Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery block (Y3) > General surgery (6) (Hernias and nutrition) > Flashcards

General surgery (6) (Hernias and nutrition) Flashcards

1
Q

hernia history

A

Introduction

  • Introduce self
  • Name and DoB
  • Explain what you are doing and consent

PC- ‘ what has brought you in today’

HPC- treated as a lump

  • Where is the lump
  • When was it first noticed
  • What made you notice it
  • Has the lump changed since it was first noticed
  • Does it ever disappear
  • What makes it reappear
  • Do you have other lumps
  • What do you think may have caused lump
  • Reducibility
  • Associated symptoms
    • Abdominal distention, vomiting, constipation, pain
      • SOCRATES inc predisposing factors
  • Constitutional symptoms
    • Fever
    • Weight loss
    • Loss of appetite
    • Night sweats
  • PMH and surgical
  • Family history of hernia
  • Drug history
    • ACEi- chronic cough
  • Allergies
  • Social history
    • How does it affect ADR
    • Support at home
    • Smoke drink
    • Weight
    • Activity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

hernia examination

A

Intro

  • Introduce self
  • Name and DoB
  • Explain exam and gain consent, chaperon
  • Adjust bed to 45 degree angle
  • Wash hand
  • Adequately expose patient
  • Ask about pain

General inspection

  • Clinical signs of underlying pathology
    • Can you see lump
  • Signs of peritonitis e.g. guarding (lying very still)

Differentiating a hernia from other lumps

  • Number of lumps
  • Cough impulse
  • Consistency
  • Ability to get above lump
  • Tenderness
  • Bowel sounds
  • Bruit
  • Transillumination

Differentiating hernia subtypes

  • Assess anatomical relationship of hernia in relation to pubic tubercle
  • Access reducibility
  • Locate deep inguinal ring (midway between anterior superior iliac spine and pubic tubercle)
  • Manually reduce hernia by compressing it towards deep inguinal ring starting at inferior aspect of hernia
  • Once hernia is reduced, apply pressure over deep inguinal ring and ask pt to cough

Scrotal exam

  • If appropriate

To complete

  • Thank patient
  • Wash hands
  • Summarise findings
  • Further assessment- testicular exam, abdominal exam, inguinal lymph node assessment, further imaging
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

DD for lump in inguinal region

A
  • Femoral hernia
  • Lymph node
  • Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
  • Femoral aneurysm
  • Abscess
  • Undescended / ectopic testes
  • Kidney transplant
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

how to distinguish between inguinal and femoral hernias

A

inguinal hernias- medial to the pubic tubercle

femoral hernia- lateral to pubic tubercle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

inguinal hernia can be

A

indirect or direct

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

indirect inguinal hernia

A
  • Where bowel herniates through inguinal canal
  • lateral to inferior epigastric vessel
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

examining for an indirect hernia

A

When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

pathophysiology of indirect inguinal hernia

A
  • Normally, after the testes descend through the inguinal canal, the deep inguinal ring closes and the processus vaginalis is obliterated. However, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

direct inguinal hernia

A
  • Due to weakness in abdominal at Hesselbachs triangle
  • Hernia protrude directly through the abdominal wall (not along the inguinal canal like indirect)
  • medial to inferior epigastric vessel
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

examination of direct inguinal henria

A
  • Pressure over the deep inguinal ring will not stop herniation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

borders of hesselbach

A
  • R – Rectus abdominis muscle – medial border
  • I – Inferior epigastric vessels – superior / lateral border
  • P –Inguinal ligament – inferior border
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

indirect inguinal hernia common in

A

children and young adults

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

direct inguinal hernia common in

A

older age- weaker abdominal muscles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

which inguinal hernia can descend intot he scortum

A

indirect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

the inguinal canal

A

The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

inguinal canal carries which important anatomy in men

A
  • In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

spermatic cord content

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

inguinal canal carries which important anatomy in females

A
  • the round ligament is attaches to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Femoral hernia

A

Femoral hernias involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh.

