ABSTRACT
The study was conducted to maintain the proper surgical procedure for umbilical her- nia and atresia ani in calves and to observe the post operative care and management.
Four clinical cases (two umbilical hernia and two atresia ani) were handled in Up- azilla Veterinary Hospital, Ishwarganj, Bangladesh. The study was conducted from November 2011 to December 2011. The operation was done by using standard proce- dure for both umbilical hernia and atresia ani. The results of operation are very good with 100% recovery. The result also revealed few complications in herniorrhaphy in- cluding swelling, muscular weakness at the site of operation, accumulation of serous fluid. In case of atresia ani there was no post operative complication.
ACKNOWLEDGEMENT
All praises are due to almighty “God” the creator and supreme authority of universe that made me enable to complete this assignment.
The author feels great pleasure to express his deepest sense of gratitude, sincere ap- preciation and profound to his reverend teacher and internship supervisor Dr. Moham- mad Mahmudul Hassan, Assistant Professor, Dept. of Physiology, Biochemistry and Pharmacology, Chittagong Veterinary and Animal Sciences University, Khulshi, Chittagong for his valuable advice, suggestions and kind cooperation during the study period.
I would like to thanks Md. Moloy kanti Modokh, ULO, Ishwarganj Upazilla Veteri- nary hospital and Md. Mofizul Islam, VS Ishwarganj Upazilla Veterinary hospital for their instructions, advice, suggestions & needful help during internship period.
Finally, by no means least I am really very much grateful to all of my teachers, friends
& my parents who have inspired me in various ways.
Author
INTRODUCTION
Bangladesh is densely populated crop growing locations in the world and livestock is an integrated component of farming system plays a crucial role in the traditional econ- omy of Bangladesh. Ruminants especially large (cattle and buffaloes) and small (sheep and goat) ruminants constitute the major portion of the livestock. Most of these animals are reared in rural areas under smallholder traditional management system.
Larger ruminates especially cattle are used for draught power, meat and milk but also important for good quality leathers and a source of income to farmers. But various kinds of surgical diseases such as atresia ani, umbilical hernia, maggot wound, ab- scess, hump sore etc are responsible for discomfort, loss of market value, loss of hide quality and draught power of animal. Annual financial loss amounting to Taka 8118 crores (US $ 221 million) was estimated due to down grading & rejection of leather associated with the defects causes by surgical intervention (Dey and Nooruddin, 1993).
Livestock rearing is the integral part of farming system in Bangladesh, contributing 20% of the total inputs needed for crop production. Again contribution of the livestock to the national GDP is around 5.5 % (Anon, 2005). In spite of all these important contribution, the overall condition of valuable resource is not satisfactory.
The management practices of animal and geoclimatic condition of Bangladesh are favorable for the occurrence of various diseases. These diseases are responsible for reduced production and also mortality at times. However, the incidence of diseases varies with the species and age of the animals and season of the year (Rahman and Ali, 1972). Therefore, in this study an attempt was made to describe the outcome and post operative complication of surgical affections in calves comprises both congenital
& acquired disorders. In Bangladesh atresia ani, umbilical hernia, dermoid cyst, non functional limb joints, supernumerary limb have been reported to occur in calves (Hossain et al., 1988). A mutant gene, chromosomal aberration or an autosomal recessive gene have been claimed to be responsible for some congenital defects (Leipold et al., 1972). In Bangladesh, atresia ani in calves at birth occurs frequently and those are corrected surgically.
A Hernia is a protrusion of the contents of a body cavity through a weak spot of the body wall. This may be from accidental or a normal anatomical opening, which does not completely fulfill its physiological function. It is a common defect in calves (Vir- tala et al., 1996). Atresia ani, (imperforated anus), is the failure of the anal membrane to break down. The rectum is intact and attached to the membrane. Atresia ani is most frequently encountered in calves and pigs. If the rectum ends blindly as a cul- de sac a short distance cranial to the anal membrane, the condition is called rectal atresia (Noden and Lahunta, 1985). Atresia ani has been reported as a congenital defect in all species of domestic animals (Van Der Gass and Tibboel, 1980). The congenital abnor- malities of the anus and rectum are fairly common in young ones (Nixon, 1972).
