24- Abdominal Wall - Explains Flashcards
What is a Spigelian hernia?
An interparietal hernia occurring at the level of the arcuate line, usually between the internal and external oblique muscles, with equal distribution in both sexes.
Where is the position of a Spigelian hernia?
Lateral to the rectus abdominis.
What are the possible repair options for a Spigelian hernia?
Both open and laparoscopic repair, with open repair preferred in cases of strangulation.
What is a lumbar hernia?
A rare hernia that occurs in the lumbar triangle bounded by the iliac crest, external oblique, and latissimus dorsi muscles.
What is the most common cause of lumbar hernias?
Most lumbar hernias are incisional hernias following renal surgery.
What is the recommended procedure for the repair of a lumbar hernia?
Direct anatomical repair with or without mesh reinforcement.
What is an obturator hernia?
A hernia that occurs through the obturator canal, more common in females and usually located behind the pectineus muscle.
How do obturator hernias typically present?
Most cases present acutely with obstruction, requiring laparotomy or laparoscopy for diagnosis and treatment.
What is a Richter’s hernia?
A condition where part of the small bowel wall is strangulated within a hernia, typically involving the anti-mesenteric border.
How do Richter’s hernias differ from typical intestinal obstructions?
Richter’s hernias do not present with typical features of intestinal obstruction as the lumenal patency is preserved.
What is an incisional hernia?
A hernia that occurs through a site of surgical access into the abdominal cavity, often following surgical wound infection.
What is the recommended technique to minimize the risk of incisional hernias after midline laparotomy?
Following the Jenkins Rule, a suture length four times the length of the incision with bites taken at 1cm intervals, 1cm from the wound edge.
What is a Bochdalek hernia?
A typically congenital diaphragmatic hernia, with 85% of cases located in the left hemidiaphragm.
What are some characteristics of Bochdalek hernias?
They are more common in males, associated with lung hypoplasia on the affected side, and may contain the stomach.
How are Bochdalek hernias treated?
Treatment may involve direct anatomical apposition or placement of mesh. Severe cases in infants may require mechanical ventilation, but the mortality rate is high.
What is a Morgagni hernia?
A rare type of diaphragmatic hernia that occurs through the foramen of Morgagni.
Where is a Morgagni hernia usually located?
On the right side and tends to be less symptomatic.
What may a more advanced Morgagni hernia contain?
Transverse colon.
What is the incidence of pulmonary hypoplasia in Morgagni hernias?
Less common due to the small defects.
What is the preferred treatment for Morgagni hernias?
Direct anatomical repair.
What is an umbilical hernia?
A hernia that occurs through a weak umbilicus.
When does an umbilical hernia usually present?
In childhood.
Are umbilical hernias often symptomatic?
Yes, they are often symptomatic.
What is the sex incidence of umbilical hernias?
Equal in both sexes.
At what age do 95% of umbilical hernias resolve?
By the age of 2 years.
When is surgery typically performed for umbilical hernias?
After the third birthday.
What is a paraumbilical hernia?
A hernia that occurs in adulthood through a defect in the linea alba.
Is paraumbilical hernia more common in males or females?
More common in females.
What are the risk factors for paraumbilical hernia?
Multiparity and obesity.
What is the traditional repair technique for paraumbilical hernia?
Mayo’s technique, which involves overlapping repair. Mesh may be used unless small bowel resection is required due to acute strangulation.
What is a Littre’s hernia?
A hernia that contains Meckel’s diverticulum.
What is usually required in the treatment of Littre’s hernia?
Resection of the diverticulum.
Can a mesh repair be performed for Littre’s hernia?
A mesh repair may not be possible if small bowel resection is required due to acute strangulation.
What is a possible cause of right iliac fossa pain with pain radiating?
Appendicitis.
What are common symptoms associated with appendicitis?
Anorexia (loss of appetite) and a short history. Diarrhea and profuse vomiting are rare.
What condition often presents with a long history, signs of malnutrition, and changes in bowel habit?
Crohn’s disease.
What condition mainly affects children and is associated with a higher temperature compared to appendicitis?
Mesenteric adenitis.
Which condition may present with right iliac fossa pain and can affect both the left and right sides?
Diverticulitis. A CT scan can help confirm the diagnosis.
What is Meckel’s diverticulitis?
A congenital abnormality present in about 2% of the population, typically located 2 feet proximal to the ileocaecal valve. It may be lined by ectopic gastric mucosal tissue and can cause bleeding.
What condition usually produces upper quadrant pain but can also cause lower abdominal pain?
Perforated peptic ulcer.
What is a possible cause of right iliac fossa pain that may be associated with a hernia or bowel obstruction?
Incarcerated right inguinal or femoral hernia.
What condition is rare for right iliac fossa pain and is associated with bowel perforation secondary to caecal or colon carcinoma?
