1. DR TOM HARDY SHO GENERAL SURGERY ???

2. 85 yo male Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis 4/7 increasing RIF Over last 24 hours has developed Nausea and 1 x vomiting Starting to feel unwell PMH – HTN, AF, Angina

3. Differentials?? Appendicitis Bowel Obstruction due to  Hernia  Ca  Adhesions Perforation Renal Colic

4. Plan? Airway – is it patent? Breathing -  RR 24  O2 saturations 99% on 5litres O2 Circulation –  BP 95/54  P 102 Disability –  AVPU Everything else –  T 37.1  U/O ??  BM – 6.9

5. On examination Cardio –  I + II + O Respiratory -  Good air entry Abdo –  V tender RIF, small lump in R groin, red, tender, no cough impulse, non-reducible  Rest of abdomen soft, bowel sounds not present  PR – empty rectum

6. Initial Management Groups please Initial investigations/beside Scans/secondary investigations Other considerations

7. Initial Management 1 Bedside –  Vital signs  Bloods  FBC, LFT, U&E, CRP, Amy, G&S/X-match  ABG  BM  Catheterise/NG Tube  IVI  NBM

8. ABG pH7.25 pO28.5 pCO23.8 Glu6.4 Hb11.2 Lac2.5 BE-6.5 HCO3-14.5

9. Initial Management 1 Scans  AXR?  CXR?  CT abdo/pelvis

12. Extras Inform theatres Inform anaesthetist Booking and consenting ECG

13. Bloods Hb 10.2TP 75Ur 12.7 MCV 94.2Alb 36Cre 147 WCC 17.8Bi 7Na 138 Neut 14.1ALT 20K 3.6 CRP 215Alk Phos 98

14. Hernias! Definition -  Protrusion of a tissue through the wall of the cavity which normally contains it

15. Reducible –  you can put it back in Irreducible –  you can’t Incarcerated –  you can’t put it back in Strangulated –  blood supply cut off

16. 1) Risk factors for developing hernia  Smoking, chronic cough, female, heavy lifting, previous surgery 2) Hernia develops, initially reducible and of no concern 3) If increases in size, may become irreducible 4) Part of bowel/tissue gets trapped leading to irritation, swelling, oedema 5) Increasing size leads to further issues which may compromise blood supply 6) Hernia becomes strangulated, can lead to necrosis as no blood supply and peritonism

17. Types of Hernia Inguinal  Direct vs Indirect Femoral Incisional – ummm...through an incision Richter’s Hernia – one side of bowel wall, may not be an obstruction Umbilical/paraumbilical Littre’s hernia

18. Up-to-date webite, viewed 3/1/12, http://www.uptodate.com/contents/image?imageKey=SURG/27585&topicKey=SURG/3686&source=outline_link &search=femoral hernia&utdPopup=true

19. Up-to-date webiste, http://www.uptodate.com/contents/image?imageKey=SURG/27584&topicKey=SURG/3686&source=outline_link&search=femoral hernia&utdPopup=true, viewed 3/1/12, hernia anatomy

20. Surface Anatomy A: Inferior epigastric artery B: Femoral nerve C: Femoral artery D: Femoral vein E is the most important … THE PUBIC TUBERCLE

21. Examination of a Hernia Examine standing and sitting How do you assess a lump?? SCRoTum  3 x S – Size, Shape, Surface  3 x C – Cough impulse, Colour, Consistency  Reducibility  3 x T – Tenderness, Transillumination, Temperature  External genetalia!!!

23. IPE Questions 1 This gentleman has a swelling in his groin, please take a history... Risk factors Features of a hernia Differential diagnosis  Don’t forget lymphadenopathy

24. IPE Questions 2 Examination... Hernia or Abdomen?? Probably Hernia first, if time/to finish abdomen

25. IPE Questions What is a hernia? How to differentiate between direct and indirect How to differentiate between inguinal and femoral How would you identify the deep inguinal ring? Treatment options Complications of hernia surgery

26. Communication in Surgery Happy PR not PV! Sad Get out of my theatre Hmmmm Good job Angry Your only fit for psych