1
Q
Define a hernia
A
Protrusion of part of whole of an organ or tissue through wall of a cavity that usually contains it
2
Q
What is the most common type of hernia?
A
Inguinal hernia (abdominal cavity contents enter into inguinal canal)
3
Q
Remind yourself of the two different types of inguinal hernia, include:
- Which is more common
- Path of each
- Why each occurs
- How and when can we reliably identify between the two?
A
Indirect (80%)
- Enters inguinal canal via deep inguinal ring
- Arise from incomplete closure of processus vaginalis. Normally after testes descend to scrotum deep inguinal ring should close and processus vaginalis should be obliterated
Direct (20%)
- Enters inguinal canal through weakness in posterior wall of inguinal canal; often it is Hesselbach’s triangle
- Commonly occur in older pts secondary to raised intra-abdominal pressure
Can only be reliably identified during surgery when look at relation to inferior epigastric vessels:
- Direct: medial
- Indirect: lateral
4
Q
Remind yourself of borders of inguinal canal
A
- Posterior: transversalis fascia & conjoint tnedon medially
- Anterior: aponeurosis of external oblique reinforced by internal oblique muscle laterally
- Roof: transversalis fascia, internal oblique, transversus abdominis
- Inferior: inguinal ligament thickened medially by lacunar ligament
5
Q
Remind yourself of the contents of inguinal canal
A
- Spermatic cord (MALES)
- Round ligament (FEMALES)
- Genital branch of genitofemoral nerve
- Ilioinguinal nerve
6
Q
Remind yourself of borders of Hesselbach’s triangle
A
- Medial: lateral border of rectus abdominis
- Superior/lateral: Inferior epigastric vessles
- Inferior: inguinal ligament
7
Q
State some risk factors for inguiinal hernias
A
- Male
- Age
- Rasied intra-abdominal pressure
- Chronic cough
- Heavy lifting
- Chronic constipation
- Obesity
8
Q
Describe clinical features of inguinal hernia that is not incarcerated
A
- Soft lump in groin
- Disappear when lie down or with minimal pressure (if reducible)
- Protrude on coughing or standing
- Aching, pulling or dragging sensation
- Discomfort with activity or standing
9
Q
Explain the difference between an incarcerated, strangulated and obstructed hernia
A
- Incarcerated= cannot be reduced
- Strangulated hernia= hernia is incarcerated and compression of hernia is compromising blood supply leading to ischaemic bowel.
- Obstructed= bowel that has herniated is obstructed leading to clinical features of bowel obstruction
10
Q
Desribe clinical features of a strangulated hernia
A
- Lot of pain
- Tenderness at hernia site
- Hernia irreducible
11
Q
What features should you look for when examining a groin lump?
A
- Cough impulse
- Location
- Reducible (on lying down +/- minimal pressure)
- Wide or narrow neck (wide neck=lower risk complications)
- If enters scrotum can you get above it/is it separate from testis
12
Q
Describe how you can attempt to differentiate between direct and indirect hernias clinically
A
- Reduce hernia
- Place pressure over deep inguinal ring (mid point inguinal ligament)
- Ask pt to cough
- If protrudes despite pressure on deep inguinal ring must be direct hernia
- *Often unreliable and can only truly differentiate at time of surgery*
- *Be sure you know difference mid inguinal point and midpoint inguinal ligament. Mid inguinal point= femoral artery*
13
Q
Discuss whether any investigations are required for inguinal hernias
A
- Clincial diagnosis
- Only do imaging if diagnostic uncertinty or to exclude other pathology:
- First line= ultrasound in outpatient setting
- CT if features of obstruction or strangulation
14
Q
Discuss the management (not specifics just general) of the following:
- Inguinal hernia no symptoms
- Symptomatic inguinal hernia
- Strangulated hernia
A
- Inguinal hernia no symptoms:
- Conservative
- Discussion about future surgical intervention and safety net strangulation
- Symptomatic inguinal hernia:
- Surgical intervention
- Strangulated hernia
- Immediate surgical exploration & intervetion
15
Q
Discuss the different surgical interventions for inguinal hernias
A
- Tension free repair:
- Place mesh over defect
- Mesh is sutured to abdominal muscles & tissues
- Over time tissues grow into mesh to provide extra support
- Tension repair (rarely done):
- Suture muscle & tissue either side of defect back together
Repairs can be open or laparscopically. Often done open unless bilateral or recurrent (then do laparscopic)
16
Q
Why are open inguinal hernias done more often?
