abdominal cases for surgical finals

Abdominal cases for Abdominal cases for SURGICAL FINALS SURGICAL FINALS

Dr. Anika KauraDr. Anika Kaura

& Dr. Upama Banerjee& Dr. Upama Banerjee

Approach to the Approach to the surgical abdomensurgical abdomen

Surgeons want it SHORT and SIMPLESurgeons want it SHORT and SIMPLE

Use your normal schema for examination but be Use your normal schema for examination but be prepared to be INTERRUPTED! And to move on quickly prepared to be INTERRUPTED! And to move on quickly from one aspect of examination to anotherfrom one aspect of examination to another

Don’t bore them with all the negatives!Don’t bore them with all the negatives!

Mention the positives and only a few RELEVANT Mention the positives and only a few RELEVANT negativesnegativesE.g. I have examined the abdominal system of this gentleman who E.g. I have examined the abdominal system of this gentleman who did not complain of any pain. The most obvious finding was a well did not complain of any pain. The most obvious finding was a well healed rooftop incision. There were no peripheral stigmata nor healed rooftop incision. There were no peripheral stigmata nor abdominal masses on palpation and bowel sounds were present abdominal masses on palpation and bowel sounds were present

ScarsScars

Abdo ScarsAbdo Scars

KochersKochers

Gable/Rooftop – join up R subcostal and LGable/Rooftop – join up R subcostal and L

LANZ LANZ

GRIDIRON/Mcburneys incisionGRIDIRON/Mcburneys incision

LoinLoin

Vascular scarsVascular scars

PfannenstielsPfannenstiels

STOMASSTOMAS““surgically created communication between the bowel and the surgically created communication between the bowel and the skin”skin” OPTIONS : ileostomy / colostomy / ileal conduitOPTIONS : ileostomy / colostomy / ileal conduitEXAMINATIONEXAMINATION

Site of the bagSite of the bag Contents- liquid/solidContents- liquid/solid OutputOutput Bowel flush/spoutedBowel flush/spouted Bowel healthy?Bowel healthy? Feel for parastoma herniasFeel for parastoma hernias Offer to digitate the stomaOffer to digitate the stoma ALWAYS OFFET TO INSEPCT PERINEUM FOR AN ANUS!!!ALWAYS OFFET TO INSEPCT PERINEUM FOR AN ANUS!!! Beware of drain bags appearing like stoma bagsBeware of drain bags appearing like stoma bags

Stoma complicationsStoma complicationsEARLYEARLY LATELATE

• Haemorrhage at siteHaemorrhage at site•High outputHigh output•Stoma ischaemiaStoma ischaemia•Stoma retractionStoma retraction•Obstruction secondary Obstruction secondary to adhesionsto adhesions

•ObstructionObstruction•DermatitisDermatitis•IntussusceptionIntussusception•ProlapseProlapse•Parastomal herniasParastomal hernias•StenosisStenosis•FisutlaeFisutlae•Psychological Psychological •Failure/re-positioningFailure/re-positioning

STOMA summarySTOMA summary 3 Ss and 3 Cs 3 Ss and 3 Cs

SiteSiteSizeSizeSkinSkinContentsContentsCondition- of stoma, and for which they Condition- of stoma, and for which they have ithave itComplications Complications

Important to know about stoma care and role of stoma Important to know about stoma care and role of stoma nurses, especially nurses, especially psychological impactpsychological impact

Which operation?!Which operation?!

Cancers…Cancers…

Right hemi-colectomyRight hemi-colectomy

Extended right hemi-colectomyExtended right hemi-colectomy

Sigmoid-colectomySigmoid-colectomy

Left hemi-colectomyLeft hemi-colectomy

(rarely transverse colectomy)(rarely transverse colectomy)

Rectal cancers:Rectal cancers: HIGH OR LOWHIGH OR LOW

Which operation?!Which operation?!

Cancers…Cancers…

ANTERIOR RESECTION

ABDOMINO-PERINEAL RESECTION

Ulcerative ColitisUlcerative Colitis

Pan Procto-colectomyPan Procto-colectomy

Subtotal colectomy + rectal treatmentSubtotal colectomy + rectal treatmentJ POUCH FORMATIONJ POUCH FORMATION

(ileo-anal pouch)(ileo-anal pouch)

Perforated DiverticulaPerforated Diverticula

HartmansHartmans

What to consider o/eWhat to consider o/e

SCARSCAR

RIGHT/LEFT STOMASRIGHT/LEFT STOMAS

MUST ASK TO EXAMINE THE MUST ASK TO EXAMINE THE PERINEUMPERINEUM

IleostomyIleostomy

ANUS? NO ANUS?

ANTERIOR RESECTION END

ILEOSTOMY

IleostomyIleostomy

ANUS? NO ANUS?