OBJECTIVES:
1. To evaluation of the outcomes of herniorrhaphy and post-operative complication of reducible umbilical hernia in calves
2. To estimate the outcomes of surgery of atresia ani and post operative cares in calves.
MATERIALS AND METHODS
Umbilical hernia:
Animals:
The calves aged between 3 to 6 months were considered for the present study.
Study period:
The present study was conducted at the the Upazilla Veterinary Hospital, Ishwargang, Bangladesh during the period from November 2011 to December 2011.
Surgical procedure:
Preparations of animals:
The animal’s feed intake was reduced for 4 days and completely stopped for 24 hours before operation. Clipping and shaving was done in the site of operation following standard procedure.
Anesthesia:
The Anesthesia was done by using the with Diazepam (Sedil 2%; Square Pharmaceu- ticals Bangladesh) at a dose rate of 0.4 mg/kg body weight. The animal was controlled in the dorsal oblique recumbency. The umbilical region was anesthetized with Circu- lar infiltration of 2% lidocaine (Jasocaine; Jayson Pharmaceuticals, Bangladesh) at a dose of 10 mg/kg body weight.
Surgical methods:
Two elliptical incisions were made through the skin on each side of the sac. The her- nial ring was adequately exposed. The patch of skin between the incisions were bluntly dissected from the peritoneal sac and discarded. The edges of the skin were re- flected from the sac by blunt dissection. The peritoneal sac was carefully dissected from the underlying tissues. Care should be taken to avoid severing the sac exposing the peritoneal cavity. The hernia was reduced by pushing the sac into the peritoneal cavity. The hernial ring was freshened and closed by overlapping (simple interrupted) suture using chromic catgut size 3 to 4 with umbilical tape. The exposed edges of the ring along with the fascia were tucked to the body wall with a simple continuous su-
ture using chromic catgut 2 or 3. It was confirmed that no viscera adhered to the inte- rior of the sac on palpation and no internal umbilical structures were infected at physi- cal examination.
Suturing:
The suturing was done by the pattern of simple interrupted suture using chromic catgut size 3.
Post operative care and management:
Systemic antibiotic Streptomycin and procaine penicillin (SP vet, ACME Laborato- ries, Bangladesh) were used for 5 to 7 days at a dose rate of 40,000 IU/kg body weight (Procaine penicillin) and 10 mg/kg body weight (Streptomycin). Skin sutures were removed 10 days after surgery. The calf was fed on reduced roughages diet for about 2 weeks after the operation to minimize the pressure on the site of incision.
Complication:
Muscular weakness at the site of operation, swelling and accumulation of serous fluid.
Diognosis by palpation Incision through skin and subcutis
Pushing back of hernial content Suturing on hernial ring
Atresia ani :
Animal preparation:
Before anesthesia cleaning and shaving around the anus was performed. After shaving the region was rubbed by applying gauze soaked with povidine iodine. Animal was controlled in dorso-ventral position with its hind quarter raised on a table.
Anesthesia
Local infiltration anesthesia was performed using injection 2% lignocaine hy- drochloride (Zylocaine, Laborate Pharmaceuticals Ltd., Ahmedabad, India) solution at the proposed site of incision.
Surgical methods:
A circular incision was made on the skin bellow the base of the tail where anus presents. Blind end of colon was located and incised. Its mucosa was fixed to skin with simple interrupted sutures. Press was made on the abdomen region and meco- nium comes out immediately. Patency of opening was maintained by interrupted su- tures between the skin and mucous coat.
Suturing:
The suturing was done by the pattern of simple interrupted suture using chromic catgut size 3.
Post operative care and management: .
The surgical wound was cleaned and dressed regularly with liquid povidone iodine and ointment acrilin was applied and injection Gentamycin (Inj. Genta 10, ACME Laboratories, Bangladesh) was given intramuscular daily for 5 days at a dose rate of 5 mg/kg body weight . The sutures were removed 10 days of operation.
