Surgical abdomen Flashcards
CLD Hand signs (6)
- clubbing
- leukonychia
- Terry’s nails
- white ground glass nail
- loss of lunula
- pink tips
- Palmer erythmea
- dupuytron’s contracture
- asterexis
Abdominal causes of clubbing
(4)
- Cirrhosis: esp with PBC
- IBD
- Coeliac
- GI lymphoma
- What are spider naevi?
- Where are they?
- How many = pathological?
- What are you differential diagnosis?
- Central arteriole with radiating vessls (fill fom the centre-telangiectasia fill from the edge!)
- found in the distribution of the SVC
- >4= abnormal
- differential diagnosis: CLD, OCP, Pregnancy
Inguinal hernia
Examination; set up/inspection/palpation/ausc/special/complete
Set up:
- Expose from umbilisu to knees
- begin with pt STANDING!
Inspection:
- look for any masses in groins
- sie, site, features of inflammation (strangulation), ask pt to cough
- look for scars:
- previous hernia op, appendicectomy (risk factor for direct hernia!)
Palpation:
- check if in pain
- palpated mass for cough impulse
- Define anatomy (relationship to PT)
- above (and medial); inguinal hernia
- below (and lateral): femoral hernia
- Does mass extend into scrotum:
- inguinoscrotal hernia; more likely to indirect
auscultate:
- bowel sounds: hernia may lack bowel sounds if only contains fat/omentum
REPEAT INSPECTION AND PALPATION with pt SUPINE!
Direct vs indirect hernia test
complete:
- Examine external genitalia: incidental lumps, testes
- contralateral groin
- examine abdomen
- evidence of increased IAP: masses, ascites
- Other hernias: paraumbilical, umbilical
Test for direct vs indirect hernia
- ask pt to reduce hernia
- place 2 fingers over deep ring (mid pt of inf lig (1.5 cm above fem pulse)) and ask pt to cough
- hernia controlled=indirect
- not controlled= direct
not accurate test: definitive determination in theatre!
Groin lump differential! (10)
- Skin: sebaceous cyst, psoas abscess
- Fat: lipoma
- CT: fibroma
- Nerves: neuroma of femoral nerve
- Lymphatics: LN
- Veins: sphena varix
- Arteries: femoral artery aneurysm
- Inguinal canal: inguinal hernia, hydrocele or lipoma of cord
- femoral canal: femoral hernia
- Testes: undescended testis
4 distinguishing features of an inguinal hernia
- Above and medial to PT
- cough impulse
- Reducible
- bowel sounds
Hx Qs for inguinal hernia
- predisposing factors: cough, straining, lifting
- pain
- reducible
- episodes of obstruction or strangulation
- previous repairs
Management of inguinal hernia
(conservative, surgical)
Conservative:
- Manage RFs e.g. constipation, cough
- weight loss
- elastic corset or truss
Surgical:
- Open: lichtenstein tension free mesh
- lap: TEP or TAPP mesh
TEP= Totally ExtraPeritoneal
TAPP=TransAbdominal PrePeritoneal (TAPP)
Inguinal hernias
definition; general
classification (2 types)
Protrusion of a viscus or part of a viscus into an abnormal position through a defect in its containing cavity
- Indirect: 80%:
- commoner in young due to congenital patent processus vaginalis
- emerge through deep ring
- same 3 coverings as cord
- descents into scrotum
- can strangulate
- Direct: 20%
- commoner in elderly
- aquired: weak posterior wall of canal
- emerges through hasselbach’s triangle
- can acquire internal and external spermatic fascia
- rarely descends into scrotum
- rarely strangulates
Inginal canal antomy
MALT
superior/anterior/lower/posterior
-
superior wall (roof): Muscles
- internal oblique M
- Transferse abdominus M
-
Anterior wall: Aponeuroses
- A of external oblique
- A of internal oblique
-
Lower wall (floor): Ligaments
- Inguinal L
- Lacunar L
-
Posterior wall: Ts
- Transfersalis fascia
- conjoint Tendon
Femoral canal anatomy
med/late/ant/post
and contents
Med: lacunar ligament
Lat: femoral vein
Ant: inguinal ligament
Posterior: pectineal ligament (of cooper)
Contents: fat and cloquet’s node
Contents of inguinal canal (MF!)