ANTERIOR RESECTION END

ILEOSTOMY

HIGH RECTAL CANCER RESECTION PAN-

PROCTOCOLECTOMY

ColostomyColostomy

ANUS? NO ANUS?

HARTMANSABDOMINO-PERINEAL

RESECTION

ColostomyColostomy

ANUS? NO ANUS?

HARTMANSABDOMINO-PERINEAL

RESECTION

PERFORATED DIVERTICULA

LOW RECTAL CANCER

CASE 1CASE 1

Present the findingsPresent the findings

Get ready for some viva questionsGet ready for some viva questions

What do you want to know about What do you want to know about the stoma??the stoma??

Single lumenSingle lumen

Bowel flush with the skinBowel flush with the skin

Solid contentsSolid contents

Anus presentAnus present

No excoriations/parastomal herniaNo excoriations/parastomal hernia

QuestionsQuestionsDifferential for midline laparotomy and left sided stomaDifferential for midline laparotomy and left sided stoma

HartmannsHartmanns- sigmoid colectomy and end colsotomy - sigmoid colectomy and end colsotomy (reversible)(reversible)

Anterior resectionAnterior resection with reversible end colostomy with reversible end colostomy (unlikely as elective so primary anastamosis)(unlikely as elective so primary anastamosis)

Abdomino perineal resection-Abdomino perineal resection- permanent end permanent end colostomy and NO anuscolostomy and NO anus

Loop colostomy-Loop colostomy- two lumens- either to defunction two lumens- either to defunction distal bowel (rare) or as palliative measure for distal distal bowel (rare) or as palliative measure for distal CaCa

Could always be Could always be ILEOSTOMYILEOSTOMY but just in a funny but just in a funny place!place!

Hartmanns procedureHartmanns procedure

EMERGENCY PROCEDUREEMERGENCY PROCEDURE

Sigmoid colectomy with end colostomy Sigmoid colectomy with end colostomy (reversible)(reversible)

Usual indications: acute diverticulits Usual indications: acute diverticulits especially perf! And acute obstructing especially perf! And acute obstructing sigmoid Casigmoid Ca

Diverticulitis Diverticulitis

Outpouchings of mucosa through the Outpouchings of mucosa through the bowel wallbowel wallDiverticulae/diverticulosis/diverticulitsDiverticulae/diverticulosis/diverticulitsComplications: diverticulitis, large PR Complications: diverticulitis, large PR Bleeds, perforation, abscess, fistulae, Bleeds, perforation, abscess, fistulae, strictures leading to obstruction. strictures leading to obstruction. Investigations: basic to complicated: Investigations: basic to complicated: bloods, AXR, colonoscopy if well NOT if bloods, AXR, colonoscopy if well NOT if risk of perf, CT in acuterisk of perf, CT in acute

Diverticulitis ACUTE MxDiverticulitis ACUTE Mx

Nil by mouthNil by mouthIV fluidsIV fluidsAnalgesiaAnalgesiaABx- cef and metABx- cef and metMost managed conservatively +/- elective Most managed conservatively +/- elective sigmoid colectomysigmoid colectomyEmergency surgery for perf/not improving Emergency surgery for perf/not improving ---- Hartmanns --- most will not have ---- Hartmanns --- most will not have colostomy reversed!colostomy reversed!

HerniasHernias

Scar relatedScar related

Groin - shorts v.commonGroin - shorts v.common

Complications of herniasComplications of hernias

Groin lumps – herniasGroin lumps – hernias– How to dd a femoral vs inguinalHow to dd a femoral vs inguinal

– More likely be to a inguinal herniaMore likely be to a inguinal herniaWhy?Why?

ABOVE & MEDIAL = INGUINAL

BELOW & LATERAL = FEMORAL

Inguinal HerniasInguinal Hernias

Inguinal anatomy!Inguinal anatomy!

Scrotal mass cannot get above itScrotal mass cannot get above it

Dd in the exam by occluding the deep ringDd in the exam by occluding the deep ring

HerniasHernias

ASIS ASIS Pubic tubercle Pubic tubercleWhat is this called?What is this called?

What lies here?What lies here?

ASIS ASIS Pubic Symphysis Pubic SymphysisWhat is this called?What is this called?

What lies here?What lies here?

DefinitiveDefinitive

OperativeOperative

Hesselbachs triangleHesselbachs triangle

Lichenstein tension free mesh repairLichenstein tension free mesh repair

Gold standard still openGold standard still open

Hesselbachs triangle:Hesselbachs triangle:

CASE 2CASE 2

Present the findingsPresent the findings

Get ready for some viva questionsGet ready for some viva questions

What do you want to know about What do you want to know about the fisutlae?the fisutlae?

old/ current??old/ current??

