1. Hernias & bowel obstruction
Richard Griffiths FY1 Surgery

2. Introduction Aims/objectives Hernias Bowel obstruction
Clinical case example
Quiz

3. 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

4. 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,

5. 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)

6. Terminology Reducible Irreducible Incarcerated Strangulated Obstructed
Richter’s

7. Risk factors Chronic cough Chronic constipation
Straining on passing urine
Heavy lifting
Obesity
Age
Previous surgery
Males = Inguinal herniae
Females = Femoral herniae

8. 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

9. 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

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

11. 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

12. Bowel Obstruction
Small bowel obstruction
Large bowel obstruction

13. 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%

14. Causes Large bowel obstruction Carcinoma of colon Diverticular disease
Volvulus

15. 4 Cardinal features Pain Abdominal distension Absolute constipation
Vomiting

16. 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

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

18. Conclusions Hernias Bowel obstruction Anatomy
Difference between incarcerated and strangulated
Examination
Bowel obstruction
4 cardinal features
Causes
Management

19. 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?

20. 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

21. Thank you Questions