M: spermatic cord + ilioinguinal N
F: Round lig + gen branch of genitofemoral N + ilioingional N
Contents of spermatic cord
- 3 layers of fascia
- External spermatic F
- Cremater musle and F
- Internal spermatic F
- 3 arteries + 3 veins
- Testicular A + Pampiniform plexus of testicular V
- Cremateric A and V
- Artery to vas deferens
- 2 nerves:
- genital branch of genitofemoral N
- Autonomic N
- 2 others:
- Vas deferens
- lymph vesels
Intra-operative distinction of indirect and direct inguinal hernia
- indirect: arise lateral to inf. epigastic vessels
-
direct: arise medical to inf. epigastric vessels through hasselbach’s triange: (RI?P)
- Med: Rectus abdominis muscle
- Lat: Inferior epigastric artery
- Inf: poupart’s ligamen (inguinal lig)
Inguinal hernia surgical approaches:
open and lap
open and lap; lap if bilateral/recurrent!
nb mention risk of testicular damage when consenting pt
open:
- open can be done under LA or GA: day case
- RCS recoments the lichtenstein tension free mesh repair
- less recurrence cf to older shouldice repair
IN CHILDREN: simple ligation and division of the patent processus suffices: no mesh req
Lap:
- 2 main techniques:
- Total ExtraPeritoneal
- TransAbdominal Pre-Peritoneal
- Better for bilateral hernias
Complications of surgical inguinal hernia repair
Early/late
management for optimal post-op recovery
- Early:
- Urinary retention
- Haematoma/seroma formation 10%
- Infection
- Intra-abdominal injury (lap!)
- Late:
- recurrence <2%
- ischaemic orchitis 0.5%; 2ndary thrombosis of pampiniform plexus
- chronic groin pain/paraesthesia 5%
- Post op recovery
- pee pre leaving; retention
- avoid constipation: lactulose
- Early mobilisation
- painful; good analgesia
- keep area clean and dry: wash carefully (can bathe immediately)
- work in 1-2wks
- heavy lifting >6wks)
Femoral hernia
general
- Commoner in Females; wider femoral canal
- middle ages and elderly
- neck is inferior and lateral to PT
- high risk of obstruction and strangulation
Femoral hernia
management
elective and emergency
50% risk of strangulation within 1 mnth -> URGENT surgery
-
Elective: lockwood low approach
- low incision over hernia with herniotomy and herniorrhaphy (suture inguinal ligament to pectineal ligament)
-
Emergency: Mc Evedy high approach
- high approach in inguinal region to allow insprection and resection of non-viable bowel
- then herniotomy and herniorrhaphy
Incisional hernia
Examination (inspection, palpation, ausc)
Examination
-
inspection:
- pt may be overweight
- describe scars and drain sites
- any evidence of inflammation
- ask pt to lift head off bed and cough
-
palpation:
- any tenderness?
- feel for presence of detect
- ask pt to cough while feeling for an impulse
- is the defect present along the whole legth of the scar?