Why are laparascopic inguinal hernia repairs sometimes done?
A
- Open: cost effective
- Laparoscopic:
- Those at high risk of chronic pain
- In some females as higher risk of femoral hernia
17
Q
State some potential complications of inguinal hernias
A
- Incarceration
- Strangulation
- Obstruction
18
Q
State some potential complications of surgical repair of inguinal hernias
A
- Generic complications e.g infection, pain etc…
- Specific:
- Recurrence
- Chronic pain (persists >3 months)
- Subfertility (due to damage to vas deferens or testicular vessels which leads to ischaemic orchitis)
19
Q
Remind yourself of the anatomy of the femoral canal
A
- Femoral ring= opening between peritoneal cavity and femoral canal
- Femoral canal boundaries:
- Medially: lacunar ligament
- Laterally: femoral vein
- Anteriorly: inguinal ligament
- Posteiror: pectineal ligament
20
Q
What is a femoral hernia?
A
Abdominal contents pass through femoral ring into femoral canal
21
Q
Which gender are femoral hernias more common in and why?
A
- Females
- Wider pelvis
22
Q
What are femoral hernias at high risk of and why?
A
- Complicaions e.g. strangulation, obstruction, incarceration
- Narow neck/femoral canal only narrow opening
23
Q
State some risk factors for femoral hernias
A
- Female
- Age
- Pregnancy
- Raised intra-abdominal pressure e.g. chronic constipation, heavy lifting
24
Q
Describe clinical features of femoral hernias
A
- Small lump in groin
- Usually asymptomatic
- May present as emergency (obstruction or strangulation. ~30%)
25
Compare positions of inguinal and femoral hernias in relation to the pubic tubercle
* Inguinal= superomedial
* Femoral= inferolateral
26
Are femoral hernias likely to be reducible?
No due to tightness of femoral ring
27
What investigations are required for femoral hernias?
Diagnosis can be made clinically but additional imaging often required:
* Ultrasound
* CT abdomen pelvis
If in doubt, surgical exploration
28
Discuss the management of femoral hernias
**ALL require surgery due to high risk of strangulation** *(if not emergency then ideally within 2 weeksas strangulation risk increases with time. If emergency= immediate surgery)*
Involves **reducing hernia then narrowing femoral ring with sutures**. Two main approaches:
* **Low approach**: incision below inguinal ligament. Doen't interfere with inguinal structures but limited space bowel resection if compromised bowel present
* **High approach:** incision above inguinal ligament. Easy to remove compromised bowel so preffered in emergencies
*\*strangulated requires emergency surgery due to risk of bowel infarction*
29
Other than femoral, inguinal and hiatus hernias state some hernias you need to be awarre of
* Incisional
* Epigastric
* Parumbilical
* Spigelian
* Obturator
* Littre's
* Lumbar
* Richter's
30
For epigastric hernia, state:
* Where it occurs
* Risk factors/secondary to
* Symptomatic or asymptomatic
* Upper midline of abdomen through fibres of linea alba
* Chronic raised intra-abdominal pressure e.g. obesity, ascites, pregnancy
* Usually asymptomatic
31
For paraumbilical hernias, state:
* Where they are
* Risk factors/secondary to
* What they usually contain
* Whether they usually strangulate
* Difference between para- and umbilical hernia
* Through linea alba in umbilical region (NOT through the umbilicus itself)
* Chronic raised intra-abdominal pressure
* Pre-peritoneal fat (but may contain bowel occasionally)
* Don't commonly strangulate
* Umbillical hernia is through the umbilicus. Common in children either as a result of omphalocele or gastrochisis or if umbilicus doesn't seal properly
32
For spigelian hernia, state:
* Where it occurs
* Risk of strangulation
* What condition found in 75% of male infants with these hernias
* Protrusion of contents through the **spigelian fascia/semilunar line around level of arcuate line.** Linea semilunaris is a line where flat tendons of three lateral abdominal muscles (external oblique, internal oblique and transversus abdominis) of one side meet the tendinous sheath enveloping the rectus abdominis muscle of the same side
* Hight risk of strangulation
* Cryptorchidism *(associated failure of gubernaculum development)*
33
For an obturator hernia, state:
* Where/whatit is
* Who common in
* Symptoms
* Abdominal contents protrude through obturator forame into obturator canal
* Women, elderly, rapid weight loss *(lose fat which is usually located in canal so large space for hernia)*
* Mass in medial thigh, small bowel obstruction,
34
What is a Littre's hernia?
