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Standing Thoracoscopic Diaphragmatic Hernia Repair Using a Dual-Facing Mesh in a Horse
Journal of Equine Veterinary Science 62 (2018) 13e17
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Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Standing Thoracoscopic Diaphragmatic Hernia Repair Using a Dual-Facing Mesh in a Horse Jacopo Corsalini*, Eleonora Lotto, Sara Nannarone, Marco Pepe, Rodolfo Gialletti Centro studi del cavallo sportivo, Department of Veterinary Medicine, University of Perugia, Perugia, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2017 Received in revised form 5 September 2017 Accepted 7 September 2017 Available online 2 November 2017
The purpose of the report, is to describe the surgical procedure adopted in a horse, to repair a diaphragmatic hernia by using a dual facing meshA 6-year-old Warmblood gelding was referred for colic surgery. Exploratory laparotomy revealed a small intestine strangulation in a 8e10 cm left dorsal diaphragmatic tear. A jejuno-jejunal anastomosis following resection of the strangulated intestine was accomplished. The horse recovered uneventfully and five days after surgery, a left sided thoracoscopy in standing position was performed. The diaphragmatic defect was repaired by using a dual facing mesh anchored with synthetic absorbable screws and permanent titanium helicoidal tacks.At follow-up thoracoscopy, 30 days later, the mesh was in the correct position, pleural tissue was covering 90% of the mesh surface, and signs of shrinking were absent. The surgical procedure performed by the authors is minimally invasive and presents some advantages compared to conventional thoracotomy as it gives an excellent visualization of the thoracic cavity combined with decreased perioperative morbidity and pain.Standing thoracoscopic application of a mesh should be considered as a reasonable option while planning the closure of a dorsal diaphragmatic tear in horses. © 2017 Elsevier Inc. All rights reserved.
Keywords: Thoracoscopy Mesh Diaphragmatic hernia Horse
1. Introduction Although diaphragmatic hernia is uncommon in the horse, it accounts for 0.67% to 7.77% of all equine surgical cases [1]. Clinical signs depend upon type and amount of abdominal viscera passed through the diaphragmatic defect, and mostly include abdominal pain but may also include respiratory compromise [2]. The degree of abdominal pain is often severe, and securing an accurate preoperative diagnosis is difficult; consequently, the correct diagnosis is often made intraoperatively or at necropsy [2]. Diagnosis may be even more challenging in horses presenting with mild respiratory compromise or other vague clinical signs [3]. Diaphragmatic tears can occur postmortem due to intestinal distension and usually are
Animal welfare/ethical statement: Animals included in the study were referred to Veterinary Teaching Hospital. They had a high standard of veterinary care, and their owners were involved in informed consensus consent. The study follows international, national, and institutional guidelines for humane animal treatment and complies with relevant legislation in the country. Conflict of interest statement: The authors declare no conflicts of interest. Funding: This study was not funded. * Corresponding author at: Jacopo Corsalini, Veterinary Medicine, University of Perugia, Via San Costanzo 4, 06126 Perugia, Italy. E-mail address: [email protected] (J. Corsalini). http://dx.doi.org/10.1016/j.jevs.2017.09.004 0737-0806/© 2017 Elsevier Inc. All rights reserved.
seen in the ventral diaphragm typically located at the ventral midline just dorsal to the xiphoid process [4]. Smooth-edged defects in the left dorsal diaphragm are believed to be congenital in origin, while acquired defects, occurring more frequently in the middle portion of the diaphragm [5], are usually larger and are commonly located at the transition of the muscular to the tendinous part of the diaphragm [6]. Successful surgical repair of diaphragmatic hernias has been reported in foals and young horses [7,8]. However, the prognosis in adult horses is guarded because of the operative access is challenging, there is a limited view of the surgical field, and significantly higher risk associated with general anesthesia [9]. Postoperative survival rate is reported to be 23% [10]. Current conventional surgical techniques involve surgical access through a retrosternal median laparotomy or transcostal access in lateral recumbency after resection of the ribs [8e10]. Some authors have recently reported a new technique for closure of diaphragmatic defects in adult horses using a minimally invasive approach that includes an intrathoracic suture [11]. The aim of this report is to describe the thoracoscopically assisted repair of a diaphragmatic hernia in a standing horse by using a dual-facing mesh, made of polyester and absorbable hydrophilic film, fixed with absorbable screws and titanium coils.