- sie of defect relates to risk of strangulation
- If a lump is present, can it be reduced
- auscultate: for bowel sounds
Incisional hernia
Important history questions
- previous surgery
- post op wound infection or other complications
- co-morbidities-> increased risk e.g. chronic cough
- discomfort or episodes of obstruction
Incisional hernia:
definition
Extrusion of peritoneum and abdominal contents through a previously acquired defect
Incisional hernias:
Complications
Intestinal obstruction
irreducible
strangulation
pain/discomfort
Incisional hernia
RF:
PreOp/Intra-op/postOp
-
Pre-Op:
- increase age
- comorbidities: DM, renal failure
- drugs: steroids, chemo, radio
- Obesity or malnutrition
- malignancy
-
Intra-Op:
-
surgical technique/skill (major factor)
- too small suture bites
- inapropriate suture material
- incisional type e.g. midline
- placing drains through wounds
-
surgical technique/skill (major factor)
-
Post-Op:
- increased IAP: chronic cough, straining, post-op ileus
- infection
- Haematoma
Management of incisional hernia
conservcative/surgical
Surgery is not appropriate for all pt
must ba;ance risk of op and recurrence with risk of obstruction/strangulation and pt cjoice
usually broad neced therefore low risk of strangulation
Conservative:
- manage RF eg, constipation, cough
- weight loss
- elasticated coset or truss
surgical:
- pre-op
- optimise cardioresp function
- encourage weight loss
- nylon mesh repair: open or lap
umbilical and paraumbilical
inspection/palpation
-
inspection:
- pt may be overweight
- ask pt to lift head off bed and to cough
- note any associated skin damage e.g. ulceration
- note any overlying scars: may indicate recurrence
-
Palpation:
- any tenderness
- feel for presence of defect
- try to assess sie
- ask pt to cough while feeling for an impulse
- if a lump is present, ask pt to reduce it
umbilical an paraumbilical hernia
history
- Predisposing factors: pregnancy, ascites, obesity
- pain
- reducible
- episodes of obstruction or strangulation
- previous repairs
Paraumbilical hernia pathogenesis and RF
- acquired defect in linea alba just above or below the umbilicus
- commoner in obese, middle aged pts
- neck is commonly narrow
- prone to befoming irreducible or strangulated
- typically contain omentum
RF:
- obesity
- pregnancy
- ascites
- fibroids
- bowel distension
Management of paraumbilical hernias
- surgery advised: high risk of strangulation
- Treat concurrent medical problems
- May repait:
- mobilise sac and reduce contents
- double breast linea alba +/- sublay mesh
Umbilical hernia
pathogenesis
RF
- congenital defect in umbilical scar (cicatrix)
- typically congenital 3% of live births
RF:
- afro-caribbean
- trisomy 21
- congenital hypothyroidism
recur in adults: pregnancy, ascites
Management of umbilical hernia
- usually asymptomatic and resolves by 2-3 yrs
- surgical repair advocated if no resolution by 3 yrs
2 other congenital defects in abdominal wall
Gastroschisis
Exomphalos
-
Gastroschisis:
- protrusion of abdo contents through defect in abdo wall to the right of the umbilicus
- not usually associated with other abnormalities
- promps surgical repair after fluid resuscitation
-
exomphalos:
- protrusion of abdo contents w/i in a 3 layered sac
- commonly associated with other defects:
- cardiac
- anencephaly
Epigastric hernia
Examination
(insprection.palpation.differential)
-
inspection:
- midline lump above the umbilicus when the pt coughs or lifts head from bed
- typically small: pea shaped
- assoc scars?
- Incisional hernia or previous repairs
-
Palpations:
- any pain
- feel for cough impulse
- establish sie of defect
-
Differential:
- incisional hernia: ?scar
- Divarification of recti: widening gap between recti muscles, not a hernia
Epigastric hernia
important history questions
History:
- predisposing factors: pregnancy
- obesity
- symptoms
- reducible
- episodes of obstruction/strangulation
- previous repair s
Epigastric hernia ke features and symptoms
-
features:
- abdnormal protrusion of abdominal contects through a defect in linea alba between xiphisternum and umbilicus
- usually contains extraperitoneal fat or omentum
- commoner in young (20s-50s)
-
symptoms:
- may be aSx
- may be confused for upper GI path
- pain: may inicreas after meals or exercise
- nause and early satiety
- Abdominal bloating
Management of
epigastric hernia
(conservative. surgical)
-
conservative:
- manage RF e.g. constipation, cough
- weight loss
-
surgical:
- reduce hernial contents and excise sac
- suture or mesh repair
*
Examination of scrotal lump
set up/infpection/palpation (4Qs!)
?pathway?
set up: best to examine pt standing (won’t miss varicocele)
Inspection:
- skin: scar, erythema, blue tinge, ulcers
- groid lumps or scars
- ask pt to cough
Palpation:
- Can you get above it? can’t get above an inguinoscrtal hernia
-
is it tender?
- torted testis or hydatic of morgagni
- epididymo-orchitis
- strangulated hernia
-
is it palpable seperately?
-
No:
- tumour
- orchitis
- hydrocele
- Yes:
- Varicocele
- spermatocele/epididymal cyst
-
No:
-
does it transluminate?