The opening between the peritoneal cavity and the femoral canal is the femoral ring.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of:

A
  • Incarceration
  • Obstruction
  • Strangulation
21
Q

femoral hernia RF

A
  • Female.
  • Pregnancy (higher incidence in multiparous women)
  • Raised intra-abdominal pressure (e.g. heavy lifting, chronic constipation, chronic cough e.g. ACEi)
22
Q

Femoral canal boundaries

A
  • F – Femoral vein laterally
  • L – Lacunar ligament medially
  • I – Inguinal ligament anteriorly
  • P – Pectineal ligament posteriorly
23
Q

Femoral triangle

A

Not the same as the femoral triangle – larger area at the tip of the thigh that does contain the femoral canal)

SAIL mnemonic:

  • S – Sartorius – lateral border
  • A – Adductor longus – medial border
  • IL – Inguinal Ligament – superior border
24
Q

Incisional hernia

A

Incisional hernias occur at the site of an incision from previous surgery.

25
Q

causes of incisional hernia

A

They are due to weakness where the muscles and tissues were closed after a surgical incision.

26
Q

Risk factors for incisional hernia

A
  • The bigger the incision, the higher the risk of a hernia forming.
  • Medical co-morbidities put patients at higher risk due to poor healing.
27
Q

management of incisional hernia

A
  • Incisional hernias can be difficult to repair, with a high rate of recurrence.
  • They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.
28
Q

Umbilical hernia

A

Occur around the umbilicus

Causes defect in the muscle around the umbilicus.

29
Q

RF for umbilical hernia

A
  • Umbilical hernias are common in neonates and can resolve spontaneously.
  • They can also occur in older adults.
30
Q

Epigastric hernia

A

An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).

31
Q

Obturator hernia

A

Adnominal or pelvic contents herniates through obturator foramen at the bottom of the pelvis

Cause effect in pelvic floor

Risk factor women, older, multiparous, vaginal deliveries

Presentation often asymptomatic – irritation of obturator nerve – pain in groin

Investigation- CT, MRI

Complications- incarceration, obstruction, strangulation

32
Q

hiatus hernia

A

An hiatus hernia refers to the herniation of the stomach up through the diaphragm.

  • The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place.
  • A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus.
  • When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.
33
Q

There are four types of hiatus hernia:

A
  • Type 1: Sliding
    • Where stomach slides up through diaphragm, with gastro-oesophageal junction passing up into the thorax
  • Type 2: Rolling
    • Where a separate portion of the stomach (i.e. fundus), folds around and enters through the diaphragm opening, alongside the oesophagus
  • Type 3: Combination of sliding and rolling
  • Type 4: Large opening with additional abdominal organs entering the thorax
    • Large hernia that allows other intra-abdominal organs to pass the diaphragm opening e.g. bowel, pancreas or omentum)
34
Q

RF for hiatus hernia

A
  • Age
  • Obesity
  • Pregnancy
35
Q

presentation of hiatus hernia

A

symptoms of dyspesisa

  • Heartburn
  • Acid reflux
  • Reflux of food
  • Burping
  • Bloating
  • Halitosis (bad breath)\
36
Q

investigations for hiatus hernia

A
  • Chest x-rays
  • CT scans
  • Endoscopy
  • Barium swallow testing
37
Q

management of hiatus hernia

A
  • Conservative (with medical treatment of gastro-oesophageal reflux)
  • Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment
38
Q

surgical repair of hiatus hernia

A

Laparoscopic fundoplication.

This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

39
Q

Malnourished patients make poor surgical candidates.

