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Any surgical procedure involving entry into a cavity containing viscera may
be complicated by post operative hernia
The deep layer of the wound has usually broken down, allowing internal
viscera to protrude through
Management is dictated by the patients clinical status and the timing of the
hernia in relation to recent surgery
Bowel obstruction or tenderness at the hernia site both mandate early surgical
intervention to reduce the risk of bowel necrosis
Mature incisional hernias with a wide neck and no symptoms may be either
left or listed for elective repair
Risk factors for the development of post operative incisional hernias include
post operative wound infections, long term steroid use, obesity and chronic
cough
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy
E. End jejunostomy
F. Loop jejunostomy
G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma
to be constructed. Each option may be selected once, more than once or not at all.
2.
3.
4.
Abdominal stomas
Stomas may be sited during a range of abdominal procedures and involve bringing the
lumen or visceral contents onto the skin. In most cases this applies to the bowel.
However, other organs or their contents may be diverted in case of need.
With bowel stomas the type method of construction and to a lesser extent the site will
be determined by the contents of the bowel. In practice, small bowel stomas should be
spouted so that their irritant contents are not in contact with the skin. Colonic stomas
do not need to be spouted as their contents are less irritant.
In the ideal situation the site of the stoma should be marked with the patient prior to
surgery. Stoma siting is important as it will ultimately influence the ability of the
patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma
contents and subsequent maceration of the surrounding skin can rapidly progress into
a spiraling loss of control of stoma contents.
Types of stomas
Name of stoma Use
Gastrostomy
Loop
jejunostomy
Feeding
Percutaneous
jejunostomy
Common sites
Epigastrium
Loop ileostomy
End ilestomy
End colostomy Where a colon is diverted or resected and Either left or right iliac
anastomosis is not primarily achievable fossa
or desirable
Loop
May be located in any
colostomy
To defunction a distal segment of region of the abdomen,
depending upon colonic
colon
segment used
Since both lumens are present the
distal lumen acts as a vent
Caecostomy
Mucous fistula
Please select the most likely cause of abdominal pain for the scenario given. Each
option may be used once, more than once or not at all.
5.
6.
7.
A 78 year old man is walking to the bus stop when he suddenly develops
severe back pain and collapses. On examination he has a blood pressure of
90/40 and pulse rate of 110. His abdomen is distended and he is obese.
Though tender his abdomen itself is soft.
Ruptured abdominal aortic aneurysm
This will be a retroperitoneal rupture (anterior ones generally don't survive
to hospital). The debate regarding CT varies, it is the authors opinion that a
systolic BP of <100mmHg at presentation mandates immediate laparotomy.
Management
Appendicectomy
Conservative
managementappendicectomy if
diagnostic doubt
Manage conservatively
if doubt or symptoms
fail to settle then
laparoscopy
Usually medically
managed- doxycycline
or azithromycin
Unstable patients
should undergo
(ruptured)
Perforated
peptic ulcer
Intestinal
obstruction
Mesenteric
infarction
radiating to the
stable should have a CT immediate surgery
back in older adults scan
(unless it is not in their
(look for risk
best interests).
factors).
Those with evidence of
Collapse.
contained leak on CT
May be moribund
should undergo
on arrival in
immediate surgery
casualty, more
Increasing aneurysmal
stable if contained
size is an indication for
haematoma.
urgent surgical
Careful clinical
intervention (that can
assessment may
wait until the next
reveal pulsatile
working day)
mass.
Sudden onset of
Erect CXR may show Laparotomy
pain (usually
free air. A CT scan may (laparoscopic surgery
epigastric).
be indicated where there for perforated peptic
Often preceding
is diagnostic doubt
ulcers is both safe and
history of upper
feasible in experienced
abdominal pain.
hands)
Soon develop
generalised
abdominal pain.
On examination
may have clinical
evidence of
peritonitis.
Colicky abdominal A plain abdominal film In those with a virgin
pain and vomiting may help with making abdomen and lower and
(the nature of
the diagnosis. A CT scan earlier threshold for
which depends on may be useful where
laparotomy should exist
the level of the
diagnostic uncertainty than in those who may
obstruction).
exists
have adhesional
Abdominal
obstruction
distension and
constipation (again
depending upon
site of obstruction).
Features of
peritonism may
occur where local
necrosis of bowel
loops is occurring.
Embolic events
Arterial pH and lactate Immediate laparotomy
present with sudden Arterial phase CT
and resection of
pain and forceful scanning is the most
affected segments, in
evacuation.
sensitive test
acute embolic events
Acute on chronic
SMA embolectomy
events usually have
may be needed.
a longer history and
previous weight
loss.
On examination the
pain is typically
greater than the
physical signs
would suggest.
Theme: Gastrointestinal bleeding
A. Haemorroids
B. Meckels diverticulum
C. Angiodysplasia
D. Colonic cancer
E. Diverticular bleed
F. Ulcerative colitis
G. Ischaemic colitis
Please select the most likely cause of colonic bleeding for the scenario given. Each
option may be used once, more than once or not at all
8.
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise
well and the bleed settles. On examination her abdomen is soft and non
tender. Elective colonoscopy shows a small erythematous lesion in the
right colon, but no other abnormality.
Angiodysplasia
Angiodysplasia can be difficult to identify and treat. The colonoscopic
stigmata are easily missed by poor bowel preparation.
9.
A 23 year old man complains of passing bright red blood rectally. It has
been occurring over the past week and tends to occur post defecation. He
also suffers from pruritus ani.
Haemorroids
Classical haemorroidal symptoms include bright red rectal bleeding, it
typically occurs post defecation and is noticed on the toilet paper and in
the toilet pan. It is usually painless, however, thrombosed external
haemorroids may be very painful.
10.
A 63 year old man presents with episodic rectal bleeding the blood tends
to be dark in colour and may be mixed with stool. His bowel habit has
Gastrointestinal bleeding
Colonic bleeding
This typically presents as bright red or dark red blood per rectum. Colonic bleeding
rarely presents as malaena type stool, this is because blood in the colon has a powerful
laxative effect and is rarely retained long enough for transformation to occur and
because the digestive enzymes present in the small bowel are not present in the colon.
Up to 15% of patients presenting with haemochezia will have an upper
gastrointestinal source of haemorrhage.
