This Boston Terrier
case was written: 25 June, 2010
Boston Terrier,
Male, Not neutered, 7 years, 12.4kg
Big swellings
besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks.
A knowledgeable young man who has his own views of dog
care.
He presented a Boston Terrier with constipation for the
past 3 weeks. He went to
 Vet
1 who referred him to another vet after taking a blood
test as she did not want to perform the surgery. She had
given him a laxative for the dog and the dog had passed
loose stools instead of hard ones.
"Why don't you see the referred vet?" I asked.
"The Surgery has a bad reputation," the young man had
googled the name of the practice he was referred to by
Vet 1. "There is a very bad complaint about the vets
from one dog owner. So I better not go there."
"All veterinary practices will have one or two nasty
complaints about service," I educated this young man.
"The busier the practice, the higher the chances of
getting complaints. This is because the vet has no time
to handle each case as thoroughly as he or she would
love to. This applies to over-worked doctors in human
medicine too especially in the emergency wards."
VACCINATION HISTORY MUST BE ASKED
"Has your dog been vaccinated?" I asked.
"No vaccination for the past few years. Do you have
parvovirus in your Surgery?" the young man asked me.
"Fortunately for your dog, my practice does not have
parvo-viral cases for many months as I seldom provide
service to the dog breeders nowadays. You have taken a
big risk exposing your dog the risk of parvoviral and
canine distemper infections."
PRE-OP BLOOD TEST IMPORTANT FOR OLD DOGS BEFORE
SURGERY
I checked Vet 1's blood test results. It is wise not to
trust the blood results of other practices based on one
of my experiences (see one case I had written). However,
he had paid $130 for the test and I would not insist as
that would increase his vet bills. Overall, the dog was
examined and was healthy. So I took the chance.
ANAESTHESIA
IV saline given. Then I gave Atropine 0.4 ml IV followed
by Domitor 0.2 ml IV
Waited 10 minutes. Isoflurane gas mask. Dog struggled.
So, I gave Zoletil 100 @ 0.1 ml IV. This sedated the dog
who was masked and given isoflurane gas at 5%. The dog
slept and was intubated. Isoflurane at 1-2% maintenance
was done by my experienced assistant, Mr Saw. I asked
him to increase the dose when the pelvic fat kept coming
out from the hernia after pushing the fat into the
abdominal cavity. The dog recovered smoothly.
SURGERY
I gave him antibiotics to take and schedule perineal
hernia surgery 2 days later. The surgery took nearly an
hour as the hernia was large. The hernia bulge with
pelvic fat is large, around 4 cm x 6 cm. An
electro-incision made a big cut to the left of the anus.
It was difficult to identify the medial coccygeal and
levator ani muscles in this case as there is a lot of
inflammation. The internal pudendal artery and vein and
the pudendal nerve on the dorsal surface of the internal
obturator muscle looked compressed as I showed to my
assistant Mr Saw who nodded his head. Judging from his
eyes, he did not believe they were what I said.
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Is there a right perineal hernia
too? |
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Electro-incision. Big amount of
pelvic fat. A retractor enabled me
to have a good field of view to
stitch up the defect |
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See the big hole through which
part of the colon and pelvic fat
herniated through causing a big
backside swelling |
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Left perineal hernia repaired.
Neutering in 3-4 weeks if the
owner wants to do it. The right
perineal hernia may need to be
repaired later. |
The internal
obturator muscle is on the ventral aspect of the pelvic
diaphragm. This was a big fatty mass horizontally
covering the muscle, unlike the no-fat muscles
illustrated in Small Animal Surgery, T.W. Fossum 1997,
pg 354.
I used a retractor to spread open up the operating area
and to see the pudendal vessels and nerve just above the
obturator muscles in this case.
Do not stitch
these vessels or nerves.
POST-OP
Dog woke up fast. Given tolfedine painkillers.
TWO HERNIAS TO BE OPERATED AT ONE GO
I doubt that it is possible to do two hernias at one go
as the muscle stitching on one side (i.e. left hernia in
this case) pulled the left anal area tightly to cover
the herniated hole. Therefore doing two hernia repair at
the same time just is not in the interest of the dog as
he will feel very uncomfortable and painful.
LOOSE STOOLS leaking out from the anus. This must be
plugged. The dog had been given an oil laxative by Vet 1
for 3 days and the loose stools start to come out
despite atropine injection.
CONCLUSION
The dog was OK and was warded for at least 4 days as the
owner did not have a crate to prevent the dog running
loose. I checked the dog every day to ensure that he had
proper nursing care and pain-killers. The boy's parents
came to visit the dog yesterday. The dog should be back
home after 7 days. He had managed to rub his backside
onto the floor of the crate despite tolfedine 60 mg at
half a tablet per day for 3 days. I decided to give him
1/4 dose of a 30mg phenobarb and then Rimadryl
for another 3 days to
prevent pain and inflammation.
 P.S
1. Yearly vaccination is important. Fortunately
this dog did not get infected with parvoviral disease in
the practice of Vet 1 which is a very busy practice and
in my surgery.
Otherwise, I end up with a dog passing blood in the
stools and dying later. At the time of writing this
report, it is still early at Day 5 after visiting Vet 1.
Parvoviral signs come in around 10-14 days after
infection.
2. "Neutering the dog when he was younger would
have decreased the chances of him getting perineal
hernia," I said. "Perineal hernia is more common in
non-neutered dogs." The young man said: "It is cruel and
that is why I don't do it." He has been advised to
neuter the dog around 2-4 weeks later. As for the right
perineal hernia, it is a smaller one. Wait and see. If
the dog is neutered and there is
no more swelling in the backside, then there is no need
to do a right perineal hernia repair.
