Dyspepsia & Peptic Ulceration

Surgical Notes - OHCM 213-217

Most uo enal ulcers occur in t!e 1st part of the duodenum " c!ronic ulcer penetrates t!e #ucosa & into t!e #uscle coat$ lea ing to %i&rosis '!ic! causes e%or#ities suc! as pyloric stenosis (!en t!ere is &ot! a posterior & anterior uo enal ulcer - 'Kissing Ulcers' Anteriorly place ulcers ten to perforate ue to t!e poor blood supply o% t!e anterior uo enal 'all '!ic! is a watershed area t!us !eals poorly. )n contrast$ posterior uo enal ulcers ten to bleed$ so#eti#es &y ero ing a large *essel e+g+ t!e gastroduodenal artery. Malignancy in t!is region is uncommon (1-5% ,astric ulcers are independent of acid secretion & can occur in ac!lor!y ic states ,astric ulcers #ay &eco#e malignant (15% & an ulcerate gastric cancer #ay #i#ic a &enign ulcer -i&rosis '!en it occurs$ #ay result in t!e no' rarely seen hour-glass contraction o% t!e sto#ac! !hronic ulcers - Occur #ore co##only on t!e lesser cur"e especially at t!e incisura angularis & e*en '!en !ig! on t!e lesser cur*e$ t!ey ten to &e at t!e boundary between the acid secreting # the non-acid secreting epithelia. ,astric ulcers #ay also occur in ectopic gastric mucosa e+g+ in $ec%el's di"erticulitis

i) Duo enal Ulcers

ii) ,astric Ulcers

iii) Sto#al ulcers - occur a%ter a gastroenterostomy e+g+ Billroth II type (Gastrojejunostomy)+ .!is ulcer is
usually %oun on t!e &e&unal si e o% t!e sto#a+

)/ - Oesop!agogastro uo enoscopy 0O,D)

1iopsies o% t!e antrum are ta2en3 * to see '!et!er t!ere is histological evidence of gastritis * a !'( test per%or#e to eter#ine t!e presence of H.pylori. " 'U' manoeu"re s!oul &e per%or#e to e/clu e ulcers aroun t!e gastro-oesophageal &unction )n t!e presence o% a sto#a$ &ot! a%%erent & e%%erent loops #ust &e entere as al#ost all sto#al ulcers 'ill &e *ery close to t!e 4unction &et'een t!e 4e4unal & gastric #ucosa .!e pylorus is e/a#ine %or ulcers or e%or#ity$ '!ic! is o%ten t!e case 'it! chronic duodenal ulceration. )% &lee ing ulcer$ in4ect sclerosant or adrenaline (1)1*+*** 5ie' all o% t!e 1st part of the duodenum+

"i#3 6e uce gastric aci secretion 6e#o*e t!e isease #ucosa )n ications3 Emergency Surgery - Complicated ulcers - "cute perforation - "cute massi"e haemorrhage - ,astric outlet o&struction - ,yloric stenosis Elective surgery - Others; - Intractability elaye !ealing or recurrence a%ter !ealing$ e*en in t!e a&sence o% pain7 suc! apparently &enign ulcers can actually &e #alignant+ - !epeated episodes of minor bleeding - "istula formation 0gastrocolic$ uo enocolic$ or %ro# t!e uo enu# into any portion o% t!e &iliary tree)+

Surgical #anage#ent o% PUD Co#plications3

9#ergency surgery
Incidence - Usually t!e elderly & associate 'it! use o% -.A/0s * 1*% - 0o not re-&lee in t!e sa#e a #ission * 5% - Continue &lee ing * 25% - 3e-bleed in same admission - #orry about these ones Sites - ,osterior uo enal ulcers ten to bleed$ so#eti#es &y ero ing a large *essel e+g+ t!e gastroduodenal artery. Mx; $edical - "ibrinolysis inhibitor e+g+ .rane/a#ic aci 4ndoscopic - $drenaline injection (%&')( diathermy( laser coagulation or heat probe. .5 - )he bleeding ulcer base is underrun or oversewn )n ications %or surgery - .!e 2:; a&o*e3 - Se*ere !ae#orr!age - " patient '!o !as re<uire *+ units o% &loo %or resuscitation - 6e-&lee ing especially in t!e el erly 0 *+,yrs old) - Patients 'it! a visible vessel in t!e ulcer &ase$ a spurting vessel or an ulcer 'it! a clot in t!e &ase - Patient on aspirin or anticoagulant therapy

