Post on 25-Feb-2016
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Hernias & bowel obstructionRichard Griffiths FY1 Surgery
Introduction Aims/objectives Hernias Bowel obstruction Clinical case example Quiz
Aims + objectives Aim
To give an overview of hernias and bowel obstruction relative to finals examinations
Objectives Key features Causes Investigations Management
Hernias Definition of a hernia
A hernia is the protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
Inguinal Direct Indirect
Femoral Incisional Others
Anatomy Inguinal hernia – Above and medical to pubic tubercle
Anterior – External oblique + internal oblique for lateral 1/3 Posterior – Transversalis fascia + conjoint tendon Roof – Arching fibres of internal oblique + transversus Floor – Inguinal ligament
Femoral hernias – Below and lateral to pubic tubercle Anterior – Inguinal ligament Posterior – Pectineal ligament Laterally – Femoral vein Medially – Lacunar ligament
Terminology Reducible
Irreducible
Incarcerated
Strangulated
Obstructed
Richter’s
Risk factors Chronic cough Chronic constipation Straining on passing urine Heavy lifting Obesity Age Previous surgery Males = Inguinal herniae Females = Femoral herniae
Symptoms and signs Lump
Painful/painless On and off for long time/Sudden onset Presents on coughing/straining Reduces on lying flat
Pain Dragging sensation in scrotum
Complications
Differentials Different type of hernia Lymph node Hydrocele Abscess Femoral aneurysm Saphena varix
Investigations Bedside – Observations
Bloods – FBC, U+Es, LFTs, amylase, G+S
Imaging – USS
Management Conservative
Manually reduced by patient Stop smoking, avoid heavy lifting/straining Truss Large defect Patient not fit for surgery
??Medical – analgesia, anti-emetics
Surgical – Hernia repair All femoral herniae Herniorrhaphy – laparoscopic or open Suture repair Mesh repair Obstructed/strangulated bowel dealt with accordingly
Bowel Obstruction Small bowel obstruction
Large bowel obstruction
Causes Small bowel obstruction
In the lumen Impacted faeces Foreign body Large polyp
In the wall Tumours Infarction Stricture – Crohn’s
Outside the wall Adhesions Volvulus Strangulated hernia Extrinsic compression
Causes Large bowel obstruction
Carcinoma of colon Diverticular disease Volvulus
4 Cardinal features Pain Abdominal distension Absolute constipation Vomiting
Investigations Bedside – Observations
Bloods: FBC, U+Es, LFTs, amylase, G+S Blood gas
Imaging: AxR, erect CxR CT with contrast
Management Conservative – “drip + suck”
NBM IVI fluids NG tube Analgesia Anti-emetics
Surgical Depends on cause Adhesiolysis Hernia repair Bowel resection
Conclusions Hernias
Anatomy Difference between incarcerated and
strangulated Examination
Bowel obstruction 4 cardinal features Causes Management
Clinical case 1 80 year old male Painful lump in groin – irreducible Present lying and standing Previous history of lump that comes and
goes What else do you want to know?
Questions Risk factors for herniae? Boundaries of the inguinal canal? What is an incarcerated hernia? What are the features of a strangulated
hernia? Four cardinal features of obstruction? Major causes of obstruction? Initial management of obstruction?
Thank youQuestions