Hernias, Stomas & Incisions

Medical student finals revision on hernias, stomas, and incisions.

Transcript

1. Hernias, Stomas & Incisions Dr Kenrick Turner F1 General Surgery Thursday, 11 February 2010
2. Overview Scope Questions WTF? Incisions Stomas Hernias Thursday, 11 February 2010
3. Scope Surgical Finals oriented Non-exhaustive Competent Thursday, 11 February 2010
4. Hernias Thursday, 11 February 2010
5. What is a hernia? (Who’s read Surgical Talk?) Thursday, 11 February 2010
6. Definition of a hernia A protrusion of a hollow viscus, or part of a viscus, through the walls of its containing cavity into an abnormal position. Thursday, 11 February 2010
7. Hernia terminology Thursday, 11 February 2010
8. Background anatomy • Two bony landmarks define the Inguinal ligament: • Anterior superior iliac spine (ASIS) • Pubic tubercle (not pubic symphasis) • Midpoint of the Inguinal ligament: • Deep ring lies 2cm superior to this point • Mid-inguinal point: (pubic symphasis to ASIS) • Femoral artery lies deep to this point Thursday, 11 February 2010
9. Anatomy of the inguinal canal • Anterior wall: External oblique aponeurosis • Posterior wall: Transversalis fascia • Superior border: Conjoint muscular tendon • Inferior border: Inguinal ligament Thursday, 11 February 2010
10. “Examine this patient’s groin...” • Surgical examination (short OSCE station) • Man • Probably obvious • Very common! Thursday, 11 February 2010
11. Hernia exam: Overview 1. Basics 2. Examine standing 3. Examine lying 4. Finishing off Thursday, 11 February 2010
12. Hernia exam: Basics • Be aware of the sensitive nature of this exam • Introduce and gain consent; explain need to examine genital area • Expose from xiphisternum to knees • Examine the patient standing first (↑intra-abdominal pressure) • May be tender, always ask about pain • When palpating, crouch to the side of the patient • Must compare both sides, even if asked only to examine one side Thursday, 11 February 2010
13. Hernia exam: Standing Inspect • Old surgical scars You must comment on recurrence • Obvious hernia If no obvious hernia: “Have you noticed a lump in your groin, sir?” • Overlying skin colour Palpate • Position Define anatomy. Palpate along inguinal ligament. State hernial position relative to ligament. Above=Inguinal; Below=Femoral Does it extend into the scrotum? • Size • Shape • Consistency & Temperature Thursday, 11 February 2010
14. Hernia exam: Lying • Attempt reduction “Does the lump ever go back in sir? Can you show me?” • Inguinal or Femoral? Reduce hernia. Place finger on pubic tubercle. Ask pt to cough. Inguinal hernia = above & medial Femoral hernia = below & lateral • ± if inguinal: Direct or Indirect? Reduce hernia again. Cover deep ring with 2 fingers (2cm above midpoint of inguinal ligament). Explain landmarks as palpating. Ask pt to cough. Controlled = Indirect; Reappears = Direct • ± if scrotal: Upper border/can you get above it? If no upper border, likely to be inguino- scrotal hernia (usually indirect via patent processus vaginalis). If can get above it, likely to be cord or testicular lump. Transilluminates? Thursday, 11 February 2010
15. Hernia exam: Finishing off • Cover and thank patient when you have finished • To complete, examine: • Contralateral side as hernias often bilateral • Scrotum for lumps (e.g. varicocoele) • Both testicles - any missing? • Full abdomen Thursday, 11 February 2010
16. Key diagnostic points To differentiate a hernia from any other lump: • Expansile cough impulse - cough impulse also present in varix • Reducible - unless it’s incarcerated... • Bowel sounds - unless it’s obstructed, or omentum Thursday, 11 February 2010
