small bowel

Question 1

INGUINAL HERNIA direct vs indirect

Answer 1

• direct(1/3) = bowel enters inguinal canal ‘directly’ through a weakness in hesselbachs triangle (??) and lies medial to inferior epigastrium vessels
• indirect (2/3) = bowel enters inguinal canal via deep inguinal ring and lies lateral to inferior epigastrium vessels

Question 2

INGUINAL HERNIA risk fax?

Answer 2

• male
• inc age
• raised intra abdo pressure eg? x3
• obesity

Question 3

INGUINAL HERNIA clinical features ?

Answer 3

presenting sx: lump in groin - disappears initially (reducible) w minimal pressure or when pt lay down. mild discomfort w activity or standing
- hernia becomes incarcerated ??? painful, tender, erythmatous. may also present w sx of bowel ob or strangulation (irreducible & tender lump w pain out of proportion to clinical signs ) if blood supply compromised

Question 4

INGUINAL HERNIA OE?

Answer 4

look for:

• cough impulse - -ve if irreducible
• location - supermedial to pubic tubercle
• reducibility - on lying down +/- minimal pressure
• if it enters the scrotum - can u get above it? is it separate from testis?

Question 5

INGUINAL HERNIA differentials

Answer 5

femoral hernia, saphena varix, lipoma, groin abscess

extends in groin ? hydrocoele, varicocoele, testicular ca

Question 6

INGUINAL HERNIA investigations?

Answer 6

dx clinical

only image if dx unsure or to exclude other path - uss. features of ob or strangulation? ct

Question 7

INGUINAL HERNIA mgmt - non symptomatic pt?

Answer 7

conservative mgmt

Question 8

INGUINAL HERNIA mgmt - pt w strangulation sx?

Answer 8

URGENT surgical exploration

Question 9

INGUINAL HERNIA mgmt - symptomatic pt (significant mass or discomfort )?

Answer 9

surgery

• open mesh repair - primary inguinal hernia any anaesthetic
• laparoscopic - in pts w bilateral or recurrent inguinal hernias, also considered in: primary unilateral hernia, those @ high risk of chronic pain (eg young&active, prev chronic pain, predominant sx is pain) or in females (due to inc femoral hernia risk)

Question 10

INGUINAL HERNIA comps

Answer 10

in creation, strangulation, obstruction

post op comps: pain bruising haematoma infection urinary retention, recurrence, chronic pain, damage to vas deference or testicular vessels

Question 11

FEMORAL HERNIA stats

Answer 11

uncommon
high risk strangulation
f>m due to wider anatomy of pelvis

Question 12

FEMORAL HERNIA risk fax?

Answer 12

female, preganancy, raised intra abdo pressure, inc age

Question 13

FEMORAL HERNIA clinical features?

Answer 13

• small lump in groin
• many asymptomatic
• 30 % present as obstruction or strangulation
• tight femoral ring means unlikely to be reducible
• location: inferolateral to the pubic tubercle (and medial to femoral pulse)

Question 14

FEMORAL HERNIA differentials?

Answer 14

inguinal hernia, lipoma, lymph node, saphena varix, femoral artery aneurysm

Question 15

FEMORAL HERNIA saphena varix differential more info

Answer 15

this is a dilation of the saphenous vein @ th saphenofemoral junction in the groin. disappears when lying flat, has a palpable thrill when coughing & therell be presence of varicose veins elsewhere. best identified by duplex us and mgmt is high saphenous ligation

Question 16

FEMORAL HERNIA investigations

Answer 16

dx clinical
uss
ct ap
doubt in diagnosis? surgical exploration

Question 17

FEMORAL HERNIA mgmt?

Answer 17

surgically within 2 wks due to high risk of strangulation. 2 approaches to reduction:
- low approach ??
- high approach ??
surgery inc reducing hernia and narrowing femoral ring with medial sutures between the pectineal and inguinal ligaments or w a mesh plug to prevent recurrence

Question 18

all about EPIGASTRIC HERNIAS

Answer 18

upper midline through linea alba typically 2 to raised chronic intra abdo pressure eg obesity, preg, ascites. common. middle aged men. asymptomatic but present as midline mass that disappears when lay on back. differential: divarication of the recti (?)

Question 19

all about PARAUMBILICAL HERNIAS

Answer 19

herniation through linea alba around the umbilical region. 2 to raised chronic intra abdo pressure eg obesity, preg. present as umbilical region lump. generally contain pre peritoneal fat but sometimes bowel. common and don’t strangulate

common in kids too either as omphalocele or gastroschisis