AS PACES Abdo Surgery Flashcards
Spider Naevi
Central arteriole filling from centre to out (telangectasia fill from edge)
Distribution of SVC
>4 abnormal
DDx CLD, OCP, prego
DDx groin lump
Skin - cyst, psoas abscess Fat - lipoma Connective tissue - fibroma Nerves - neuroma LN Saphena Varix Femoral aneurysm Inguinal hernia Femoral hernia Undescended testes
Inguinal hernia
Above and medial to pubic tubercule Cough impulse Reducible Bowel sounds Hx --> predisposing factors Indirect vs Direct? Bowel sounds? Pain?
Definition hernia
Protrusion of a viscous or part of it into an abdominal position through a defect in its containing cavity
Anatomy of inguinal canal
MALT
M - Superior: external oblique and transverse abdominis
A - Anterior: aponeurosis of internal and external oblique
L - Inferior: inguinal ligament
T - Posterior: transversalis fascia and conjoit tendon
Anatomy of femoral canal
Med: lacunar ligament
Lat: femoral vein
Ant: inguinal ligament
post: pectineal ligament (of Cooper)
Contents of inguinal canal
Male: Spermatic cord (3 fascia, 3 arteries, 3 veins, 2 nerves) + ilioinguinal N.
Female: Round ligament, ilioinguinal nerve N, ten branch of genitofemoral N
Hesselbach’s triangle
Rectus abdominis muscle
Inguinal ligament
Inferior epigastric artery
Indirect vs direct inguinal hernias
Indirect (80%) –> patent processes vaginalis, through deep ring, prone to strangulation
Direct (20%) –> elderly, weak posterior wall of canal, through Hesselbach’s, rarely into scrotum or strangulate
Clinically even surgeons poor at distinguishing
Complications of hernia repair
Retention, haematoma, infection, intra-abdominal injury
Recurrance, ischaemic orchitits (2* to thrombosis of pampiniform plexus), chronic groin pain
Mx femoral hernia
50% risk of strangulation w/i one month, urgent surgery
Elective –> low approach, incision over hernia + herniotomy and heriorrhaphy
Emergency –> high approach to allow inspection/resection of non viable bowel
RF Incisional hernia
Pre op –> Age, co-morbidities, steroids, chemo, radio, obese/malnurished, malignancy
OP –> surgical skill, too small suture bites, inappropriate suture, incision type, drains
Post op –> IAP, cough, straining, post op ileus
Paraumbilical hernia
Acquired defect in line alba above/below umbilicus
Obese, middle aged pts, neck is narrow (prone to strangulation), typically momentum ± bowel
RF: obese, prego, ascites, fibroids, distension
Mx: Mayo repair (mobilise sac and reduce contents, double-breast line alba ± sub lay mesh)
Umbilical hernia
Congenital defect (±3% live births)
RF: Black, Downs, Cretin
Usually self resolves <3yrs, if >3yrs surgical
Epigastric hernia
Midline lump above umbilicus when pt coughs, typically small pea shaped
RF: prego, obese, age 20-50
Defect in line alba between xiphisternum and umbilicus, usually extra peritoneal fat / momentum
Likely asymptomatic, can cause nausea, early satiety, pain + after meals, bloating
Conservative –> RF: constipation, cough, weight
Surgical –> suture / mesh
Examining scrotal lumps
STANDING
- Can you get above it? (if not, hernia)
- Is it tender? (if not, torsion, hydatid of Morgani, epididymo-orchitis, strangulated hernia)
- Is testes palpable? (No, tumour, orchitits, hydrocele. Yes, varicocele, spermatocele, cyst)
- Does it transilluminate? (Yes, hydrocele, spermatocele)
Hydrocele
Accumulation of fluid w/i tunica vaginalis; remnant of processes vaginalis which forms one of the adult coverings of the testes
Mx: Excluse Ca (USS); watch and wait, ?aspiration for symptom relief
Surgical –> plication of tunica vaginalis or eversion of the sac
Hydrocele classification
Classification: Vaginal (in tunica vaginalis, doest extend into cord);
Congenital (proximal part of process has not obliterated;
Infantile
Hydrocele of Cord (around ductus deferens, difficult to distinguish from inguinal hernia)
Epididymal Cyst
O/E normal looking scrot, can get above, separate from testes, firm, transilluminates
Retention cyst of tubule of rate testes of epidermis, often multiple, may contain sperm, generally asymptomatic
Conservative –> if it ain’t causing no trouble leave it alone
Surgical –> V large / painful can be remover. Risk sub/infertility. Exision of entire epidermidis may be sometimes indicated
Varicocele - Bag of worms
Dilated veins of pampiniform plexus, 98% L, 50% B/L
2* varicoceles in older gentlemen = retroperitoneal disease affecting L testicular vein (e.g. RCC, doesn’t disappear when pt supine)
Conservative: scrotal support
Non-surgical: transferral radiological embolisation of testicular vein
Surgical: high approach with transverse incision above and medial to asis, vein exposed and ligated. Or inguinal approach.
Why varicoceles L>R
L testicular vein more vertical where it joins L renal vein (R testicular joins IVC), is longer than R, and often lack terminal valve preventing backflow. LRV can be compressed by colon.