As a general rule right sided bleeds tend to present with darker coloured blood than
left sided bleeds. Haemorrhoidal bleeding typically presents as bright red rectal
bleeding that occurs post defecation either onto toilet paper or into the toilet pan. It is
very unusual for haemorrhoids alone to cause any degree of haemodynamic
compromise.
Causes
Cause
Colitis
Diverticular
disease
Cancer
Haemorrhoidal
bleeding
Angiodysplasia
Management
Presenting features
Bleeding may be brisk in advanced cases, diarrhoea is commonly
present. Abdominal x-ray may show featureless colon.
Acute diverticulitis often is not complicated by major bleeding and
diverticular bleeds often occur sporadically. 75% all will cease
spontaneously within 24-48 hours. Bleeding is often dark and of
large volume.
Colonic cancers often bleed and for many patients this may be the
first sign of the disease. Major bleeding from early lesions is
uncommon
Typically bright red bleeding occurring post defecation. Although
patients may give graphic descriptions bleeding of sufficient
volume to cause haemodynamic compromise is rare.
Apart from bleeding, which may be massive, these arteriovenous
lesions cause little in the way of symptoms. The right side of the
colon is more commonly affected.
In others who are more stable the standard procedure would be a colonoscopy
in the elective setting. In patients undergoing angiography attempts can be
made to address the lesion in question such as coiling. Otherwise surgery will
be necessary.
Management
References
http://www.sign.ac.uk/guidelines/fulltext/105/index.html
heme: Surgical signs
A. Rovsing's sign
B. Boas' sign
C. Psoas stretch sign
D. Cullen's sign
E. Grey-Turner's sign
F. Murphy's sign
G. None of the above
Please select the most appropriate eponymous abdominal sign for the scenario given.
Each option may be used once, more than once or not at all.
11.
12.
13.
In appendicitis palpation of the left iliac fossa causes pain in the right iliac
fossa.
Rovsing's sign
Rovsings sign elicits tenderness because the deep palpation induces shift
of the appendix (which is inflamed) against the peritoneal surface. This
has somatic innervation and will therefore localise the pain. It is less
reliable in pelvic appendicitis and when the appendix is truly retrocaecal
Abdominal signs
A number of eponymous abdominal signs are noted. These include:
14.
A 78 year old lady is admitted with a tender lump in her right groin. It is
within the femoral triangle and there is concern that there may be small
bowel obstruction developing.
McEvedy
This is one approach to an obstructed femoral hernia. It is possible to
undertake a small bowel resection through this approach. Although
recourse to laparotomy may be needed if access is difficult.
15.
A 45 year old woman with end stage renal failure is due to undergo a
cadaveric renal transplant. This will be her first transplant.
Rutherford Morrison
This is the incision of choice for the extraperitoneal approach to the iliac
vessels which will be required for a renal transplant.
16.
appendicectomy.
Lanz
Either a Lanz or Gridiron incision will give access for appendicectomy.
However, in the case described a Lanz incision will give better cosmesis
and can be extended should pelvic surgery be required eg for
gynaecological disease.
Abdominal incisions
Theme in January 2012 exam
Midline incision
Paramedian
incision
Battle
Kocher's
Lanz
Gridiron
Gable
Pfannenstiel's
McEvedy's
Rutherford
Morrison
Theme: Hernias
A. Littres hernia
B. Richters hernia
C. Bochdalek hernia
D. Morgagni hernia
E. Spigelian hernia
F. Lumbar hernia
G. Obturator hernia
Please select the type of hernia that most closely matches the description given. Each
option may be used once, more than once or not at all.
17.
A 73 year old lady presents with peritonitis and tenderness of the left
groin. At operation she has a left femoral hernia with perforation of the
anti mesenteric border of ileum associated with the hernia.
Richters hernia
When part of the bowel wall is trapped in a hernia such as this it is termed
a Richters hernia and may complicate any hernia although femoral and
obturator hernias are most typically implicated.
18.
A 22 year old man is operated on for a left inguinal hernia, at operation the
sac is opened to reveal a large Meckels diverticulum.
Littres hernia
Hernia containing Meckels diverticulum is termed a Littres hernia.
19.
20.
A 52 year old obese lady reports a painless grape sized mass in her groin
area. She has no medical conditions apart from some varicose veins. There
is a cough impulse and the mass disappears on lying down.
Saphenous varix
The history of varicose veins should indicate a more likely diagnosis of a
varix. The varix can enlarge during coughing/sneezing. A blue
discolouration may be noted.
21.
A 32 year old male is noted to have a tender mass in the right groin area.
There are also red streaks on the thigh, extending from a small abrasion.
You answered Lymphangitis
22.
A 23 year old male suffering from hepatitis C presents with right groin
pain and swelling. On examination there is a large abscess in the groin.
Adjacent to this is an expansile swelling. There is no cough impulse.
False femoral artery aneurysm
False aneurysms may occur following arterial trauma in IVDU. They may
have associated blood borne virus infections and should undergo duplex
scanning prior to surgery. False aneurysms do not contain all layers of the
arterial wall.
Herniae
Lipomas
Lymph nodes
Undescended testis
Femoral aneurysm
In the history features relating to systemic illness and tempo of onset will often give a
clue as to the most likely underlying diagnosis.
Groin lumps- some key questions
Examine the ano rectum as anal cancer may metastasise to the groin
In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound
scan is often the most convenient next investigation.
heme: Right iliac fossa pain
A. Urinary tract infection
B. Appendicitis
C. Mittelschmerz
D. Mesenteric adenitis
E. Crohns disease
F. Ulcerative colitis
G. Meckels diverticulum
Please select the most likely cause for right iliac fossa pain for the scenario given.
Each option may be used once, more than once or not at all.
23.
and ulceration.
24.
A 14 year old female is admitted with sudden onset right iliac fossa pain.
She is otherwise well and on examination has some right iliac fossa
tenderness but no guarding. She is afebrile. Urinary dipstick is normal.
Her previous menstrual period two weeks ago was normal and pregnancy
test is negative.
Mittelschmerz
Typical story and timing for mid cycle pain. Mid cycle pain typically
occurs because a small amount of fluid is released at the time of ovulation.
It will usually resolve over 24-48 hours.
25.