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2. Clinical Report 2.1. History and Clinical Findings A 6-year-old Warmblood gelding was referred for signs of acute abdominal pain. The owner reported no previous episodes of abdominal pain. At physical examination, the horse was unable to stand despite the repetitive use of sedative and analgesic drugs. Heart rate 60 beats/min, respiratory rate 36 breaths/min, absent intestinal sounds, moderate abdominal distension, congested mucous membranes, capillary refill time of 3 seconds, and rectal temperature 38.3 C were the main clinical parameters. Multiple distended small intestine loops were detected at rectal exploration. Abdominal ultrasound confirmed the presence of several distended immotile loops of small intestine and revealed an increase of both peritoneal and pleural fluid (left hemithorax). Emergency laboratory parameters included packed cell volume of 48%, total serum protein of 7.8 g/dL, and blood lactate of 6.3 mmol/L. Clinical findings were suggestive of small intestine strangulation consequently the horse laparotomy. Surgical exploration of the abdomen revealed a tear (8e10 cm) in the left dorsal tendinous part of the diaphragm, dorsal to the spleen. Within the defect, a portion of small intestine was incarcerated. The herniated viscera were not reducible by manual traction until the defect of the diaphragm had been enlarged of few cms using the laparoscopic scissors. Six meters of necrotic jejunum was resected, and a side-to-side jejunojejunal anastomosis was performed. Since the defect was located in the dorsal part of the diaphragm, next to the abdominal vault, herniorrhaphy in dorsal recumbency would have been technically difficult to perform, so the abdomen was closed and a plan for a less invasive approach was programmed. Considering the size of the diaphragmatic defect and in order to prevent a relapse, a left-sided thoracoscopy in standing position was scheduled to be performed as soon as the horse's clinical condition would have been adequate for having the surgical procedure accomplished safely. 2.2. Materials and Methods 2.2.1. Surgical Procedure Five days after laparotomy, food was withheld 12 hours prior to surgery, while free access to water was allowed. Procaine penicillin (Depomicina; MSD Animal Health S.r.l., Segrate, Milano, Italy) (22,000 UI/kg bodyweight [bwt], intramuscular [IM]), streptomycin (Depomicina) (11 mg/kg bwt, IM), and flunixin meglumine (Flunifen; Ceva Salute Animale S.p.A., Agrate Brianza, Monza, Italy) (1.1 mg/kg bwt, intravenously [IV]) were administered within 30 minutes prior to surgery. The horse was restrained in stocks, and the left thoracic wall was clipped and aseptically prepared. Sedation was achieved with detomidine hydrochloride (Domidine; FATRO S.p.A, Italy) (8.4 mg/kg bwt, IV) and butorphanol tartrate (Dolorex; MSD Animal Health S.r.l.) (20 mg/kg bwt, IV) and maintained via continuous rate infusion of detomidine hydrochloride as previously described [12]. Oxygen 100% was administered at 6.5 L/min by nasal insufflation. After draping, local anesthesia was obtained by infiltration of 2% mepivacaine (Carbosen 20 mg/mL, Industria Farmaceutica Galenica Senese S.r.l) (20 mL per portal site) through skin, intercostal musculature, and parietal pleura. A 1-cm stab incision was made through the skin and the serratus ventralis thoracis muscle in the 10th intercostal space, just ventral to the epaxial muscles at the level of the ventral border of the tuber coxae. The optical portal was created through the introduction of the trocar (5e11 mm fixation cannula and 11-mm gun-like optical
obturator [Visiport Plus RPF 5e11 mm Optical Trocar with Versaport Plus RPF Single Use Radiolucent Converterless Trocar Sleeve; Covidien Italia Spa, Segrate, Milano, Italy]). Pneumothorax was induced by opening the trocar valve until complete collapse of the ipsilateral lung [13]. Following the examination of the diaphragmatic defect through a 30 telescope (Fig. 1), two instrumental portals (one 5 mme12 mm Versaport [Versaport Plus V2 5e12 mm; Covidien Italia Spa] and one 10 mme15 mm Versaport [Versaport Plus RPF 10 mme15 mm Bladed Trocar, Smooth Cannula; Covidien Italia Spa]) were created in the 13th intercostal space, 3 cm dorsal, and 3 cm ventral to the optical portal. A dual-facing mesh (Parietex Optimized Composite Mesh; 20 cm 15 cm; Covidien, Italia Spa) was used to repair the diaphragmatic tear. The mesh is made of both absorbable and nonabsorbable materials (Fig. 2). The parietal side consists of nonabsorbable three-dimensional polyester mesh, which is designed to provide long-term reinforcement of the soft tissue repaired. The visceral side is covered by an absorbable hydrophilic film (porcine collagen), which prevents adhesions in case of direct contact with viscera. The mesh was cut with surgical scissors in order to have 4 cm minimum overlap between the diaphragmatic defect and the mesh. It was rolled into a cylinder and inserted through the 10-mm trocar. In order to manipulate the mesh for accurate placement, two laparoscopic babcock forceps were used with the help of the second surgeon and three further instrumental portals (5 mme12 mm Versaport [Versaport Plus V2 5e12 mm]) were created in the 14th intercostal space, 2 cm dorsal, 2 cm ventral, and 6 cm ventral to the optical portal. The polyester side was placed in contact with the diaphragm and fixed with helical titanium coils (Pro-tack [ProTack 5 mm Fixation Device, titanium helical tack, Medtronic, Covidien, Italia Spa]) and absorbable poly (D, L)-lactide screws (Sorbafix [SorbaFix Absorbable Fixation system; BARD Srl, Via Cina, 444, 00144 Roma]) (Fig. 3). High differential pressure was noticed between thoracic and abdominal cavity at each respiratory movement, hence several coils (10 titanium coils and 20 absorbable screws) were used to establish a successful fixation of the mesh. After the tear was completely sealed, pneumothorax was reduced using a suction system connected to the trocar valve until expansion of the lung was achieved. Pneumoperitoneum was not reduced since the amount of air passing from the thorax into the abdomen was considered of minor importance (pneumothorax was
Fig. 1. Visualization of the 10-cm sized defect in the left dorsal part of the diaphragm. The adhesion was severed with an electrothermal bipolar tissue sealing system (Ligasure) before the application of the mesh.