Atresia ani in calf Incision on skin
Incision on submucosa Crushing of the skin
Meconium comes out
REVIEW OF LITERATURE:
Umbilical hernia:
Etiology:
Umbilical hernias are secondary to failure of the normal closure of the umbilical ring and result in protrusion of abdominal contents into the overlying sub cutis. Size varies depending on the extent of the umbilical defect and the amount of abdominal contents contained within it. The etiology in small animals is likely to have a genetic compo- nent, excess traction on an oversized fetus or cutting the umbilical cord too close to the abdominal wall are other possible causes (Aiello, 1998). Sire and umbilical infec- tions are associated with risk of an umbilical hernia in calves during the first 2 months of life (Steenholdt and Hernandez, 2004). The etiology of an umbilical hernia may be an umbilical infection or abscess (Gadre et al., 1989). Umbilical hernias are sec- ondary to failure of the normal closure of the umbilical ring and result in protrusion of abdominal contents under the skin. Size varies depending on the extent of the defect and amount of abdominal contents contained. The etiology is likely to have a genetic component. The possible causes are excess traction on an oversized fetus or cutting the umbilical cord too close to the abdominal wall (Donal, 2010). Multiple births and shortened gestation lengths are two important risk factors for congenital umbilical hernias in calves (Herrmann et al., 2001).
Diagnosis:
Calves with simple hernias may be completely asymptomatic (no clinical signs) ex- cept for the presence of a reducible umbilical hernia (where the hernia contents can be pushed back into the abdomen). Structures most commonly found within an umbili- cal hernia are the abomasums (the "true stomach" of the calf) and the omentum, a filmy membrane that provides blood supply and healing factors to abdominal organs.
On examination, these structures can usually be pushed easily into the abdomen and the hernia ring palpated. In a very large or heavy animal it may be necessary to sedate the calf and put it in lateral or dorsal recumbency (on its side or back, respectively).
By performing this maneuver it is very simple to palpate the hernia and associated structures. A calf with an infection of umbilical remnants may have a fever, in appe- tence, and poor growth rate. If the umbilical arteries are involved, the calf voids small
amounts of urine frequently. The reason for this is that the urinary bladder is tied down to the umbilicus and never empties properly. A more worrisome condition is extension of infection to the remnants of the umbilical vein, which leads toward the liver. These calves may be more ill and less thrifty than other calves (Susan and Fu- bini, 2009). Diagnosis is usually straightforward, especially if the hernia can be re- duced manually. If the hernia is not reduced manually, it must be differentiated from an umbilical abscess, which is common in calves. Umbilical hernia and umbilical ab- scess may occur together, especially in cattle and swine. Exploratory puncture may be required for confirmation (Donal, 2010).
Treatment and prevention
Several methods for hernial treatment have been described. Ligation of the hernial sac, use of clamps, suturing of the hernial sac and radical operation are normally per- formed to correct the umbilical hernia, although open herniorrhaphy is the most com- mon method of treatment (Fahad and Ahmed, 2007). Various methods have been de- scribed in the literature for the treatment of umbilical hernia including counter irrita- tion, Clumping, suturing and safety pins and commercially-available rubber bands.
These methods are suitable only for reducible hernia and not for strangulated or com- plicated ones (Turner and McIlwraith, 1989). Open method of herniorrhaphy is al- ways indicated for older calves when adhesion or abscess is commonly associated with umbilical hernia (Horney et al., 1984). In case of open herniorrhaphy, elliptical skin incisions were made and the adhesions between the parietal peritoneum and skin were freed using both blunt and sharp dissection. The hernial rings were exposed and freshened before their suturing and finally closed by interrupted horizontal mattress sutures mostly with No. 2 chromic catgut (Surgigut; United States Surgical, USA).
The subcutaneous tissues were then sutured continuously with No. 1-0 chromic catgut and excessive skin was removed for better apposition and finally sutured with No. 2 silk or nylon in a simple interrupted suture pattern (Sutradhar et al., 2009). An ellipti- cal skin incision was performed and the adhesions between the parietal peritoneum and skin were freed with using both blunt and sharp dissection. The hernial ring was exposed and freshened. The subcutaneous tissue was then sutured by catgut and the excessive skin was removed before its suture with using polypropylene (Ethicon, UK) or silk suture (Fahad and Ahmed, 2007).
