Colorectal surgery Flashcards
Small bowel obstruction causes
Hernia
Adhesions
Tumour
Large bowel obstruction causes
Cancer
Volvulus
Strictures (diverticular disease > IBD)
Obstruction Ix
AXR
Definitive: CT abdomen
Colorectal cancer S+S
Change in bowel habit PR bleeding WL Fatigue Anaemia - more likely a R sided colorectal cancer if this is found (more indolent bleeding)
Colorectal Ca Ix
Sigmoidoscopy –> colonoscopy
Screening
55y = flexi sig –> colonoscopy if +
- Once
- Male and female
60-74 = faecal immunochemical test
- every 2 years
- male and female
- if +ve, colonoscopy is offered
Colorectal Ca Mx
- Resection (sigmoid colectomy is not a cancer operation – need to take the entire IMA for all lymph supply)
- Heparin SC enoxaparin for 28d
± pre-operative (neoadjuvant) chemoradiotherapy if pelvic LN spread
Colorectal Ca post-op complications
Ileus - peristalsis halted - fluids stop moving in intestine - electrolytes diffuse into lumen –> low electrolytes in blood and dehydrated pictures despite positive fluid balance
Anasamotic dehiscence – day 6, fever, septic
Ileus Mx
NG + IV fluids
Blood supply to the large bowel
IMA splits into Left colic artery
SMA splits into R colic artery –> ileocolic and middle colic arteries
3 areas of bowel with poor perfusion
R colon - vulernable in systemic low flow states as marginal artery of Drummond is poorly develop in 50% of population
Splenic flexure - marginal artery of Drummond is tenuous here/ absent in 5%
Rectosigmoid junction - distal to last collateral connection with proximal arteries
Syndromes associated with colorectal cancer
Familial adenomatous polyposis
MYH associated polyposis
Peutz Jegher’s syndrome
Cowden disease
HNPCC
FAP inheritance pattern
AD
FAP features
> 100 colonic adenomas
Cancer risk of 100%
20% are new mutations
FAP screening and Mx
Risk –> predictive genetic testing as teenager
Annual flexi-sig from 15 years
No polyps found –> 5 yearly colonoscopies from 20yo
Polyps found = resection
FAP associated disorders
Gastric fundal polyps (50%)
Duodenal polyps 90%
If severe duodenal polyposis cancer risk of 30% at 10y
Abdominal desmoid tumours
MYH associated polyposis inheritance pattern
AR
MYH associated polyposis features
Multiple colonic polyps
Later onset right sided cancers more common than in FAP
100% cancer risk by age 60
MYH associated polyposis Mx
Resection and ileoanal pouch
Attenuated phenotype –> regular colonoscopy
MYH associated polyposis associations
Duodenal polyposis in 30%
Associated with increased risk of breast cancer
Peutz-Jegher’s syndrome inheritance pattern
AD
Peutz-Jegher’s syndrome features
Multiple benign intestinal hamartomas
Episodic obstruction / intussusception
Risk GI cancers (CRC 20%, gastric 5%)
Increased risk of breast, ovarian, cervical pancreatic and testicular cancers
Peutz-Jegher’s syndrome Ix Mx
Annual examination
Pan intestinal endoscopy every 2-3 years
Peutz-Jegher’s syndrome associations
Malignancies at other sites
Pigmentation pattern
Cowden disease inheritance pattern
AD
Cowden disease features
Macrocephaly
Multiple intestinal hamartomas
Multiple trichilemmomas
89% risk of cancer at any site
16% risk of colorectal cancer
Cowden disease screening and Mx
Targeted individualised screening
Cowden disease associated disorders
Breast cancer (81% risk)
Thyroid ca, non-toxic goitre
Uterine cancer
HNPCC (Lynch syndrome) features
CRC 30-70%
Endometrial cancer 30-70%
Gastric cancer 5-10%
Scanty colonic polyps may be present
Colonic tumours likely to be right sided and mucinous
HNPCC (Lynch syndrome) Screening and Mx
Colonoscopy every 1-2 years from 25yo
Prophylactic surgery
Extra colonic surveillance recommended
HNPCC (Lynch syndrome) associated disorders