-
No:
- tumour
- testis
- varicocele
- spermatocele
- Yes:
- hydrocele
- epididymal cyst
-
No:
Hydrocele
Examination
(inspection.palpation)
- Inspection:
- swollen scrotum
- palpation:
- can get above it
- cannot feel testis seperately
- Firm/tense
- Transluminates
Hydrocele
History Qs
- duration
- pain, discomfort, other symptoms
- previous testicular masses or infections
- recent trauma
- treatment so far
- co-morbidities e.g. HF
hydrocele
definition
accumulation of fluid within the tunica vaginalis
TV: remnant of the processus vaginalis that accompanied the testicle during its descent. forms one of the adult coverings of the testis
Anatomical classification of hydroceles
x4
- vaginal: accumulation in the tunica vaginalis that doesn’t extend up the cord
- congenital: proximal part of the processus has not obliterated and the sac communicates directly with the peritoneum
- infantile: processus is obliterated at the deep ring but still extends up the cord
- hydrocele of the cord: fluid accumulates around the ductus deferens. Can be hard to distinguish from inguinal hernia as it may extend proximal to the superficial ring. testicular tractin will pull it inferiorly (c.f. to inguinal hernia
Aeitiological classification of hydroceles (x2)
-
primary:
- caused by a patent processus vaginalis
- commonest type!
- young men, large, tense
-
secondary:
- vaginal type, can be caused by a variety of pathologies incl:
- testicular tumours
- epididymo-orchitis
- trauma
- torsion
- vaginal type, can be caused by a variety of pathologies incl:
Single investigation of hydrocele
US to exclude malignanacy!
Management of hydrocele
non-surgical and surgical
- non-surgical:
- watch and wait (ensure no Ca)
- aspiration: symptom relief only as will accumulate
- Surgical:
- lord’s repair: plication of tunical vaginalis
- jaboulay’s repair: eversion of sac
Epididymal cyst
exmination
(inspection.palpation)
-
inspection:
- normal appearing scrotum
-
palpation:
- can get above it
- seperate from testis: typically above and behind
- Firm
- Transiluminates: unless its a spermatocele
Epididymal cyst
history! and features
- History:
- duration
- pain, discomfort, other Sx
- treatment so far
- Features:
- retention cyst of tubule of the rete testis or epididymis
- often multiple
- may contain sperm: spermatocele (does not transluminate)
- generally aSx
Classification of testicular tumour
and table (age/markers/ early/lateMx)
- 95% are germ cell tumours
- 50% are pure cell populations:
- pure seminomatous: 50%
- non-seminomatous: teratoma is commones
- Other types:
- yolk sack: commenest testicular tumour in children
- choriocarcinoma
- leydig or sertoli cell; may secrete oestrogens -> gynaecomastia
- lymphoma: NHL is commonest testicular mass >60yrs
Testicular tumour Investigations
- Tumour markers AFP, bHCG, placental ALP
- CxR: mets
- US scrotum: diagnostic
- CT abdomen: staging
Nutcracker syndrome
- a vascular compression disorder*
- compression of the left renal vein between the superior mesenteric artery (SMA) and aorta*
Distinction :
ileostomy vs colostomy
location/appearance, contents, examples (perm/temp)
Ileostomy/urostomy
2 types
(features/surgeries/indications)
located in RIF
Small bowel content is irritant therefore ileostomies = spouted
ileal pouch–anal anastomosis (IPAA)
Colostomy
2 types: features/surgery/indication
Name
anatomical order of structures
use (emergency/elective)
features: pros/cons
closure (rule)
- Midline laparotomy
- Aproach:
- skin
- camper’s fascia
- scarpa’s fascia
- linea alba
- transversalis fascia
- pre-peritoneal fat
- peritoneum
- use:
- emergency:
- perforated DU
- trauma
- ruptured AAA
- hartmann’s
- elective:
- colectomy
- AAA
- vasc bypass
- emergency:
- Features:
- good:
- good access
- bloodless line
- minimal nerve and muscle injury
- bad:
- long midline scar
- pain
- good:
- closure:
- PDS blunt J shaped feature en mass
