One of the many enjoyable veterinary experiences is the puppy or kitten examination. We are looking at a bundle of life that has the potential to bring so much happiness into a family. Anyone that has experienced the pleasure of a great pet knows what I mean.
On the day that Dr. Wohlfahrt examined this unusually handsome group of four Labrador Retriever puppies all seemed well as she gave the first two pups their physical exams and initial puppy vaccinations. As she examined the third puppy, named Jack, the first abnormality noted was a finger-sized hernia at the umbilicus. This is the point where the puppy is attached to its mother by the umbilical cord. Umbilical hernias are not uncommon and rarely pose serious risk to an individual. Externally all that is seen is a small nodule of tissue or fat that varies in size depending on the size of the defect in the abdominal wall. Most umbilical hernias are repaired without complications. As Dr. Wohlfahrt continued her exam she became more concerned as she listened to Jack’s heart and lung sounds. Jacks heart sounds were murmur free but muffled and the heart sounds were heard best much further back in the chest cavity than was normal. Dr. Wohlfahrt discussed these findings with Jack’s owner and suggested abdominal and chest x-rays to further investigate the abnormal physical findings.
Jacks x-rays were cause for concern. The chest radiograph revealed that his cardiac silhouette was extremely large and the abdominal radiograph showed that his abdominal organs were more forward than they should be.
The term cardiac silhouette refers to the shape of the heart on a radiograph. What the veterinarian is really looking at is the heart itself within a thin-walled sac, the pericardial sac. When the cardiac silhouette is enlarged the increase in size may be because the heart itself is enlarged or because abnormal fluid or organs are trapped around the heart within the pericardial sac. It is often not possible to distinguish between the two conditions radiographically. Ultrasound, on the other hand, can be very helpful in these cases. It will make it possible to look within the pericardial sac and image the contents.
Dr. Wohlfahrt discussed the options with Jack’s owner. The fact that Jack’s heart sounds were normal but muffled, coupled with the presence of an umbilical hernia, made it most likely that he had a relatively rare condition known as PPH or Peritoneal Pericardial Hernia.
Jack’s owners considered their options. Jack seemed to be doing ok but they had noticed that he wasn’t quite as playful as the other pups and he often developed labored breathing. A decision was made to have an ultrasound done and if the diagnosis was confirmed the hernia would be surgically repaired.
Jack’s ultrasound confirmed the presence of the peritoneal pericardial hernia. His gallbladder, much of his liver, and some loops of small intestines were imaged within the pericardial sac.
Drs. Lemieux and Wohlfahrt discussed the protocol for Jack’s surgery with his owners. The surgery would be performed through the abdominal cavity. Displaced abdominal organs would then be gently returned to their normal position and the defect in the diaphragm would be closed. Jack would be placed on a mechanical ventilator or respirator to maintain his breathing throughout the procedure. At the time of his surgery Jack would be only ten weeks old and his thin pericardial sac would be the only barrier that would prevent a collapsed lung. If it were damaged during the procedure Jack would be unable to inflate his lungs.
To help monitor Jack and reduce his surgical risk several standard operating room procedures would be in place. His body temperature would be maintained with a circulating warm water blanket.
He would be on an IV pump to help maintain his blood pressure during anesthesia. Compatible packed red blood cells would be available for transfusion in the event of unexpected blood loss. He would have continuous monitoring of his heart rate, blood pressure, and blood oxygen saturation throughout the surgery.
Drs. Lemieux and King performed Jack’s repair while Dr. Wohlfahrt and Veterinary Technician Cathy Hall, monitored the anesthesia and provided the surgical support. Jack’s defect was very large. The ultrasound images had accurately portrayed the displaced organs. The displaced liver had continued to grow within the pericardial sac and it was no longer possible for the liver lobes to move in and out of the defect. With very gentle traction, and manipulation of the defect, the abdominal organs were returned to the abdominal cavity. At this point in the surgery we could clearly see through the defect in the diaphragm and we were looking at Jack’s beating heart. It was a moving experience for everyone in the operating room. It’s was hard to believe that this small organ had been doing its work under such adverse conditions and we were all hoping that we had given Jack a chance to live a full and healthy life.
The defect in the diaphragm was repaired. The pericardial sac had been greatly stretched and now the space that had been occupied by liver and other organs was filled with air. We removed as much air as possible and then closed the abdominal incision repairing Jack’s umbilical hernia with the closure. Jack was placed in intensive care recovery. Pain relief is an integral part of patient care and Jack was given pain relievers to keep him as comfortable as possible throughout his recovery.
Peritoneal Pericardial Hernia is a congenital defect that puppies can be born with. It is caused by a failure in the development of the diaphragm, a thin muscle that separates the chest and abdominal cavities. As the diaphragm develops it fails to close completely leaving a communication between the abdominal cavity and the pericardial sac surrounding the heart.
The size of this defect determines what abdominal organs are likely to pass through the opening into the pericardial sac. How compromised an individual becomes depends on the organs that are displaced, the size of the defect and the integrity of the organs that are displaced. Some dogs with this defect can live years without symptoms while others develop life-threatening complications.
Jack had a very smooth recovery. The following photo was taken about three hours after his surgery. Jack’s attitude was incredible. He continued to have such a positive and outgoing outlook in spite of the dramatic change in the position of his organs and the tension created by closing his defect.
Everyone that worked with Jack fell in love with him and it was clear that one veterinary assistant in particular was forming a real bond with him. Jack left the hospital two days after his surgery. Erin Frissell and her mom and dad soon visited Jack at his home. Erin’s parents agreed that Jack was an incredible pup and made arrangements for him to become a part of their family.