Premedication was performed with butorphanol tartrate (0.2 mg/kg IM, Torbugesic®, Fort Dodge) and xylazine maleate (0.15 mg/kg IM, Xilagesic®,Calier ). After the in- sertion of an intravenous catheter into the left jugular vein, anesthesia was induced with propofol (3 mg/kgIV, Propovet®).The animal was then intubated with an orotra- cheal tube and the anesthesia was maintained with oxygen and a 2%-3% isoflurane mixture. The patient was positioned in dorsal recumbency and the skin incision was made directly over the hernia. After skin and subcutaneous tissue dissection, the con- dition of the hernial sac and hernial ring were examined to confirm the absence of ad- hesions in the abdominal organs. The herniated viscera were repositioned in the ab- dominal cavity by manual taxis. Then, a 2-mm dissection was performed eccentrically around the ring between the peritoneum and tendon-muscle layer, with the aim of cre- ating space between these 2 anatomic formations where the mesh could be easily in- terposed. Two small incisions with Metzembaun scissors were necessary in the cranial and caudal points of the hernial ring because of the presence of physiological peri- toneum-linea alba tight adhesion.The hernioplasty was achieved through the use of a polypropylene mesh with margins interposed between the parietal peritoneum and the muscle-fascial layer The mesh was folded into 2 layers and sutured to the abdominal muscle layer and the fascia, 5 mm along the hernial circumference. The suture was performed using a single U suture of polyglycolic acid (Safi l® 0, Braun). Single stitches were preset and held with mosquito forceps. Once all of the single sutures were positioned, they were tied. Subcutaneous tissue and skin were routinely sutured;
during the subcutaneous closing, the suture also involved the mesh to avoid the cre- ation of dead space. The excess of distended skin was left because it would shrink to its original anatomic dimensions and position postoperatively (Jose et al., 2011).
The calf was simply tied with a halter and remained in the standing position. The sur- geon returned the hernia to the abdominal cavity without difficulty and with the aid of an assistant the bandage was applied to the abdomen. The first wrap of bandage is ap- plied directly over the hernia, with successive overlapping wraps being applied cranial and caudal to the hernia. A safety pin was used to secure the end of the bandage (An- derson, 2007). In case of closed herniorrhaphy, the hernia contents were pushed-back into the abdominal cavity in a ventro-dorsal position before suturing. It was confirmed that no viscera adhered to the interior of the sac on palpation and no internal umbilical structures were infected at physical examination. Then, a series of interrupted vertical
mattress sutures were made using No. 3-4 nylon suture to close the hernial ring from the outside of the skin about 0.5 inch apart from each other. Each animal was treated postoperatively with penicillin-streptomycin at a dose rate of 30,000 IU/kg for the penicillin and 10 mg/kg streptomycin for 5 days (Das et al., 2009).
Atresia ani:
Etiology :
Atresia ani is the congenital absence of anal opening or its obliteration by membrane causing a build up of feces and consequence distension of abdomen (Roberts, 1986).
It may be genital defect resulting in arrested development at the terminal portion of the digestive system (Roberts, 1986). Congenital defects, abnormalities of structure or function present at birth, may be caused by genetic or environmental factors, or a combination of both; in many cases, the causes are unknown. Developmental defects may be lethal, semi-lethal, or compatible with life causing aesthetic defects or having no effect on the animal (Johnson et al., 1985). Atresia ani is a congenital anomaly observed in calves, lambs, and kids. It may be a condition of its own or associated with atresia or agenesis of other parts like atresia recti, rectovaginal fistula, rectocystic fistula, vaginourethral agenesis, taileness, hypospadias, cleft serota etc. Atresia ani or atresia recti have been associated with abnormal chromosomes. Developmental anomalies of the fetal life, e.g. failure of the anal membrane to become perforated, failure of the bowel to become canalized, and interruption of the fetal blood supply to the anus may lead to atresia ani or atresia ani et recti (Tyagi and Sing, 1993).
