AS PACES Abdo Surgery Flashcards
(47 cards)
Spider Naevi
Central arteriole filling from centre to out (telangectasia fill from edge)
Distribution of SVC
>4 abnormal
DDx CLD, OCP, prego
DDx groin lump
Skin - cyst, psoas abscess Fat - lipoma Connective tissue - fibroma Nerves - neuroma LN Saphena Varix Femoral aneurysm Inguinal hernia Femoral hernia Undescended testes
Inguinal hernia
Above and medial to pubic tubercule Cough impulse Reducible Bowel sounds Hx --> predisposing factors Indirect vs Direct? Bowel sounds? Pain?
Definition hernia
Protrusion of a viscous or part of it into an abdominal position through a defect in its containing cavity
Anatomy of inguinal canal
MALT
M - Superior: external oblique and transverse abdominis
A - Anterior: aponeurosis of internal and external oblique
L - Inferior: inguinal ligament
T - Posterior: transversalis fascia and conjoit tendon
Anatomy of femoral canal
Med: lacunar ligament
Lat: femoral vein
Ant: inguinal ligament
post: pectineal ligament (of Cooper)
Contents of inguinal canal
Male: Spermatic cord (3 fascia, 3 arteries, 3 veins, 2 nerves) + ilioinguinal N.
Female: Round ligament, ilioinguinal nerve N, ten branch of genitofemoral N
Hesselbach’s triangle
Rectus abdominis muscle
Inguinal ligament
Inferior epigastric artery
Indirect vs direct inguinal hernias
Indirect (80%) –> patent processes vaginalis, through deep ring, prone to strangulation
Direct (20%) –> elderly, weak posterior wall of canal, through Hesselbach’s, rarely into scrotum or strangulate
Clinically even surgeons poor at distinguishing
Complications of hernia repair
Retention, haematoma, infection, intra-abdominal injury
Recurrance, ischaemic orchitits (2* to thrombosis of pampiniform plexus), chronic groin pain
Mx femoral hernia
50% risk of strangulation w/i one month, urgent surgery
Elective –> low approach, incision over hernia + herniotomy and heriorrhaphy
Emergency –> high approach to allow inspection/resection of non viable bowel
RF Incisional hernia
Pre op –> Age, co-morbidities, steroids, chemo, radio, obese/malnurished, malignancy
OP –> surgical skill, too small suture bites, inappropriate suture, incision type, drains
Post op –> IAP, cough, straining, post op ileus
Paraumbilical hernia
Acquired defect in line alba above/below umbilicus
Obese, middle aged pts, neck is narrow (prone to strangulation), typically momentum ± bowel
RF: obese, prego, ascites, fibroids, distension
Mx: Mayo repair (mobilise sac and reduce contents, double-breast line alba ± sub lay mesh)
Umbilical hernia
Congenital defect (±3% live births)
RF: Black, Downs, Cretin
Usually self resolves <3yrs, if >3yrs surgical
Epigastric hernia
Midline lump above umbilicus when pt coughs, typically small pea shaped
RF: prego, obese, age 20-50
Defect in line alba between xiphisternum and umbilicus, usually extra peritoneal fat / momentum
Likely asymptomatic, can cause nausea, early satiety, pain + after meals, bloating
Conservative –> RF: constipation, cough, weight
Surgical –> suture / mesh
Examining scrotal lumps
STANDING
- Can you get above it? (if not, hernia)
- Is it tender? (if not, torsion, hydatid of Morgani, epididymo-orchitis, strangulated hernia)
- Is testes palpable? (No, tumour, orchitits, hydrocele. Yes, varicocele, spermatocele, cyst)
- Does it transilluminate? (Yes, hydrocele, spermatocele)
Hydrocele
Accumulation of fluid w/i tunica vaginalis; remnant of processes vaginalis which forms one of the adult coverings of the testes
Mx: Excluse Ca (USS); watch and wait, ?aspiration for symptom relief
Surgical –> plication of tunica vaginalis or eversion of the sac
Hydrocele classification
Classification: Vaginal (in tunica vaginalis, doest extend into cord);
Congenital (proximal part of process has not obliterated;
Infantile
Hydrocele of Cord (around ductus deferens, difficult to distinguish from inguinal hernia)
Epididymal Cyst
O/E normal looking scrot, can get above, separate from testes, firm, transilluminates
Retention cyst of tubule of rate testes of epidermis, often multiple, may contain sperm, generally asymptomatic
Conservative –> if it ain’t causing no trouble leave it alone
Surgical –> V large / painful can be remover. Risk sub/infertility. Exision of entire epidermidis may be sometimes indicated
Varicocele - Bag of worms
Dilated veins of pampiniform plexus, 98% L, 50% B/L
2* varicoceles in older gentlemen = retroperitoneal disease affecting L testicular vein (e.g. RCC, doesn’t disappear when pt supine)
Conservative: scrotal support
Non-surgical: transferral radiological embolisation of testicular vein
Surgical: high approach with transverse incision above and medial to asis, vein exposed and ligated. Or inguinal approach.
Why varicoceles L>R
L testicular vein more vertical where it joins L renal vein (R testicular joins IVC), is longer than R, and often lack terminal valve preventing backflow. LRV can be compressed by colon.
Classification of testicular tumours
95% germ cell tumours
Seminoma (40%): 30-40yrs, normal markers, spread para aortic LN, platinum based Cx + surg
Teratoma: 20-30yrs, AFP + bHCG + 1-2 cycles of chemo + surg
Yolk sac: children
Leydig / Sertoli cell (rare, may secrete oestrogens = gynaecomastia)
Lymphoma: NHL is commonest testicula mass >60 yrs
All tumours surg: groin incision + early clamping of spermatic cord to stop seeding
Stoma: Definition
Artificial union between conduits or between conduit and the outside
Stoma: Indications
Exteriorisation: Perforated/Contaminated: Hartmann’s; Permanent: AP resection
Diversion: Protection of distal anastamosis, acute crohn’s, urinary
Decompression: Bypass of distal obstruction
Feeding: Gastrostomy / Jejunostomy
Lavage: Caecostomy