A
  • Surgery causes physiological stress with a resultant
    • hyper-metabolic state
    • catabolic response
    • Not favoured in the malnourished patient.
  • Proportion of surgical patients will have a degree of malnutrition owing to their underlying disease process thus reducing their nutritional reserves in the post-operative period.
    • Malnourished patients are at increased risk of post-operative complications, such as
      • Reduced wound healing
      • Increased infection rates
      • Skin breakdown.
  • All patient should be assessed for evidence of malnutrition
40
Q

assessment of malnutrition

A

MUST tool

41
Q

MUST tool

A

Tools used to assess nutritional state are

  • Weight
  • Body Mass Index (BMI)
  • Grip Strength
  • Triceps Skin Fold thickness and
  • Mid Arm Circumference.
42
Q

BMI

A

= Weight(kg) / Height(m)2 (normal range 18.5-24.9 kg/m2)

43
Q

Intra-operative nutrition

A
  • Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
  • Pre-operative carbohydrate loading
  • Minimally invasive surgery
  • Minimising the use of drains and nasogastric tubes
  • Rapid reintroduction of feeding post-operatively
  • Early mobilisation
44
Q

Post-Operative Nutrition

.

A

There is good evidence that early post-operative feeding reduces post-operative complications and the Enhanced Recovery After Surgery (ERAS) protocol is designed to start post-operative feeding as soon as possible (coupled with early mobilisation to reduce muscle loss).

It is now recognised that most surgical patients can safely tolerate an enteral diet within 24 hours of uncomplicated gastrointestinal surgery without increasing the risk of post-operative complications

45
Q

High Output Stoma

A

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion

The nutritional support and treatment for High Output Stoma (HOS) is dependent upon:

Length of Bowel to Stoma

Medical Management

Once active disease or infection has been excluded, then a reduction in stoma output can be achieved by:

  1. Reduction in hypotonic fluids to 500ml/day
  2. Reduction in gut motility with high dose loperamide and codeine phosphate
  3. Reduction in secretions with high dose proton pump inhibitors (a twice daily dose)
  4. Use of WHO solution to reduce sodium losses
  5. Low fibre diet to reduce intraluminal retention of water
46
Q

The feeding hierarchy

A

Best → worse

  • Normal oral feeding
  • Oral nutritional supplements
  • NG feed
  • PEG (percutaneous endoscopic gastrostomyà a feeding tube fitted during endoscopy)/ RIG (radiologically inserted gastrotomy (no endoscopy required)
  • PEG-J (percutaneous endoscopic gastrostomy with jejunal extension) / NJT (naso-jejunal tube)
  • PN- parenteral nutrition
  • TPN- total parenteral nutrition
47
Q

Nasogastric feeding

A
  • Short to medium term feeding
  • Nutritional bridge to:
    • Recovery
    • Gastrostomy
  • Not entirely benign
    • Gastric erosions
48
Q

PEG feeding

A
  • PEG fitted during endoscopy
  • Medium to long term feeding
  • Nutritional support for:
    • Chronic disease
    • Radiotherapy
    • Chemotherapy
    • Palliative care
  • Considerations
    • Mouth opening
    • Neck flexion
    • Abdominal scars
    • Respiratory reserve
    • Does not protect against aspiration
      • reflux
      • saliva

Remember…

that an endoscopy is required for the insertion of a PEG feeding tube and therefore the patient has to be anatomically and physically able to have an endoscopy. If PEG is not possible a RIG can often be inserted as this is placed with direct puncture of the abdominal wall, but as this is held in place with a balloon only it does need to be regularly changed and is more prone to becoming dislodged.

49
Q

RIG feeding

A
  • Same as PEG except guided by barium swallow and X-ray instead of endoscopy
  • Nutritional support where:
    • Upper GI tract inaccessible
    • Respiratory disease present
    • Disadvantages
    • More complications than PEGs
    • Have to be changed
    • Relatively easily dislodged

NG/PEG/RIG feeds

  • Generally 1 kcal/ml (Nutrison)
  • Some 1.5-2.0 kcal/ml (Nutrison energy)

Can also give supplementary water via

Surgery block (Y3) (38 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions