7 - Common General Surgical Problems Flashcards
What is a hernia?
What type of hernias are most common in the abdominal wall?
Inguinal
What is the chance of having bilateral inguinal hernias?
20%
What are the RF for inguinal hernia?
Older age
Patient processus vaginalis
Connective tissue differences
BMI
Daily lifting
How does BMI affect risk of inguinal hernias?
Low BMI may be more RF than high BMI - although recent study found normal BMI had the most significant risk.
High BMI = definitely greatest risk for recurrence of hernia after surgery to fix
What types of inguinal hernia are there?
Direct
Indirect 75%
How does an indirect inguinal hernia occur?
Bowel enters the deep inguinal ring
By definition, a direct inguinal hernia occurs medially to the inferior epigastric vessels (through the inguinal triangle), and an indirect hernia occurs laterally to these vessels.
What are the borders of Hesselbach’s triangle?
RIP
R = Rectus abdominus (medial)
I = Inferior epigastric vessels (superior and lateral)
P = Inguinal ligament (inferior)
How does a direct inguinal hernia occur?
In a direct inguinal hernia, bowel herniates through a weakness in the inguinal triangle, and enters the inguinal canal. Bowel can then exit the canal via the superficial inguinal ring and form a ‘lump’ in the scrotum or labia majora. Direct hernias are acquired (usually in adulthood), due to weakening in the abdominal musculature.
By definition, a direct inguinal hernia occurs medially to the inferior epigastric vessels (through the inguinal triangle), and an indirect hernia occurs laterally to these vessels.
What S&S can present with a symptomatic inguinal hernia?
Groin pain
Bulge in groin
Referred pain to testicle or thigh
May be worse after physical activity
May cause bowel / bladder Sx if large
Reduction may provide temporary relief
What is a trapped hernia called?
Incarcerated hernia - can’t push it back in
How should you examine a P for a hernia?
Standing first - examine both groins and other hernia areas
Then lay the P down - see if the hernia reduces or ask the P to reduce the hernia
Ask P to cough
How can you differentiate between a direct and indirect hernia on exam?
Reduce the hernia by applying pressure over the deep inguinal ring (midway between ASIS and pubic tubercle). Then ask P to stand whilst you apply pressure.
Indirect - will be controlled
Direct - will not
What are the DDs for inguinal hernia?
Femoral hernia (more F)
Lymph node
Psoas abscess
Vascular abnormality
Malignancy
Testicular pathology - undescended, epididymal cyst, hydrocele, lipoma of spermatic cord, varicocele
What is the first line investigation for inguinal hernia?
What is better imaging modality?
USS - but misses 10-15%
CT or MRI more useful
What is Rx for inguinal hernia?
If asymptomatic / not very symptomatic = conservative management - operation carries 10% risk of chronic pain! Consider truss/support belt - but doesn’t prevent strangulation / incarceration.
Symptomatic - surgery - open or laparoscopic (trans-abdominal or extra-peritoneal)
What are the principles of hernia surgery?
What percentage of hernia surgeries will have
- recurrence
- chronic pain?
Up to 15% recurrence
Up to 10% chronic pain
How can an incarcerated hernia present?
Irreducible hernia that is acutely painful / large
Can get bowel obstruction
What is the complication of incarcerated hernia?
Can become strangulated then gangrenous - bowel loop gets stuck, pressure inside increases - exceeds venous blood pressure - arterial pressure continues to flow in - inc pressure further until it fails = gangrene.
How can strangulated inguinal hernia present?
Painful, irreducible, bowel obstruction
Can feel systemically unwell
Hernia may be warm - reddening of skin
Should you reduce a strangulated hernia?
No! Risk of gangrenous bowel being reduced
How should strangulated hernia be treated?
Emergency surgical repair of the hernia + resection of any gangrenous bowel if present
What percentage of hernias are femoral hernias?
3%
60% of femoral hernias occur on the R or L side?
Right side
What are the RF for femoral hernia?
F (2:1 to M)
Inc abdo pressure = pregnancy, obesity
Connective tissue disorders
What is the risk of strangulation of a femoral hernia?
20-40%
Why do femoral hernias strangulate more than inguinal hernias?
3 sides of the femoral canal are inflexible = reduced space for expansion with bowel contents
What are the boundaries of the femoral canal?
