MET3 Revision: Colorectal Surgery II

Question 2

What type of stoma is this? [1]

Answer 2

Colostomy: flushed appearance

Question 3

What type of stoma is this? [1]

Answer 3

Ileostomy: spouted appearance

Question 4

What type of stoma is this? [1]

Answer 4

Loop stoma

Question 5

What type of stoma is this? [1]
Label which of A & B is the proximal and distal part [2]

Answer 5

Double barrel stoma
A: Proximal
B: Distal

Question 6

State the following for an ileostomy [6]

Where it is formed
Appearance
Location
Contents
Quantity
Odour

Answer 6

Ileostomy
Small intestine
Spout appearance
RIF site
Liquid / semi liquid formed
Large volume
Mild odour

Question 7

State the following for an colostomy [6]

Where it is formed
Appearance
Location
Contents
Quantity
Odour

Answer 7

Colostomy
Large intestine
Flush appearance
LIF
Formed / more solid contents
Small volume
Offensive odour

Question 8

Which muscle do you use when stoma site marking? [1]

Answer 8

Rectus muscle; at least 2/3” away from scars / bony prominance

Question 9

State what the three different types of colostomy are [3]

Answer 9

Loop colostomy
End colostomy
Double barrel colostomy

Question 10

Describe what a loop colostomy is [3]

Answer 10

Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery

Allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function, by draining into a stoma bag

They are usually reversed around 6-8 weeks later

Question 11

Describe how you differentiate between the proximal and distal end of a loop colostomy [1]

Answer 11

The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin.

This distal end is flatter

Question 12

Describe what a double barrel stoma is [1]

Answer 12

Divides the colon into 2 ends that form separate stomas:

Stool exits from one of the stomas & mucus made by the colon exits from the other

Question 13

Describe what is meant by pancaking of a stoma [1]

Answer 13

Internal layers of the stoma bag stick together causing a vacuum which prevents the contents from dropping to the bottom. The stool remains at the top of the stoma bag which can potentially block the filter. The bag can also be forced off the body.

Question 14

Physiological complications of high output ileostomy? [2]

Answer 14

○ > 1.5 - 2 litres

○ Fluid & Electrolyte imbalance
■ Dehydration, AKI
■ ↓Na, ↑K, ↓Mg (Addison’s picture)
■ Vitamin B12, Folate Def.}}

Question 15

Problems associated with low volume ileostomy? [2]

Answer 15

● Low Volume (↓frequency & or quantity)
○ Stenosis
○ Impending obstruction}

Question 16

Treatment for high output stomas? [5]

Answer 16

● Hydrate (fluid and high salt replacement)
○ Glucose-electrolyte solution aids sodium absorption
○ Restrict low sodium (Hypotonic) fluid (500-1000ml/day)

● Anti-diarrhoeal medication, eg loperamide

● Anti-secretory drugs
○ PPI (omeprazole) ○ Octreotride (rarely)

● Correct Hypomagnesaemia

● Opiates (codeine phosphate)

Question 17

Where exactly are loop colostomies located? 1[]

Answer 17

usually in the right transverse colon, proximal to the middle colic artery

Question 18

Ileostomies can be low or highoutput:

Low output tends to output [] ml/day for a low output ileostomy, and [] ml/day for a high output ileostomy

Answer 18

tends to output 500 ml/day for a low output ileostomy, and 1000 ml/day for a high output ileostomy

Question 19

How do you know if stoma retraction has occurred? [2]

Answer 19

Stoma retraction presents with persistent leakage and peristomal irritant dermatitis.

Question 20

When is stoma ischaemia most likely to occur? [1]

Answer 20

24hrs post op

Question 21

Define what is meant by a parasternal hernia [1]

Answer 21

Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma

Question 22

How do you determine if a stoma has a parasternal hernia?

Answer 22

Positive cough impulse and and lump at the hernia site

Question 23

What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3]
How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]

Answer 23

Classification of risk and advised management in patients with colorectal adenomas are as follows:

Low risk
- one or two adenomas smaller than 10 mm
- should be considered for colonoscopy at five years

Intermediate risk
- three/four adenomas smaller than 10 mm
or
- one/two adenomas if one is 10 mm or larger
- should be offered a colonoscopy at three years

High risk
- five or more adenomas smaller than 10 mm
or
- three or more adenomas if one is 10 mm or larger
- offered a colonoscopy at one year.