Anorexia
Crohn's disease
Signs of malnutrition
Mesenteric adenitis
Diverticulitis
Meckel's diverticulitis
Incarcerated right
inguinal or femoral
hernia
Bowel perforation
secondary to caecal or
colon carcinoma
Gynaecological causes
Urological causes
Other causes
A 78 year old lady presents with colicky abdominal pain and a tender mass in her
groin. On examination there is a small firm mass below and lateral to the pubic
tubercle. Which of the following is the most likely underlying diagnosis?
A. Incarcerated inguinal hernia
B. Thrombophlebitis of a saphena varix
C. Incarcerated femoral hernia
D. Incarcerated obturator hernia
E. Deep vein thrombosis
Femoral hernia = High risk of strangulation (repair urgently)
Femoral herniae account for <10% of all groin hernias. In the scenario the
combination of symptoms of intestinal compromise with a mass in the region of the
femoral canal points to femoral hernia as the most likely cause.
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath
is a fascial tunnel containing both the femoral artery laterally and femoral vein
medially. The canal lies medial to the vein.
Borders of the femoral canal
Laterally
Medially
Anteriorly
Posteriorly
Femoral vein
Lacunar ligament
Inguinal ligament
Pectineal ligament
Contents
Lymphatic vessels
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower
limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places
these at high risk of strangulation.
Examination
Diagnosis
Treatment
Patients without peritonitis who have an appendix mass should receive broad
spectrum antibiotics and consideration given to performing an interval
appendicectomy.
Be wary in the older patients who may have either an underlying caecal
malignancy or perforated sigmoid diverticular disease.
An 28 year old man presents with a direct inguinal hernia. A decision is made to
perform an open inguinal hernia repair. Which of the following is the best option for
abdominal wall reconstruction in this case?
A. Suture plication of the transversalis fascia using PDS
only
B. Suture plication of the hernial defect with nylon and
placement of prolene mesh anterior to external
oblique
C. Suture plication of the hernia defect using nylon and
re-enforcing with a sutured repair of the abdominal
wall
D. Sutured repair of the hernial defect with prolene and
placement of prolene mesh over the cord structures
in the inguinal canal
E. Sutured repair of the hernial defect using nylon and
placement of a prolene mesh posterior to the cord
structures
Inguinal herniorrhaphy
Shouldice repair
Darn repair
Open mesh repair and laparoscopic repair are the two main procedures in mainstream
use. The Shouldice repair is a useful procedure in cases where a mesh repair would be
associated with increased risk of infection, e.g. repair of case with strangulated bowel,
as it avoids the use of mesh. It is, however, far more technically challenging to
perform.
Inguinal hernia surgery
Inguinal hernias occur when the abdominal viscera protrude through the anterior
abdominal wall into the inguinal canal. They may be classified as being either direct
or indirect. The distinction between these two rests on their relation to Hesselbach's
triangle.
Boundaries of Hesselbach's Triangle
Hernias occurring within the triangle tend to be direct and those outside - indirect.
Diagnosis
Most cases are diagnosed clinically, a reducible swelling may be located at the level
of the inguinal canal. Large hernia may extend down into the male scrotum, these will
not trans-illuminate and it is not possible to "get above" the swelling.
Cases that are unclear on examination, but suspected from the history, may be further
investigated using ultrasound or by performing a herniogram.
Treatment
Hernias associated with few symptoms may be managed conservatively. Symptomatic
hernias or those which are at risk of developing complications are usually treated
surgically.
First time hernias may be treated by performing an open inguinal hernia repair; the
inguinal canal is opened, the hernia reduced and the defect repaired. A prosthetic
mesh may be placed posterior to the cord structures to re-inforce the repair and reduce
the risk of recurrence.
Recurrent hernias and those which are bilateral are generally managed with a
laparoscopic approach. This may be via an intra or extra peritoneal route. As in open
surgery a mesh is deployed. However, it will typically lie posterior to the deep ring.
Inguinal hernia in children
Inguinal hernias in children are almost always of an indirect type and therefore are
usually dealt with by herniotomy, rather than herniorraphy. Neonatal hernias
especially in those children born prematurely are at highest risk of strangulation and
should be repaired urgently. Other hernias may be repaired on an elective basis.
References
The UK Based National Institute of Clinical Excellence has published guidelines
relating to the choice between open and laparoscopic inguinal hernia repair. Which
users may find interesting:
Theme: Abdominal closure methods
A. Looped 1/0 PDS (polydiaxone)
B. Looped 1/0 silk
C. 1/0 Vicryl (polyglactin)
D. 1/0 Vicryl rapide
E. 2/0 Prolene (Polypropylene)
F. Re-inforced 1/0 Nylon
G. Re-inforced 1/0 Silk
H. Application of VAC system without separation film
I. Application of VAC System with separation film
J. Application of a 'Bogota Bag'
Please select the most appropriate wound closure method (for the deep layer) for the
abdominal surgery described.
29.
30.
A 73 year old lady undergoes a low anterior resection for carcinoma of the
rectum.
Looped 1/0 PDS (polydiaxone)
Mass closure obeying Jenkins rule is required and this states that the
suture must be 4 times the length of the wound with tissue bites 1cm deep
and 1 cm apart.
31.
It can be subdivided into superficial, in which the skin wound alone fails and
complete, implying failure of all layers.
Options
Resuturing of the This may be an option if the wound edges are healthy and there is
wound
enough tissue for sufficient coverage. Deep tension sutures are
32.
33.
34.
Hernia
Hernias occur when a viscus or part of it protrudes from within its normal anatomical
cavity. Specific hernias are covered under their designated titles the remainder are
addressed here.
Spigelian hernia
Rare.
May lie beneath internal oblique muscle. Usually between internal and
external oblique.
Both open and laparoscopic repair are possible, the former in cases of
strangulation.
Lumbar hernia
The lumbar triangle (through which these may occur) is bounded by:
Primary lumbar herniae are rare and most are incisional hernias following
renal surgery.
Obturator hernia
Commoner in females.
Richters hernia
Condition in which part of the wall of the small bowel (usually the anti
mesenteric border) is strangulated within a hernia (of any type).
Incisional hernia
Bochdalek hernia
Morgagni Hernia
Umbilical hernia
Often symptomatic.
95% will resolve by the age of 2 years. Thereafter surgical repair is warranted.
Paraumbilical hernia
Littres hernia
Resection of the diverticulum is usually required and this will preclude a mesh
repair.
35.
36.
An 8 year old boy presents with a 4 hour history of right iliac fossa pain
with nausea and vomiting. He has been back at school for two days after
being kept home with a flu like illness. On examination he is tender in the
37.