J. Corsalini et al. / Journal of Equine Veterinary Science 62 (2018) 13e17
induced by opening the trocar valve only, and CO2 was not insufflated), and the creation of an abdominal portal was regarded as invasive. After removal of the trocars, the skin was closed with a 1 nylon simple continuous suture. Surgical procedure lasted 58 minutes, from the creation of the first portal to the closure of the last incision. Postoperative treatment included antibiotics (procaine penicillin [Depomicina]: 22,000 UI/kg bwt, IM, BID and streptomycin [Depomicina]: 11 mg/kg bwt, IM, BID) and NSAID (flunixin meglumine [Flunifen] 1.1 mg/kg bwt, IV, SID). Recovery was uneventful initially. On day 3, a low grade fever (38.8 C) and increased respiratory rate (20 breaths/min) occurred. Thoracic ultrasound examination revealed an increased amount of hypo-echoic fluid on the left hemithorax. A per-cutaneous sample collection was performed and submitted to analysis. As Pseudomonas spp. serofibrinous pleuritis was diagnosed, excessive pleural fluid was drained at the level of seventh and eighth left intercostal space every other day (three times overall) by using a 20F silicone trocar catheter, and antibiotic therapy was implemented (marbotoquinol Italia S.r.l., Bertinoro, Italy]: floxacin [Marbocyl 10%; Ve 2 mg/kg bwt, IV, SID) until complete normalization of pleural fluid analysis achieved 20 days later. 2.2.2. Follow-up Thirty days postoperative, a thoracoscopic follow-up was performed both to assess the position of the mesh and to remove the fibrinous material persisting in the pleural cavity [13]. The diaphragmatic defect was completely sealed. Some tissue ingrowth into the polyester layer was observed, and signs of shrinking or wrinkling were not noticed (Fig. 4). At 6 months, follow-up physical examination was unremarkable. The owner reported no recurrence of neither abdominal nor respiratory symptoms when the horse went back to work. 3. Discussion Surgical repair of diaphragmatic hernia in horses poses anesthetic and surgical challenges that contribute to the poor prognosis generally associated with this condition [10]. Conservative management of diaphragmatic hernia is reported [14]. The horse, affected by a diaphragmatic hernia involving the large colon, remained comfortable at pasture for 2 years but was unable to exercise due to dyspnea, had occasional bouts of abdominal discomfort, and eventually was euthanized due to severe colic. Kelmer et al [15] reported a case of a mare presented with acute
Fig. 2. Dual facing 20 cm 15 cm three-dimensional polyester mesh with absorbable (porcine collagen) hydrophilic film. The mesh was formerly split into two.
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Fig. 3. Mesh fixed with titanium coils and absorbable screws all around the diaphragmatic defect during thoracoscopy. Fixing the mesh smoothly was technically challenging because of both the continuous movements of the diaphragm and the flow of air passing through the diaphragmatic tear during respiration. Consequently, the mesh appears “bunched up.”
abdominal pain that responded well to aggressive medical management. Although diaphragmatic hernia involving the large colon was diagnosed, surgery was not an option. The mare was comfortable at pasture for 2 months and was eventually euthanized due to severe colic. As evidenced by several reports describing the successful surgical treatment of diaphragmatic hernia in horses [2,7e9,16e19], success rate of surgical management has recently improved. One reason that can explain this improvement is the use of novel surgical approaches that provide better access to the lesions which are not readily accessible via a routine ventral midline approach. According to several reports, a diaphragmatic defect is often surgically inaccessible, giving to the surgeon few options: (1) to tilt the surgical table with the aim of making the lesion more accessible, (2) to repair the rent blindly using a polypropylene mesh secured with stainless steel staples [16], (3) to recover the horse in the attempt to repair the lesion using a different approach, (4) to recover the horse without repairing the diaphragmatic defect, (5) to euthanize the horse on the table. Several surgical approaches have been used for diaphragmatic hernia repair [2,20,21]. In foals, the cranioventral midline approach can provide adequate access to all the regions of the diaphragm. In adult horses, this approach provides excellent access to the central ventral aspect of the diaphragm but limited access to the dorsal diaphragm. Slightly more than one-third (34/96) of diaphragmatic hernia cases involved the ventral aspect of the diaphragm only [22]. Thus, a cranioventral midline celiotomy provides very limited access to and visibility of most (>60%) of the diaphragmatic hernias in horses. Several manipulations can improve the surgeon's access to a lesion when a cranioventral midline approach is used. Tilting the surgery table into a reverse Trendelenburg position (head up 30 ) facilitates caudal displacement of the viscera, thus improving visibility of the diaphragm, especially its dorsal aspect [21]. In addition, tilting the table laterad away from the affected side may provide better access to a diaphragmatic defect [21,23]. Extending the cranioventral midline incision 15e20 cm laterad and parallel to the last rib at the level of the xiphoid process can increase accessibility to dorsal diaphragmatic defects. This approach requires incising the abdominal muscles and can result in significant intraoperative hemorrhage [24]. Exteriorizing the ascending and descending colon onto a colon tray may also improve
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Fig. 4. Thoracoscopic follow-up at 30 days. Tissue ingrowth over the mesh can be appreciated. Signs of shrinking or wrinkling are absent.
