BOWEL OBSTRUCTION AND HERNIAS SLIME TEACHING 2013 Richard

BOWEL OBSTRUCTION AND HERNIAS - SLIME TEACHING 2013 Richard Marks – FY 1 Orthopaedics @ Warwick

AIMS Hernias What are they? Anatomy Presentation Complications Bowel Obstruction Types Complications Investigation Management

So what is a hernia? ? ? “A hernia is the protrusion of a viscus or part of a viscus outside the cavity which normally contains it”

WHAT ARE THE TYPES?

CASE 1 A 54 year old builder attends your GP clinic with a testicular mass. Its painful, mildly tender to palpation. Differentials? What if he’s vomiting?

THE INGUINAL CANAL Split it into the four “walls” - Anterior - Posterior - Roof - Floor Where are the deep & superficial rings?

ANATOMY. . . YAY. . .

THE FEMORAL CANAL Anteriorly: inguinal lig. Medial: lacunar lig. Lateral: Femoral vein + illopsoas Posterior: pectineal lig. + pectineus

INGUINAL OR FEMORAL? The key to remember is: Femoral = inferior and lateral to the pubic tubercle Inguinal = Superior and medical to the tubercle

DIRECT OR INDIRECT INGUINAL HERNIA? Almost pointless clinically to distinguish. . . But loved by finals examiners How would you do this? What is the “gold standard” way of finding this out?

WHY BOTHER REPAIRING THEM? - - Complications are serious, and include. . . Bowel Obstruction Incarcerate Strangulation Necrosis Peritonitis Death! But. . . would you rush to repair a 95 year old man's painless, reducible inguinal hernia?

SO HOW TO INVESTIGATE? Painless, reducable? Vomiting, painful, stuck? ? USS FBC, U&E, CRP Pre-op investigations G&S Glucose, amylase Erect CXR – perf? AXR – exclude obstruction

MANAGEMENT Conservative. . . e t a l u Medical. . . Surgical. . . r t S g n a ? d

BOWEL OBSTRUCTION

CAUSES Intra-luminal: Faecal impaction Gallstone ileus Intramural Cancers Strictures – IBD, diverticulitis Extraluminal Adhesions Hernias Volvulus Foreign body. . . TB (developing world)

WHAT TO DO? “Drip and suck” – why? NBM Analgesia (IV) Bloods: FBC, U&E, CRP, amylase AXR Erect CXR Catheterise “Gastrografin” ? CT ? ? ? Colonoscopy Seniors ASAP - theatre

SMALL OR LARGE BOWEL OBSTRUCTION?

SMALL OR LARGE?

SMALL VERSUS LARGE?

“PSEUDO-OBSTRUCTION” . . . So don’t worry too much about it!

CLINICAL FINALS. . . Clinical scenario: A 72 year old man presents with a painful swelling in his right groin. He explains that he has ‘had a lump’ there for years and it’s never given him any trouble before. On examination he has a 4 cm tender mass which is not reducible. The skin overlying is dusky coloured. It is located laterally and superior to the pubic tubercle

ON THE SPOT. . . 1) What type of hernia is this likely to be, and why? 2) How would you investigate this man? 3) What is the initial management in the acute setting? 4) And the long term management?

MORE QUESTIONS. . . 5) What - are the borders of the inguinal canal? Floor? Anterior? Roof? Posterior? 6) Risk factors for hernias? 7) Remind 8) What me again. . . What is a hernia? are the main complications of hernias?

PLEASE EXPLAIN. . . Please take a few minutes to explain to Mr Hunt that he needs a CT scan. . .

ALMOST THERE. . . As there’s no orthopaedic session by SLIME, make sure you at least skim the basics on #NOF’s. . . And don’t suggest exercise tolerance test as a pre-op investigation in a hip fracture like a few 2009 cohort guys did. . .

FINALLY. . . Good luck!! (They let me pass, so you’ll be absolutely fine!) http: //radiologymasterclass. co. uk