A tale of two hernias

hiatal herniaA small problem!

RJ came to Northwest Surgeons when he was just over two months old. Since RJ was born his owner had noticed that he seemed to breathe faster than his sister: he had also had one episode of more severe difficulty breathing. Although he ate regularly, he seemed to be always hungry and wasn’t growing as fast as his sister.

RJ’s investigation

RJ’s vet took some x-rays of his chest and suspected he might have a diaphragmatic hernia (a hole in the muscle sheet dividing the chest from the abdomen) so he was referred for specialist investigation.

The most common type of diaphragmatic hernia in puppies and kittens is a peritoneopericardial diaphragmatic hernia, where the abdominal cavity which contains the liver, spleen, intestines, bladder etc. communicates with the pericardium (the fibrous bag surrounding the heart) because the middle part of the diaphragm doesn’t form properly and organs can slip through the hole. When you x-ray an animal with this type of hernia the pericardium appears enlarged and the organs in the hernia obscure the normal outline of the diaphragm towards the bottom of the chest.

The specialist findings

When we examined RJ and looked at his x-rays we agreed that a hernia was the most likely explanation for his signs. The appearance of the x-rays was slightly unusual, however, because along with the enlargement of the pericardium (labelled A on the x-ray below) and loss of the outline of the diaphragm (labelled B on the x-ray below) the area at the top of RJ’s chest close to the diaphragm was abnormal as well (labelled C on the x-ray below). This area also appeared to have an organ protruding into it, which shouldn’t happen with this type of hernia.rj-thorax-right-lateral-labelled

To try to get more information about what was going on we did an ultrasound scan of RJ’s chest. This confirmed that he had a peritoneopericardial hernia and also that the second abnormal area on the x-ray was caused by part of his stomach lying inside his chest. However, because RJ was so tiny it wasn’t clear on the scan how the stomach had got into the chest. Although we could have done further tests like a CT scan to get additional information, after discussion with RJ’s owner we decided to proceed with surgery to fix the peritoneopericardial hernia and investigate what was going on with the stomach at the same time.

A big surgery for a small hole

At surgery we found that RJ had an extremely unusual combination of problems: he did have a peritoneopericardial hernia involving his liver and had a hiatal hernia as well. Hiatal hernias occur when the opening in the diaphragm thrspecialist surgeonough which the oesophagus (tube from the mouth to the stomach) passes is too wide, allowing the stomach to slide forwards into the chest. While we see hiatal hernias fairly often in dogs they are rare in cats and extremely rare in as young a cat as RJ. We were able to bring both the stomach and liver back into the abdomen where they belong and then repair both hernias. The peritoneopericardial hernia was relatively straightforward to fix by stitching the gap in the diaphragm closed. The hiatal hernia was more complicated, needing a combination of 3 techniques to close it (placing some stitches to narrow the opening in the diaphragm, stitching the oesophagus to the diaphragm to stop it slipping forwards and stitching the stomach to the inside of the muscle of the abdominal wall to prevent it from sliding forwards into the chest). A diagram of this is shown in the picture below.

RJ recovered well after the surgery and went home two days later, once we were happy with his progress and felt that he would be comfortable at home. He has done very well since surgery and is eating larger meals, feeling less hungry and growing much better. His breathing has settled down too!