Herniation of Meckel's diverticulum- most commonly into inguinal canal. Many become strangulated.
35
What is a Richter's hernia?
* Partial herniation fo bowel (only part of lumen of bowel is in hernial sac)
* Antimesenteric border becomes strangulated
* Can occur at any of sites mentioned
* Cause obstruction therefore urgent surgery needed
36
What is a Maydl's hernia?
Two different loops of bowel are contained in same hernia
37
For incisional hernias, state:
* Why they occur
* What puts pt at risk of incisional hernia
* Management
* Weakness where muscles & tissues were closed after surgical incision
* Comorbidities that affect healing
* Difficult to repair with high rate recurrence so typically left if have wide neck and low risk complications
38
What is gastroenteritis?
Inflammation of GI tract- usually infective in origin but an be non-infective. Most common cause= viral.
39
Define dysentery
Gastroenteritis (inflammation of GI tract) characterised by loose stools with blood and/or mucus
40
What invetigations would you do for gastroenteritis?
_Bedside_
* Stool culture
_Bloods_
* FBC:*infection*
* CRP: *infection*
* U&Es: *baseline*
* LFTs: *baseline*
41
Discuss the general principles of management of gastroenteritis
* Rehydration
* Exclusion from work (usually 48hrs from last episode)
* Education to prevent episodes in future
* Notify appropriate personnel:
* Food poisoning & infectious bloody diarrhoea= diagnosing doctor must notify appropriate body
* Certain organisms e.g. salmonella & campylobacter requuire laboratory to notify public health
42
How long approximately can it take for the following cuases of gastroenteritis to cause symptoms:
* Bacterial toxins
* Viruses
* Bacteria
* Parasites
* Bacterial toxins= hours
* Viruses= days
* Bacteria= weeks
* Parasites= months
43
Remind yourself of some:
* Viruses
* Bacteria
* Bacterial toxins
* Parasites
... that can cause gastroenteritis
_Viruses_
* Norovirus
* Rotavirus
* Adenovirus
_Bacteria_
* Campylobacter
* E.Coli
* Salmonella
* Shigella
_Bacterial toxins (can arise from following organisms):_
* Staphylococcus aureus
* Bacillus cereus
* Clostridium perfringes
* Vibrio cholera
_Parasites_
* Entamoeba histolytica
* Giardia
* Schistomiasis
44
MUST REVISE YR3 INFECTION: GI INFECTIONS
45
What is diastasis recti?
* Widening of linea abla whic can result in a protruding bulge along middle of abdomen which is most prominent when pt lies on back and lifts their head.
* Not technically a hernia
* Can be congenital in newborns or due to weakness of CT e.g. following preganncy or in obese pts
46
What is the most common vascular abnormality in GI tract?
Angiodysplasia
*\*NOTE: angiodysplasia is most common cause for bleeding in small bowel*
47
What is angiodysplasia?
