GSs Diaphragm and Incisions

Question 1

For the following incisions, name their location and 1 use:

1. Midline
2. Paramedian
3. Transverse
4. Subcostal
5. Gridiron
6. Pfannenstiel

Answer 1

1. Midline
   Vertically at midline, skirting around umbilicus
   Use: Abdominal operations when full access is required
2. Paramedian
   2.5-4cm parallel and lateral to midline
   Use: Ops that required full access to half of abdomen
3. Transverse
   Sup to umbilicus, transversely through either one or both rectus muscles
   Use: Ascending colon
4. Subcostal
   2.5 cm below the xiphisternum and extends parallel to, and 2.5 cm below the costal margin.
   Use: Biliary surgery on RHS
5. The Gridiron
   Centred at McBurney’s point (two-thirds of the way laterally along the line from the umbilicus to the anterior superior iliac spine). Or horizontal incision (Lan approach)
   Uses: Appendicectomy
6. Pfannenstiel
   5cm above pubic symphysis, transverse cut
   Use: Caesarean sections

Question 2

1. Why is the pain of hiatus hernia worse after eating food?

Answer 2

Food and fluid in the stomach stimulates the release of gastric acid that will then irritate the lower oesophagus and cause increased pain and discomfort – the hiatus hernia disrupts the cardiac sphincter and allows reflux from the stomach into the lower oesophagus.

Question 3

2. If there were intestinal structures in the left hemi-thorax of a neonate what do you think you would find on examination of their respiratory, cardiovascular and gastrointestinal systems?

Answer 3

Briefly, there will be asymmetry in the thoracic examination – loss of resonance and dull to percussion on the side with the intestine instead of the lung (left in this case); the apex beat of the heart may well be shifted to the right because of the pressure created by intestine in the left thorax.

Question 4

3. How could you differentiate between pain from a bleeding duodenal ulcer and someone having a myocardial infarction?

Answer 4

Both will cause a sympathetic response to compensate for the inadequate tissue perfusion, resulting in a tachycardia, and the patient will be pale and sweating. An MI tends to be considerably more painful (central chest radiating down left arm). A DU is often not painful, although there may be a history of epigastric pain. There will be altered blood in the stool – melaena.

Question 5

4. Why is pericardial or diaphragmatic pain referred to the shoulder tip?

Answer 5

Both the diaphragm and the pericardium are supplied by the phrenic nerve – C3, 4, 5. The brain cannot localise visceral pain and thinks it is coming from the skin. The C4 dermatome is over the shoulder tip.