A 21 year old women presents with right iliac fossa pain. She reports some
bloodstained vaginal discharge. She has a HR of 65 bpm.
Ultrasound scan abdomen/pelvis
This patient is suspected of having an ectopic pregnancy. She needs an
urgent HCG and USS of the pelvis. If she were haemodynamically
unstable then laparotomy would be indicated.
Anorexia
Signs of malnutrition
Crohn's disease
Mesenteric adenitis
Incarcerated right
inguinal or femoral
hernia
Bowel perforation
secondary to caecal or
colon carcinoma
Diverticulitis
Meckel's diverticulitis
Urological causes
Other causes
Features such as lethargy, nausea, backache and bladder symptoms may also support
the diagnosis
Red flag features should be inquired about:
Rectal bleeding
ESR/CRP
The NICE criteria state that blood tests alone will suffice in people fulfilling the
diagnostic criteria. We would point out that luminal colonic studies should be
considered early in patients with altered bowel habit referred to hospital and a
diagnosis of IBS should still be largely one of exclusion.
Treatment
39.
40.
41.
Acute on chronic
mesenteric
ischaemia
Mesenteric vein
thrombosis
Low flow
mesenteric
infarction
compromise.
Diagnosis
Management
Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where
surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment
delay. The other conditions carry worse survival figures.
Theme: Groin masses
A. Femoral aneurysm
B. Lymphadenitis
C. Saphena varix
D. Femoral hernia
E. Indirect inguinal hernia
F. Direct inguinal hernia
G. Psoas abscess
What is the likely diagnosis for the groin mass described? Each option may be used
once, more than once or not at all.
42.
43.
A 52 year old obese lady reports a painless mass in the groin area. A mass
is noted on coughing. It is below and lateral to the pubic tubercle.
Femoral hernia
A mass below and lateral to the pubic tubercle is indicative of a femoral
hernia.
44.
A 21 year old man is admitted with a tender mass in the right groin, fevers
and sweats. He is on multiple medical therapy for HIV infection. On
examination he has a swelling in his right groin, hip extension exacerbates
the pain.
Psoas abscess
Psoas abscesses may be either primary or secondary. Primary cases often
occur in the immunosuppressed and may occur as a result of
haematogenous spread. Secondary cases may complicated intra abdominal
diseases such as Crohns. Patients usually present with low back pain and if
the abscess is extensive a mass that may be localised to the inguinal region
or femoral triangle . Smaller collections may be percutaneously drained. If
the collection is larger, or the percutaneous route fails, then surgery (via a
retroperitoneal approach) should be performed.
Herniae
Lipomas
Lymph nodes
Undescended testis
Femoral aneurysm
In the history features relating to systemic illness and tempo of onset will often give a
clue as to the most likely underlying diagnosis.
Groin lumps- some key questions
Examine the ano rectum as anal cancer may metastasise to the groin
In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound
scan is often the most convenient next investigation.
A 56 year old lady is admitted with colicky abdominal pain. A plain x-ray is
performed. Which of the following should not show fluid levels on a plain abdominal
film?
A. Stomach
B. Jejunum
C. Ileum
D. Caecum
E. Descending colon
Fluid levels in the distal colon are nearly always pathological. In general contents of
the left colon transit quickly and are seldom held in situ for long periods, the content
is also more solid.
Abdominal radiology
Plain abdominal x-rays are often used as a first line investigation in patients with
acute abdominal pain. A plain abdominal film may demonstrate free air, evidence of
bowel obstruction and possibly other causes of pain (e.g. renal or gallbladder stones).
Investigation of potential visceral perforation is usually best performed by obtaining
an erect chest x-ray, as this is a more sensitive investigation for suspected visceral
perforation.
Features which are usually abnormal
Large amounts of free air (colonic perforation), smaller volumes seen with
more proximal perforations.
Ground glass appearance to film (usually due to large amounts of free fluid).
Following ERCP (and sphincterotomy) air may be identified in the biliary tree.
A 56 year old lady presents with a large bowel obstruction and abdominal distension.
Which of the following confirmatory tests should be performed prior to surgery
A. Abdominal ultrasound scan
B. Barium enema
C. Rectal MRI Scan
D. Endoanal ultrasound scan
E. Gastrograffin enema
Patients with clinical evidence of large bowel obstruction, should have the presence or
absence of an obstructing lesion confirmed prior to surgery. This is because colonic
pseudo-obstruction may produce a similar radiological picture. A gastrograffin enema
is the traditional test, as barium is too toxic if it spills into the abdominal cavity. An
MRI scan will not provide the relevant information, unless the lesion is rectal and
below the peritoneal reflection.
Abdominal radiology
Plain abdominal x-rays are often used as a first line investigation in patients with
acute abdominal pain. A plain abdominal film may demonstrate free air, evidence of
bowel obstruction and possibly other causes of pain (e.g. renal or gallbladder stones).
Investigation of potential visceral perforation is usually best performed by obtaining
an erect chest x-ray, as this is a more sensitive investigation for suspected visceral
perforation.
Features which are usually abnormal
Large amounts of free air (colonic perforation), smaller volumes seen with
more proximal perforations.
Ground glass appearance to film (usually due to large amounts of free fluid).
Following ERCP (and sphincterotomy) air may be identified in the biliary tree.
1.
A 7 year old boy falls off a wall the distance is 7 feet. He lands on his left
side and there is left flank bruising. There is no haematuria. He is otherwise
stable and haemoglobin is within normal limits.
Ultrasound scan
This will demonstrate any overt splenic injury. A CT scan carries a
significant dose of radiation. In the absence of haemodynamic instability or
other major associated injuries the use of USS to exclude intraabdominal
free fluid (blood) would seem safe when coupled with active observation.
An USS will also show splenic haematomas.
2.
3.
Splenic trauma
The spleen is one of the more commonly injured intra abdominal organs
In most cases the spleen can be conserved. The management is dictated by the
associated injuries, haemodynamic status and extent of direct splenic injury.
Splenectomy
Technique
Trauma
GA
Large amount of free blood is usually present. Pack all 4 quadrants of the
abdomen. Allow the anaesthetist to 'catch up'
Remove the packs and assess the viability of the spleen. Hilar injuries and
extensive parenchymal lacerations will usually require splenectomy.
