ABDOMEN EMRCS Flashcards
A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis?
A-Haematoma
B-Intra abdominal adhesions
C-Anastomotic leak
D-Anastomotic stricture
E-Obstructed incisional hernia
Theme from September 2011 Exam
In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections.
Acute incisional hernia
Any surgical procedure involving entry into a cavity containing viscera may be complicated by post operative hernia
The abdomen is the commonest site
The deep layer of the wound has usually broken down, allowing internal viscera to protrude through
Management is dictated by the patients clinical status and the timing of the hernia in relation to recent surgery
Bowel obstruction or tenderness at the hernia site both mandate early surgical intervention to reduce the risk of bowel necrosis Mature incisional hernias with a wide neck, and no symptoms, may be either left or listed for elective repair
Risk factors for the development of post operative incisional hernias include; post operative wound infections, long term steroid use, obesity and chronic cough
Theme: Abdominal stomas
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy
E. End jejunostomy
F. Loop jejunostomy
G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all.
A 56 year old man is undergoing a low anterior resection for carcinoma of the rectum. A primary anastomosis is planned.
Loop ileostomy
Theme from April 2014 Exam
Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse.
Theme: Abdominal stomas
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy E. End jejunostomy F. Loop jejunostomy G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all.
A 23 year old man with uncontrolled ulcerative colitis is undergoing an emergency sub total colectomy.
The correct answer is End ileostomy
Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe.
Theme: Abdominal stomas
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy E. End jejunostomy F. Loop jejunostomy G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all.
A 63 year old women presents with large bowel obstruction. On examination she has a carcinoma 10cm from the anal verge.
The correct answer is Loop colostomy
Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended.
Theme: Appendicitis
A. Colonoscopy
B. MRIAbdomen
C. Appendicectomy
D. AbdominalCTscan
E. Barium enema
F. Exploratory laparotomy
G. Conservative management with intravenous antibiotics H. Re-assure and discharge
I. Abdominal ultrasound scan
Please select the most appropriate management option for the following patients. Each option may be used once, more than once or not at all.
A 24 year old man presents with a 10 day history of right sided abdominal pain. Prior to this he was well. On examination he has a low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix.
The correct answer is Conservative management with intravenous antibiotics
This man is likely to have an appendix mass. There is no history suggestive of inflammatory bowel disease. These are usually managed without surgery, especially in the absence of peritoneal signs. Broad spectrum antibiotics are required. In the past an interval appendicectomy was performed. This is rare now and in most cases the process resolves with fibrosis of the appendix.
Theme: Appendicitis
A. Colonoscopy
B. MRIAbdomen
C. Appendicectomy
D. AbdominalCTscan
E. Barium enema
F. Exploratory laparotomy
G. Conservative management with intravenous antibiotics H. Re-assure and discharge
I. Abdominalultrasoundscan
Please select the most appropriate management option for the following patients. Each option may be used once, more than once or not at all.
A 22 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with voluntary guarding in the right iliac fossa. His blood tests reveal a WCC of 13 and a CRP of 6. A urine dipstick is positive for leucocytes.
Appendicectomy
This is a typical history for acute appendicitis and in a young male, few differentials would be compatible with this history and signs. Whilst inflammatory markers may be raised this is by no means universal. Further imaging will delay treatment and is unlikely to alter the eventual surgical outcome.
Theme: Appendicitis
A. Colonoscopy
B. MRIAbdomen
C. Appendicectomy
D. AbdominalCTscan
E. Barium enema
F. Exploratory laparotomy
G. Conservative management with intravenous antibiotics H. Re-assure and discharge
I. Abdominalultrasoundscan
Please select the most appropriate management option for the following patients. Each option may be used once, more than once or not at all.
A 63 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with some voluntary guarding in the right iliac fossa. Some of his blood tests are reproduced below:
Hb 8.1 WCC 13.8 Platelets 438 Albumin 22 CRP 24
The correct answer is Abdominal CT scan
This man’s investigations point to a more longstanding disease process (Hb and albumin), right sided colonic cancer being the most likely. For this reason a CT scan is a sensible option as it will adjust the surgical planning.
Theme: Acute abdominal pain
A. Ruptured abdominal aortic aneurysm B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Small bowel obstruction
F. Large bowel obstruction G. Pelvic inflammatory disease
H. Mesenteric adenitis I. Pancreatitis
J. Noneoftheabove
Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once, more than once or not at all.
A 75 year old man is admitted with sudden onset severe generalised abdominal pain, vomiting and a single episode of bloody diarrhoea. On examination he looks unwell and is in uncontrolled atrial fibrillation. Although diffusely tender his abdomen is soft.