Bowel perforation secondary to caecal or colon carcinoma.
What are some gynecological causes of right iliac fossa pain?
Pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion/mittelschmerz.
What are some other possible causes of right iliac fossa pain?
TB (tuberculosis)/typhoid/herpes zoster/AAA (abdominal aortic aneurysm)/situs inversus.
What are some urological causes of right iliac fossa pain?
Ureteric colic/urinary tract infection/testicular torsion.
What is the typical location of abdominal pain in appendicitis?
Peri-umbilical (around the belly button), which then radiates to the right iliac fossa due to inflammation of the appendix.
Is marked and persistent vomiting common in appendicitis?
No, it is unusual. Patients may vomit once or twice, but persistent vomiting is uncommon.
Is diarrhea a common symptom of appendicitis?
No, diarrhea is rare. However, pelvic appendicitis or a pelvic abscess may cause some loose stools.
What is the typical temperature range in patients with appendicitis?
Mild pyrexia, usually around 37.5-38°C. Higher temperatures are more typical of conditions like mesenteric adenitis.
Is anorexia common in patients with appendicitis?
Yes, anorexia (loss of appetite) is very common. It is unusual for patients with appendicitis to feel hungry.
What are the signs on examination for appendicitis?
Generalized peritonitis if perforation has occurred or localized peritonism. Retrocecal appendicitis may have relatively few signs. Digital rectal examination may reveal a boggy sensation if a pelvic abscess is present or even tenderness with a pelvic appendix.
What diagnostic findings justify an appendectomy?
Raised inflammatory markers, compatible history, and examination findings.
What is the role of ultrasound in the diagnosis of appendicitis?
Ultrasound is useful in females when pelvic organ pathology is suspected. While the appendix may not always be visualized, the presence of free fluid should raise suspicion.
What is the treatment for appendicitis?
Appendectomy, which can be performed via open or laparoscopic approach. Metronidazole administration helps reduce wound infection rates. Patients with perforated appendicitis require abdominal lavage. Patients without peritonitis but with an appendix mass should receive broad-spectrum antibiotics and may require an interval appendectomy.
What should you be cautious about in older patients with suspected appendicitis?
Underlying caecal malignancy or perforated sigmoid diverticular disease.
What structures are divided in a midline incision?
Linea alba, transversalis fascia, extraperitoneal fat, peritoneum.
How can the bladder be accessed in a midline incision?
Through the extraperitoneal approach via the space of Retzius.
What structures are divided/retracted in a paramedian incision?
Anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum.
What is the location of a battle incision?
Similar to paramedian, but the rectus muscle is displaced medially and denervated.
What is the purpose of a Kocher’s incision?
It is used for procedures like cholecystectomy and is made under the right subcostal margin.
Where is a Lanz incision made and what procedure is it commonly used for?
It is made in the right iliac fossa and is commonly used for appendicectomy.
What is a gridiron incision and where is it centered?
It is an oblique incision centered over McBurney’s point and is typically used for appendicectomy.
What is the purpose of a Gable rooftop incision?
There is no specific information provided about this incision.
What is the location and purpose of a Pfannenstiel’s incision?
It is a transverse supra-pubic incision primarily used to access pelvic organs.
What is the purpose of a McEvedy’s incision and where is it made?
It is a groin incision commonly used for emergency repair of a strangulated femoral hernia.
What is the purpose of a Rutherford Morrison incision?
It is an extraperitoneal approach to the left or right lower quadrants, providing access to the iliac vessels. It is the preferred approach for first-time renal transplantation.
What are the most common causes of colonic obstruction?
Malignancy (60%) and diverticular disease (20%).
What percentage of colonic obstruction cases are due to volvulus?
5%
What is a potential differential diagnosis for colonic obstruction?
Acute colonic pseudo-obstruction.
What is a rare but recognized cause of colonic obstruction?
Intussusception, often due to tumors in the adult population.
What are the typical symptoms of a patient with large bowel obstruction?
Gradual onset of progressive abdominal distension, colicky abdominal pain, obstipation or absolute constipation.
What is a useful sign on examination for colonic obstruction?
Presence of caecal tenderness (assuming no overt evidence of peritonitis).
What imaging modality is commonly used as the first line investigation for large bowel obstruction in the UK?
CT scan
What is the surgical indication for prompt surgery in large bowel obstruction?
A caecal diameter of 12cm or more in the presence of complete obstruction, with a competent ileocaecal valve and caecal tenderness, indicating impending perforation.
What is the recommended treatment for right-sided lesions causing large bowel obstruction?
Right hemicolectomy or its extended variant, with the possibility of constructing an ileocolic anastomosis.
What are the treatment options for left-sided lesions causing obstruction?
Subtotal colectomy and anastomosis, left hemicolectomy with on-table lavage and primary anastomosis, left hemicolectomy with end colostomy formation, or colonic stent insertion.