3. High anaesthetic risks. I don't enjoy doing
high anaesthetic risk surgeries as they are very
stressful for me. If the dog survives, everybody is
pleased. There will be deaths and the owners may be very
emotional and angry. Some may post a nasty complaint in
the internet. To minimise risks of deaths of old dogs on
the operating table, I don't force myself to perform
hernia repair and neutering at the same time. The owner
has to appreciate that I don't take risks unnecessary.
UPDATE AS AT JULY
11, 2011
No news from the owner since the surgery in Jun 2010. I
presume all are OK as now news is good news.
ANOTHER MORE
CHALLENGING CASE ONE YEAR LATER
THE MALE DOG HAD A VERY LARGE BACKSIDE SWELLING - PART 1
Dr
Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case:
Updated:
17 July, 2011
This Silkie Terrier
case was written: 24 June 2011
Silkie Terrier,
Male, Not neutered, 1- years, 6.5kg
Big swellings
besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks. I have not seen perineal hernias since I operated on the
above-mentioned Boston Terrier one year ago. Surprisingly, on Sunday,
July 10, 2011, my assistant Mr Min said that a couple
insisted on seeing me. Normally, all cases go to Dr
Vanessa Lin but I was around at the reception to get a
pulse of the grass-roots from 9 am to 6 pm and to ensure
that the waiting times are kept to the minimum. Only at
the receptionist's counter can I know what is the
situation of the waiting time like, rather than depend
on the receptionist to enlighten me.
 The couple said to me: "My vet said that no vets in
Singapore would operate on my 10-year-old Silkie
Terrier. He had said that the dog is old and to leave
the swelling alone. But it kept growing bigger!"
He was not neutered and had a backside lump 3/4 the size
of the biggest mango you can see in Singapore. The dog
had difficulty in pooping and the older parents were
concerned about his quality of life. The dog could eat,
drink, poop and pee without difficulty and was active.
"There will be vets in Singapore that will operate on
this dog," I said when the couple brought the dog in
later for examination. "The main issue is that the
operation will take a long time and the dog may just die
on the operating table. No vets want to do a dog that
dies on the operating table."
I had asked them
to illustrate as they did not bring the dog down at
first. A male dog, not neutered, big swelling from below
the anus (in this case) instead of to the sides of the
anus as in unilateral perineal hernias. The couple had
actually diagnosed perineal hernias via the internet
education and so they knew what was wrong with their
dog. The problem was that their vet did not want to
operate and put his reputation on the line when the dog
dies on the operating table. What should I do?
This was the "mother" of all perineal hernias. Both left
and right perineal hernias have "amalgamated" to form a
large 3/4-Taiwanese mango-sized lump to the right, left
and below the anus. Taiwanese mangoes are gigantic but
are not sweet and they measure around 25 cm x 10 cm x 7
cm. So, you can imagine that the swelling was really
gigantic.
The surgery will take over 1.5 hours and the old dog's
heart may just stop beating. The dog needs to be
operated as he has had been licking his skin thin.
Continuous licking to relieve his pain and irritation as
the intestines and omental fat prolapse through the
pelvic muscular defect from both the left and right
side. It was hard for him just to sit down too.
"Do your parents know that they may not see the dog
alive once he gets operated?" I asked. The aged parents
are the care-givers. The couple said: "My parents say it
is better to take the risk rather than let the dog
suffer with such a big dangling mass. The groomer had
nicked the lump earlier and discovered this hernia.
Otherwise, we would not know it exists!"
The dog was in good body condition. I checked his heart.
His heart was surprisingly normal. He was alive and
active now. As if he has not a worry in this world while
his caregivers bear the burden and surgical risks on
their shoulders. Should I pass the buck? And to whom? To
my two associate vets? This is the type of challenging
cases that I prefer not to take on and it will be most
unkind to pass the buck to my two associate vets as
there is the possibility of post-surgical complications
like infections, bleeding and nerve damages in addition
to death on the operating table. So, I did not refer the
case to them. It is a moderately difficult surgery but
it will take a long time to do. The longer the time of
anaesthesia and surgery, the likely that the old dog's
heart will just stop and the dog dies on the operating
table!
 If the surgery can be completed in 15 minutes, the old
dog is very likely to survive the anaesthesia.
Unfortunately, this surgery will take a long time as
both hernias seem to be required to be operated on at
the same time since the intestines and omental fat have
leaked and spread to each other's sides! That is why I
say that this case is the "mother" of all perineal
hernias.
The dog was operated on July 13, 2011. The whole process
started from 9 am and ended at 12 noon. The surgery
itself started from 9.30 am to 12 noon. It was the type
of surgery that most vets would prefer not to be
challenged to do as there were 3 hernias. The main one
was the left perineal hernia with defect from above the
anal area to the ventral most part of the backside. This
would be at least 6 inches long, 3 inches wide and 5
inches deep. (1 inch = 2.5 cm). The right perineal
hernia was two smaller holes separated by a band of
muscle.
In the left perineal hernia, the bladder and large
intestines had prolapsed. Over time, the
 intestines have
had shifted from the left half of the backside to the
right half. The dog licked the swollen area
(mango-sized) over the months and the skin had become
very thin and about to rupture. You can see the
intestinal coils more prominent on the right side. So, I
thought this was a right perineal hernia. Actually, it
was a left!
Details of the surgery and anaesthesia done on June 13,
2011 will be recorded in Part 2 at:
http://www.sinpets.com/F5/20110714perineal_hernia_old_Silkie_Terrier
_male_dysuria_painful_backside_singapore_ToaPayohVets.htm
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