Received: 5 August 2023 | Accepted: 11 August 2023 DOI: 10.1111/eve.13886


C L INI C A L COMMENTA RY


Improving your waistline, six pack or fit for purpose: Herniorrhaphy decisions


Nigel Woodford Hird and Partners , Shelf, Halifax , UK


Correspondence : Nigel Woodford Email: nigel_woodford@yahoo.com


Developmental variations on accepted normality are genetic efforts to obtain an advantage for that species within their environment as each species strives to maximise their chance to succeed through natural selection, however unsuitable that variation might seem, such as the variation described by Ramos et al. ( 2024 ) in comparison with the advantage achieved by a Pseudomonas bacterial colony, re- sistant to every antibiotic on a sensitivity plate. Publications of rare, isolated cases are warranted; Lawsonia intracel-


lularis started life as single case reports (Duhamel & Wheeldon, 1982 ; Frank et al., 1998 ) and are particularly refreshing when an honest small oversight during the work- up is included (Ramos et al., 2024 ), as occurs in busy veterinary practice. Such deceptive cases are encountered in- dividually, such as this soft highly compressible ‘reducible’ mass (Fig- ure 1 ), on the ventrolateral abdomen, masquerading, due to its location and palpable characteristics, as a flank wall rent, which when subject to transcutaneous ultrasonography had the appearance of varicosity (Video S1 ) the clinical characteristics and findings making a vascular derived neoplasm much less likely. Link this with a case report, re- garding the treatment of periorbital vascular malformations (Stonex et al., 2021 ) and with due careful considerations, the possible potential for treatment becomes a possibility from two case reports. Our commonest clinical ventral abdominal hernia cases are the


umbilical hernia with good simple treatment options, inguinal hernia and incisional hernia, the latter of which can be managed conserva- tively or surgically dependant on size and usage and about which this commentary is focussed. Incisional hernia post- laparotomy has an incidence of about 8%–


16% (Toth & Schumacher, 2019 ). Horses compete with incisional hernia, mares foal with incisional hernia (Freeman, 2005 ), but own- ers ' perspectives vary widely. So indications for conservative man- agement or surgical management will overlap until these issues are dissected out. However, some hernias will interfere with athletic ac- tivity, some will interfere with normal gestation and parturition (Toth & Schumacher, 2019 ), and some will be repeatedly traumatised. The optimal management also brings into consideration, long- term objectives and risks. Using a mesh, gunning for a perfect wall


Equine Vet Educ. 2024;36:21–25.


repair but encountering occasional implant infections requiring mesh removal may be less desirable than primary repair which has resulted in a fit for intended purpose result, for which post- op complications of surgical site infection are likely to be much easier to manage. Post- operative infection occurred in the case report (Ramos et al., 2024 ) highlighting again this decision between primary repair and mesh hernioplasty. Undoubtedly, globally with this choice, there will be multiple


treatment variations deployed. Initial approach is usually a choice between fusiform skin incision or a hemifusiform flap approach. The 40 repairs described by Kelmer and Schumacher ( 2008 ) is perhaps a good place to start deciding on which repair option to select. Serious surgical complications for mesh hernioplasty are de-


scribed (Elce et al., 2005 ). These authors addressed incisional hernia management in large horses. The complications included implant infection, adhesions, peritonitis, recurrence and a newly reported complication of rupture of the internal abdominal oblique mus- cle, noted particularly in heavy >590 kg and/or pregnant horses. This mesh hernioplasty was retroperitoneal (human classification: preperitoneal underlay). There was a mortality of 50% for these 13 challenging cases. Edwards ( 2002 ) also reported a series of 36 large incisional hernias using mesh repair. Vilar et al. ( 2009 ) reported mesh hernioplasty in 15 horses, placing a double- layer polypropyl- ene mesh, at preperitoneal underlay location. Various complications were described, but none required mesh removal. On a practical point, trying to dissect the retroperitoneal space may be completely thwarted by scar tissue between the peritoneum and the internal rectus sheath resulting in multiple disruptions to the peritoneum, creating exposure of mesh to the serosal surfaces of the viscera. If this is the site you select to mesh, release of the hernial sac from more superficial fascial scar will help give you the plasticity to roll the peritoneum dorsal to the internal rectus fascia to apply the mesh. Van der Velden and Klein ( 1994 ) describe placing the mesh su-


perficial to the hernial ring (classification: onlay). They saw a 6% inci- dence of post- mesh hernioplasty swelling or drainage.


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