- jenkin’s rule
- length of suture = 4x length of incision
- 1 cm bite, 1cm apart
Name
use (emergency/elective)
features: location, anat aproach, downside
- Right paramedian
- use: not commonly used now as closure techniques have improved
- location: 3cm lat to midline
- aproach: rectus sheath opened and rectus displaced laterally slips back to cover the defect
- bad: tme consuming
Name
use (R/L)
- Kocher’s (subcostal)
- R Open cholecystectomy, L Kocher’s used for splenectomy
Name
use
disadvantage/adaptability
- Rooftop
- Uses:
- hepatobilary surgery:
- liver transplant
- whipple’s; remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct
- liver resection
- gastric surgery
- hepatobilary surgery:
- disadvantage: longer to close than a midline as the incision is closed in 3 layers
- adaptability: modified to a mercedes ben incision
Name of surgery
Use of surgery (2)
- pfannenstiel
- use:
- gynae surgery
- lower UTI
Name
anatomical order of structures on approach
use
features of the two types
risks of approach
- Two
- McBurney’s: oblique
- Lan: Transverse
- Anatomy:
- skin
- camper’s fascia
- scarpa’s fascia
- external oblique
- Internal oblique
- Transversus
- Transversalis fascia
- pre-peritoneal fat
- peritoneum
- use: appendectomy
- Two types: BOTH, follow langer’s lines
- Lan: favoured hidden in skin creases
- risk: of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia
NAme
Use
- Thoracoabdominal
- Use: oesophagogastrectomy
Name
use
disadvantage/advantage (2)
- Transverse muscle splitting
- Right hemicolectomy
- disadv: limited acces to midline incision
- adv:
- reduced damage to rectus
- segmental nerve supply means the muscle can be cut transversely without weakening
Name
Use (2)
features
risk
- Name; inguinal hernia incision
- Use:
- Open inguinal hernia repair
- ORchidectomy
- features: incision over the inguinal ligament follow’s langer’s lines
- risk: high rates of chronic neuropathic pain
Name/aka
Use (1)
Advantage
- Name/aka: Mc Evedy-modified/aka half pfanenstiel
- Use: emergency femoral hernia
- Advantage: allows inspection of peritoneal cavity with easy confersion to laparotomy if necessary
Name
use (1)
- Loin
- Nephrectomy
Name
USe (6)
- Vasc access
- Use:
- bypass
- embolectomy
- EVAR/TEVAR
- Stent insertion
- Fem endartectomy
- angioplasty
Right hemicolectomy
Features
- Indication:
- Scars:
- Stoma:
- Anastomosis:
- Differential:
Right hemicolectomy
Features
- Indication: tx in the cecum and proximal part of ascending colon
-
Scars:
- midline laparotomy
- Transverse muscle splitting
- Laparoscopic ports
- Stoma: none
- Anastomosis: ileocolic
- Differential: midline laparotomy differential
Extended Right hemicolectomy
Features
- Indication:
- Scars:
- Stoma:
- Anastomosis:
- Differential:
Extended Right hemicolectomy
Features
- Indication: tumours in the distal ascending colon or transverse colon
-
Scars:
- midline laparotomy
- laparoscopic ports
- Stoma: none
- Anastomosis: ileocolic
- Differential: midline laparotomy differential
Left hemicolectomy
Features
- Indication:
- Scars:
- Stoma:
- Anastomosis:
- Differential:
Left hemicolectomy
Features
- Indication: tumours in the descending colon
-
Scars:
- midline laparotomy
- laparoscopic ports
- Stoma: none
- Anastomosis: colocolic
- Differential: midline laparotomy differential
Hartmann’s procedure
Features
- Indication:
- Description:
- Scars:
- Stoma:
- Differential:
Hartmann’s procedure
Features
- Indication: obstruction or perforation secondary to sigmoid tymour or diverticulitis
-
Description:
- emergency procedure
- sigmoid colectomy
- proximal bowel exteriorised as an end colostomy
- distal bowel oversewn to form a rectal stump
- MAY be reversed after 3-6mo (>50% of pts ARE NOT reversed)
-
Scars:
- midline laparotomy
- may have previous stoma acr in LIF if it has been reversed
- Stoma: single lumen colostomy in LIF
- Differential: APR!
