sarah carney m chowdhury fy1 cmft 5 th yr finals revision day n.
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Sarah Carney & M. Chowdhury FY1 CMFT 5 th Yr Finals Revision Day. Hernias & Stomas: OSCE Finals. Predisposing factors and Presentation:. Predisposing factors: Chronic cough (smoking) Chronic constipation Straining to pass faeces Straining to void Obesity Increasing age Surgery

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predisposing factors and presentation
Predisposing factors and Presentation:
  • Predisposing factors:
    • Chronic cough (smoking)
    • Chronic constipation
    • Straining to pass faeces
    • Straining to void
    • Obesity
    • Increasing age
    • Surgery
    • Prostatic disease
    • Ilioinguinal nerve damage
    • Occupation/heavy lifting
  • Presentation:
    • Lump
    • Pain
    • Complication: obstruction, strangulation
classification of hernias
Classification of hernias
  • Congenital and acquired
  • Abdominal and extra-abdominal
  • Groin hernias
    • Inguinal: direct and indirect
    • Femoral
    • Inguinal scrotal
femoral hernias
Femoral hernias:
  • Femoral canal:
    • Position: BELOW and LATERAL to pubic tubercle
    • Borders of femoral ring:
      • Medial: lacunar ligament (↑strangulation)
      • Anterior: inguinal ligament
      • Posterior: pectineal ligament and pectineus
      • Lateral: femoral vein
    • Management:
      • Elective: low approach: excision of the sac (herniotomy) and repair (herniorraphy): suture inguinal to pectineal ligament
      • Emergency: high approach: similar but done through the abdominal wall?/nguinal canal to assess plus/minus resect bowel
hernias inguinal anatomy
Hernias: Inguinal: Anatomy
  • Boundaries
    • Superior: fibres of transversalis, internal oblique and conjoint tendon medially
    • Inferior : inguinal ligament and lacunar ligament medially
    • Anterior: external oblique aponeurosis and internal oblique for the lateral third , superficial ring medially
    • Posterior : laterally transversalis fascia including deep inguinal ring, medially conjoint tendon
  • Contents of inguinal canal:
    • Males: spermatic cord and ilioinguinal nerve
    • Females: round ligament and ilioinguinal nerve
inguinal hernias direct and indirect
Inguinal hernias: direct and indirect

Deep inguinal ring: hole in transversalis fascia (midpoint of the inguinal ligament)

Superficial ring: hole in external aponeurosis, found above and medial to pubic tubercle