Classification of testicular tumours
95% germ cell tumours
Seminoma (40%): 30-40yrs, normal markers, spread para aortic LN, platinum based Cx + surg
Teratoma: 20-30yrs, AFP + bHCG + 1-2 cycles of chemo + surg
Yolk sac: children
Leydig / Sertoli cell (rare, may secrete oestrogens = gynaecomastia)
Lymphoma: NHL is commonest testicula mass >60 yrs
All tumours surg: groin incision + early clamping of spermatic cord to stop seeding
Stoma: Definition
Artificial union between conduits or between conduit and the outside
Stoma: Indications
Exteriorisation: Perforated/Contaminated: Hartmann’s; Permanent: AP resection
Diversion: Protection of distal anastamosis, acute crohn’s, urinary
Decompression: Bypass of distal obstruction
Feeding: Gastrostomy / Jejunostomy
Lavage: Caecostomy
End ileostomy
Permanent: Panproctocolectomy (no anus) in UC, ileal conduit
Temporary: Total colectomy (FAP), later IPAA
Loop Ileostomy
Temporary stoma to de-function distal bowel, may be supported by bridge/rod
Anterior resection colon Ca; Crohn’s disease
End Colostomy
Permanent: AP resection (rectal Ca)
Temporary: Hartmann’s (proctosigmoidectomy) (acute obstructing Ca, diverticulitis)
Loop Colostomy
RUQ (rare): defunctioning transverse colostomy to cover distal anastamosis (Colon Ca, Ant Resection)
LIF: Apex of sigmoid exteriorised w/o resection for inoperable Ca rectum likely to obstruct
Stoma complications
Early –> Haemorrhage, ischaemia, high output (watch K, loperamide ±codeine), stoma retraction
Delayed –> parastomal hernia, adhesions, herniation, dermatitis, prolapse, stenosis, stricture, fistulae, psychosexual
Urostomy
(following cystectomy)
Ileal conduit –> ureters attached to portion of resected ileum. Bowel primary anastamosis. Incontinent
Indiana Pouch –> Pouch created from 2ft ascending colon and portion of ileum including ileocaecal valve, preventing urinary leak from pouch. Pt self catheterises to drain pouch.
Midline laparotomy
Emergency laparotomy (perf DU, trauma, AAA, Hartman’s).
Good access, bloodless line
Minimal nerve and muscle injury, but pain and poor cosmetic effect.
Jenkin’s rule of suturing
Length of suture = 4x length of incision
1cm bite, 1cm apart
Kocher’s
R –> open cholecystectomy
L –> Splenectomy
Rooftop
Hepatobiliary (liver Tx, resection, Whipple’s),
Can be extended to Mercedes Benz, closed in 3 layers
Phannenstiel
Gynae
Lower urinary tract
Mcburney’s Incision / Lanz
Both follow Langer’s lines. Risk of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia
Lanz = transverse (favoured, scar hidden in skin crease)
McBurney’s = oblique
Skin - Camper’s Fascia - Scarpa’s Fascia - External Oblique - Internal Oblique - Transversus - Transversalis Fascia - Pre peritoneal fat - peritoneum
R hemicolectomy
Tumours in cecum and proximal ascending colon
Midline lap / laparoscopic / transverse muscle splitting
Ileocolic anastamosis
Extended R Hemicolectomy
Tumour in distal ascending / transverse colon
Midline / Laparoscopic
Ileocolic anastamosis
Left Hemicolectomy
Tumours in descending colon
Colocolic anastamosis
Hartmann’s Procedure
Proctosigmoidectomy, obstruction/perforation 2* to sigmoid tumour or diverticulitis
End colostomy + oversewn rectal stump; reversible in 70% after 3-6 months
Midline lap + stoma scar in LIF if reversed.
DDx APR
APR
Rectal Ca <4-5 cm from anal verge Sigmoid, rectum, mesorectal nodes removed via abdominal incision. Anus removed via perineal incision Midline lap + no anus Single lumen end colostomy DDx Hartmann's
Anterior Resection
Rectal Ca >4-5 cm from anal verge
Excision of part of rectum + sigmoid. May be high or low depending on site ± total mesorectal excision. Primary colocolic anastamosis but poor blood supply so covered with temp loop ileostomy.
Midline lap / laparoscopic / scar or stoma in RIF
Double lumen loop ileostomy in RIF
Ddx - end ileostomy (panproctocolectomy, subtotal colectomy, cystectomy + ileal conduit), loop ileostomy (temp diversion in CD)
Subtotal colectomy
Acute severe UC
All colon except distal sigmoid and rectum. Temp end ileostomy. Rectosigmoid stump may be exteriorised as mucus fistula. 3mo later ileorectal anastamosis or permanenent end ileostomy or ileo anal pouch
Midline / Lap
Single lumen end ileostomy in RIF
Panproctocolectomy
UC / FAP
All colon, rectum and anus removed. Permanent end ileostomy
Indications for surgery in UC
Megacolon >6cm on AXR
Perforation (30-40% mort)
Severe GI bleed
Malignancy
Indications for surgery in CD
Obstruction 2* to stenosis Perforation Severe GI bleed Peri-anal disease (fistulae and abscesses) Intra abdominal abscesses Medical failure - temp defunct ion Entero-cutaneous fistulae
Surgical options for UC
Curative intent - IPAA or IRA offer continence but increased BM, pouchitits, risk of malignancy
Subtotal colectomy, end ileostomy ± mucus fistula
Proctocolectomy and permanent ileostomy
Restorative proctocolectomy