The correct answer is Mesenteric infarction
In mesenteric infarction there is sudden onset of pain together with vomiting and occasionally passage of bloody diarrhoea. The pain present is usually out of proportion to the physical signs.
Theme: Acute abdominal pain
A. Ruptured abdominal aortic aneurysm B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Smallbowelobstruction
F. Largebowelobstruction G. Pelvic inflammatory disease
H. Mesenteric adenitis I. Pancreatitis
J. Noneoftheabove
Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once, more than once or not at all.
A 19 year old lady is admitted with lower abdominal pain. On examination she is diffusely tender. A laparoscopy is performed and at operation multiple fine adhesions are noted between the liver and abdominal wall. Her appendix is normal.
The correct answer is Pelvic inflammatory disease
This is Fitz Hugh Curtis syndrome in which pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions.
Theme: Acute abdominal pain
A. Ruptured abdominal aortic aneurysm B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Smallbowelobstruction
F. Largebowelobstruction G. Pelvic inflammatory disease
H. Mesenteric adenitis I. Pancreatitis
J. Noneoftheabove
Please select the most likely cause of abdominal pain for the scenario given. Each option may be used once, more than once or not at all.
A 78 year old man is walking to the bus stop when he suddenly develops severe back pain and collapses. On examination he has a blood pressure of 90/40 and pulse rate of 110. His abdomen is distended and he is obese. Though tender his abdomen itself is soft.
The correct answer is Ruptured abdominal aortic aneurysm
This will be a retroperitoneal rupture (anterior ones generally don’t survive to hospital). The debate regarding CT varies, it is the authors opinion that a systolic BP of <100mmHg at presentation mandates immediate laparotomy.
Theme: Management of splenic trauma
A. Splenectomy
B. Angiography
C. CT Scan
D. Admit for bed rest and observation E. Ultrasound scan
F. Splenic conservation G. MRIoftheabdomen
Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all.
A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left side and there is left flank bruising. There is no haematuria. He is otherwise stable and haemoglobin is within normal limits.
The correct answer is Ultrasound scan
This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS will also show splenic haematomas.
Theme: Management of splenic trauma
A. Splenectomy
B. Angiography
C. CT Scan
D. Admit for bed rest and observation E. Ultrasound scan
F. Splenic conservation G. MRIoftheabdomen
Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all.
A 42 year old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid and a laparotomy is performed. At operation there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen.
Splenic conservation
As minimum damage, attempt conservation.
Theme: Management of splenic trauma
A. Splenectomy
B. Angiography
C. CT Scan
D. Admit for bed rest and observation E. Ultrasound scan
F. Splenic conservation G. MRIoftheabdomen
Please select the most appropriate intervention for the scenario given. Each option may be used once, more than once or not at all.
An 18 year old man is involved in a road traffic accident. A CT scan shows disruption of the splenic hilum and a moderate sized perisplenic haematoma.
The correct answer is Splenectomy
Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that he will rebleed and with hilar injuries this can be dramatic.
Theme: Gastrointestinal bleeding
A. Haemorrhoids
B. Meckels diverticulum C. Angiodysplasia
D. Colonic cancer
E. Diverticular bleed
F. Ulcerativecolitis
G. Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once, more than once or not at all
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On examination her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality.
A n g io d y s p la s ia
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.
Theme: Gastrointestinal bleeding
A. Haemorrhoids
B. Meckels diverticulum C. Angiodysplasia
D. Colonic cancer
E. Diverticular bleed
F. Ulcerativecolitis
G. Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once, more than once or not at all
A 23 year old man complains of passing bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani.
Haemorrhoids
Classical haemorrhoidal symptoms include bright red rectal bleeding, it typically occurs post defecation and is noticed on the toilet paper and in the toilet pan. It is usually painless, however, thrombosed external haemorrhoids may be very painful.
Theme: Gastrointestinal bleeding
A. Haemorrhoids
B. Meckels diverticulum C. Angiodysplasia
D. Colonic cancer
E. Diverticular bleed
F. Ulcerativecolitis
G. Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each option may be used once, more than once or not at all
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously.
The correct answer is Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
Theme: Surgical signs
A. Rovsing’s sign
B. Boas’ sign
C. Psoas stretch sign D. Cullen’s sign
E. Grey-Turner’ssign F. Murphy’ssign
G. None of the above
Please select the most appropriate eponymous abdominal sign for the scenario given. Each option may be used once, more than once or not at all.
Severe acute peri-umbilical bruising in the setting of acute pancreatitis.