17. Direct vs Indirect Indirect Direct Can descend into scrotum Rarely extends to scrotum Reduces upwards and laterally Reduces upward and back May be controlled by pressure over deep ring Not controlled Impalpable defect Defect may be palpable above pubic tubercle After reduction, lump moves medially before inferiorly Lump reappears in same position Seen in children & young adults Uncommon in younger patients Thursday, 11 February 2010
18. Types of hernias • Inguinal: M>F, 75% of all hernias • Femoral: F>M, 40% present with strangulation • Paraumbilical • Incisional • Lots of others (obturator, hiatus, pantaloon, Spigellan, Richter’s etc) but less important for finals Thursday, 11 February 2010
19. Δ Δ for a groin lump • Inguinal hernia • Femoral hernia • Encysted hydrocoele of the cord • Ectopic/Undescended testis • Inguinal lymphadenopathy • Saphena varix • Femoral artery aneurysm • Lipoma of the cord Thursday, 11 February 2010
20. Complications of hernias • Obstruction: abdominal distention, absolute constipation, vomiting, pain • Strangulation: tender lump ± obstruction but pain does not always localise, so examine orifices in all obstructed patients • Perforation: unwell, peritonitic (rigid abdomen, guarding, percussion pain) • Recurrence Thursday, 11 February 2010
21. Inguinal hernia repair • When to operate? • Open vs Laparoscopic: • Currently NICE says only indications for laparoscopic repair are recurrence and bilateral hernias. • Magic Words: “Tension-free mesh repair” • Consent form: remember recurrence as a risk Thursday, 11 February 2010
22. Mx of strangulated hernia • Focused hx and examination: • Unwell with abdo pain + tender, hot, non-reducible lump • IV access & urgent bloods for FBC, U&Es, CRP, Coag, and G&S • ABG: ?lactic acidosis • Drip & Suck: NBM, IV fluids, NG tube, urinary catheter • Analgesia + Antiemetics + Thromboprophylaxis • Senior r/v, then consent, book, inform anaesthetist etc. Thursday, 11 February 2010
23. Incisions Thursday, 11 February 2010
24. Midline laparotomy Hockeystick Right paramedian Right subcostal/Kocher’s Femoral hernia repair Pflannenstiel Open inguinal hernia repair Lanz Gridiron Rooftop Mercedes-Benz Femoral artery bypass/aneurysm repair Thursday, 11 February 2010
25. Key points about incisions/scars • Proper name - or anatomical position if stuck • Anatomy - what’s under the incision? • Age - how old is it? • Complications - incisional hernias, healing by 2º intention • Don’t miss: old stoma scars, drain scars, nephrectomy/thorocotomy scars Thursday, 11 February 2010
26. Stomas Thursday, 11 February 2010
27. Stoma examination 1. Site 2. Calibre 3. Number of lumens 4. Spout 5. Bag contents 6. Scars 7. Complications 8. Perineum 9. General condition of patient 10.Type of appliance Thursday, 11 February 2010
28. Types of stoma • Ileostomy: Spouted, usually right sided, ‘porridge’ consistency • Loop: Temporary defunctioning to protect anastamosis (post low anterior resection). Occasionally for severe Crohn’s colitis. • End: Panproctocolectomy (removal of colon, rectum and anal canal) e.g. for UC. • Colostomy: Flush, usually left sided, solid faecal output • Loop: Defunctioning rectum e.g. neoadjuvant chemoradiotherapy for rectal ca. • End: Hartmann’s procedure - sigmoid colectomy w/o anastomosis AP resection - removal of rectum and anal canal for low rectal/anal ca Thursday, 11 February 2010
29. Complications of stomas Early • Fluid disturbance • Electrolyte disturbance • Psychological/body image Late • Prolapse • Hernias • Strictures • Retraction • Ischaemia Thursday, 11 February 2010
30. Think surgically 1 2 3 Anatomy! What are the complications? Are they present? Does it need an operation? Thursday, 11 February 2010
31. ? Any Questions? Thursday, 11 February 2010
32. Resources Slides: http://kenners.org/talks/hsi.pdf Email: kenrick@cantab.net References Thursday, 11 February 2010