Hernias & bowel obstruction Richard Griffiths FY1 Surgery

Introduction Aims/objectives Hernias Bowel obstruction Clinical case example Quiz

Aims + objectives Aim Objectives To give an overview of hernias and bowel obstruction relative to finals examinations Objectives Key features Causes Investigations Management Why bother about hernias – Very common presentation in A+E on surgical on call, high yield for finals exams in clinicals and writtens

Hernias Definition of a hernia Inguinal Femoral Incisional Others 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 We will focus on abdominal hernias though there are many different types of hernia Indirect inguinal make up 80% of inguinal herniae Others – Tonsillar herniation, hiatus, Richters,

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 Significance of lacunar ligament – increases likelihood of strangulation – therefore all femoral herniae need repair Mid inguinal point – femoral artery (symphysis to ASIS) Mid point of the inguinal ligament – deep ring (tubercle to ASIS)

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 Pain Complications Painful/painless On and off for long time/Sudden onset Presents on coughing/straining Reduces on lying flat Pain Dragging sensation in scrotum Complications Dragging particularly with indirect Examination of herniae briefly: lying/standing inspection – lump, erythema/skin changes (bad sign), previous scars, pulsations, cough impulse seen Palpation – Can it be gotten above? Is it reducible, tender, hot, pulsations, cough impulse Percussion – no real role Auscultation – bowel sounds

Differentials Different type of hernia Lymph node Hydrocele Abscess Femoral aneurysm Saphena varix How do you think of differentials? Split up into anatomy, systems into likely diagnosis by age? Whatever system you use stick with it. Surgical sieve can be useful in exams especially in the thinking time in between taking the history and presenting the case

Investigations Bedside – Observations Bloods – FBC, U+Es, LFTs, amylase, G+S Imaging – USS

Management Conservative ??Medical – analgesia, anti-emetics 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 In the wall Impacted faeces Foreign body Large polyp In the wall Tumours Infarction Stricture – Crohn’s Outside the wall Adhesions Volvulus Strangulated hernia Extrinsic compression Adhesions 60%

Causes Large bowel obstruction Carcinoma of colon Diverticular disease Volvulus

4 Cardinal features Pain Abdominal distension Absolute constipation Vomiting

Investigations Bedside – Observations Bloods: Imaging: FBC, U+Es, LFTs, amylase, G+S Blood gas Imaging: AxR, erect CxR CT with contrast Valvulae conniventes >5cm dilatation

Management Conservative – “drip + suck” Surgical NBM IVI fluids NG tube Analgesia Anti-emetics Surgical Depends on cause Adhesiolysis Hernia repair Bowel resection

Conclusions Hernias Bowel obstruction 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? Due to adhesions in the sack Tender, tense, no bowel sounds, irreducible – tachycardia, N+V

Thank you Questions