Abdominal Flashcards
Persistence of the Vitello-Intestinal Duct
Vitelline Fistual (meconium through umbilicus)
Proximal part only = Meckel’s Diverticulum
Does not communicate with ileum = Enterocystoma
Persistent umbilical portion of the duct, which forms a polypoidal raspberry-like tumour of the umbilicus = Entroteratoma
Meckel’s Diverticulum
Remnant of vitello-intestinal duct
Asymptomatic : ileal mucosa
Symptomatic: Gastric
Located on anti mesenteric border of the ileum
2% (of the population)
2 feet (proximal to the ileocecal valve)
2 inches (in length)
2 types of common ectopic tissue (gastric and pancreatic)
2 years is the most common age at clinical presentation
2:1 male:female ratio
Complications:
Bleeding
Obstruction
Hernia (Littre’s)
Diverticulitis
Neoplastic change
Urachus
Urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.
Runs from apex of the bladder to the umbilicus
Normally obliterated
Persistence can cause:
-Discharging umbilicus sinus
-Cyst
-Urinary fistula
Umbilical Sepsis
Neonatal
Causes serious complications:
-Portal thrombophlebitis
-Liver abscess
-Jaundice
-Portal vein thrombosis
-Liver failure
Adults
Caused by retention of sebum within folds of umbilicus or from pilonidal sinus infection of umbilicus
Erythematous
Mixed staphylococcus and streptococcus growth
Haematoma of the rectus sheath
Spontaneous rupture of a branch of the inferior epigastric artery –> haematoma in rectus sheath
Presents as abdominal pain + rigidity on one side
More common in elderly people on anticoagulation
USS used to Dx
Mx: Conservative or drainage if problematic
Desmoid Tumour
Rare tumour of fibrous intra-muscular septa in the lower rectus abdominis
More common in females CBA
Associated with Gardener’s syndrome (AD polyposis with intra colic and extra colic tumours)
Mx: excised widely as high recurrence and can undergo malignant transformation (fibrosarcoma)
Littre’s Hernia
Hernia of Meckel’s Diverticulum
Richter’s Hernia
Hernia only involving part of the circumference of the bowel wall
Do not present with usual obstructive features
May present with ileum due to peritonism caused by necrotic bowel
Amyand’s Hernia
Hernia of incarcerated appendix
Sliding inguinal hernia
Herniating viscus forms part of the of the wall of the hernia sac
Pantaloon Hernia
Direct and indirect inguinal hernia
Hernias straddle inferior epigastric artery with bulges either side
Borders of the Inguinal Canal
Anterior: External oblique aponeurosis
Lateral 1/3: +Internal oblique
Floor: Inguinal ligament
Reinforced by lacunar ligament medial end
Posterior: Transversalis fascia
Roof: Internal oblique, transversis abdominis (and transversalis fascia)
Location of Deep Inguinal Ring
1cm above the Mid-point of the inguinal ligament
1/2 way along the inguinal ligament that arises at the ASIS and inserts on the pubic tubercle
Bound medially by inferior epigastric artery
Deep ring is defect in the transversalis fascia
Location of the Superficial Inguinal Ring
Just above and medial to the pubic tubercle
Defect in external oblique aponeurosis
Reinforced by medial and lateral crura
Contents of the Inguinal Canal
M: Spermatic Cord
F: Round ligament
Ilioinguinal nerve
-Doesn’t enter through the deep ring
-At -risk during hernia repair
-Sensation to external genitalia
Genital branch of the the genitofemoral nerve
-Supplies crmaster muscle
-Anterior scrotal skin / mons pubis + labia majora
Coverings of the spermatic cord
Embryologically, takes a covering from each layer of the abdominal wall
Transversalis fascia –> Internal spermatic fascia
Internal oblique –> cremasteric muscle and fascia
External oblique –> external spermatic fascia
Contents of the spermatic cord
Spermatic cord contents “3 arteries, 3 nerves, 3 other things”:
3 arteries:
1. Testicular artery (branch of aorta on R, branch of renal artery L)
2. Deferential artery (artery to the ductus deferens)
3. Cremasteric artery (branch of inferior epigastric)
3 nerves:
1. Genital branch of the genitofemoral
2. Cremasteric nerve
3. Autonomics.
3 other things:
Ductus deferens
Pampiniform plexus
Lymphatics
Ilioinguinal nerve
Hernia passes above and medial to pubic tubercle
INGUINAL HERNIA
Hernia passes below and lateral to pubic tubercle
FEMORAL HERNIA
Hesselbach’s Triangle
Medial: lateral border of the rectus abdominis
Lateral: Inferior epigastric artery
Below: Inguinal ligament
(Above: Conjoint tendon)
Managemet of uncomplicated inguinal hernia
Neonate –> emergency
Children –> elective herniotomy
Symptomatic adults –> offered surgery
Indications for laparoscopic hernia repair
Bilateral hernias for repair
Recurrent hernia
Exploration of the groin when a symptomatic
hernia is suspected from
Age at which conservative management for umbilical hernia is switched to surgical management:
3 years
-95% resolve by then
Surgery to correct para-umbilical hernia
Mayo procedure
-Flap of rectus sheath and line alba above and below defect