FLIP
F = Femoral vein (lateral)
L = Lacunar ligament (medial)
I = Inguinal ligament (anterior)
P = pectineal ligament (posterior)
Only femoral vein has some give
Where are femoral hernias found?
Below and lateral to pubic tubercle
Where are inguinal hernias found?
Above and medial to the pubic tubercle
If in doubt about a hernia - what investigations can be ordered?
USS
CT / MRI
How are femoral hernias managed?
Wherever possible - need elective surgery to correct as risk of strangulation high.
Emergency surgery is strangulation already suspected.
What ventral hernias can occur?
Paraumbilical / Umbilical
Epigastric
Incisional
What are the RF for paraumbilical hernias?
Inc abdo pressure
F>M 3:1 (men have higher risk of incarceration)
Where does a paraumbilical hernia occur?
In the linea alba close to the umbilicus
What’s a malignant peritoneal nodule that presents at the umbilicus called?
Sister Mary Joseph nodule
What is separation of the abdominal muscles called?
Diastasis rectus (divarication of the rectus muscles)
How can you tell if a P has diastases rectus clinically?
When they lie flat and raise their head - get a prominent midline bulge
Where do epigastric hernias occur?
In the midline linea alba between the peri-umbilical regions and the diploid process
Do you get bowel in epigastric hernias?
Not usually - bowel lies posterior to the falciform ligament
Most defects are tiny and only contain abdominal wall fat
How strong is a healed scar compared to the original tissue strength?
Never more than 70%
What are the RF for incisional hernias?
Wound infection
Wounds closed under tension
DM
IC
Obesity
Midline incision (more risky than transverse)
Previous repair
Smoking
How do you manage an incisional hernia?
Can be very complex hernias
What is an abscess?
A collection of pus (dead and dying Ns in protinaceous exudate)
What are the most common organisms which cause abscesses in UK?
Staph aureus
then Strep pyogenes
E coli
What are the RF for abscess?
IC
DM
Breach of skin - esp IVDU
Smoking
Obesity
What is the pathogenesis of abscess?
Pyogenic bacteria get into tissue - attract Ns - resist phagocytosis & destruction = infection however is contained by defence mechanisms => localised tissue necrosis
What is it called when pus reaches the epithelial surface from an abscess?
Pointing
What can a deep abscess cause?
Cellulitis
Sepsis
How do abscesses present?
What is a Pseudoaneurysm?
A pseudoaneurysm occurs when a blood vessel wall is injured. Blood leaking from the vessel collects in surrounding tissue.
What are the DDs for abscess?
What investigations can be done for an abscess?
How are abscesses treated?
Abx
Drainage if needed
Most abscesses should heal by secondary intention. If they dont and recur - what should be done?
Further investigations - suggests may be other pathology underpinning them
Which disease occurs in the natal cleft causing abscesses?
Pilonidal disease
Where can pilonidal disease occur?
Natal cleft
Axilla
Scalp
Fingers (barbers)
What are the RF for pilonidal disease?
M x2-x4 > F
15-40
White
Hirsutism (abnormally hairy)
Obesity
Deep natal cleft
How can pilonidal disease present?
Can be asymptomatic
Acute abscess, intermittent swelling, discharge, pain
How is pilonidal disease managed?
Can drain abscess
Elective excision of sinus
How do we assess a lump?
Site
Size
Shape
Surface
Consistence
Compressibility
Pulsatility
Reducability
Fluctuation
Transillumination
Mobility
What are the following biopsies called?
- cytology only
- percutaneous biopsy
- surgical removal of part of the lesion
- removal of the whole lesion for diagnosis
Needle biopsy
Core biopsy
Incision biopsy
Excision biopsy
What must you be careful of when biopsying a lump?
Need to be cautious as to tumour seeding in the biopsy tract if you suspect things like sarcomas
What are common epidermal benign lesions?
Skin tags
Warts
Naevi
What are common cystic lesions?
Epidermoid cysts (sebaceous cysts)
Dermoid cysts
What is a common fatty lesion from deeper tissues?
Lipomas
- can feel tethered if IM
- differentiate from soft tissue sarcoma
What is a common lesion that is attached to joint capsules or tendon sheaths?
How are they Rx?
Ganglia (mucin-filled cysts)
- can cause pain
Rx - can spontaneously resolve - if asymptomatic leave alone
However if Sx - surgical excision or needle aspiration (but often come back)