Diagnosis:
Atresia ani is clinically diagnosed by distension of the abdomen, straining, and abdominal pain. The “meconium” is not expelled and the absence of the anal opening can be detected. If the rectum is fully developed without the anal opening, bulging of the anal region during straining is noticed. On palpation, the fluctuation of the rectal cul-de-sac can be recognized. If relief is not afforded, the animal dies within 4 or 5 days. If there is a partial opening in the anal region for the passage of feces, the animal may not have much difficulty so long as the feces remain soft and semisolid.
In recto-vaginal fistula, feces are passed partly through vulva (Kumar, 2004).
The diagnosis of intestinal atresia is often presumptive based on the age, history, and physical examination findings. Artesia ani can be diagnosed by visual Inspection of the perineal region or by limited digital palpation if a vestigial anal Opening is present. Further diagnostic testing or surgery is required for confirmation of intestinal atresia in a more proximal location. Exploratory laparotomy or necropsy must be per- formed for confirmation of the diagnosis and identification of affected segments lo- cated proximal to the anus (Killic and Sarierler, 2003).
Treatment and prevention :
The calf was controlled in dorso-ventral position with its hindquarter raised high on a table and restrained. The perineal region below the base of the tail was prepared for aseptic surgery. Local infiltration anaesthesia was performed using injection 2% lig- nocaine hydrochloride (Zylocaine, Laborate Pharmaceuticals Ltd., Ahmedabad, India) solution at the proposed site of incision. A circular incision was made upon the bulge of the anus and the circular piece of incised skin was removed. Meconium came out immediately. The patency of opening was maintained by application of interrupted su- tures by black braided silk size 2 between rectal mucosa and skin to make a perma- nent anal orifice. Post-operatively, the surgical wound was cleaned and dressed regu- larly with liquid povidone iodine and ointment acrilin was applied daily till recovery and injection gentamycin 3ml was given intramuscular daily for 5 days. The sutures were removed after ten days of operation (Suthar et al., 2010). Where the anus and rectum were not fully developed, there the rectal cul-de-sac was brought backward to the level of the anal opening. A circular piece of the rectal end was removed and the corresponding skin and mucus edges was sutured (Singh, 1989).
Surgery was performed under local infiltration anesthesia using Lignocaine HCl 2%.
In all atresia ani cases the abdomen was compressed initially and the animal devel- oped a bulge at the perineal area. A circular skin incision was made on the perineal re- gion (bulge) and the blind rectal culde-sac was identified exteriorized and opened, which voided feces and air. The rectal walls were sutured with the skin (Shiju et al., 2010). Atresia ani was treated by excision of a circular piece of skin. The blind end of the rectum was stitched to the circular skin opening by four stitches (dorsally, ven- trally and on both sides). The tip of the blind end of the rectum was snipped to evacu- ate the contents. The circumference of the rectal opening was sutured to the skin opening (Suess et al.,1992).
The animal is placed in sternal recumbency. Local anesthesia through infiltration of 2% Lidocaine HCL.A circular skin incision is made over the bulge or in the absence of a bulge, the anal depression is located and the underlying skin is brought out with a thumb or tissue forceps and the circular loose skin is dissected out. The rectum is then opened by a vertical incision to discharge the feces.After sufficient evacuation of the vowel by gentle pressure on abdominal wall. Simple interrupted suture is applied at 3,12,9 and 6 o clock position to suture the rectal wall to the skin (Remi-Adewunmi et al., 2007).
Result and discussion
Umbilical hernia :
In the present study the umbilical hernia was successfully reduced. After operation, the calves were followed 2 weeks of post operative care. There was only swelling, muscular weakness and accumulation of serous fluid were observed during the post operative period. According to Jose et al., (2010) there was a mild post operative edema due to the use of double layer mesh hernioplasty for repairing umbilical hernia.
He always used the ultrasonography to observe the stability and the position of the polypropylene mesh, and verified the local inflammatory edema and its resolution.
Echography also confirmed the presence of a mild postoperative edema during the first week of surgery. The edema reduced daily, until a complete resolution in patients between 15 and 30 days of surgery.
