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Abdominal cases for SURGICAL FINALS. Dr. Anika Kaura & Dr. Upama Banerjee. Approach to the surgical abdomen. Surgeons want it SHORT and SIMPLE Use your normal schema for examination but be prepared to be INTERRUPTED! And to move on quickly from one aspect of examination to another - PowerPoint PPT Presentation
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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- [email protected]
UPI- UPI- [email protected]