Clamp the splenic artery and vein. Two clamps on the patient side are better
and allow for double ligation and serve as a safety net if your assistant does
not release the clamp smoothly.
Be careful not to damage the tail of the pancreas, if you do then this will need
to be formally removed and the pancreatic duct closed.
Wash out the abdomen and place a tube drain to the splenic bed.
Some surgeons implant a portion of spleen into the omentum, whether you
decide to do this is a matter of personal choice.
Elective
Elective splenectomy is a very different operation from that performed in the
emergency setting. The spleen is often large (sometimes massive). Most cases can be
performed laparoscopically. The spleen will often be macerated inside a specimen bag
to facilitate extraction.
Complications
Haemorrhage (may be early and either from short gastrics or splenic hilar
vessels
Which of the following does not increase the risk of abdominal wound dehiscence
following laparotomy?
A. Jaundice
B. Abdominal compartment syndrome
C. Poorly controlled diabetes mellitus
D. Administration of intravenous steroids
It can be subdivided into superficial, in which the skin wound alone fails and
complete, implying failure of all layers.
Options
Resuturing of the This may be an option if the wound edges are healthy and there is
wound
enough tissue for sufficient coverage. Deep tension sutures are
traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable
wound manager when some granulation tissue is present over the viscera or where
there is a high output bowel fistula present in the dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges
'Bogota bag'
5.
A 23 year old lady has suffered from diarrhoea for 8 months, she has also
lost 2 Kg in weight. At colonoscopy appearances of melanosis coli are
identified and confirmed on biopsy
You answered Ulcerative colitis
The correct answer is Laxative abuse
This may occur as a result of laxative abuse and consists of lipofuschin
laden marcophages that appear brown.
6.
7.
Diarrhoea
World Health Organisation definitions
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Acute Diarrhoea
Gastroenteritis
Diverticulitis
Antibiotic therapy
Constipation causing
overflow
Chronic Diarrhoea
Irritable
Extremely common. The most consistent features are abdominal pain,
bowel
bloating and change in bowel habit. Patients may be divided into
syndrome
those with diarrhoea predominant IBS and those with constipation
predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms
may also be present
Ulcerative
Bloody diarrhoea may be seen. Crampy abdominal pain and weight
colitis
loss are also common. Faecal urgency and tenesmus may occur
Crohn's
Crampy abdominal pains and diarrhoea. Bloody diarrhoea less
disease
common than in ulcerative colitis. Other features include
malabsorption, mouth ulcers perianal disease and intestinal
obstruction
Colorectal
Symptoms depend on the site of the lesion but include diarrhoea,
cancer
rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss
and anorexia
Coeliac
disease
In children may present with failure to thrive, diarrhoea and
abdominal distension
Thyrotoxicosis
Laxative abuse
Radiation enteritis
Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose
A 6 year old child presents with colicky abdominal pain, vomiting and the passage of
red current jelly stool per rectum. On examination the child has a tender abdomen and
a palpable mass in the right upper quadrant. Imaging shows an intussusception. Which
of the conditions below is least recognised as a precipitant
A. Inflammation of Payers patches
B. Cystic fibrosis
C. Meckels diverticulum
D. Mesenteric cyst
E. Mucosal polyps
Mesenteric cysts may be associated with intra abdominal catastrophes where these
occur they are typically either intestinal volvulus or intestinal infarction. They seldom
cause intussusception. Cystic fibrosis may lead to the formation of meconium ileus
equivalent and plugs may occasionally serve as the lead points for an intussusception.
Intussusception- Paediatric
Intussusception typcially presents with colicky abdominal pain and vomiting. The
telescoping of the bowel produces mucosal ischaemia and bleeding may occur
resulting in the passage of "red current jelly" stools. Recognised causes include
coeliac disease
Crohn's disease
tropical sprue
Whipple's disease
Giardiasis
chronic pancreatitis
cystic fibrosis
pancreatic cancer
biliary obstruction
Other causes
lymphoma
10.
11.
A 62 year old man is admitted with dull lower back pain and abdominal
discomfort. On examination he is hypertensive and a lower abdominal
fullness is elicited on examination. An abdominal ultrasound demonstrates
hydronephrosis and intravenous urography demonstrated medially
displaced ureters. A CT scan shows a periaortic mass.
You answered Metastatic colonic cancer
The correct answer is Retroperitoneal fibrosis
Retroperitoneal fibrosis is an uncommon condition and its aetiology is
poorly understood. In a significant proportion the ureters are displaced
medially. In most retroperitoneal malignancies they are displaced laterally.
Hypertension is another common finding. A CT scan will often show a
para-aortic mass
12.
Pseudomyxoma Peritonei
Most commonly arising from the appendix (other abdominal viscera are also
recognised as primary sites)
Treatment
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f
Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin
C.
Survival is related to the quality of primary treatment and in Sugarbakers own centre
5 year survival rates of 75% have been quoted. Patients with disseminated
intraperitoneal malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this
routinely.
Theme: Abdominal pain
A. Acute mesenteric embolus
B. Acute on chronic mesenteric ischaemia
C. Mesenteric vein thrombosis
D. Ruptured abdominal aortic aneurysm
E. Pancreatitis
F. Appendicitis
G. Acute cholecystitis
Please select the most likely underlying diagnosis from the list above. Each option
may be used once, more than once or not at all.
13.
A 72 year old man collapses with sudden onset abdominal pain. He has
been suffering from back pain recently and has been taking ibuprofen.
Ruptured abdominal aortic aneurysm
Back pain is a common feature with expanding aneurysms and may be
miss classified as being of musculoskeletal origin.
14.
A 73 year old women collapses with sudden onset of abdominal pain and
the passes a large amount of diarrhoea. On admission she is vomiting
repeatedly. She has recently been discharged from hospital following a
myocardial infarct but recovered well.
You answered Mesenteric vein thrombosis
The correct answer is Acute mesenteric embolus
Sudden onset of abdominal pain and forceful bowel evacuation are
15.
A 66 year old man has been suffering from weight loss and develops
severe abdominal pain. He is admitted to hospital and undergoes a
laparotomy. At operation the entire small bowel is infarcted and only the
left colon is viable.
You answered Mesenteric vein thrombosis
The correct answer is Acute on chronic mesenteric ischaemia
This man is likely to have underlying chronic mesenteric vascular disease.