The correct answer is Cullen’s sign
Cullens sign occurs when there has been intraabdominal haemorrage. It is seen in cases of severe haemorrhagic pancreatitis and is associated with a poor prognosis. It is also seen in other cases of intraabdominal haemorrhage (such as ruptured ectopic pregnancy).
Theme: Surgical signs
A. Rovsing’s sign
B. Boas’ sign
C. Psoas stretch sign D. Cullen’s sign
E. Grey-Turner’ssign F. Murphy’ssign
G. None of the above
Please select the most appropriate eponymous abdominal sign for the scenario given. Each option may be used once, more than once or not at all.
In acute cholecystitis there is hyperaesthesia beneath the right scapula.
The correct answer is Boas’ sign
Boas sign refers to this hyperaesthesia. It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level.
Theme: Surgical signs
A. Rovsing’s sign
B. Boas’ sign
C. Psoas stretch sign D. Cullen’s sign
E. Grey-Turner’ssign F. Murphy’ssign
G. None of the above
Please select the most appropriate eponymous abdominal sign for the scenario given. Each option may be used once, more than once or not at all.
In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa.
The correct answer is Rovsing’s sign
Rovsings sign elicits tenderness because the deep palpation induces shift of the appendix (which is inflamed) against the peritoneal surface. This has somatic innervation and will therefore localise the pain. It is less reliable in pelvic appendicitis and when the appendix is truly retrocaecal
Theme: Surgical access
A. Gridiron
B. Lanz
C. McEvedy
D. Midline abdominal E. Rutherford Morrison F. Battle(abdominal) G. Lower midline
Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all.
A 78 year old lady is admitted with a tender lump in her right groin. It is within the femoral triangle and there is concern that there may be small bowel obstruction developing.
The correct answer is McEvedy
This is one approach to an obstructed femoral hernia. It is possible to undertake a small bowel resection through this approach. Recourse to laparotomy may be needed if access is difficult.
Theme: Surgical access
A. Gridiron
B. Lanz
C. McEvedy
D. Midline abdominal E. Rutherford Morrison F. Battle(abdominal) G. Lower midline
Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all.
A 45 year old woman with end stage renal failure is due to undergo a cadaveric renal transplant. This will be her first transplant.
Rutherford Morrison
This is the incision of choice for the extraperitoneal approach to the iliac vessels which will be required for a renal transplant.
Theme: Surgical access
A. Gridiron
B. Lanz
C. McEvedy
D. Midline abdominal E. Rutherford Morrison F. Battle(abdominal) G. Lower midline
Please select the most appropriate incision for the procedure required. Each option may be used once, more than once or not at all.
A slim 20 year old lady is suffering from appendicitis and requires an appendicectomy.
The correct answer is Lanz
Either a Lanz or Gridiron incision will give access for appendicectomy. However, in the case described a Lanz incision will give better cosmesis and can be extended should pelvic surgery be required eg for gynaecological disease.
Theme: Hernias
A. Littres hernia
B. Richters hernia C. Bochdalek hernia D. Morgagnihernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia
Please select the type of hernia that most closely matches the description given. Each option may be used once, more than once or not at all.
A 73 year old lady presents with peritonitis and tenderness of the left groin. At operation she has a left femoral hernia with perforation of the anti mesenteric border of ileum associated with the hernia.
The correct answer is Richters hernia
When part of the bowel wall is trapped in a hernia such as this it is termed a Richters hernia and may complicate any hernia although femoral and obturator hernias are most typically implicated.
Theme: Hernias
A. Littres hernia
B. Richters hernia C. Bochdalek hernia D. Morgagnihernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia
Please select the type of hernia that most closely matches the description given. Each option may be used once, more than once or not at all.
A 22 year old man is operated on for a left inguinal hernia, at operation the sac is opened to reveal a large Meckels diverticulum.
Littres hernia
Hernia containing Meckels diverticulum is termed a Littres hernia.
Theme: Hernias
A. Littres hernia
B. Richters hernia C. Bochdalek hernia D. Morgagnihernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia
Please select the type of hernia that most closely matches the description given. Each option may be used once, more than once or not at all.
A 45 year old man has recurrent colicky abdominal pain. As part of a series of investigations he undergoes a CT scan and this demonstrates a hernia lateral to the rectus muscle at the level of the arcuate line.
The correct answer is Spigelian hernia
This is the site for a spigelian hernia.
Theme: Groin masses
A. Femoralhernia
B. Lymphadenitis
C. Inguinalhernia
D. Psoas abscess
E. Saphenousvarix
F. Femoral artery aneurysm
G. Metastatic lymphadenopathy H. Lymphoma
I. Falsefemoralarteryaneurysm
What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all.