Venepuncture marksVenepuncture marks

Palpable thrillPalpable thrill

Audible murmurAudible murmur

multiple.--- prev failure of fistulamultiple.--- prev failure of fistula

Thinks about complicationsThinks about complications

The renal transplant patientThe renal transplant patient

Approach to examinationApproach to examinationLOADS of signs and clues!LOADS of signs and clues!- Iliac fossa scar and mass – uni/bilatIliac fossa scar and mass – uni/bilat- Nephrectomy scars??Nephrectomy scars??- Previous renal replacement Tx- old AV fistulae, Previous renal replacement Tx- old AV fistulae,

HD scars in neck, PD scars abdoHD scars in neck, PD scars abdo- Immunosuppresion SEs- cushingoid features, Immunosuppresion SEs- cushingoid features,

gum hypertrophy, BCC/SCCgum hypertrophy, BCC/SCC- Evidence of underlying renal disease- diabetic? Evidence of underlying renal disease- diabetic?

etcetc

PRESENTATIONPRESENTATIONExampleExample

““I have just examine the abdominal system of I have just examine the abdominal system of this lady. The most obvious finding is scar in this lady. The most obvious finding is scar in the RIF with a mass beneath consistent with a the RIF with a mass beneath consistent with a renal transplant without nephrectomy. She has renal transplant without nephrectomy. She has an old AV fistula in the right arm and I can see an old AV fistula in the right arm and I can see well healed PD scars on the abdomen, well healed PD scars on the abdomen, indicating previous methods of renal indicating previous methods of renal replacement therapy. I notice some cushingoid replacement therapy. I notice some cushingoid features including striae and bruising on her features including striae and bruising on her legs. The transplant appears to still be working legs. The transplant appears to still be working as the patient is euvolaemic and not uraemic; as the patient is euvolaemic and not uraemic; and there is no evidence of other current renal and there is no evidence of other current renal replacement therapy.”replacement therapy.”

COMPLICATIONS of transplantCOMPLICATIONS of transplant

REJECTION- hyperacute/acute/chronicREJECTION- hyperacute/acute/chronic

IMMUNOSUPPRESIONIMMUNOSUPPRESION- increase opportunistic infection PCP CMV- increase opportunistic infection PCP CMV

- increase risk of skin malignancies- increase risk of skin malignancies - PTLD- PTLD

TOXICITY OF IMMUNOSUPPRESANTSTOXICITY OF IMMUNOSUPPRESANTS- hepato and nephrotoxic- hepato and nephrotoxic

- cushings disease- cushings disease - ciclopsorin- gum hypertrophy- ciclopsorin- gum hypertrophy

COMPLICATIONS of transplantCOMPLICATIONS of transplant

VASCULAR- thrombosis, RASVASCULAR- thrombosis, RAS Hypertension and increased risk of CV diseaseHypertension and increased risk of CV disease

URINARY- UTIs and vesicoureteric refluxURINARY- UTIs and vesicoureteric reflux

Chronic graft dysfunction +/- post transplant Chronic graft dysfunction +/- post transplant nephrectomynephrectomy

Recurrence of the original diseaseRecurrence of the original disease

Psychological Psychological

COMPLICATIONS of COMPLICATIONS of haemodialysishaemodialysis

FLUID BLANCE Hypotension vs pulmonary FLUID BLANCE Hypotension vs pulmonary oedemaoedemaHypokalaemiaHypokalaemiaDisequilibirum syndrome- cerebral oedemaDisequilibirum syndrome- cerebral oedemaAluminium toxicityAluminium toxicityInfection from vascular accessInfection from vascular accessStenosis/thrombosis of access siteStenosis/thrombosis of access siteDialysis related amyloid AADialysis related amyloid AA

Complications of av fistulaComplications of av fistula

Failure to matureFailure to mature

Stenosis/thrombosisStenosis/thrombosis

Aneurysm/pseudoaneurysmAneurysm/pseudoaneurysm

Infection Infection

Venous hypertensionVenous hypertension

Steal phenomenon- distal tissue ischaemiaSteal phenomenon- distal tissue ischaemia

High output CFHigh output CF

Ishcaemic monomelic neuropathyIshcaemic monomelic neuropathy

Urology - haematauriaUrology - haematauria

Vascular scarsVascular scars

Other topics to revise that we have Other topics to revise that we have touched on!touched on!

Bowel caner: screening programme, Bowel caner: screening programme, Dukes post op histology vs staging and Dukes post op histology vs staging and grading grading

Different types of anastomsis, anastomitc Different types of anastomsis, anastomitc leaks, complcations of a colectomy leaks, complcations of a colectomy

Indications for dialysis; nephrectomyIndications for dialysis; nephrectomy

CAPD and HD via tesioCAPD and HD via tesio

THE ENDTHE END

PLEASE DO THE FEEDBACK FORMS!PLEASE DO THE FEEDBACK FORMS!

QUESTIONS??QUESTIONS??

ANIKA- ANIKA- ak8009@ic.ac.uk

UPI- UPI- ub06@ic.ac.uk