Only 15% of emboli will occlude SMA orifice leading to entire small
bowel infarct. The background history of weight loss also favours an acute
on chronic event.
Acute on chronic
mesenteric
ischaemia
80%.
Mesenteric vein
thrombosis
Low flow
mesenteric
infarction
Diagnosis
Management
Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where
surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment
delay. The other conditions carry worse survival figures.
Theme: Surgical incisions
A. Lanz incision
B. Gridiron incision
C. Kochers incision
D. Rutherford Morrison
E. Rooftop incision
F. McEvedy Incision
G. Lothissen Incision
Please select the most appropriate incision for the procedure described.
Each option may be used once, more than once or not at all.
1
6.
1
7.
A 15 year old girl presents with right iliac fossa pain and
guarding, pregnancy test is negative and WCC is 16.
Lanz incision
1
8.
Abdominal incisions
Paramedian
incision
Battle
Kocher's
Lanz
Gridiron
Gable
Rooftop incision
F. Pneumonia
G. Sickle cell crisis
H. Spontaneous bacterial peritonitis
I. Rupure of follicular cyst
Please select the most likely cause of abdominal pain for the scenario given. Each
option may be used once, more than once or not at all.
19.
20.
21.
urine.
Management
Appendicectomy
Conservative
managementappendicectomy if
diagnostic doubt
Manage conservatively
if doubt or symptoms
fail to settle then
laparoscopy
Usually medically
managed- doxycycline
or azithromycin
inflammation and
subsequent
adhesion formation.
Abdominal
Sudden onset of
Patients who are
Unstable patients
aortic aneurysm abdominal pain
haemodynamically
should undergo
(ruptured)
radiating to the
stable should have a CT immediate surgery
back in older adults scan
(unless it is not in their
(look for risk
best interests).
factors).
Those with evidence of
Collapse.
contained leak on CT
May be moribund
should undergo
on arrival in
immediate surgery
casualty, more
Increasing aneurysmal
stable if contained
size is an indication for
haematoma.
urgent surgical
Careful clinical
intervention (that can
assessment may
wait until the next
reveal pulsatile
working day)
mass.
Perforated
Sudden onset of
Erect CXR may show Laparotomy
peptic ulcer
pain (usually
free air. A CT scan may (laparoscopic surgery
epigastric).
be indicated where there for perforated peptic
Often preceding
is diagnostic doubt
ulcers is both safe and
history of upper
feasible in experienced
abdominal pain.
hands)
Soon develop
generalised
abdominal pain.
On examination
may have clinical
evidence of
peritonitis.
Intestinal
Colicky abdominal A plain abdominal film In those with a virgin
obstruction
pain and vomiting may help with making abdomen and lower and
(the nature of
the diagnosis. A CT scan earlier threshold for
which depends on may be useful where
laparotomy should exist
the level of the
diagnostic uncertainty than in those who may
obstruction).
exists
have adhesional
Abdominal
obstruction
distension and
constipation (again
depending upon
site of obstruction).
Features of
peritonism may
occur where local
necrosis of bowel
loops is occurring.
Mesenteric
Embolic events
Arterial pH and lactate Immediate laparotomy
infarction
present with sudden Arterial phase CT
and resection of
affected segments, in
acute embolic events
SMA embolectomy
may be needed.
This is clearly a very broad area and impossible to cover comprehensively. There is
considerable overlap with other topic areas within the website.
Avoiding complications
Some points to hopefully avert complications:
Use tourniquets with caution and with respect for underlying structures
Remember the danger of end arteries and in situations where they occur avoid
using adrenaline containing solutions and monopolar diathermy.
Handle tissues with care- devitalised tissue serves as a nidus for infection
Be very wary of the potential for coupling injuries when using diathermy
during laparoscopic surgery
The inferior epigastric artery is a favourite target for laparoscopic ports and
surgical drains!
Anatomical principles
Understanding the anatomy of a surgical field will allow appreciation of local and
systemic complications that may occur. For example nerve injuries may occur
following surgery in specific regions the table below lists some of the more important
nerves to consider and mechanisms of injury
Nerve
Accessory
Sciatic
Common peroneal
Long thoracic
Pelvic autonomic nerves
Recurrent laryngeal nerves
Hypoglossal nerve
Ulnar and median nerves
Mechanism
Posterior triangle lymph node biopsy
Posterior approach to hip
Legs in Lloyd Davies position
Axillary node clearance
Pelvic cancer surgery
During thyroid surgery
During carotid endarterectomy
During upper limb fracture repairs
These are just a few. The detailed functional sequelae are particularly important and
will often be tested. In addition to nerve injuries certain procedures carry risks of
visceral or structural injury. Again some particular favourites are given below:
Structure
Thoracic duct
Parathyroid
glands
Ureters
Bowel
perforation
Bile duct injury
Mechanism
During thoracic surgery e.g. Pneumonectomy, oesphagectomy
During difficult thyroid surgery
During colonic resections/ gynaecological surgery
Use of Verres Needle to establish pneumoperitoneum
Physiological derangements
A very common complication is bleeding and this is covered under the section of
haemorrhagic shock. Another variant is infection either superficial or deep seated. The
organisms are covered under microbiology and the features of sepsis covered under
shock. Do not forget that immunocompromised and elderly patients may present will
atypical physiological parameters.
Selected physiological and biochemical issues are given below:
Complication
Arrhythmias following
cardiac surgery
Neurosurgical electrolyte
disturbance
Ileus following
gastrointestinal surgery
Pulmonary oedema
following pneumonectomy
Anastamotic leak
Myocardial infarct
Try making a short list of problems and causes specific to your own clinical area.
Diagnostic modalities
Depends largely on the suspected complication. In the acutely unwell surgical patient
the following baseline investigations are often helpful:
Full blood count, urea and electrolytes, C- reactive protein (trend rather than
absolute value), serum calcium, liver function tests, clotting (don't forget to
repeat if on-going bleeding)
CTPA for PE
Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if
pancreatic injury suspected)
Management of complications
The guiding principal should be safe and timely intervention. Patients should be
stabilised and if an operation needs to occur in tandem with resuscitation then
generally this should be of a damage limitation type procedure rather than definitive
surgery (which can be more safely undertaken in a stable patient the following day).
Remember that recent surgery is a contra indication to thrombolysis and that in some
patients IV heparin may be preferable to a low molecular weight heparin (easier to
reverse).
