Colorectal II Flashcards
Low rectal cancer is usually treated with [] surgery.
How do you adapt ^ to avoid the high risk of anastomotic leak? [1]
What is the contraindication to this? [1]
Low rectal cancer is usually treated with a low anterior resection
- Contraindications to this include involvement of the sphincters
- Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients
What type of stoma is this? [1]
Loop stoma
What type of stoma is this? [1]
Label which of A & B is the proximal and distal part [2]
Double barrel stoma
A: Proximal
B: Distal
State what the three different types of colostomy are [3]
Loop colostomy
End colostomy
Double barrel colostomy
Describe what a loop colostomy is [3]
Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery
Allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function, by draining into a stoma bag
They are usually reversed around 6-8 weeks later
Describe how you differentiate between the proximal and distal end of a loop colostomy [1]
The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin.
This distal end is flatter
Describe what a double barrel stoma is [1]
Divides the colon into 2 ends that form separate stomas:
Stool exits from one of the stomas & mucus made by the colon exits from the other
Describe what is meant by pancaking of a stoma [1]
Internal layers of the stoma bag stick together causing a vacuum which prevents the contents from dropping to the bottom. The stool remains at the top of the stoma bag which can potentially block the filter. The bag can also be forced off the body.
Physiological complications of high output ileostomy? [2]
○ > 1.5 - 2 litres
○ Fluid & Electrolyte imbalance
■ Dehydration, AKI
■ ↓Na, ↑K, ↓Mg (Addison’s picture)
■ Vitamin B12, Folate Def.}}
Problems associated with low volume ileostomy? [2]
● Low Volume (↓frequency & or quantity)
○ Stenosis
○ Impending obstruction}
Treatment for high output stomas? [5]
● Hydrate (fluid and high salt replacement)
○ Glucose-electrolyte solution aids sodium absorption
○ Restrict low sodium (Hypotonic) fluid (500-1000ml/day)
● Anti-diarrhoeal medication, eg loperamide
● Anti-secretory drugs
○ PPI (omeprazole) ○ Octreotride (rarely)
● Correct Hypomagnesaemia
● Opiates (codeine phosphate)
Where exactly are loop colostomies located? 1[]
usually in the right transverse colon, proximal to the middle colic artery
Ileostomies can be low or highoutput:
Low output tends to output [] ml/day for a low output ileostomy, and [] ml/day for a high output ileostomy
tends to output 500 ml/day for a low output ileostomy, and 1000 ml/day for a high output ileostomy
Define what is meant by a parasternal hernia [1]
Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma
How do you determine if a stoma has a parasternal hernia?
Positive cough impulse and and lump at the hernia site
What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3]
How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]
Classification of risk and advised management in patients with colorectal adenomas are as follows:
Low risk
- one or two adenomas smaller than 10 mm
- should be considered for colonoscopy at five years
Intermediate risk
- three/four adenomas smaller than 10 mm
or
- one/two adenomas if one is 10 mm or larger
- should be offered a colonoscopy at three years
High risk
- five or more adenomas smaller than 10 mm
or
- three or more adenomas if one is 10 mm or larger
- offered a colonoscopy at one year.
National Institute for Health and Care Excellence (NICE) guidelines recommend a surveillance colonoscopy for patients with UC how often for low, medium and high risk patients? [3]
aLow: every 5 years
Medium: every 3 years
High: annually
What are the borders of Hesselbach’s triangle? [3]
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
Define what is meant by a Pantaloon hernia [1]
A pantaloon hernia, also known as a saddlebag hernia, is defined as any combination of two adjacent hernia sacs of the femoral or inguinal region (direct or indirect inguinal hernias (alternative plural: herniae)) on the same side
Thus, examples include: femoral with direct hernias, femoral with indirect hernias, indirect with direct hernias.
Difference in anatomy of femoral and inguinal hernia? [2]
Inguinal:
superomedial to the pubic tubercle
Femoral:
inferolateral to the pubic tubercle
Describe the management of uncomplicated hernia [4]
Surgery:
Open mesh repair:
- Direct hernia: plication
- Indirect: sac excision
- Both: add mesh which produces fibrosis
Laporoscopic mesh repair:
- As above, but reduced injury of nerves & post-op chronic pain
- Reinforces wall to elimiante reoccurence
Laporoscopic pre-peritoneal mesh repair
Suture repair (high chance of reoccurance
PassMed:
Primary unilateral/ bilateral hernia:
* Mesh repair(Lichtenstein’s or endoscopic repair), the mesh repair uses polypropylene mesh to reinforce the posterior wall. A recurrence rate of 2-10% for both procedures.
Recurrent inguinal hernia:
* If previous anterior hernia repair: open preperitoneal mesh or endoscopic approach
* If previous posterior hernia repair: Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.
Which nerves are present in area that open and laparoscopic mesh repair occur in? [3]
The iliohypogastric nerve, ilioinguinal nerve and genital branch of the genitofemoral nerve
Laparoscopic mesh repair is particularly good for repairing what type of hernias? [1]
Bilateral hernias
What is a spigelian hernia? [2]
A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris.
This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain.
Inguinal hernias are more commonly found on which side? [1]
Why? [2]
Right sided
Due to descend of the testis or previous appendectomy
Label E & F
What type of surgeries would they be used for? [1]
E: Battle
F: Lanz
Both for open appendicectomy
Label B [1]
What is the indication for B? [1]
Rooftop scar: Liver transplant
Label A [1]
What would indicate A? [1]
Kocher scar: open cholecystectomy
Name [1] and describe the classification used for PAD [4]
Fontaine classification
Describe the surgical procedures used to treat AAA [2]
Open AAA surgery:
- cross clamp the AA above & below aneursym
- open aneursym and remove clot
- stitch in graft
Endovascular aneurysm repair (EVAR)
- A wire is passed under fluoroscopic guidance through the aneurysm sac and a stent-graft is inserted to occlude the aneurysm from the inside
- local anaesthetic
Dukes Classification of colorectal cancer:
What are the 4 stages? [4]
T1 and T2 is when the tumour is still within the mucosal wall.
