DR TOM HARDYSHO GENERAL SURGERY

???

85 yo male

Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis

4/7 increasing RIFOver last 24 hours has developed Nausea and

1 x vomitingStarting to feel unwellPMH – HTN, AF, Angina

Differentials??

AppendicitisBowel Obstruction due to

Hernia Ca Adhesions

PerforationRenal Colic

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

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

Initial Management

Groups please

Initial investigations/beside

Scans/secondary investigations

Other considerations

Initial Management 1

Bedside – Vital signs Bloods

FBC, LFT, U&E, CRP, Amy, G&S/X-match ABG BM Catheterise/NG Tube IVI NBM

ABG

pH 7.25

pO2 8.5

pCO2 3.8

Glu 6.4

Hb 11.2

Lac 2.5

BE -6.5

HCO3- 14.5

Initial Management 1

Scans AXR? CXR?

CT abdo/pelvis

Extras

Inform theatresInform anaesthetistBooking and consentingECG

Bloods

Hb 10.2 TP 75 Ur 12.7

MCV 94.2 Alb 36 Cre 147

WCC 17.8 Bi 7 Na 138

Neut 14.1 ALT 20 K 3.6

CRP 215 Alk Phos 98

Hernias!

Definition - Protrusion of a tissue through the wall of the cavity

which normally contains it

Reducible – you can put it back in

Irreducible – you can’t

Incarcerated – you can’t put it back in

Strangulated – blood supply cut off

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

Types of Hernia

Inguinal Direct vs Indirect

FemoralIncisional – ummm...through an incisionRichter’s Hernia – one side of bowel wall,

may not be an obstructionUmbilical/paraumbilicalLittre’s hernia

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

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

Surface Anatomy

A: Inferior epigastric artery

B: Femoral nerveC: Femoral arteryD: Femoral veinE is the most

important …THE PUBIC

TUBERCLE

Examination of a Hernia

Examine standing and sittingHow 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!!!

IPE Questions 1

This gentleman has a swelling in his groin, please take a history...

Risk factorsFeatures of a herniaDifferential diagnosis

Don’t forget lymphadenopathy

IPE Questions 2

Examination...

Hernia or Abdomen??

Probably Hernia first, if time/to finish abdomen

IPE Questions

What is a hernia?How to differentiate between direct and

indirectHow to differentiate between inguinal and

femoralHow would you identify the deep inguinal

ring?

Treatment optionsComplications of hernia surgery

Communication in Surgery

Happy

PR not PV!

Sad

Get out of my theatre

Hmmmm

Good job

Angry

Your only fit for psych