As a general rule laparotomies for bleeding should follow the core principle of
quadrant packing and then subsequent pack removal rather than plunging large clamps
into pools of blood. The latter approach invariable worsens the situation is often
accompanied by significant visceral injury particularly when done by the
inexperienced. If packing controls a situation it is entirely acceptable practice to leak
packs in situ and return the patient to ITU for pack removal the subsequent day.
Theme: Abdominal pain
A. Appendicitis
B. Threatened miscarriage
C. Ectopic pregnancy
D. Irritable bowel syndrome
E. Mittelschmerz
F. Pelvic inflammatory disease
G. Adnexial torsion
H. Endometriosis
I. Degenerating fibroid
Please select the most likely cause of abdominal pain for the clinical scenario given.
Each option may be used once, more than once or not at all.
23.
24.
25.
Treatment
Conservative
Laparoscopy
Laparoscopy or laparotomy
is haemodynamically
unstable. A salphingectomy
is usually performed.
Usually medical
management
It can be subdivided into superficial, in which the skin wound alone fails and
complete, implying failure of all layers.
Options
Resuturing of the This may be an option if the wound edges are healthy and there is
wound
enough tissue for sufficient coverage. Deep tension sutures are
traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable
wound manager when some granulation tissue is present over the viscera or where
there is a high output bowel fistula present in the dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges
'Bogota bag'
and is only a temporary measure to be adopted when the wound
cannot be closed and will necessitate a return to theatre for
definitive management.
Application of a These can be safely used BUT ONLY if the correct layer is
VAC dressing
interposed between the suction device and the bowel. Failure to
system
adhere to this absolute rule will almost invariably result in the
development of multiple bowel fistulae and create an extremely
difficult management problem.
Which of the following statements about diarrhoea is false?
A. Nocturnal diarrhoea is uncommon in irritable bowel syndrome
B. World Health Organisation definition of diarrhoea is greater than 3
episodes of loose or watery stool a day
C. Pancreatic disease causes osmotic diarrhoea
D. Vitamin C deficiency causes diarrhoea
E. The World Health Organisation definition of chronic diarrhoea is greater
than 14 days of diarrhoea
Vitamin C toxicity causes osmotic diarrhoea.
Diarrhoea
World Health Organisation definitions
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Acute Diarrhoea
Gastroenteritis
Diverticulitis
Antibiotic therapy
Constipation causing
overflow
Chronic Diarrhoea
Irritable
Extremely common. The most consistent features are abdominal pain,
bowel
bloating and change in bowel habit. Patients may be divided into
syndrome
those with diarrhoea predominant IBS and those with constipation
predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms
may also be present
Ulcerative
Bloody diarrhoea may be seen. Crampy abdominal pain and weight
colitis
loss are also common. Faecal urgency and tenesmus may occur
Crohn's
Crampy abdominal pains and diarrhoea. Bloody diarrhoea less
disease
common than in ulcerative colitis. Other features include
malabsorption, mouth ulcers perianal disease and intestinal
obstruction
Colorectal
Symptoms depend on the site of the lesion but include diarrhoea,
cancer
rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss
and anorexia
Coeliac
disease
In children may present with failure to thrive, diarrhoea and
abdominal distension
Thyrotoxicosis
Laxative abuse
Radiation enteritis
Diagnosis
Stool culture
Abdominal and digital rectal examination
Consider colonoscopy (radiological studies unhelpful)
Thyroid function tests, serum calcium, anti endomysial antibodies, glucose
Hernias occurring within the triangle tend to be direct and those outside indirect.
Diagnosis
Most cases are diagnosed clinically, a reducible swelling may be located at
the level of the inguinal canal. Large hernia may extend down into the
male scrotum, these will not trans-illuminate and it is not possible to "get
above" the swelling.
Cases that are unclear on examination, but suspected from the history,
may be further investigated using ultrasound or by performing a
herniogram.
Treatment
Hernias associated with few symptoms may be managed conservatively.
Symptomatic hernias or those which are at risk of developing
complications are usually treated surgically.
First time hernias may be treated by performing an open inguinal hernia
repair; the inguinal canal is opened, the hernia reduced and the defect
repaired. A prosthetic mesh may be placed posterior to the cord structures
to re-inforce the repair and reduce the risk of recurrence.
Recurrent hernias and those which are bilateral are generally managed
with a laparoscopic approach. This may be via an intra or extra peritoneal
route. As in open surgery a mesh is deployed. However, it will typically lie
posterior to the deep ring.
A 60 year old women has fully recovered from an attack of pancreatitis. Over the
following 12 months she develops episodic epigastric discomfort. Un upper GI
endoscopy shows gastric varices only. An abdominal CT scan demonstrates a splenic
vein thrombosis. What is the treatment of choice?
A. Splenectomy
B. Insertion of transjugular porto-systemic shunt
C. Surgical bypass of the splenic vein
D. Gastrectomy
E. Stapling of the gastro-oesophgeal junction
E. Grey-Turner's sign
F. Murphy's sign
G. None of the above
Please match the clinical sign to the clinical scenario described. Each
option may be used once, more than once or not at all.
3
0.
3
1.
3
2.
Abdominal signs
Appendicitis (17%)
Pancreatitis (2%)
Abdominal ultrasound is safe, non invasive and cheap and yields significantly
more information than plain radiology. However, plain radiology is still the
main test for suspected perforated viscus, especially out of hours.
In up to 50% cases with perforated peptic ulcer, the plain x-rays may show no
evidence of free air. If clinical signs suggest otherwise, then a CT scan may be
a more accurate investigation, if plain films are normal.
Plain film radiology usually cannot detect <1mm free air, and is 33% sensitive
for detection of 1-13mm pockets of free air (Stoker et al. Radiology 2009 253:
31-46).
Think of strangulated intestine when there is fever, raised white cell count,
tachycardia and peritonism.
Where need for surgery is difficult to define and imaging is inconclusive the
use of laparoscopy as a definitive diagnostic test is both safe and sensible.
A 72 year old obese man undergoes and emergency repair of a ruptured abdominal
aortic aneurysm. The wound is closed with an onlay prolene mesh to augment the
closure. Post operatively he is taken to the intensive care unit. Over the following
twenty four hours his nasogastric aspirates increase, his urine output falls and he has a
metabolic acidosis. What is the most likely underlying cause?