accessibility to the diaphragm [8]. A flank approach can be used to localize the lesion by manual palpation, and the results of this surgery can be used to determine how best to approach the lesion via thoracotomy [9]. The case reported here presented some complexities regarding the best surgical approach to use. The diaphragmatic tear was difficult to treat from the laparotomy incision because of its extremely dorsal position and conservative treatment was not an option because the defect was even enlarged during the extraction of the incarcerated intestine. As reported in the literature, an alternative approach involves thoracoscopy, a technique that provides excellent visibility of the diaphragm both in standing and laterally recumbent horses [13,25]. Thoracoscopy has proven to be safe in diagnosing and treating thoracic lesions in horses [26]. Although the fenestrated mediastinum [27] of the horse makes bilateral pneumothorax a concern when thoracoscopy is performed, experience indicates that the contralateral lung usually remains inflated during thoracoscopic procedures [25]. Nevertheless, having a suction device ready to use remains of invaluable utility in case respiratory distress occurs. Although thoracoscopy is the preferred technique for diaphragmatic hernia repair in human patients [28,29], diaphragmatic repair using a thoracoscopic approach has not been reported in horses until recently when Rocken et al [11] have been successful at suturing a diaphragmatic tear in a mare. Instead of using intracavitary suture, mesh has widely gained popularity for closure of abdominal tears [30], thoracic defects [31], inguinal rings [32], incisional hernia [33], nephrosplenic space closure [34], and most recently foramen epiploicum closure [35]. Advantages of using mesh and coils include lack of technical difficulties associated with making knots with laparoscopic instruments [36], tension is spread across the tissue [37], opportunity to close larger defect [38], and reduced risk of herniation relapse [39]. Pros and cons of using different meshes in equine surgery are still poorly documented. Recently, a review regarding the use of various meshes in human beings has been published [40]. The most important properties of meshes were the type of filament, the tensile strength, and the porosity. These features determine the weight of the mesh and its biocompatibility. In most situations, surgeons should look for a light-weight mesh, with large pores and minimal surface area [40]. Ideally, it should consist of a monofilament. Polypropylene or polyester meshes are comfortable and have a lower risk of infection, therefore, usually suitable. These meshes are the most commonly used in horses [30e38].
For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others [40]. All meshes produce adhesions when placed adjacent to the bowl, but their extent is determined by pore size, filament structure, and surface area. Heavy-weight meshes induce an intense fibrotic reaction which ensures strong adherence to the abdominal wall but also causes dense adhesions. In contrast, microporous expanded polytetrafluoroethylene does not allow tissue in growth. It has a very low risk of adhesion formation but is unable to adhere strongly to the abdominal wall. Composite meshes provide the advantage of having an additional surface which can be safely placed in contact with viscera, while peritoneal mesothelial cells grow over the mesh and once a peritoneal layer has formed, it should prevent adhesions. Despite manufacturers' claims, the differences between the various types of these are unproven and it is currently difficult to recommend a single material [40]. The mesh chosen in this case report has already been being used by the authors for laparoscopic nephrosplenic closure for years with good results (unpublished data). It is a composite mesh with a hydrophilic three-dimensional polyester textile on one side and a porcine collagen film on the other side. The polyester frame encourages rapid abdominal wall integration and superior cellular proliferation when compared to polypropylene mesh in vitro [41] and provides rapid fibrous ingrowth [42,43] and minimal shrinkage [42,44]. Also, polyester meshes coated with a layer of porcine collagen have been associated with less adhesions formation in the first 7 days after surgery in comparison with polypropylene meshes coated with a layer of cellulose [45]. The composite polyester meshes have costs similar to the composite polypropylene meshes. Advantages of using a dual-facing mesh were taken into account when surgical procedure was planned. We report a successful thoracoscopic herniorrhaphy of a 8- to 10-cm defect in the dorsal diaphragm without rib resection in a Warmblood gelding by using a dual-facing mesh. Titanium coils and absorbable screws were used for mesh fixation. Despite continuous movement of the diaphragm during respiration, mesh was fixed to the diaphragm. It is in the authors' experience (abdominal wall hernia, nephrosplenic closure, inguinal ring closure) that preventing short-term recurrence of hernia due to mesh shrinkage and movement is of primary importance, particularly when the mesh is placed on areas subjected to movements. Consequently, the mesh was placed with the polyester side facing the diaphragmatic muscle in order to have both a fast and secure mesh-tissue integration and to prevent adhesions between the mesh and the lungs. Titanium coils are reported to have more tenacity at fixation than absorbable screw but are more likely to cause adhesions [46]. In order to have both a secure fixation of the mesh and a small number of titanium coils (n ¼ 10), 20 absorbable screws were used. Thoracoscopy provided excellent visualization of the diaphragmatic tear. Mild perioperative pain and low postoperative morbidity were achieved. Major postoperative complications were not observed. Mesh application is reported to be associated with an increased rate of infection in human patients [47]. The horse in this report developed a postoperative infection of the pleural cavity that required protracted antibiotic therapy and multiple (three) chest drainage procedures. An association between mesh application and postoperative infection was suspected, but removal of the implant was not necessary. This is in contrast with several studies reporting the need of implant removal in case of prosthesis infection in human patients [48].
