Common general surgical problems Flashcards
What is a hernia?
A protrusion of all or part of a viscus through it’s coverings and into an abnormal position
How are there natural weaknesses in the abdomen?
Due to structures entering and leaving the abdomen
What is the epidemiology of inguinal hernias?
100,000 hernia repairs
70,000 are inguinal
What is the most common type of abdominal wall hernia?
Inguinal hernias
What are the risk factors for inguinal hernias?
Older age
Patent processus vaginalis
Connective tissue variations
BMI
Daily lifting and standing/walking may increase risk
Which BMI may be a risk factor for inguinal hernias?
Low may be more risk compared to high
High BMI carries significant risk for hernia recurrence after surgery
What are the types of inguinal hernias?
Indirect
Direct
Which type of inguinal hernia is more common?
Indirect - 75%
What is an indirect hernia?
Failure of the embryonic closure of the deep inguinal ring after passage to the testicle.
Sac originates through the deep ring (lateral to inferior epigastric)
May also pass through superficial ring
What is a direct inguinal hernia?
Sac originates medial to the inferior epigastric artery in Hasselbach’s triangle
May also pass through the superficial ring
What symptoms would you get with an inguinal hernia?
May be asymptomatic
Groin pain
Bulge/lump in groin
Referred pain to testes of thigh
May be worse after physical activity
May have bowel or bladder symptoms if larger
How would you examine a patient for an inguinal hernia?
Patient standing - assess for any lumps.
Lay down - Reduce hernia. Check cough impulse
How would you differentiate between direct and indirect inguinal hernias?
Reduce hernia.
Apply pressure over deep inguinal ring (midway between ASIS and pubic tubercle).
Ask patient to stand whilst keeping pressure on
Indirect hernia will be controlled whereas a direct hernia will not
What are the differential diagnoses for an inguinal hernia?
Femoral hernia
Lymph node
Skin lesion
Psoas abscess
Vascular abnormality
Malignancy
Testicular pathology
What is the first line investigation for an inguinal hernia?
USS but miss 10-15% of hernias.
CT + MRI more useful to r/o alternative pathology as MSK cause of groin pain or assess anatomy if complex
How are inguinal hernias treated?
Mostly conservatively if asymptomatic as low strangulation risk.
Risk of chronic pain after surgery up to 10%.
What are the surgical options for inguinal hernia repair?
Open
Laparoscopic - Trans-abdominal approach or Extra-peritoneal approach
What are the risks of hernia repair surgery?
Recurrence - 15%
Mesh infection - <1%
Chronic pain - 10%
Nerve injury
Haematoma
What is an incarcerated hernia?
Irreducible
May be more painful + bigger than normal
May present with bowel obstruction
Surgery likely needed to prevent recurrence or progression
How does gangrene occur in hernias?
Bowel loop incarcerates in hernia
Increasing pressure inside hernia
Pressure exceeds venous blood pressure
Arterial blood continues to flow in
Pressure rapidly rises in hernia - exceeding arterial pressure
Causing gangrene
How does a strangulated inguinal hernia present?
Painful
Irreducible
Bowel obstruction if bowel involved
Systemically unwell
Hernia feels warm, may be red skin change
Should you reduce a strangulated hernia?
No - there is risk of gangrenous bowel being reduced
How is a strangulated inguinal hernia managed?
Emergency surgery
Repair hernia
Resect gangrenous bowel if present
Which side do femoral hernias most commonly occur?
60% on the right
Which sex is more at risk of femoral hernias?
Females
What are the risk factors for femoral hernias?
Increased abdominal pressure - twice as common in porous women compared with nulliparous
Connective tissue disorders
What is the risk of strangulation in femoral hernias?
20-40%
Which canal does a femoral hernia travel through?
Femoral canal
Why do femoral hernias strangulate more than inguinal?
Because of the anatomy of the femoral ring;
Three sides are inflexible structures
1. Inguinal ligament anterior
2. Pectineus/pectineal ligament posterior
3. Lacunar ligament medial
This reduces the pace available for expansion of the contents at the hernia neck
Where are femoral hernias located?
Below and lateral to the pubic tubercle (site of femoral ring)
Where are the neck of inguinal hernias located?
Above and medial to the pubic tubercle (site of external inguinal ring)
How are femoral hernias managed?
Mainly surgical unless patient very unfit for surgery
What are ventral hernias?
Ventral = front
Non-groin hernia in the anterior abdominal wall
Paraumbilical/umbilical
Epigastric
Incisional
What is a paraumbilical/umbilical hernia?
A midline defect in linea alba close to the umbilicus
What are the risk factors for a paraumbilical/umbilical hernia?