A. Colonic ischaemia
B. Abdominal compartment syndrome
C. Peritonitis
D. Reactionary haemorrhage
E. Aorto-duodenal fistula
Obese patients with ileus following major abdominal surgery are at increased risk of
intra abdominal compartment syndrome.The risk is increased by the use of prosthetic
meshes, which some surgeons favor following a major vascular case as they may
reduce the incidence of incisional hernia. They prevent abdominal distension and may
increase the risk of intra abdominal hypertension in the short term. Although colonic
ischaemia may occur following major aortic surgery it would not typically present in
this way.
Abdominal compartment syndrome
Background
Intra-abdominal pressure is the steady state pressure concealed within the abdominal
cavity.
Management
Once the diagnosis is made non operative measures should be instituted including:
Gastric decompression
In those whom non operative treatment is failing; the correct treatment is laparotomy
and laparostomy. Options for laparostomy are many although the Bogota bag or VAC
techniques are the most widely practised. Re-look laparotomy and attempts at delayed
closure will follow in due course.
Theme: Surgical drains
A. Redivac suction drain
B. Corrugated drain
C. Wallace Robinson drain
D. Penrose tubing
E. Latex T Tube drain
F. Silastic T Tube drain
Please select the most appropriate surgical drainage system for the indication given.
Each option may be used once, more than once or not at all.
35.
36.
37.
Surgical drains
Drains are inserted in many surgical procedures and are of many types.
As a broad rule they can be divided into those using suction and those which
do not.
The diameter of the drain will depend upon the substance being drained, for
example smaller lumen drain for pneumothoraces vs haemothorax.
Drains can be associated with complications and these begin with insertion
when there may be iatrogenic damage. When in situ they serve as a route for
infections. In some specific situations they may cause other complications, for
example suction drains left in contact with bowel for long periods may carry a
risk of inducing fistulation.
Drains should be inserted for a defined purpose and removed once the need
has passed.
Low suction drain or free drainage systems may be used for situations such as
drainage of sub dural haematomas.
CVS
In this setting drains are usually used to prevent haematoma formation (with
associated risk of infection). Some orthopaedic drains may also be specially
adapted to allow the drained blood to be auto transfused.
Gastro-intestinal surgery
Drain types
Type of drain
Redivac
Features
Low pressure
drainage systems
Chest drains
Corrugated drain
Please select the most likely diagnosis for the scenario given. Each option may be
used once, more than once or not at all.
38.
39.
An 8 year old boy presents with abdominal pain,a twelve hour history of
vomiting, a fever of 38.3 oC and four day history of diarrhoea. His
abdominal pain has been present for the past week.
Appendix abscess
The high fever and diarrhoea together with vomiting all point to a pelvic
abscess. The presence of pelvic pus is highly irritant to the rectum, and
many patients in this situation will complain of diarrhoea.
40.
A 7 year old boy presents with a three day history of right iliac fossa pain
and fever. On examination he has a temperature of 39.9o C. His abdomen
is soft and mildly tender in the right iliac fossa.
You answered Campylobacter infection
The correct answer is Mesenteric adenitis
High fever and mild abdominal signs in a younger child should raise
suspicion for mesenteric adenitis. The condition may mimic appendicitis
and many may require surgery.
Appendicitis
Anorexia
Signs of malnutrition
Crohn's disease
Mesenteric adenitis
Diverticulitis
Meckel's diverticulitis
Incarcerated right
inguinal or femoral
hernia
Bowel perforation
secondary to caecal or
colon carcinoma
Gynaecological causes
Urological causes
Other causes
A 56 year old man undergoes a difficult splenectomy and is left with a pancreatic
fistula. There are ongoing problems with very high fistula output. Which of the
following agents may be administered to reduce the fistula output?
A. Metoclopramide
B. Erthyromycin
C. Octreotide
D. Loperamide
E. Omeprazole
Octreotide is a useful agent in reducing the output from pancreatic fistulae. Prokinetic
agents will increase fistula output and should be avoided.
Fistulas
There are many types ranging from Branchial fistulae in the neck to enterocutaneous fistulae abdominally.
In general surgical practice the abdominal cavity generates the majority and
most of these arise from diverticular disease and Crohn's.
Where there is skin involvement, protect the overlying skin, often using a well
fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of
octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high
jejunal or duodenal) these may necessitate the use of TPN to provide
nutritional support together with the concomitant use of octreotide to reduce
volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula
where acute inflammation is present, this almost always worsens outcomes.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that
have an intra abdominal source the use of barium and CT studies should show
a track. For perianal fistulae surgeons should recall Goodsall's rule in relation
to internal and external openings.
4
2.
Inguinal herniotomy
Infants usually suffer from a patent processus vaginalis (a
congential problem). As a result a simple herniotomy is all that is
required. A mesh is not required as there is not specific muscle
weakness.
4
3.
4
4.
Inguinal hernias occur when the abdominal viscera protrude through the
anterior abdominal wall into the inguinal canal. They may be classified as
being either direct or indirect. The distinction between these two rests on
their relation to Hesselbach's triangle.
Boundaries of Hesselbach's Triangle
Hernias occurring within the triangle tend to be direct and those outside indirect.
Diagnosis
Most cases are diagnosed clinically, a reducible swelling may be located at
the level of the inguinal canal. Large hernia may extend down into the
male scrotum, these will not trans-illuminate and it is not possible to "get
above" the swelling.
Cases that are unclear on examination, but suspected from the history,
may be further investigated using ultrasound or by performing a
herniogram.
Treatment
Hernias associated with few symptoms may be managed conservatively.
Symptomatic hernias or those which are at risk of developing
complications are usually treated surgically.
First time hernias may be treated by performing an open inguinal hernia
repair; the inguinal canal is opened, the hernia reduced and the defect
repaired. A prosthetic mesh may be placed posterior to the cord structures
4
5.
4
6.
4
7.
Abdominal incisions
Paramedian
incision
Battle
Kocher's
Lanz
Gridiron
Gable
Rooftop incision
D. Pfannenstiel's
E. Midline
F. Paramedian incision
G. Mcevedy
Please select the most appropriate incision for the procedure described.
Each option may be used once, more than once or not at all.
4
5.
4
6.
4
7.
Abdominal incisions
Paramedian
incision
Battle
Kocher's
Lanz
Gridiron
Gable
Rooftop incision