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Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Case Report
Standing Thoracoscopic Diaphragmatic Hernia Repair Using a Dual-Facing Mesh in a Horse Jacopo Corsalini*, Eleonora Lotto, Sara Nannarone, Marco Pepe, Rodolfo Gialletti Centro studi del cavallo sportivo, Department of Veterinary Medicine, University of Perugia, Perugia, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2017 Received in revised form 5 September 2017 Accepted 7 September 2017 Available online 2 November 2017
The purpose of the report, is to describe the surgical procedure adopted in a horse, to repair a diaphragmatic hernia by using a dual facing meshA 6-year-old Warmblood gelding was referred for colic surgery. Exploratory laparotomy revealed a small intestine strangulation in a 8e10 cm left dorsal diaphragmatic tear. A jejuno-jejunal anastomosis following resection of the strangulated intestine was accomplished. The horse recovered uneventfully and five days after surgery, a left sided thoracoscopy in standing position was performed. The diaphragmatic defect was repaired by using a dual facing mesh anchored with synthetic absorbable screws and permanent titanium helicoidal tacks.At follow-up thoracoscopy, 30 days later, the mesh was in the correct position, pleural tissue was covering 90% of the mesh surface, and signs of shrinking were absent. The surgical procedure performed by the authors is minimally invasive and presents some advantages compared to conventional thoracotomy as it gives an excellent visualization of the thoracic cavity combined with decreased perioperative morbidity and pain.Standing thoracoscopic application of a mesh should be considered as a reasonable option while planning the closure of a dorsal diaphragmatic tear in horses. © 2017 Elsevier Inc. All rights reserved.
Keywords: Thoracoscopy Mesh Diaphragmatic hernia Horse
1. Introduction Although diaphragmatic hernia is uncommon in the horse, it accounts for 0.67% to 7.77% of all equine surgical cases [1]. Clinical signs depend upon type and amount of abdominal viscera passed through the diaphragmatic defect, and mostly include abdominal pain but may also include respiratory compromise [2]. The degree of abdominal pain is often severe, and securing an accurate preoperative diagnosis is difficult; consequently, the correct diagnosis is often made intraoperatively or at necropsy [2]. Diagnosis may be even more challenging in horses presenting with mild respiratory compromise or other vague clinical signs [3]. Diaphragmatic tears can occur postmortem due to intestinal distension and usually are
Animal welfare/ethical statement: Animals included in the study were referred to Veterinary Teaching Hospital. They had a high standard of veterinary care, and their owners were involved in informed consensus consent. The study follows international, national, and institutional guidelines for humane animal treatment and complies with relevant legislation in the country. Conflict of interest statement: The authors declare no conflicts of interest. Funding: This study was not funded. * Corresponding author at: Jacopo Corsalini, Veterinary Medicine, University of Perugia, Via San Costanzo 4, 06126 Perugia, Italy. E-mail address: [email protected] (J. Corsalini). http://dx.doi.org/10.1016/j.jevs.2017.09.004 0737-0806/© 2017 Elsevier Inc. All rights reserved.
seen in the ventral diaphragm typically located at the ventral midline just dorsal to the xiphoid process [4]. Smooth-edged defects in the left dorsal diaphragm are believed to be congenital in origin, while acquired defects, occurring more frequently in the middle portion of the diaphragm [5], are usually larger and are commonly located at the transition of the muscular to the tendinous part of the diaphragm [6]. Successful surgical repair of diaphragmatic hernias has been reported in foals and young horses [7,8]. However, the prognosis in adult horses is guarded because of the operative access is challenging, there is a limited view of the surgical field, and significantly higher risk associated with general anesthesia [9]. Postoperative survival rate is reported to be 23% [10]. Current conventional surgical techniques involve surgical access through a retrosternal median laparotomy or transcostal access in lateral recumbency after resection of the ribs [8e10]. Some authors have recently reported a new technique for closure of diaphragmatic defects in adult horses using a minimally invasive approach that includes an intrathoracic suture [11]. The aim of this report is to describe the thoracoscopically assisted repair of a diaphragmatic hernia in a standing horse by using a dual-facing mesh, made of polyester and absorbable hydrophilic film, fixed with absorbable screws and titanium coils.
