you don't want to cut, the muscles that you're incorporating in your repair. Let's see a video now. This is a 13 year old male in the Pomeranian with a perineal hernia, with a right perineal hernia.

We are making our initial incision from the base of the tail to the ischial tuberosity. You will see me here, just securing that I'm in the right spot. The ischial tuberosity, the original sac is already being seen just underneath the subcutaneous tissue.

You can see here the content of the hernia, which is the rectum. This is a great trick that I will, that I've already talked to you about. I like to Isolate my field in this way.

I find it very practical. Those of you who like can definitely do this. This is the internal muscle.

And we will start replacing the sutures in a few seconds. This is the IOM and how we are elevating the IOM with our periosteal elevator. You can see here how nicely it provides ventral support to the perineal hernia.

The coccygu muscle has been incorporated in our repair. This is a nice trick to get wide bites to the external and sphincter muscle. You can see how many fibres.

I incorporate In this way, Same way we're going from dorsal to ventral. The easiest way of placing sutures, we must place at least 6 to 8 sutures. In order to have a successful repair, sometimes, sometimes even more.

Can be 10, can be 12, depending on the size of the hernia. Here you can see the sutures have been all pre-placed and we will start tightening. Very nice and slow.

For because tissue may be viable. We are done. We have the closure of the reverse wire has been formatted.

Scans subcutaneous tissues are closely routinely and always at the end of surgery we are testing that we have done a good job and as you can probably see here, the pelvic diaphragm has been reconstructed successfully. The rectal support has been established again. There's no hook sign in the repair.

This is a friend's bulldog, 8 year old male intact. I want to show you here how you can raise the internal ovulator muscle flap doing this dorsal lateral incision to the IOM. Try to incorporate the periosteum in order to have all the fibres with you.

And this is the way you elevate the flap. Sometimes this muscle may be thick, like in this case, sometimes may be thin like the cocker spangle that I show you. At the beginning of the lecture, you can see here it's tendon of insertion.

I won't cut it in this case cause it's OK, the rest of the muscle for me to do my repair safely. This is the anatomy of the area of this patient, after suture replacement, contiguous muscle, lava and muscle, external sphincter muscle, the IOM and the ism. This is the patient 10 days postoperatively, the incisions have bone being healed, and the precotal castration also along with the, perineal hernia incision.

Now, postoperatively, how are dealing with these patients, antibiotics should be discontinued within 24 hours of surgery unless otherwise indicated. For example, we've had some necrotic tissue around, we may give antibiotics for more days. I like to use cold compresses 2 to 3 times daily for the 1st 2 or 3 days and then I go to warm compresses for a week.

Analgesics as necessary, non-steroidals or opioids or both of them, at least for a week, and Elizabethan colour, in order to prevent, self-mutilation, high fibre diet. For a couple of months, stool softeners like lactulose, and I'd like to monitor my wound for infection daily. Well, at this point, I think it's time to have a poll question.

I would ask you to choose the correct statement from this poll. . Anthony, OK, thank you.

Which one of those is the correct statement? The most common type of perinal hernia is ventral perinal hernia. Reposition technique is adequate for perinal hernia repair.

Preoperative enemas should be avoided. Multifilament sutures can be used for perineal her repair. Can you see the the voting, or do you want me to shout it out to you, Stefanos?

I, I'm seeing no results. Right, OK, I see the poll. I, I'm just seeing the poll.

Oh, you are. OK, now I'm seeing the results. Oh, OK, so we're doing.

Fine. 87% of our audience says that we should avoid preoperative enemas, and they are right. That's what we should do.

The most common type of perineal hernia is not ventral perinal hernia are caudal and lateral and . reposition technique is not adequate for perennial hernal repair because it does not provide good support at the ventral part of our ears. And of course, using multi-filament sutures, in this area should be avoided because with infection, if it happens, may give us an additional problem.

So thank you very much, everybody, for answering this poor question. . We can go on with the next slide.

Complications, there are a few. Wood infection, tenesmus, rectal prolapse, faecal incontinence, dysuria, urinary incontinence, sciatic nerve injury, or even worse entrapment. And urinary recurrences are things that we may see after a perineal urnary repair.

Well, regarding what infection, this is probably the most common complication we see. We may see a skin incision, with, in red, maybe in pain. swelling may be present or even discharge.

What should we do? We may remove, a couple of distal sutures to allow drainage if there is discharge. And based on culture and sensitivity testing, we may add some antibiotics, to help our patient and usually when the infection goes very well after these actions and it resolves.

Tenesmus is due to pain and inflammation. Analgesics is all you need to do. If you prescribe analgesics, this usually results in a few days, but please consider, during surgery if you had any sutures through the retal mucosa or the anal sacs because if you have created a fistula, no matter how many analgesics you will give, won't be resolved and you will probably need to go back and remove these sutures from the rectum by doing a rectal approach.