assessing for direct or indirect hernia
Assessing for direct or indirect hernia:
  • Reduce the hernia
  • Apply pressure with a finger over the deep inguinal ring
    • 1.5cm above midpoint of inguinal ligament (ASIS to pubic tubercle)
    • NB: midinguinal point (ASIS to pubic symphysis): femoral artery
  • Ask patient to cough/strain
  • If controlled, probably indirect. If not controlled, probably direct hernia
differential diagnoses lumps in the groin
Differential diagnoses lumps in the groin:
  • Inguinal lymph node/lymphadenopathy
  • Saphena varix: dilated vein at SFJ which disappears on lying flat
  • Femoral artery aneurysm
  • Encysted hyrocele of the cord
  • Lipoma of the cord
  • Incompletely descended testicle
  • Hernia: inguinal, inguinal scrotal, femoral
  • Psoas abscess
management of hernia
Management of hernia:
  • Investigation: USS, MRI scan
  • Conservative: treatment of causes, truss
  • Surgical:
  • open approach (GA/LA/regional)
  • Laparoscopic: define anatomy, inspect and excise hernial sac, close the defect (tension-free)
  • Herniorraphy: suture the defect (shouldice repair)
  • Hernioplasty: prosthetic mesh (lichtenstein mesh tension-free repair)
other hernias
Other hernias
  • Incisional hernias
  • Umbilical hernias: mayo repair
  • Richter’s: only part of the circumference of the bowel is within the sac. Can strangulate without obstruction
  • Epigastric: through linea alba
  • Spigelian: through arcuate line of douglas (where posterior rectus sheath becomes deficient)
  • Obturator: thin old ladies
examination of hernia
Examination of Hernia
  • Introduction, Inspection, Palpation, Percussion, Auscultation
  • Intro:
    • Introduce, explain, consent, exposure, chaperone, patient name and DOB.
    • Ask about pain, fever, bowel movements
    • Exposure: abdomen, groin, legs.
inspection
Inspection
  • Ask patient to stand up
  • Inspection:
    • Lumps/swellings
    • Scars (surgery  predisposing factor for hernias)
    • Skin changes over hernia (redness/shinyness): suggestive of acute inflammation/strangulation
    • Tenderness/ redness/ swelling
  • Unilateral or bilateral swellings.
  • Does the lump extend into the scrotum
  • Describe the shape and size when hernia is fully distended (ask patient to cough):
    • Pyriform shape of indirect hernia
    • Globular shape of direct hernia
  • Any other scrotal swellings/ Previous operation scars
  • Describe the position of the swelling:
    • Inguinal hernias  above and medial to pubic tubercle
    • Femoral hernias  below and lateral to pubic tubercle
palpation
Palpation
  • Palpate for:
    • Temperature
    • Tenderness
    • Size and shape
    • Consistency
  • For inguinal scrotal swellings:
    • confirm that it is not possible to get above the swelling
    • Palpate the testes and see if the hernia stops above the testis (acquired hernia) or incorporates the testis (congenital)
  • See if hernia is reducible
  • Tests for distinguishing indirect from direct inguinal, and for distinguishing inguinal from femoral
differentiating between inguinal and femoral hernia
Differentiating between inguinal and femoral hernia:
  • Find pubic tubercle
  • Reduce the hernia
  • Ask patient to cough
  • See if and where hernia re-emerges: above and medial  inguinal. Below and lateral  femoral.
to complete the examination
To complete the examination:
  • Auscultate over any hernia: bowel sounds if hernia is enterocele. Otherwise, auscultation is of no diagnostic value
  • Other tests/ examinations:Examine patient on lying down:
    • Direct hernia usually reduces by itself on lying down (unless strangulated)
    • Indirect hernia usually requires manual reducing
    • Hydrocele reduces over several hours of sleep
  • Examine the abdomen (and possible the respiratory system for evidence of chronic cough, e.g. chronic bronchitis or TB, etc.)
  • Examine the testicles. To differentiate a hernia from a testicular swelling. Test this by seeing if you can get your fingers above the testicular swelling. With a testicular swelling you will, with a hernia, you won’t.
  • Examine scrotum, cord, testes of both sides. Need to confirm contralateral side is normal.
  • Perform a DRE to see if prostate is enlarged  straining. Commonest cause for direct hernias in the elderly
  • Examine and take a history to assess the risk factors.
stomas
Stomas:
  • Colostomy: surgical procedure that involves connecting part of the bowel onto the anterior abdominal cavity. Patient has an opening on the abdomen: stoma.
  • Permanent or temporary
  • Urostomies
  • http://www.allaboutbowelsurgery.com/shared/stoma_care/stoma_surgery/
examination of stoma
Examination of stoma
  • Site
  • Calibre – thin/wide
  • Number of lumens
  • Functioning/healthy?
  • Colour/surface
  • Bag: contents, surrounding skin
  • Contact dermatitis/blisters
  • Any parastomal hernia
  • Inspect perineum
complications of stomas
Complications of stomas:
  • Anatomical and metabolic
  • Early and late
  • Metabolic:
    • Renal calculi
    • Electrolyte imbalance
  • Psychological/psychosexual
  • Anatomical:
    • Parastomal hernia
    • Prolapse of ileostomies
    • Parastomal dermatitis