how to describe stomas
- location +/- any abdominal scars
- contents of stoma bag
- number of lumens
- color of mucosa
- presence of sprout
- complications
complications of stoma (quantify early vs late in terms of no of days)
early (<30days)
- infection
- ischemia/necrosis
- retraction/dehiscence
- post op ileus
- stomatitis
late (>30days)
- **parastomal hernia
- prolapse of bowel into stoma bag
- high o/p stoma
what is considered a high o/p stoma and what is the concern and how to track?
1.5-2L/day
electrolyte imbalances and dehydration (measure BP)
ileostomy vs colostomy in terms of how the stoma will look
ileo: small lumen, watery enteric contents, sprouted, RIF
colo: wider lumen, hard feculant stools, non-sprouted, LIF
indications for stoma
- diversion - anastomotic leak
- decompression - SBO or LBO -> peritonitis
- defunctioning - tumour, trauma
practice describing a stoma
this patient has a single/double lumen stoma in their right/left iliac fossa of their abdomen.
the stoma bag contains watery enteric contents/hard feculant stools. the mucosa appears pink and healthy and the stoma is sprouted/non-sprouted
i looked for but did not note the presence of any complications such as infection, ischemia and retraction for early and parastomal hernia and prolapse for late
overall my impression is that this is likely a ileostomy/colostomy secondary to (etiology)
what are some pre-operative considerations when making the stoma?
- away from bone, previous scars and skin folds/creases
- stoma should be brought through the rectus abdominis muscle
- stoma should be in a location clearly visible for patient to take care of it properly
inguinal vs femoral hernia
inguinal hernia lies ABOVE inguinal ligament and superior medial to pubic tubercle
femoral hernia lies BELOW inguinal ligament and inferior lateral to pubic tubercle
borders of hesselbach’s triangle
lateral: inferior epigastric artery
inferior: inguinal ligament
medial: lateral border of rectus abdominis
direct vs indirect hernia
direct is due to weakness of posterior wall of inguinal canal, specifically the hesselbach triangle area (hence more common in OLD PEOPLE)
indirect is congenital -> patent processus vaginalis
definition of a hernia
abnormal protrusion of a viscus or part of a viscus through a defect (either congenital or acquired) of the wall of its containing cavity
causes of inguinal hernia
congenital or acquired
- congenital: patent processus vaginalis
- acquired: pathologies that cause weakness in the posterior wall of Hesselbach’s triangle area
eg. chronic cough or constipation/straining, pregnancy, high BMI, old age, smoking
direct vs indirect inguinal hernia
direct
- medial to inferior epigastric artery
- within hesselbach’s triangle
indirect
- lateral to inferior epigastric artery (start of deep inguinal ring)
- extends through superficial inguinal ring and may follow spermatic cord and affect the scrotum
midpoint of inguinal ligament
VS
mid-inguinal point
midpoint of inguinal ligament: midpoint between ASIS and pubic tubercle, 2FB above is deep inguinal ring
mid-inguinal point is where the femoral artery is
complications of hernia
incarceration
obstruction
strangulation
management of hernia
conservative
- abdominal truss
- lifestyle modification: avoid carrying heavy objects or standing for long periods
- treat underlying etiology like chronic cough or constipation
surgical
- open - tension-free mesh repair
- laparoscopic - totally extra-peritoneal (TEP) or transabdominal preperitoneal (TAPP)
how to confirm incisional hernia
US looking for presence of a fascial gap with hernia and contents
protruding through
practice presenting a hernia
my main finding is a unilateral right direct inguinal hernia which is reducible and has a positive cough impulse
i say it is a direct hernia because i am unable to fully reduce it and the mass still prolapses despite occlusion of the deep inguinal ring.
he does not exhibit any signs of complications of hernia such as strangulation or obstruction
i would like to complete my examination by offering to do a full abdominal and respiratory examination as well as do a DRE