A 52 year old obese lady reports a painless grape sized mass in her groin area. She has no medical conditions apart from some varicose veins. There is a cough impulse and the mass disappears on lying down.
The clinical description of a painless grape-sized mass in the groin area with a cough impulse that disappears when lying down suggests a condition that involves a protrusion or herniation. Given these characteristics, the most likely diagnosis is:
E. Saphenous varix
Explanation:
• Femoral hernia (A): Often presents as a groin mass and can have a cough impulse, but it tends to be more common in older women and can be painful. • Lymphadenitis (B): Typically presents with painful and swollen lymph nodes, often accompanied by signs of infection. • Inguinal hernia (C): More common in men, and the description matches this condition; however, the disappearance on lying down is more classically described with saphenous varix. • Psoas abscess (D): Usually presents with fever and back pain, not a typical groin mass. • Saphenous varix (E): A dilated saphenous vein at the saphenofemoral junction. It presents as a compressible, painless mass that can have a cough impulse and disappears when lying down, fitting the description perfectly. • Femoral artery aneurysm (F): Would be pulsatile and generally does not disappear when lying down. • Metastatic lymphadenopathy (G): Typically presents as a firm, non-tender, non-reducible mass. • Lymphoma (H): Presents with firm, non-tender lymph nodes that do not change with position. • False femoral artery aneurysm (I): Would be pulsatile and does not typically disappear when lying down.
Conclusion:
The most likely diagnosis for the described groin mass is a saphenous varix (E). This condition is characterized by a painless, compressible mass with a cough impulse that disappears on lying down, matching the patient’s symptoms.
Theme: Groin masses
A. Femoralhernia
B. Lymphadenitis
C. Inguinalhernia
D. Psoas abscess
E. Saphenousvarix
F. Femoral artery aneurysm
G. Metastatic lymphadenopathy H. Lymphoma
I. Falsefemoralarteryaneurysm
What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all.
A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion.
The correct answer is Lymphadenitis
The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes.
Theme: Groin masses
A. Femoralhernia
B. Lymphadenitis
C. Inguinalhernia
D. Psoas abscess
E. Saphenousvarix
F. Femoral artery aneurysm
G. Metastatic lymphadenopathy H. Lymphoma
I. Falsefemoralarteryaneurysm
What is the likely diagnosis for groin mass described? Each option may be used once, more than once, or not at all.
A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On examination there is a large abscess in the groin. Adjacent to this is an expansile swelling. There is no cough impulse.
The correct answer is False femoral artery aneurysm
False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall.
Theme: Right iliac fossa pain
A. Urinary tract infection B. Appendicitis
C. Mittelschmerz
D. Mesenteric adenitis
E. Crohnsdisease
F. Ulcerativecolitis
G. Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all.
A 17 year old male is admitted with lower abdominal discomfort. He has been suffering from intermittent right iliac fossa pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
The correct answer is Meckels diverticulum
This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration.
Theme: Right iliac fossa pain
A. Urinary tract infection B. Appendicitis
C. Mittelschmerz
D. Mesenteric adenitis
E. Crohnsdisease
F. Ulcerativecolitis
G. Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all.
A 14 year old female is admitted with sudden onset right iliac fossa pain. She is otherwise well and on examination has some right iliac fossa tenderness but no guarding. She is afebrile. Urinary dipstick is normal. Her previous menstrual period two weeks ago was normal and pregnancy test is negative.
The correct answer is Mittelschmerz
Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours.
Theme: Right iliac fossa pain
A. Urinary tract infection B. Appendicitis
C. Mittelschmerz
D. Mesenteric adenitis
E. Crohnsdisease
F. Ulcerativecolitis
G. Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for the scenario given. Each option may be used once, more than once or not at all.
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination he has some right iliac fossa tenderness and is febrile.
The correct answer is Crohns disease
Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here would be locally perforated Crohns disease with a small associated abscess.
A 78 year old lady presents with colicky abdominal pain and a tender mass in her groin. On examination there is a small firm mass below and lateral to the pubic tubercle. Which of the following is the most likely underlying diagnosis?
A-Incarcerated inguinal hernia
B-Thrombophlebitis of a saphena varix
C-Incarcerated femoral hernia
D-Incarcerated obturator hernia
E-Deep vein thrombosis
Femoral herniae account for <10% of all groin hernias. In the scenario the combination of symptoms of intestinal compromise with a mass in the region of the femoral canal points to femoral hernia as the most likely cause.
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.