Abdomino-perineal resection (APR)
Features
- Indication:
- Description:
- Scars:
- Stoma:
- Differential:
Abdomino-perineal resection (APR)
Features
- Indication: rectal Ca <4-5cm from anal verge
-
Description:
- sigmoid rectum and mesorectal nodes removed via abdominal incision
- anus removed via perineal incision
-
Scars:
- midline laparotomy
- no anus
- Stoma: single lumen colostomy in LIF
- Differential: Hartmann’s procedure; look for patent anus
Anterior resection
Features
- Indication:
- Description:
- Scars:
- Stoma:
- Differential:
Anterior resection
Features
- Indication: rectal Ca >4-5cm from anal verge
-
Description:
- excision of part of the rectum and sigmoid colon
- may be high or low depending on site of tumour
- total mesorectal excision for tumours in the middle or lower 1/3
- rectal blood supply is poor!!:
- THEREFORE colorectal anastomosis is convered by temporary loop ileostomy
-
Scars:
- midline laparotomy
- laparoscopic port scars
- stoma OR SCAR in RIF
- Stoma: double lumen loop ileostomy in RIF
-
Differential:
-
End ileostomy:
- panproctocolectomy: UC, FAP
- subtotal colectomy: acute severe UC
- cystectomy + ileal conduit
-
loop ileostomy:
-
Temporary diversion:
- crohn’s
- anterior resection; alows healing of colorectal anastomosis
-
Temporary diversion:
-
End ileostomy:
Subtotal colectomy
Features
- Indication:
- Description:
- Scars:
- Stoma:
- Differential:
Subtotal colectomy
Features
- Indication: acute severe UC
-
Description:
- all colon excised except distal sigmoid and rectum
- temporary end ileostomy
- Rectosigmoid stump may be exteriorised as mucus fisula
- followed after 3mo by either:
- completion protectomy + IPAA (ileal pouch anal anastomosis) or permenent end ileostomy
- ileorectal anastomosis (IRA)
-
Scars:
- midline laparotomy
- laparoscopic port sites
- Stoma: single lumen end ileostomy in RIF
-
Differential:
-
end ileostomy:
- panprotocolectomy: UC, FAP
- subtotal colectomy: acute severe UC
- cystectomy and ileal conduit
- Loop ileostomy
- temporary diversion: anterior resection or crohn’s
-
end ileostomy:
Panproctocolectomy
Features
- Indication:
- Description:
- Scars:
- Stoma:
- Differential:
Panproctocolectomy
Features
- Indication: Uc or FAP
-
Description:
- all colon, rectum and anus removed
- permenant end ileostomy
-
Scars:
- midline laparotomy
- laparoscopic port sites
- Stoma: single lumen end ileostomy in RIF
-
Differential:
- end ileostomy:
- panprotocolectomy: UC, FAP
- subtotal colectomy: acute severe UC
- cystectomy and ileal conduit
- Loop ileostomy
- temporary diversion: anterior resection or crohn’s
- end ileostomy:
Pathology of IBD
UC vs crohn’s
IBD
differentiate complications
UC vs Crohn’s
Surgical jaundice
Examination
inspection; peripheral/abdo, palpation, completion
- Inspection:
- Peripheral:
- Cachexia
- signs of CLD
- look in sclera and at frenulum (of tongue): jaundice
- Palpate for virchow’s node
- Abdo:
- ascites
- dilated abdo veins
- umbilical/para-umbilical hernia
- Peripheral:
- Palpation:
- hepatomegaly
- splenomegaly
- palpable gallbladder
- Completion:
- check temp: obstruction complicated by infection
- dipstick urine: bilirubin, urobilinogen, hb
Differential for surgical jaundice
(3/3-6/3-5)
Key history Qs
Post-H; MOST LIKELY IN PACES
H
Pre-H
Post-hepatic:
- Dark urine, pale stools
- Itching
- Stones: RUQ pain or biliary colic
- Malignancy
- Wt. ↓ and ↓ appetite
- Change in bowel habit: esp. steatorrhoea
- Back pain
Hepatic
- EtOH intake
- Foreign travel: Hep A
- Blood transfusions, IVDU, Sex: Hep B and C
- Sore throat: EBV
- Drug Hx: OCP, Abx, neuroleptics, OTCs
Pre-hepatic
- Anaemia: tired, SOB, palpitations, ankle swelling
- FH
DIFFERENTIALS!
Mass differential
Mass differential