Rectal prolapse, this is more often seen with bilateral repairs and mostly in patients that already have even before surgery, a pre-existing, rectal disease. A temporary pre poor string suture is all that we need to do in order to alleviate the symptoms, but if in case of recurrence, calopexy may be considered. Faecal incontinence is one complication we may, we may see damage to your dental or caudal rectal nerve is why is this happening.

It may be unilateral and if it's unilateral, it's gonna be temporary, a few weeks. To resolve. If it's bilateral, it can be permanent.

Dyseria or even worse auria, this is due to a retroflex urinary bladder case. We may have some damage to the detritial muscle of the nerve that supply the urinary bladder and the proximal urethra. It's not a bad idea to place.

The urinary catheter preoperatively, even if you are an experienced surgeon in order to be able to identify where the urethra is at the pelvic floor at any time during your surgery. Urinary incontinence, this is rare. This is the cause of neurological damage to the urinary bladder or the proximal urethra.

And it usually resolves with alpha-addrenergic agonists like phenyl propanolamine in the standard and usual dosages. This is one of the worst things that may happen. The sign of injury or even worse entrapment.

You will have a patient with a severe non-weight bearing lameness, immediately after surgery or with many, or with some sciatic nerve deficits. What we, what we have to do is to go back to surgery and remove the offending sutures with a quadrilateral approach to the hip joint. At this time and recovery depends on severity.

It may take weeks or even months for our patient to recover. If you see here a paper from a good friend of mine, Max Papaolo, and other colleagues back to 2007 from JSOP. You can see here this suture that has been trapped, the sciatic nerve and the only way that the patient should walk again, in a good way after that was to go to surgery and remove the offending su and Please remember that the the easiest way to not to have those kind of, this kind of complication is if you decide to use the sacred tuberous ligament in your repair, you have to go your sutures through the ligament and not around.

If you go around, you may harm the sciatic nerve which lies just lateral to the sacro tubular ligament. Recurrence is something that none, none of us would like to see and it's a nightmare for any surgeon. This is probably due to poor identification of the anatomy of the area.

And this is the common, the most common cause of failure. Or due to the fact that we haven't constrained our patient, castration should be done for every male dog that is presented with a perineal hernia. What about prevention?

Prevention means castration. We should, we must cast. In order to avoid perinal hernias from occurrence or recurrence, threefold, possibilities of relapse if we are not constrained, our patients.

What about prognosis? Prognosis is fairly good. If we have good tissue integrity, if we can provide a tension-free repair, and always depends on surgeons' expertise.

Learning to doing this kind of surgery has a learning curve and as many operations as you do. You have to get better every time. This is what we like to call the learning curve.

And wrapping up, I will just try to give you my tips that I want you to remember before going to surgery, review your anatomy. This is the number one for every surgeon before entering the OR. Review the anatomy.

Avoid performing enemas. Try to digitally evacuate the rectum from faeces. This is the best way to do it.

EMS will provide liquid faeces, and those liquids may cause good infection to your perineal skin incision, and this may harm your repair. At surgery, number one, preoperative management, place your patient, in, sternal recumbency, . Do what we've already said, a white clip, empty the anal sacks, provide analgesia, give antibiotics, and do these things very meticulously in order to have, all the things that should be done, done.

The iron flap and castration is the best thing you have to do to repair this kind of earnings. Learn this technique and you will be able to address 95% of perennial earnings that you will be presented with. Use small filament sutures only use them from dorsal to ventral, and if you use them in the right way, if you put them in the right way, you will have a reverse wi formed after placement.

What kind of sutures? Polypropylene is number one, but if you use sutures like PDS or Maxon, is very reasonable options too. Remember for the external anal sphincter muscle when Putting your sutures through this muscle go wide, have wild bites.

Don't go deep. If you go deep, it may cause a fistula, and you don't want this to happen because this will cause as much and pain to the animal. And if you incorporate the sacred children's ligament, I'm saying again, go through the ligament with your sutures, not around.

If you go around, you may harm the sciatic nerve and believing no one wants that to happen. If you like the drape trick, you're free to do it. I like it a lot.

It's a nice trick to do. Don't leave any drains on your skin after closure. I know that many of these guys, many of these cases are chronic cases, and maybe the skin is very loose.

If there is redundant skin and you're afraid that you will have that space around after skin closure, you can excise all the redundant skin. In order to have no dead space behind, that space means seroma in place, so we don't want seroma to be formed, and the easiest way to do that is to remove the redundant skin. Drains may aid in wood infection, and we don't want that to happen.

And in reds, try to remember to always remove the poor string suture is not. Wise to leave a poor, your poor thing future in the end or after completion of surgery. This is the worst thing that may happen to you.

So This is a pic of my country from Greece. I hope that when pandemic goes away, we will, you will have the chance to visit Greece if you haven't done already. Until then, I wish you stay safe.

Hope you enjoy the rest of VC 2021. I'm here for any questions you may have. I will be very happy to answer.

And you can send me an email anytime in my email or reach me through social media or even the Huo app, which is a great app that Anthony and his team has created for this conference, . I'm waiting for your questions, hope you like it.