Hernias & bowel obstructionRichard Griffiths FY1 Surgery

Introduction Aims/objectives Hernias Bowel obstruction Clinical case example Quiz

Aims + objectives Aim

To give an overview of hernias and bowel obstruction relative to finals examinations

Objectives Key features Causes Investigations Management

Hernias Definition of a hernia

A hernia is the protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position

Inguinal Direct Indirect

Femoral Incisional Others

Anatomy Inguinal hernia – Above and medical to pubic tubercle

Anterior – External oblique + internal oblique for lateral 1/3 Posterior – Transversalis fascia + conjoint tendon Roof – Arching fibres of internal oblique + transversus Floor – Inguinal ligament

Femoral hernias – Below and lateral to pubic tubercle Anterior – Inguinal ligament Posterior – Pectineal ligament Laterally – Femoral vein Medially – Lacunar ligament

Terminology Reducible

Irreducible

Incarcerated

Strangulated

Obstructed

Richter’s

Risk factors Chronic cough Chronic constipation Straining on passing urine Heavy lifting Obesity Age Previous surgery Males = Inguinal herniae Females = Femoral herniae

Symptoms and signs Lump

Painful/painless On and off for long time/Sudden onset Presents on coughing/straining Reduces on lying flat

Pain Dragging sensation in scrotum

Complications

Differentials Different type of hernia Lymph node Hydrocele Abscess Femoral aneurysm Saphena varix

Investigations Bedside – Observations

Bloods – FBC, U+Es, LFTs, amylase, G+S

Imaging – USS

Management Conservative

Manually reduced by patient Stop smoking, avoid heavy lifting/straining Truss Large defect Patient not fit for surgery

??Medical – analgesia, anti-emetics

Surgical – Hernia repair All femoral herniae Herniorrhaphy – laparoscopic or open Suture repair Mesh repair Obstructed/strangulated bowel dealt with accordingly

Bowel Obstruction Small bowel obstruction

Large bowel obstruction

Causes Small bowel obstruction

In the lumen Impacted faeces Foreign body Large polyp

In the wall Tumours Infarction Stricture – Crohn’s

Outside the wall Adhesions Volvulus Strangulated hernia Extrinsic compression

Causes Large bowel obstruction

Carcinoma of colon Diverticular disease Volvulus

4 Cardinal features Pain Abdominal distension Absolute constipation Vomiting

Investigations Bedside – Observations

Bloods: FBC, U+Es, LFTs, amylase, G+S Blood gas

Imaging: AxR, erect CxR CT with contrast

Management Conservative – “drip + suck”

NBM IVI fluids NG tube Analgesia Anti-emetics

Surgical Depends on cause Adhesiolysis Hernia repair Bowel resection

Conclusions Hernias

Anatomy Difference between incarcerated and

strangulated Examination

Bowel obstruction 4 cardinal features Causes Management

Clinical case 1 80 year old male Painful lump in groin – irreducible Present lying and standing Previous history of lump that comes and

goes What else do you want to know?

Questions Risk factors for herniae? Boundaries of the inguinal canal? What is an incarcerated hernia? What are the features of a strangulated

hernia? Four cardinal features of obstruction? Major causes of obstruction? Initial management of obstruction?

Thank youQuestions