Question 24

National Institute for Health and Care Excellence (NICE) guidelines recommend a surveillance colonoscopy for patients with UC how often for low, medium and high risk patients? [3]

Answer 24

aLow: every 5 years
Medium: every 3 years
High: annually

Question 25

Define the following terms:
- Strangulated hernia [1]
- Sliding hernia [1]

Answer 25

Strangulated hernia:
- Intestine present in a hernia may become strangulated as the vascular supply to this loop of bowel becomes compromised.
- Blood may still enter, yet if venous drainage is reduced then swelling can occur, causing ischemia and the hernia to become gangrenous
- Risk of sepsis

Sliding hernia:
- Type of hiatus hernia
- stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.

Question 26

What are the borders of Hesselbach’s triangle? [3]

Answer 26

R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border

Question 27

Define what is meant by a Pantaloon hernia [1]

Answer 27

A pantaloon hernia, also known as a saddlebag hernia, is defined as any combination of two adjacent hernia sacs of the femoral or inguinal region (direct or indirect inguinal hernias (alternative plural: herniae)) on the same side

Thus, examples include: femoral with direct hernias, femoral with indirect hernias, indirect with direct hernias.

Question 28

Difference in anatomy of femoral and inguinal hernia? [2]

Answer 28

Inguinal:
superomedial to the pubic tubercle

Femoral:
inferolateral to the pubic tubercle

Question 29

Describe the management of uncomplicated hernia [4]

Answer 29

Surgery:
Open mesh repair:
- Direct hernia: plication
- Indirect: sac excision
- Both: add mesh which produces fibrosis

Laporoscopic mesh repair:
- As above, but reduced injury of nerves & post-op chronic pain
- Reinforces wall to elimiante reoccurence

Laporoscopic pre-peritoneal mesh repair

Suture repair (high chance of reoccurance

Question 30

Which nerves are present in area that open and laparoscopic mesh repair occur in? [3]

Answer 30

The iliohypogastric nerve, ilioinguinal nerve and genital branch of the genitofemoral nerve

Question 31

Laparoscopic mesh repair is particularly good for repairing what type of hernias? [1]

Answer 31

Bilateral hernias

Question 32

What is a spigelian hernia? [2]

Answer 32

A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris.

This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain.

Question 33

Inguinal hernias are more commonly found on which side? [1]

Why? [2]

Answer 33

Right sided

Due to descend of the testis or previous appendectomy

Question 34

Which medical conditions might predispose a patient to an inguinal hernia? [2]

Answer 34

collagen defect medical conditions such as Ehlers-Danlos syndrome, Marfan’s syndrome.

Question 35

Describe the method used to test for indirect inguinal hernia c.f. direct [2]

Answer 35

To test for indirect inguinal hernias:
- finger pressure should be applied over the deep inguinal ring. The finger pressure will control the hernia when the patient coughs.

To test for direct hernias:
- instruct the patient to cough, and a bulge should appear medial to point of finger pressure.
- If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia.

Question 36

What is the treatment plan for mild/asymptomatic hernias? [2]

Answer 36

For mild/asymptomatic hernias, the treatment management plan would be conservative watchful waiting.

Ask for a 6-month follow up

Question 37

What is the surgical procedure for recurrent inguinal hernia:
- If previous anterior hernia repair? [1]
- If previous posterior hernia repair? [1]

Answer 37

If previous anterior hernia repair:
- open preperitoneal mesh or endoscopic approach

If previous posterior hernia repair:
- Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.

Question 38

If a hernia cannot be reduced it is referred to as an [] hernia - these are typically [painful / painless]

Answer 38

If a hernia cannot be reduced it is referred to as an incarcerated hernia - these are typically painless

Question 39

What is the most sensitive investigation for hiatus hernia? [1]

Answer 39

Barium swallow

Question 40

Describe the medical and surgical management for hiatus hernias [2]

Answer 40

medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias

Question 41

What is the clinical consensus about treating inguinal hernias? [1]

Answer 41

the clinical consensus is currently to treat medically fit patients even if they are asymptomatic with surgery

Question 42

Which type of repair is best suited for unilateral [1] and bilateral or recurrent inguinal hernias [1]?

Answer 42

unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically

Question 43

What is the most likely diagnosis?

Answer 43

Hiatus hernia