Guided Studies W1/2 Flashcards
Why is the pain of sliding hernia worse after eating food ?
Normally all of the acid secreting parts of the stomach are below the oesophageal opening of the diaphragm thus preventing reflux. However, in this condition a section of the cardia of the stomach is above these constrictions allowing acid to be secreted into the lower oesophagus. Food and fluid in the stomach stimulates the release of gastric acid that will then irritate the lower oesophagus and cause increased pain and discomfort.
If there were intestinal structures in the left hemithorax of a neonate what do you think you would find on examination of their respiratory, cardiovascular and gastrointestinal systems?
Briefly, there will be asymmetry in the thoracic examination - loss of resonance and dull to percussion on the side with the intestine instead of the lung (L in this case); the apex beat of the heart may well be shifted to the right because of the pressure created by intestine in the L thorax.
How could you differentiate between the pain from a bleeding duodenal ulcer and someone having an MI ?
Both will cause a sympathetic response to compensate for the inadequate tissue perfusion, resulting in tachycardia and the patient will be pale and sweating. An MI tends to be considerably more painful (central chest pain radiating down the L arm). A DU is often not painful, although there may be a history of epigastric pain. There will also be altered blood in the stool (malaena).
Why is peripheral or diaphragmatic pain referred to the shoulder tip ?
Both the diaphragm and the pericardium are supplied by the phrenic nerve – C3,4,5. The brain cannot localise visceral pain and thinks it is coming from the skin.The C4 dermatome is over the shoulder tip.
Give an example of why a scar on a patient may help you in a differential diagnosis.
Confirming that a scar you see on the abdomen is indeed the result of an appendicectomy a long time ago can, for example, help to rule appendicitis out of your differential diagnosis on this occasion.
Identify the main kinds of surgical incisions in the abdomen.
Midline Incision Paramedian Incision Transverse Incision Subcostal Incision The Gridiron (Muscle Split) and/or Lanz Approach to the Appendix Pfannenstiel Incisions Laparoscopic Incisions Thoraco-abdominal Incisions Abdominoplasty Mercedes Incision Nephrectomy Incision
MIDLINE INCISION
- How is it performed
- When is it used ?
- Pros and Cons
MIDLINE INCISION
1) How:
- made vertically skirting around the left edge of the umbilicus
2) Uses:
- Emergency laparotomy
- Almost all abdominal operations where full access is required.
3) Pros:
- Almost bloodless (because made of fibrous tissue only)
- Very quick access to the abdominal cavity
- Minimal restriction of view
- Good for those who may require further laparotomies such as Crohn’s patients.
- Can be closed swiftly without the need for closure in layers.
4) Cons:
- Large unsightly scar
- Painful postop
- Higher risk of wound breakdown
PARAMEDIAN INCISION
- How is it performed
- When is it used ?
- Pros and Cons
PARAMEDIAN INCISION
1) How:
placed 2.5cm to 4cm lateral, and parallel, to the midline
2) Uses:
Most operations that require good access to a specific half of the abdomen
3) Pros:
- Provides better access to lateral structures than the midline approach (e.g. the kidneys).
- The separate incision in the posterior rectus sheath allows buttressing of the wound and that reduces the chance of herniation through the incision site.
4) Cons:
- Requires more time.
- Interrupts vessels and nerves passing from lateral to medial thus resulting in atrophy of muscle medial to the incision.
TRANSVERSE INCISION
- How is it performed
- When is it used ?
- Pros and Cons
TRANSVERSE INCISION
1) How:
performed superior to the umbilicus passing transversely through either one or both of the rectus muscles
2) Uses:
- Ascending and/or descending colon
- Duodenum
- Pancreas
3) Pros:
- Less painful.
- Better cosmetic result
- No denervation of the rectus abdominis
- Reduced chance of herniation when compared to midline incisions.
4) Cons:
- Less exposure
- Slower access
- Can obstruct the most appropriate site for stoma formation
SUBCOSTAL INCISION
- How is it performed
- When is it used ?
- Pros and Cons
SUBCOSTAL INCISION (=Kocher’s incision)
1) How:
The skin incision commences at the midline 2.5cm below the xiphisternum and extends parallel to, and 2.5cm below the costal margin
2) Uses:
- Biliary surgery on the right
- Access to the spleen on the left
3) Pros:
- Good access to inferior surface of liver
- Less painful than midline incision
4) Cons:
- Less exposure
- Must be closed in layers
Define rooftop, or Chevron incision.
Bilateral subcostal incisions can be combined to form a“rooftop” or“chevron” incision.
GRIDIRON (MUSCLE SPLIT) AND/OR LANZ APPROACH TO THE APPENDIX
- How is it performed
- When is it used ?
- Pros and Cons
GRIDIRON (MUSCLE SPLIT) AND/OR LANZ APPROACH TO THE APPENDIX
1) How:
The oblique skin incision for the Gridiron approach is centered at McBurney’s point (two-thirds of the way laterally along the line from the umbilicus to the anterior superior iliac spine). More commonly the horizontal Lanz approach is now used as this incision lies parallel to the skin creases and thus provides better cosmetic result, furthermore it lies along the bikini line allowing the scar to be hidden easily.
2) Uses:
- Appendicectomy on the right
- Occasionally access the descending and/or sigmoid colon on the left
3) Pros:
- Layered closure of muscles provides excellent strength to the wound
- Good acces to appendix and caecum
4) Cons:
- Limited and specific access
- Potential damage to the ilioinguinal and iliohypogastric nerves
PFANNENSTIEL INCISION
- How is it performed
- When is it used ?
- Pros and Cons
PFANNENSTIEL INCISION
1) How:
Slightly convex transverse incision is made in the suprapubic skin crease roughly 5cm above the pubic symphysis. It is~12cm long and lies below the arcuate line
2) Uses:
- Access to pelvic viscera
- Most commonly in C-sections and hysterectomies
3) Pros:
- Good access to pelvic cavity
- Minimal scarring and hidden easily
- Unlikely to interrupt nervous supply
4) Cons:
- Very poor access to abdominal viscera
- Danger of damage to the bladder which sits just behind the abdominal wall, with no peritoneum, or posterior rectus sheath to protect it.
LAPAROSCOPIC INCISIONS
-How is it performed
LAPAROSCOPIC INCISIONS
1) How:
Variable in location, but there is almost always a peri-umbilical incision. They tend to range in length from 0.5 to 2 cm depending on the scopes being used. Often they will be found in specific quadrants overlying or pointing towards the intended target of the operation.
THORACO-ABDOMINAL INCISIONS
-How is it performed
THORACO-ABDOMINAL INCISIONS
1) How:
An upper paramedian or upper oblique abdominal incision can be extended through the 8th or 9th intercostal space, the diaphragm incised and an extensive exposure achieved of both upper abdomen and thorax.
