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Case #2: Mr. Lewis Objective : 5 Taylor Vaughan. Doc, it’s really hard talking to a complete...
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Transcript of Case #2: Mr. Lewis Objective : 5 Taylor Vaughan. Doc, it’s really hard talking to a complete...
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Case #2: Mr. Lewis
Objective : 5
Taylor Vaughan
![Page 2: Case #2: Mr. Lewis Objective : 5 Taylor Vaughan. Doc, it’s really hard talking to a complete stranger about this, but I think I might need Viagra If it’s.](https://reader031.fdocuments.net/reader031/viewer/2022032607/56649ec65503460f94bd1f4f/html5/thumbnails/2.jpg)
Doc, it’s really hard talking to a
complete strangerabout this, but I
think I might need Viagra
If it’s hardtalking to strangers,
sounds like wemay not need the
Viagra… Just talk tomore strangers
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ObjectivesCategorize different types of
hernias
Describe management of reducible vs incarcerated hernias
Summarize causes and management of postoperative ileus
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DefinitionsHernia – protrusion of organ/tissue
through wall defect
Incarcerated – unable to be reduced
Strangulated – blood supply to enclosed bowel has been compromised
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Inguinal Hernias75% of all hernias
1/3 direct
2/3 indirect
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Direct Inguinal HerniaBowel travels through abdominal
fascia → external inguinal ring
Medial to inf. epigastric vessels
More common in older individuals
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Indirect Inguinal HerniaBowel travels through internal
ring → external ring
Lateral to inf. epigastric vessels
Via patent processus vaginalis
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Management AlgorithmReducible
Asymptomatic
Observation
Symptomatic
Elective Repair
Emergent repair
Incarcerated
Exquisite tendernessPeritoneal signs
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Repair700,000/yr in the US
Herniotomy – removal of hernia sac
-rrhaphy – hernia sac removal with defect pathway obliteration
-plasty – repair with autogenous or autologous material
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Other Hernia Types
Ventral Hernias
Incisional – midline in people predisposed to poor wound healing
Umbilical – often congenital◦Observe unless >5yo or >2cm
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Other Hernia Types
Femoral Hernias
Bulge below inguinal ligament
Female>Male 2:1
Commonly strangulate → Repair
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Post Operative Ileus (POI)
“Loss of intestinal peristalsis in the absence of mechanical obstruction”
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PathogenesisInhibitory neural reflexes
◦Increased sympathetic toneInflammation
◦Injury→macrophages→COX2/PG→ decreased intestinal contraction
Neurohumoral peptides◦NO, VIP, Sub P – inhibitory GI NTs
Opioids◦↑ resting tone, ↓ gastric motility, ↓
colonic propulsion
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EvaluationIleus is often normal/physiologic
Abdominal XR ◦Rule out obstruction or foreign body
Vitals/Labs◦Rule out infection or correctable
electrolyte disturbance (K / Mg)
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ManagementGentle diet advancement
Midthoracic epidural◦Blocks nociceptive afferents
NG Tube??
Chewing gum??
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ManagementPeripherally acting opioid
antagonists◦Don’t effectively cross BBB◦Block mu-opioid efffects peripherally◦Maintains central effects… analgesia!
Methylnaltrexone (Relistor)
Almivopan (Entereg)
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References Delaney, CP, Wolff, BG, Viscusi, ER, et al. Almivopan, for
postoperative ileus following bowel resection: a pooled analysis of Phase III studies. Ann Surg 2007; 245:355.
Holzer, P. Treatment of opioid-induced gut dysfunction. Expert opin investing drugs. 2007; 16:181.
Karthikesalingam, A, Markar, SR, Holt, PJ, et al. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4.
UpToDate.com (abdominal wall hernias, groin hernias, postoperative ileus)
Viscusi, ER, Gan, TJ, Leslie, JB, et al. Peripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability. Anesth analg 2009; 108:1811.
Wikipedia (hernia, ileus)