Extra colonic cancers
Volvulus - what % many sigmoid and caecal
80% sigmoid
20% caecal
what is a sigmoid volvulus
large bowel obstruction caused by sigmoid colon twisting on the sigmoid mesocolon
What is a caecal volvulus
small bowel obstruction caused from a proximal LBO cause of a congenital abnormality
Sigmoid volvulus associations
older chagas disease chronic constipation pyschiatric condiiton (schizo) neuro condiiton (PD)
Caecal volvulus associatoins
all ages
adhesions
pregnancy
volvulus S+S
constipation
abdo pain
abdo bloating
N/V
volvulus Ix
AXR
sigmoid - LBO coffee bean sign –haustra, large dilated loops of colon, often with air-fluid levels
Caecal - SBO valvule conniventes, mucosal folds that cross entire width of bowel wall
Volvulus Mx
Sigmoid - therapeutic sigmoidoscopy with rectal tube insertion (if peritonism – laparotomy)
Caecal volvulus – laparotomy (R hemicolectomy often needed)
Bowel obstruction Mx
1st - drip and suck - + conservative
2nd - adhesiolysis
Position of inguinal hernia
Above and medial to pubic tubercle
Femoral hernia position
Below and lateral to pubic tubercle
Is inguinal or femoral more common in women
Femoral
Inguinal hernia - strangulation risk
rare
Femoral hernia - strangulation risk
high risk of obstruction and strangulation
Femoral hernia Mx
surgical repair needed
Difference between umbilical and paraumbilical hernia
Umbilical = symmetrical bulge under umbilicus
Paraumbilical = asymmetrical bulge - half the sac is covered by skin of abdomen directly above or below the umbilicus
Paraumbilical = high risk of strangulation
Paraumbilical hernia Mx
Mayo repair
Epigastric hernia location
Most common in
Lump in midline between umbilicus and xiphisternum
men aged 20-30
Spigelian hernia also known as
lateral ventral hernia
Spigelian hernia location
seen in
A hernia through the spigelian fascia (aponeurotic layer between rectus abdominis muscle and semilunar line)
Rare and seen in older patients
Obturator hernia location
F or M?
hernia which passes through obturator foramen
F>M
Obturator hernia presentation
obstruction
Richter hernia location and presentation
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect (i.e. only ONE of the intestinal walls herniates through the bowel wall)
Richter’s hernia can present with strangulation without symptoms of obstruction
Types of hernia surgery
herniotomy - ligation and excision of hernial sac
herniorrhaphy - repair of abdominal wall defect
hernioplasty - mesh implant
Hernia RF
obesity, ascites, increasing age, surgical wounds
Hernia Mx
Strangulated/ incarcerated - emergency surgery
Not strangulated/ incarcerated
Adult - inguinal - repeat
femoral - urgent repair
Child inguinal <6w - operate within 2 days <6m - operate within 2 weeks <6y - operate within 2 months
umbilical
- most resolve by 4-5y
Femoral hernia repair approaches
elective vs emergency
eLective = Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)
eMergency = McEvedy high approach (via inguinal region to inspect and resect non-viable bowel)
Hernia repair incision and risk of damage to
McBurney’s - oblique
Lanz - transverse incision
to Iliohypogastric and ilioinguinal nerves
Hernia post-op advice
Must pass urine before discharge
Mobilise early (work in 1-2 weeks; ≥6 weeks if work involves heavy lifting)
Adequate analgesia and avoid constipation (lactulose prescription)
Keep area clean and dry
Can bathe immediately
Complications of gastrectomy
Physical:
- Gastric cancer risk
- Reflux / bilious vomiting
- Abdominal fullness
- Stricture
- Stump leakage
Metabolic:
- Dumping syndrome (abdominal distension, flushing, fainting, sweating)
- Blind loop syndrome (malabsorption, diarrhoea)
- Malnutrition:
• Vitamin deficiency
• Weight loss