What two ‘types’ can it be split into?
Arteriovenous malformations in the GI tract
Most commonly in caecum and ascending colon
Divided into acquired or congenital
48
The exact cause of angiodysplasia is unknown but discuss the suggested pathophysiology of acquired angiodyplasia
* Repeated episodes of high intramural pressure reduces submucosal venous drainage
* Dilated and tortuous veins
* Loss of pre-capillary sphincter competency
* Leads to dilation of arterioles
* Formation of arterio-venous communications
*\*Much of theory based on fact that angiodysplasia common in ascending colon which has high intraluminal pressures*
49
How does angiodyplasia present
*\*HINT: presents in 1 of 3 ways usually*
- 10% are asymptomatic
- Majority of cases present with painless PR bleeding
- 10-15% present with acute haemorrhage
Symptoms depends on where in GI tract malformations are and also the severity of malformations e.g. may present with hematemesis or melena if in upper GI tract whereas lower GI present with haematochezia. If chronic may present with symptoms of anaemia.
50
What may you find on blood tests of elderly pts who are undiagnosed with chronic angiodysplasia?
Anaemia
51
What investigations are required for angiodysplasia?
_Bedside_
* FIT test (faecal immunochemical tests)
_Bloods_
* FBC: anaemia
* U&Es: baseline
* LFTs: baseline
* Clotting: baseline/bleeding
* Group & save or crossmatch
* Ferritin, TIBC, transferrin saturation: 10% have Fe deficiency anaemia
_Imaging_
* Endoscopy: if occult angiodysplasia to rule out malignancy
* Colonscopy: if suspect lower GI bleeding
* Capsule endoscopy: can’t visualise via endoscopy or colonscopy
* Angiography (MRI, CT after injecting contrast): if apparent angiodysplastic bleed and need to confirm location to plan for intervention
52
Discuss the management of angiodysplasia if there is only minimal limited bleeding in haemodynamically stable pt
* Most bleeds stop spontaneously so just require supportive treatment
* Interventional endoscopy (e.g. band ligation, cautery, photocoagulation etc)…
* Mesenteric angiography with embolisation
* Resection of affected bowel (only done if absolutely necessary e.g. severe bleeding despite therapy, multiple lesions that can’t be treated medically)
*\*If pt is unstable, proceed to treatment options*
53
What % of pts with angiodysplasia present with a major GI bleed?
10%
54
State some potential complications of angiodysplasia
* Anaemia
* Rebleeding
55
State some potential complications of the treatments for angiodysplasia
* Bowel perforation (endoscopic)
* Thrombosis (mesenteric angiography with embolization)
* Bowel ischaemia (mesenteric angiography with embolization)
56
Small bowel tumours are rare but when they do occur where are they most common?
Duodenum
57
Small bowel tumours can be benign (typically adenomas) or malignant (either adenocarcinoma or neuroendocrine tumours). Small intestine adenocarcinomas are believed to arise from pre-existing adenomas due to sequential accumulation of genetic abnormalities; true or false?
True
58
State some risk factors for small bowel tumours
* Age
* Afrocarribean
* Crohn’s disease
* Coeliac disease
* MEN-1
* Smoking
* Obesity
* Alcohol excess
59
How do small bowel tumours commonly present?
* As small bowel obstruction (asymptomatic in early stages and only symptomatic when causing luminal narrowing leading to obstruction)
* Symptomatic anaemia (less commonly)
60
Small bowel tumours usually found incidentally on investigations hence already had numerous investigations e.g. endoscopy, CT etc… true or false?
True
61
Discuss the management of small bowel tumours
* Benign= resection is ideal (endoscopic or surgical)
* Adenocarcinoma= surgical resection of bowel and corresponding mesentery +/- adjuvant chemotherapy
62
At time of diagnosis, roughly what % of pts with small bowel adenocarcinoma have potentially resectable disease?
70%