Fahad and Ahmed, (2007) reported that the umbilical opening was not closed properly due to the umbilical abscess and umbilical inflammation. The age of the calves were in between 3-6 months which is not similar in range (3-17 months) reported by Fahad and Ahmed, (2007
Fahad and Ahmed, (2007). also reported that surgical complications like abscesses and recurrence of hernia were occurred of the 2 goats due to previous surgeries.
In present cases the hernial ring size was 2-3cm in width and horizontal interrupted suture were used. According to Fahad and Ahmed, (2007) the size of umbilical rings were 5-10 cm and the gaps were reduced by using a horizontal mattress pattern of su- tures, as a result there were minor complications (abscesses) and chance of recur- rence.
According to O’Connor, (1980) open method of herniorrhaphy has many demerits es- pecially bacterial infection that might cause recurrence of hernia. Closed herniorrha- phy can minimize these postoperative complications.
Das et al., (2009) reported that treatment by closed herniorrhaphy appeared to be a more satisfactory (80%) regimen for reducible umbilical hernia in calves. Healing was
completed within 2 weeks of surgery. The healing was smoother and shorter in dura- tion. The sutures in closed methods of surgery help to promote adhesion by cicatriza- tion between the surface in contact and consequent closure of the hernial orifice (Das et al., 2009). So if the hernial ring size is less than 1 cm close method of herniorrha- phy is better.
Open method of herniorrhaphy is always indicated for older calves when adhesion or abscess is commonly associated with umbilical hernia (Horney et al., 1984).
Masakazu, (2005) reported that maggot infestation were occurred in open herniorrha- phy due to the direct contact with the floor and licking by the cows. Traintos et al., (2011) reported that the most common complications of umbilical hernia were cirrho- sis and ascites include leakage, ulceration, rupture and incarceration. In that study there was a high mortality rate after surgical repair.
Atresia ani:
In case of Atresia ani, Procaine penicillin and Streptomycin (SP vet, ACME Laborato- ries, Bangladesh) was used as post operative treatment and there was no post opera- tive complication observed. The injection was given intramuscularly for 7 days at a dose rate of 10000 IU/kg body weight (Procaine penicillin) and 5 mg/kg body weight (Streptomycin). The skin suture was removed 10 days of operation. According to Remi-Adewunmi et al., (2007) post surgical complications resulting from convection of atresia ani were uncommon. Some complications recorded were trauma to the sur- rounding structures, intrapelvic sepsis and cicitrical stricture of the anal opening. Ci- catricle stricture of the anal opening requires a secondary surgery. According to Suthar et al., (2010) the calf showed marked improvement in defecation and general behavior within 3rd day of surgery and uneventful recovery within 10th post-opera- tive day.
In present study, the case of atresia ani with it’s simple form of agenesis (without in- volving other parts) uneventful recovery after surgical intervention and similar find- ings in calves were reported by Steenhaunt et al., (1976) and Nagaraja, (2001).
Azizi et al., (2010) showed that surgical treatment of atresia ani through circular anal skin removal has a good prognosis for survival.
Vianna and Tobias, (2005) reported that few postoperative complications occured, in- cluding fecal incontinencey and colonic atony secondary to prolonged preoperative distension.
CONCLUSION
A hernia is a protrusion of the contents of a body cavity through a weak spot of the body wall. Several methods for hernial operation and treatment have been described.
Ligation of the hernial sac, use of clamps, suturing of the hernial sac and radical oper- ation are normally performed to correct the umbilical hernia. Open herniorrhaphy is the most common method of veterinary practice. Despite of its common use, the study reveals that open method of herniorrhaphy has many demerits especially muscular weakness at the site of operation, inflammatory swelling, accumulation of serous fluid etc.
The diagnosis of atresia ani is often presumptive based on the age, history, and physi- cal examinations. Atresia ani can be diagnosed by visual inspection of the perineal re- gion or by limited digital palpation if a vestigial anal opening is present. Surgical in- tervention is the only technique of choice for the treatment in such acute abdominal discomfort and it was attempted successfully in this present case which revealed that there was no post operative complication.
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