What did the Cochrane review and meta-analysis conclude about the use of colonic stents?
Both reviews concluded that there was no benefit from using colonic stents over conventional surgical resection, with better outcomes observed in the surgical group.
What did the CREST trial suggest about the use of self-expanding metallic stents?
The trial suggested that self-expanding metallic stents can improve outcomes and avoid the need for a stoma.
How should rectosigmoid lesions causing obstruction be treated?
Generally, a loop colostomy is performed. For lesions in the distal sigmoid colon, a high anterior resection is usually performed, and the decision to restore intestinal continuity is made by the operating surgeon.
How is a fistula defined?
An abnormal connection between two epithelial surfaces.
What are the two types of fistulas mentioned in general surgical practice?
Diverticular disease and Crohn’s disease.
What is the general rule for fistulas?
They will resolve spontaneously as long as there is no distal obstruction.
What is an enterocutaneous fistula?
A fistula that links the intestine to the skin. It can be high output (>500ml) or low output (<250ml) depending on the source.
What are the four types of fistulas?
Enterocutaneous, enteroenteric or enterocolic, enterovaginal, and enterovesical.
What are the symptoms and characteristics of a colo-cutaneous fistula?
It tends to leak faeculent material.
What can cause the formation of an enterocutaneous or enterocolic fistula?
Spontaneous rupture of an abscess cavity onto the skin or iatrogenic input.
What is an enterovaginal fistula?
A fistula that goes from the intestine to the vagina.
What is an enterovesical fistula?
A fistula that goes from the intestine to the bladder. It can result in frequent urinary tract infections or the passage of gas from the urethra during urination.
What are some important rules to remember for fistula management?
Fistulas will heal if there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option.
How should the overlying skin be protected in cases of fistulas with skin involvement?
Using a well-fitted stoma bag to prevent skin damage, which can be difficult to treat.
What can be used to manage high output fistulas?
Octreotide, which can reduce the volume of pancreatic secretions and make the fistula more manageable.
What are common nutritional complications associated with high fistulas?
Nutritional complications, such as those seen in high jejunal or duodenal fistulas, may require the use of total parenteral nutrition (TPN) to provide nutritional support, along with the concomitant use of octreotide to reduce volume and protect the skin.
What should surgeons avoid when managing perianal fistulas with acute inflammation?
Probing the fistula, as this almost always worsens outcomes.
What is the recommended management option for perianal fistulas secondary to Crohn’s disease?
Draining acute sepsis and maintaining drainage through the judicious use of setons, while implementing medical management.
Why is it important to delineate the anatomy of a fistula?
To understand the track and source of the fistula. For intra-abdominal abscesses and fistulas, barium and CT studies can be used. For perianal fistulas, surgeons should recall Goodsall’s rule in relation to internal and external openings.
What are stomas?
They are created during abdominal procedures to bring the lumen or visceral contents onto the skin.
Which organ is most commonly involved in the creation of stomas?
The bowel.
Can other organs or their contents be diverted through stomas if needed?
Yes, depending on the situation, other organs or their contents may be diverted through stomas.
Why should small bowel stomas be spouted?
To prevent the irritant contents of the small bowel from coming into contact with the skin.
Do colonic stomas need to be spouted?
No, colonic stomas do not need to be spouted as their contents are less irritant.
Why is stoma siting important?
Stoma siting influences the patient’s ability to manage their stoma and reduces the risk of leakage.
What can happen if there is leakage of stoma contents?
Leakage of stoma contents can lead to maceration of the surrounding skin and a loss of control of stoma contents.
What is the purpose of a gastrostomy stoma?
Gastric decompression or fixation, as well as feeding.
Where is the common site for a gastrostomy stoma?
Epigastrium.
What is the purpose of a loop jejunostomy stoma?
It is seldom used and may be used following emergency laparotomy with planned early closure.
Where can a loop jejunostomy stoma be located?
Any location according to need.
What is the purpose of a percutaneous jejunostomy stoma?
Usually performed for feeding purposes and is located in the proximal bowel, typically in the left upper quadrant.
What is the purpose of a loop ileostomy stoma?
Defunctioning of the colon, for example, following rectal cancer surgery.
Where is the common site for a loop ileostomy stoma?
Usually in the right iliac fossa.
What is the purpose of an end ileostomy stoma?
It is usually created following complete excision of the colon or when an ileo-colic anastomosis is not planned.
Where is the common site for an end ileostomy stoma?
Usually in the right iliac fossa.
What is the purpose of an end colostomy stoma?
It is created when a colon is diverted or resected, and an anastomosis is not primarily achievable or desirable.
Where can an end colostomy stoma be located?
Either in the left or right iliac fossa.
What is the purpose of a loop colostomy stoma?
To defunction a distal segment of the colon, with the distal lumen acting as a vent.