Increased abdominal pressure (pregnancy, ascites)
Females (3:1)
Men have higher strangulation risk - so 70% of repairs carried out in men
10% congenital
90% acquired
Majority are asymptomatic
How does a congenital paraumbilical/umbilical hernia occur?
Failure of closure of the abdominal wall after involution of umbilical vessels
What are the differentials for paraumbilical hernias?
Sister Mary Joseph nodule (malignant peritoneal nodule at umbilicus. 50% GI malignancy, 25% gynae malignancy)
Divarication of the rectus muscles
What is a divarication of the rectus muscles?
Increase in distance between the two rectus abdominis muscles - usually umbilicus to xiphoid.
Stretches but does not breach line alba - therefore not a hernia.
What are the risk factors of a divarication of the rectus muscles?
Obesity
Increasing age
Increasing abdominal pressure
What is an epigastric hernia?
Defect in the line alba between the peri-umbilical region and the xiphoid process.
2-3% of abdominal hernias in adults
Is bowel present in epigastric hernias?
Not usually as posteriorly lies falciform ligament.
A healed scar is never more than what % of the original tissue strength?
70%
What are the risk factors for incisional hernias?
Would infections
Would closed under tension
Diabetes
Immunosuppression
Obesity
Midline incisions (Up to 20% for midline laparotomies)
Pervious repair
Smoking
What is the gold standard test for incisional hernias?
Small - USS
Big - CT
What is an abscess?
Collection of pus (dead + dying neutrophils in proteinaceous exudate)
What bacteria most commonly causes abscesses?
Staphylococcus aureus
What are the risk factors for abscess formation?
Immunosuppression
Skin breach (IVDU, 60% will get abscess)
Smoking
Obesity
What is the pathogenesis of abscesses?
Pyogenic bacteria introduced into tissue
Commonest bacteria - Staph. aureus, Strep. pyogenes. E-coli.
Attracts neutrophils
Resistant to phagocytosis and lysosomal destruction
Infection contained by defence mechanisms
Also localised tissue necrosis and foreign bodies
What is the term called when pus reaches the epithelial surface in abscesses?
Pointing
How can infection spread in abscesses?
Locally e.g. cellulitis
Generally e.g. sepsis
How do abscesses present?
Warm, pain, red, swelling
Pointing
Spreading cellulitis
Patient systemically unwell
Advanced changes e.g. necrosis
What are the differential diagnoses for abscess?
Malignancy
Vascular abnormality - pseudoaneurysm in groin of IVDU
Infection without abscess
Collection arising from deeper structure - Psoas abscess, Diverticular disease
How are abscesses diagnosed?
Mostly clinical. CT/MRI to check for complexity e.g. post-op
How are abscesses treated?
Abxs may treat some
Drainage if some fail - Spontaneous, Surgical, Percutaneous, Pus for micro.
What does a recurrence of an abscess indicate?
ongoing pathology
What is pilonidal disease?
Inflammatory skin condition, mainly affecting natal cleft
What are the risk factors for pilonidal disease?
Male 4:1
Age 15-40
White ethnicity
Hirsutism
Obesity
Deep natal cleft
What is the aetiology for pilonidal disease?
Uncertain
Thought to be loose hair driven into natal cleft, causing foreign body reaction.
Pit then forms (Fistulous opening) and fills with debris, causing chronic inflammation and sinus formation.
Can get secondary openings in midline or laterally
How does pilonidal disease present?
Asymptomatic
Acute abscess (50% develop chronic sinus)
Intermittent swelling or discharge
Pain
How is pilonidal disease managed?
Drainage of acute abscess
Elective excision of sinus (15-40% recurrence rate) to remove pits and abnormal skin. May need skin flap if significant skin loss.
How are lumps assessed?
Size
Shape
Site
Surface
Consistency (hard/soft)
Pulsatility (direct or transmitted)
Compressibility
Reducibility
Fluctuation
Transillumination
Mobility
Percussion
Auscultation (bruits or bowel sounds)
What are some common benign epidermal lesions?
Skin tags
Wards
Naevi
What are some common benign cystic lesions?
Epidermoid cysts (also called sebaceous cysts, but don’t originate from sebaceous glands).
- Filled with sebum and keratin.
- Excision must include cutaneous punctum and cyst sac
Dermoid cysts
- Congenital usually in midline
- Remnants at lines of embryological fusion
- Risk of inflammation or infection so removal usually needed
What are lipomas?
Benign tumours of fat
Encapsulated
Soft to palpate
Can feel tethered if intramuscular
Differentiate from soft tissue sarcoma
What is a ganglia?
Mucin-filled cysts attached to joint capsule or tendon sheaths
Firm
Attached to deeper tissues
Can be painful
Surgical excision if symptomatic or needle aspiration (but recurrence common)