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2. Clinical Report 2.1. History and Clinical Findings A 6-year-old Warmblood gelding was referred for signs of acute abdominal pain. The owner reported no previous episodes of abdominal pain. At physical examination, the horse was unable to stand despite the repetitive use of sedative and analgesic drugs. Heart rate 60 beats/min, respiratory rate 36 breaths/min, absent intestinal sounds, moderate abdominal distension, congested mucous membranes, capillary refill time of 3 seconds, and rectal temperature 38.3 C were the main clinical parameters. Multiple distended small intestine loops were detected at rectal exploration. Abdominal ultrasound confirmed the presence of several distended immotile loops of small intestine and revealed an increase of both peritoneal and pleural fluid (left hemithorax). Emergency laboratory parameters included packed cell volume of 48%, total serum protein of 7.8 g/dL, and blood lactate of 6.3 mmol/L. Clinical findings were suggestive of small intestine strangulation consequently the horse laparotomy. Surgical exploration of the abdomen revealed a tear (8e10 cm) in the left dorsal tendinous part of the diaphragm, dorsal to the spleen. Within the defect, a portion of small intestine was incarcerated. The herniated viscera were not reducible by manual traction until the defect of the diaphragm had been enlarged of few cms using the laparoscopic scissors. Six meters of necrotic jejunum was resected, and a side-to-side jejunojejunal anastomosis was performed. Since the defect was located in the dorsal part of the diaphragm, next to the abdominal vault, herniorrhaphy in dorsal recumbency would have been technically difficult to perform, so the abdomen was closed and a plan for a less invasive approach was programmed. Considering the size of the diaphragmatic defect and in order to prevent a relapse, a left-sided thoracoscopy in standing position was scheduled to be performed as soon as the horse's clinical condition would have been adequate for having the surgical procedure accomplished safely. 2.2. Materials and Methods 2.2.1. Surgical Procedure Five days after laparotomy, food was withheld 12 hours prior to surgery, while free access to water was allowed. Procaine penicillin (Depomicina; MSD Animal Health S.r.l., Segrate, Milano, Italy) (22,000 UI/kg bodyweight [bwt], intramuscular [IM]), streptomycin (Depomicina) (11 mg/kg bwt, IM), and flunixin meglumine (Flunifen; Ceva Salute Animale S.p.A., Agrate Brianza, Monza, Italy) (1.1 mg/kg bwt, intravenously [IV]) were administered within 30 minutes prior to surgery. The horse was restrained in stocks, and the left thoracic wall was clipped and aseptically prepared. Sedation was achieved with detomidine hydrochloride (Domidine; FATRO S.p.A, Italy) (8.4 mg/kg bwt, IV) and butorphanol tartrate (Dolorex; MSD Animal Health S.r.l.) (20 mg/kg bwt, IV) and maintained via continuous rate infusion of detomidine hydrochloride as previously described [12]. Oxygen 100% was administered at 6.5 L/min by nasal insufflation. After draping, local anesthesia was obtained by infiltration of 2% mepivacaine (Carbosen 20 mg/mL, Industria Farmaceutica Galenica Senese S.r.l) (20 mL per portal site) through skin, intercostal musculature, and parietal pleura. A 1-cm stab incision was made through the skin and the serratus ventralis thoracis muscle in the 10th intercostal space, just ventral to the epaxial muscles at the level of the ventral border of the tuber coxae. The optical portal was created through the introduction of the trocar (5e11 mm fixation cannula and 11-mm gun-like optical
obturator [Visiport Plus RPF 5e11 mm Optical Trocar with Versaport Plus RPF Single Use Radiolucent Converterless Trocar Sleeve; Covidien Italia Spa, Segrate, Milano, Italy]). Pneumothorax was induced by opening the trocar valve until complete collapse of the ipsilateral lung [13]. Following the examination of the diaphragmatic defect through a 30 telescope (Fig. 1), two instrumental portals (one 5 mme12 mm Versaport [Versaport Plus V2 5e12 mm; Covidien Italia Spa] and one 10 mme15 mm Versaport [Versaport Plus RPF 10 mme15 mm Bladed Trocar, Smooth Cannula; Covidien Italia Spa]) were created in the 13th intercostal space, 3 cm dorsal, and 3 cm ventral to the optical portal. A dual-facing mesh (Parietex Optimized Composite Mesh; 20 cm 15 cm; Covidien, Italia Spa) was used to repair the diaphragmatic tear. The mesh is made of both absorbable and nonabsorbable materials (Fig. 2). The parietal side consists of nonabsorbable three-dimensional polyester mesh, which is designed to provide long-term reinforcement of the soft tissue repaired. The visceral side is covered by an absorbable hydrophilic film (porcine collagen), which prevents adhesions in case of direct contact with viscera. The mesh was cut with surgical scissors in order to have 4 cm minimum overlap between the diaphragmatic defect and the mesh. It was rolled into a cylinder and inserted through the 10-mm trocar. In order to manipulate the mesh for accurate placement, two laparoscopic babcock forceps were used with the help of the second surgeon and three further instrumental portals (5 mme12 mm Versaport [Versaport Plus V2 5e12 mm]) were created in the 14th intercostal space, 2 cm dorsal, 2 cm ventral, and 6 cm ventral to the optical portal. The polyester side was placed in contact with the diaphragm and fixed with helical titanium coils (Pro-tack [ProTack 5 mm Fixation Device, titanium helical tack, Medtronic, Covidien, Italia Spa]) and absorbable poly (D, L)-lactide screws (Sorbafix [SorbaFix Absorbable Fixation system; BARD Srl, Via Cina, 444, 00144 Roma]) (Fig. 3). High differential pressure was noticed between thoracic and abdominal cavity at each respiratory movement, hence several coils (10 titanium coils and 20 absorbable screws) were used to establish a successful fixation of the mesh. After the tear was completely sealed, pneumothorax was reduced using a suction system connected to the trocar valve until expansion of the lung was achieved. Pneumoperitoneum was not reduced since the amount of air passing from the thorax into the abdomen was considered of minor importance (pneumothorax was
Fig. 1. Visualization of the 10-cm sized defect in the left dorsal part of the diaphragm. The adhesion was severed with an electrothermal bipolar tissue sealing system (Ligasure) before the application of the mesh.