Borders of the femoral canal Laterally: Femoral vein Medially: Lacunar ligament Anteriorly : Inguinal ligament Posteriorly: Pectineal ligament
Which of the following is not a typical feature of acute appendicitis?
Neutrophilia
Profuse vomiting
A n o r e x ia
Low grade pyrexia
Small amounts of protein on urine analysis
Profuse vomiting and diarrhoea are rare in early appendicitis
Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions.
An 28 year old man presents with a direct inguinal hernia. A decision is made to perform an open inguinal hernia repair. Which of the following is the best option for abdominal wall reconstruction in this case?
Suture plication of the transversalis fascia using PDS only
Suture plication of the hernial defect with nylon and placement of prolene mesh anterior to external oblique
Suture plication of the hernia defect using nylon and re-enforcing with a sutured repair of the abdominal wall
Sutured repair of the hernial defect with prolene and placement of prolene mesh over the cord structures in the inguinal canal Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures
During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord structures results in chronic pain and usually a higher risk of recurrence.
Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias.
Types of surgery include:
Onlay mesh repair (Litchenstein style) Inguinal herniorrhaphy
Shouldice repair
Darn repair
Laparoscopic mesh repair
Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g. repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically challenging to perform.
Inguinal hernia surgery
Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests on their relation to Hesselbach’s triangle.
Boundaries of Hesselbach’s Triangle
Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament
Theme: Abdominal closure methods
A. Looped 1/0 PDS (polydiaxone) B. Looped 1/0 silk
C. 1/0 Vicryl (polyglactin)
D. 1/0 Vicryl rapide
E. 2/0 Prolene (Polypropylene) F. Re-inforced 1/0 Nylon
G. Re-inforced 1/0 Silk
H. Application of VAC system without separation film I. ApplicationofVACSystemwithseparationfilm
J. Applicationofa’BogotaBag’
Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery described.
A 59 year old man with morbid obesity undergoes a laparotomy and Hartmans procedure for perforated sigmoid diverticular disease. At the conclusion of the procedure the abdomen cannot be primarily closed. The Vac system is not available for use.
The correct answer is Application of a ‘Bogota Bag’
Application of a Bogota bag is safest as attempted closure will almost certainly fail. Repeat look at 48 hours to determine the best definitive option is needed.
Theme: Abdominal closure methods
A. Looped 1/0 PDS (polydiaxone) B. Looped 1/0 silk
C. 1/0 Vicryl (polyglactin)
D. 1/0 Vicryl rapide
E. 2/0 Prolene (Polypropylene) F. Re-inforced 1/0 Nylon
G. Re-inforced 1/0 Silk
H. Application of VAC system without separation film I. ApplicationofVACSystemwithseparationfilm
J. Applicationofa’BogotaBag’
Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery described.
A 73 year old lady undergoes a low anterior resection for carcinoma of the rectum.
The correct answer is Looped 1/0 PDS (polydiaxone)
Mass closure obeying Jenkins rule is required and this states that the suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart.
Theme: Abdominal closure methods
A. Looped 1/0 PDS (polydiaxone) B. Looped 1/0 silk
C. 1/0 Vicryl (polyglactin)
D. 1/0 Vicryl rapide
E. 2/0 Prolene (Polypropylene) F. Re-inforced 1/0 Nylon
G. Re-inforced 1/0 Silk
H. Application of VAC system without separation film I. ApplicationofVACSystemwithseparationfilm
J. Applicationofa’BogotaBag’
Please select the most appropriate wound closure method (for the deep layer) for the abdominal surgery described.
A 67 year old is returned to theatre after developing a burst abdomen on the ward. She has originally undergone a right hemicolectomy and the SHO who closed the wound had failed to tie the midline suture correctly. The wound edges appear healthy.
The correct answer is Re-inforced 1/0 Nylon
Attempt at re-closing the wound is reasonable in which case 1/0 nylon (reinforced with drainage tubing) is often used.
Abdominal wound dehiscence
This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis. Traditionally, it is said to occur when all layers of an abdominal mass closure fail and the viscera protrude externally (associated with 30% mortality).
It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers.
Theme: Hernias
A. Umbilicalhernia
B. Paraumbilicalhernia C. Morgagnihernia
D. Littres hernia
E. Bochdalek hernia
F. Richtershernia
G. Obturator hernia
Please select the hernia that most closely matches the description given. Each option may be used once, more than once or not at all.
A 1 day old infant is born with severe respiratory compromise. On examination he has a scaphoid abdomen and an absent apex beat.
The correct answer is Bochdalek hernia
Theme from 2011 exam
The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development.
