Colorectal Flashcards
Features of hernias?
soft lump protruding through abdominal wall
lump may be reducible
lump may protrude on coughing (raising intra-abdominal pressure)
lump may protrude on standing (gravity)
aching, pulling or dragging sensation
3 key complications of hernias?
incarceration
obstruction
strangulation
What is a Richter’s hernia?
when only part of the bowel wall and lumen herniate through the defect, while the other section remains within the peritoneal cavity
high risk of strangulation, ischaemia and necrosis
What is a Maydl’s hernia?
when two different loops of bowel are contained within the hernia
Management of hernias?
conservative
tension-free repair
tension repair
Tension-free repair vs tension repair?
Tension-free repair involves placing a mesh over the hernia to prevent recurrence
Tension repair uses sutures (rarely done anymore)
DDx for inguinal lump?
inguinal hernia
femoral hernia
lymph node
saphena varix
femoral aneurysm
abscess
undescended/ectopic testis
kidney transplant
hydrocele
testicular torsion
Indirect vs Direct inguinal hernias?
indirect hernias protrude through the inguinal canal (when reduced, hernia will remain reduced if pressure is applied to the deep inguinal ring)
direct hernias protrude directly through the abdo wall, through Hesselbach’s triangle (pressure to deep inguinal ring will not stop herniation)
Boundaries of Hesselbach’s triangle?
Rectus abdominis
Inferior epigastric vessels
Poupart’s ligament (inguinal ligament)
Contents of the inguinal canal?
3 vessels (testicular artery + vein, vas deferens a+v, cremasteric a+v)
3 fasciae (external spermatic fascia, cremasteric fascia, internal spermatic fascia)
4 nerves (cremaster, sympathetic, ilioinguinal, genitofemoral)
3 others (spermatic cord, vas deferens, lymphatics)
Where do femoral hernias occur?
through the femoral canal, below the inguinal ligament
femoral ring is narrow -> high risk for incarceration, obstruction and strangulation
Boundaries of the femoral canal?
Femoral vein
Lacunar ligament
Inguinal ligament
Pectineal ligament
Boundaries of the femoral triangle?
Sartorius (lateral)
Adductor longus (medial)
Inguinal ligament (superior)
Contents of the femoral triangle?
Femoral Nerve
Femoral Artery
Femoral Vein
Femoral Canal (lymph)
Where does a Spigelian hernia occur?
between the lateral border of rectus abdominis and the linea semilunaris
not always a lump -> US used to confirm diagnosis
What occurs in diastasis recti?
widening of the linea alba, the aponeurosis which connects the two sides of the rectus abdominis muscle
can be congenital, or occur in pregnancy or obesity
Where do obturator hernias occur?
through the obturator foramen at the bottom of the pelvis
due to pelvic floor weakness (older women post-pregnancy)
often asymptomatic and found incidentally but may irritate the obturator nerve
CT or MRI to confirm diagnosis
Definition of a hernia?
abnormal protrusion of an organ (or part of an organ) through its containing body wall
Epidemiology of inguinal hernias?
M:F 8:1
men - 50-70yrs
women - 60-80yrs
What is a pantaloon hernia?
a combination of both an indirect and direct inguinal hernia
Investigations for inguinal hernia?
exam - often a clinical diagnosis
get to stand/cough/Valsalva
examine scrotum
bloods (WBC, CRP, U&E, lactate)
imaging (groin US if occult hernia or obstruction suspected)
Complications of inguinal hernia repair?
scrotal haematoma
wound infection
urinary retention
damage to ilioinguinal nerve (paraesthesia/pain in scrotum/labia)
damage to testicular artery (atrophy)
recurrence
Risk Factors for recurrence of hernias post-repair?
infection
poor operative technique
coughing
constipation
bladder outlet obstruction
heavy lifting (avoid for 6-8wks)
Epidemiology of femoral hernias?
more common in women
>70yrs
DDx for femoral hernias?
femoral canal lipoma
saphena varix
lymphadenopathy
femoral artery aneurysm
femoral artery pseudoaneurysm (post-angiography)
sarcoma
Risk Factors for incisional hernias?
post-op wound infection
abdominal obesity
poor muscle quality (smoking, anaemia)
multiple operations through same incision
incision size
poor choice of incision
inadequate closure
What is appendicitis?
inflammation of the appendix
most common cause of acute abdomen and most common indication for emergency surgery
Presentation of acute appendicitis?
abdominal pain (typically peri-umbilical that migrates to RIF within 24hrs)
tenderness in McBurney’s point
anorexia
nausea & vomiting
low-grade fever
Rovsing’s sign
guarding
rebound tenderness (peritonitis)
percussion tenderness (peritonitis)
Where is McBurney’s point?
imaginary point 1/3rd of the way between ASIS and umbilicus
Diagnosis of appendicitis?
clinical diagnosis
raised inflammatory markers
CT scan if doubt
US (exclude gynae)
DDx for appendicitis?
ectopic pregnancy
ovarian cyst
Meckel’s diverticulum
mesenteric adenitis (children)
What is an appendix mass?
occurs when the omentum surrounds and sticks to the inflamed appendix, forming a RIF mass
managed with supportive treatment and antibiotics and appendicectomy once resolved
Management of acute appendicitis?
laparoscopic or open appendicectomy
Complications of appendicectomy?
Thromboembolic events
Bleeding
Infection (wound/intra-abdominal)
Removal of normal appendix
Damage to bladder, bowel, other organs
Dehiscence of wound
Scarring
Anaesthetic risks
Components of Alvarado Score?
abdo pain
anorexia
nausea/vomiting
RIF tenderness
rebound tenderness
temp > 37.5
WCC > 10
neutrophils > 75%
Complications of acute appendicitis?
perforation
RIF appendix mass
RIF abscess
pelvic abscess
Causes of small bowel obstruction?
adhesions
hernias
malignancy
intussusception
strictures (Crohn’s, radiation)
Meckel’s diverticulum
Causes of large bowel obstruction?
malignancy
hernias
diverticulitis
volvulus
intussusception
stricture
What causes adhesions?
abdo or pelvic sx (particularly open)
peritonitis
abdo or pelvic infections (PID)
endometriosis
congenital
secondary to radiotherapy
What is a closed-loop obstruction?
when there a two points of obstruction within the bowel, causing increased pressure and rupture of the compressed bowel
requires emergency sx
Causes of a closed-loop obstruction?
adhesions
hernias
volvulus (twist isolates section)
single point of obstruction with a competent ileocecal valve
Presentation of bowel obstruction?
vomiting
abdo distension
diffuse abdo pain
obstipation
‘tinkling’ bowel sounds in early obstruction
Diagnosis of bowel obstruction?
PFA -> dilated loops of bowel
3, 6, 9 (small, large, caecum)
valvulae conniventes in small bowel
haustra in large bowel
CXR for air under diaphragm if perforation suspected
contrast CT to confirm and to see cause
Management of bowel obstruction?
nil by mouth
IV fluids
NG tube with free drainage
Sx intervention if needed - depends on cause (adhesiolysis, hernia repair, emergency resection, stents, colonoscopy and pneumatic decompression)
Complications of bowel obstruction?
hypovolaemic shock (third-spacing)
bowel ischaemia
bowel perforation
sepsis
metabolic alkalosis (vomiting)