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induced by opening the trocar valve only, and CO2 was not insufflated), and the creation of an abdominal portal was regarded as invasive. After removal of the trocars, the skin was closed with a 1 nylon simple continuous suture. Surgical procedure lasted 58 minutes, from the creation of the first portal to the closure of the last incision. Postoperative treatment included antibiotics (procaine penicillin [Depomicina]: 22,000 UI/kg bwt, IM, BID and streptomycin [Depomicina]: 11 mg/kg bwt, IM, BID) and NSAID (flunixin meglumine [Flunifen] 1.1 mg/kg bwt, IV, SID). Recovery was uneventful initially. On day 3, a low grade fever (38.8 C) and increased respiratory rate (20 breaths/min) occurred. Thoracic ultrasound examination revealed an increased amount of hypo-echoic fluid on the left hemithorax. A per-cutaneous sample collection was performed and submitted to analysis. As Pseudomonas spp. serofibrinous pleuritis was diagnosed, excessive pleural fluid was drained at the level of seventh and eighth left intercostal space every other day (three times overall) by using a 20F silicone trocar catheter, and antibiotic therapy was implemented (marbotoquinol Italia S.r.l., Bertinoro, Italy]: floxacin [Marbocyl 10%; Ve 2 mg/kg bwt, IV, SID) until complete normalization of pleural fluid analysis achieved 20 days later. 2.2.2. Follow-up Thirty days postoperative, a thoracoscopic follow-up was performed both to assess the position of the mesh and to remove the fibrinous material persisting in the pleural cavity [13]. The diaphragmatic defect was completely sealed. Some tissue ingrowth into the polyester layer was observed, and signs of shrinking or wrinkling were not noticed (Fig. 4). At 6 months, follow-up physical examination was unremarkable. The owner reported no recurrence of neither abdominal nor respiratory symptoms when the horse went back to work. 3. Discussion Surgical repair of diaphragmatic hernia in horses poses anesthetic and surgical challenges that contribute to the poor prognosis generally associated with this condition [10]. Conservative management of diaphragmatic hernia is reported [14]. The horse, affected by a diaphragmatic hernia involving the large colon, remained comfortable at pasture for 2 years but was unable to exercise due to dyspnea, had occasional bouts of abdominal discomfort, and eventually was euthanized due to severe colic. Kelmer et al [15] reported a case of a mare presented with acute
Fig. 2. Dual facing 20 cm 15 cm three-dimensional polyester mesh with absorbable (porcine collagen) hydrophilic film. The mesh was formerly split into two.
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Fig. 3. Mesh fixed with titanium coils and absorbable screws all around the diaphragmatic defect during thoracoscopy. Fixing the mesh smoothly was technically challenging because of both the continuous movements of the diaphragm and the flow of air passing through the diaphragmatic tear during respiration. Consequently, the mesh appears “bunched up.”
abdominal pain that responded well to aggressive medical management. Although diaphragmatic hernia involving the large colon was diagnosed, surgery was not an option. The mare was comfortable at pasture for 2 months and was eventually euthanized due to severe colic. As evidenced by several reports describing the successful surgical treatment of diaphragmatic hernia in horses [2,7e9,16e19], success rate of surgical management has recently improved. One reason that can explain this improvement is the use of novel surgical approaches that provide better access to the lesions which are not readily accessible via a routine ventral midline approach. According to several reports, a diaphragmatic defect is often surgically inaccessible, giving to the surgeon few options: (1) to tilt the surgical table with the aim of making the lesion more accessible, (2) to repair the rent blindly using a polypropylene mesh secured with stainless steel staples [16], (3) to recover the horse in the attempt to repair the lesion using a different approach, (4) to recover the horse without repairing the diaphragmatic defect, (5) to euthanize the horse on the table. Several surgical approaches have been used for diaphragmatic hernia repair [2,20,21]. In foals, the cranioventral midline approach can provide adequate access to all the regions of the diaphragm. In adult horses, this approach provides excellent access to the central ventral aspect of the diaphragm but limited access to the dorsal diaphragm. Slightly more than one-third (34/96) of diaphragmatic hernia cases involved the ventral aspect of the diaphragm only [22]. Thus, a cranioventral midline celiotomy provides very limited access to and visibility of most (>60%) of the diaphragmatic hernias in horses. Several manipulations can improve the surgeon's access to a lesion when a cranioventral midline approach is used. Tilting the surgery table into a reverse Trendelenburg position (head up 30 ) facilitates caudal displacement of the viscera, thus improving visibility of the diaphragm, especially its dorsal aspect [21]. In addition, tilting the table laterad away from the affected side may provide better access to a diaphragmatic defect [21,23]. Extending the cranioventral midline incision 15e20 cm laterad and parallel to the last rib at the level of the xiphoid process can increase accessibility to dorsal diaphragmatic defects. This approach requires incising the abdominal muscles and can result in significant intraoperative hemorrhage [24]. Exteriorizing the ascending and descending colon onto a colon tray may also improve
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Fig. 4. Thoracoscopic follow-up at 30 days. Tissue ingrowth over the mesh can be appreciated. Signs of shrinking or wrinkling are absent.
accessibility to the diaphragm [8]. A flank approach can be used to localize the lesion by manual palpation, and the results of this surgery can be used to determine how best to approach the lesion via thoracotomy [9]. The case reported here presented some complexities regarding the best surgical approach to use. The diaphragmatic tear was difficult to treat from the laparotomy incision because of its extremely dorsal position and conservative treatment was not an option because the defect was even enlarged during the extraction of the incarcerated intestine. As reported in the literature, an alternative approach involves thoracoscopy, a technique that provides excellent visibility of the diaphragm both in standing and laterally recumbent horses [13,25]. Thoracoscopy has proven to be safe in diagnosing and treating thoracic lesions in horses [26]. Although the fenestrated mediastinum [27] of the horse makes bilateral pneumothorax a concern when thoracoscopy is performed, experience indicates that the contralateral lung usually remains inflated during thoracoscopic procedures [25]. Nevertheless, having a suction device ready to use remains of invaluable utility in case respiratory distress occurs. Although thoracoscopy is the preferred technique for diaphragmatic hernia repair in human patients [28,29], diaphragmatic repair using a thoracoscopic approach has not been reported in horses until recently when Rocken et al [11] have been successful at suturing a diaphragmatic tear in a mare. Instead of using intracavitary suture, mesh has widely gained popularity for closure of abdominal tears [30], thoracic defects [31], inguinal rings [32], incisional hernia [33], nephrosplenic space closure [34], and most recently foramen epiploicum closure [35]. Advantages of using mesh and coils include lack of technical difficulties associated with making knots with laparoscopic instruments [36], tension is spread across the tissue [37], opportunity to close larger defect [38], and reduced risk of herniation relapse [39]. Pros and cons of using different meshes in equine surgery are still poorly documented. Recently, a review regarding the use of various meshes in human beings has been published [40]. The most important properties of meshes were the type of filament, the tensile strength, and the porosity. These features determine the weight of the mesh and its biocompatibility. In most situations, surgeons should look for a light-weight mesh, with large pores and minimal surface area [40]. Ideally, it should consist of a monofilament. Polypropylene or polyester meshes are comfortable and have a lower risk of infection, therefore, usually suitable. These meshes are the most commonly used in horses [30e38].
For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others [40]. All meshes produce adhesions when placed adjacent to the bowl, but their extent is determined by pore size, filament structure, and surface area. Heavy-weight meshes induce an intense fibrotic reaction which ensures strong adherence to the abdominal wall but also causes dense adhesions. In contrast, microporous expanded polytetrafluoroethylene does not allow tissue in growth. It has a very low risk of adhesion formation but is unable to adhere strongly to the abdominal wall. Composite meshes provide the advantage of having an additional surface which can be safely placed in contact with viscera, while peritoneal mesothelial cells grow over the mesh and once a peritoneal layer has formed, it should prevent adhesions. Despite manufacturers' claims, the differences between the various types of these are unproven and it is currently difficult to recommend a single material [40]. The mesh chosen in this case report has already been being used by the authors for laparoscopic nephrosplenic closure for years with good results (unpublished data). It is a composite mesh with a hydrophilic three-dimensional polyester textile on one side and a porcine collagen film on the other side. The polyester frame encourages rapid abdominal wall integration and superior cellular proliferation when compared to polypropylene mesh in vitro [41] and provides rapid fibrous ingrowth [42,43] and minimal shrinkage [42,44]. Also, polyester meshes coated with a layer of porcine collagen have been associated with less adhesions formation in the first 7 days after surgery in comparison with polypropylene meshes coated with a layer of cellulose [45]. The composite polyester meshes have costs similar to the composite polypropylene meshes. Advantages of using a dual-facing mesh were taken into account when surgical procedure was planned. We report a successful thoracoscopic herniorrhaphy of a 8- to 10-cm defect in the dorsal diaphragm without rib resection in a Warmblood gelding by using a dual-facing mesh. Titanium coils and absorbable screws were used for mesh fixation. Despite continuous movement of the diaphragm during respiration, mesh was fixed to the diaphragm. It is in the authors' experience (abdominal wall hernia, nephrosplenic closure, inguinal ring closure) that preventing short-term recurrence of hernia due to mesh shrinkage and movement is of primary importance, particularly when the mesh is placed on areas subjected to movements. Consequently, the mesh was placed with the polyester side facing the diaphragmatic muscle in order to have both a fast and secure mesh-tissue integration and to prevent adhesions between the mesh and the lungs. Titanium coils are reported to have more tenacity at fixation than absorbable screw but are more likely to cause adhesions [46]. In order to have both a secure fixation of the mesh and a small number of titanium coils (n ¼ 10), 20 absorbable screws were used. Thoracoscopy provided excellent visualization of the diaphragmatic tear. Mild perioperative pain and low postoperative morbidity were achieved. Major postoperative complications were not observed. Mesh application is reported to be associated with an increased rate of infection in human patients [47]. The horse in this report developed a postoperative infection of the pleural cavity that required protracted antibiotic therapy and multiple (three) chest drainage procedures. An association between mesh application and postoperative infection was suspected, but removal of the implant was not necessary. This is in contrast with several studies reporting the need of implant removal in case of prosthesis infection in human patients [48].
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