Hae#orr!age - OHCM 228

Per%oration
Incidence - Co##only in elderly females - -.A/0s appear to &e responsi&le3 "lso .mo%ing. Sites; Anterior uo enal ulcers - Most common (25% -ill perforate) Anterior # incisural gastric ulcers C/ ; H/ o% peptic ulceration .rescendo abdominal pain - )nitially se"ere localised abdominal pain t!at cli#a/es t!en su&si es to moderate generalised abdominal pain ue to t!e irritant e%%ect o% gastric aci on t!e peritoneu# 1acterial peritonitis 5o#iting o% large a#ounts o% %oo so#e !ours a%ter #eals !!x - Di*erticulosis 'it! per%oration Ix; 4rect A63 - -ree gas un er t!e iap!rag# ,astrogra%%in stu y 01ariu# #eal is irritating to t!e peritoneu#) - "ree peritoneal lea/ DP= Seru# "#ylase - to r0o acute pancreatitis C. scan 0( -(7 perform 4ndoscopy as it &lo's air o'n t!e ,). t!at coul pus! intestinal content into t!e peritoneu# Mx; ,re-op8 3esuscitation # analgesia ! on s er "a t i" e $ 5 - I n pa ti e n ts w it " o u t ge ne r a l i1 ed pe r i to n i ti s - N 1 M $ N , t u& e $ )5 a nt i& i o ti c s . 5 8 'aparoscopic repair of the hole - an o#ental patc! is place o*er t!e per%oration in t!e !ope o% en!ancing t!e c!ances o% sealing t!e lea2 9astric ulcers M#S$ be excised 0& tissue !istology one - to e/clu e #alignancy) 2 closed /f massi"e - %illrot" II resection &'astro(e(unostomy) 3eritoneal toilet to re#o*e all t!e %lui & %oo e&ris ,ost-op8 )5 anti&iotics H+ pylori era ication

Surgery Page 82

,astric Outlet O&struction

Causes; Gastric cancer .hort !istory in an old patient yloric stenosis; Congenital - (:!$ ;<; 45 to duodenal ulceration .!e stenosis is %oun in t!e 1st part of the duodenum+ t!e #ost co##on site %or a peptic ulcer C/ ; H/ o% long standing PUD 5o#iting without bile (eig!t loss$ #alaise & e!y ration */E; Disten e sto#ac! .uccussion splash #ay &e au i&le on s!a2ing t!e patient>s a& o#en +"rs post prandial Ix; .!e *o#iting o% HC= results in :ypochloraemic metabolic al%alosis - Usually only seen 'it! PUD3 * )nitially *o#iting lea s to hypoK= # al%alosis t!us initially t!e 2i neys co#pensate &y retaining C=- & secreting NaHCO3 0al/alotic urine) lea ing to Hypo6a7 '!ic! couple 'it! t!e e!y ration causes t!e 2i ney to retain -a= # e5crete := instea o% ?@ &ecause o% !ypo2alae#ia$ pro ucing acidic urine+ "l2alosis lea s to >!a2=$ & tetany can occur+ 9n oscopic &iopsy to rAo #alignancy Mx; Hypoc!lorae#ic al2alosis - -. = K= M/ anae#ia !onser"ati"e - -or early cases3 Presu#a&ly as t!e oe e#a aroun t!e ulcer i#inis!es$ t!e o&struction is !eale 4ndoscopic &alloon ilatation %ollo'e &y #a/i#al aci suppression 0rainage procedure 0e+g+ gastro-enterostomy or pyloroplasty) ? high selecti"e "agotomy
-

9lecti*e Surgery %or Duo enal ulcer3

a %illrot" II gastrectomy/ olya 'astrectomy &'astro(e(unostomy)
Follow ing resection of the antrum & distal body of the stomach (Distal Two-thirds of the stomach), the distal end of the stomach is narrowed by the closure of the lesser curve aspect of the remnant & the greater curve aspect is then anastomosed, usually in a retrocolic fashion, to the jejunum leaving as short an affarent loop as feasible

Closed duodenal stump

b 9astro&e&unostomy - !eflu8 al/ali from the small bo-el into t!e sto#ac! re uces uo enal aci e/posure & is o%ten success%ul in !ealing t!e ulcer * 0isad"antage - 1ecause t!e 4e4unal loop is e/pose irectly to gastric aci $ stomal ulceration is e/tre#ely co##on !ence t!e proce ure in isolation is ine%%ecti*e c 7runcal "agotomy # 0rainage - )n*ol*es division of the anterior , posterior vagal trun-s at t!e le*el o% t!e distal oesophagus & dissection of all t"e nerves in the lower .cm of the oesophagus in or er to eliminate the 9criminal nerve of Grassi9 ot!er'ise$ apprecia&le *agal inner*ation 'oul re#ain+ 1ase on t!e principle t!at section of the vagus nerve; i) reduces the ma8imal acid output &y appro/i#ately 5*% %ro# t!e stomach body # fundus i) reduces gastrin production i) Causes motor denervation o% t!e antropyloroduodenal segment resulting in gastric stasis t!us re<uiring drainage &y3 * /eine-e-Mi-ulic0 pyloroplasty or * 'astro(e(unostomy d 7runcal "agotomy # Antrectomy - )n a ition to truncal *agoto#y$ t!e antrum o% t!e sto#ac! is remo"ed+ t!us re#o*ing t!e source o% t!e gastrin$ & t!e gastric remnant is &oined to t!e duodenum (%illrot" I e :igh .electi"e "agotomy - Only the parietal cell mass o% t!e sto#ac! is ener*ate &y co#plete neuro"ascular clearance o% t!e pro5imal lesser cur"e+ fundus # body of stomach+ up to the lower 1cm o% t!e oesop!agus+ * )he anterior 2 posterior vagus nerves are preserved1 * )he nerve o2 3aterget to the pylorus is le2t intact; thus gastric emptying is una22ected1

9lecti*e Surgery %or ,astric Ulcers

Ma4or o&4ecti*e is to re#o*e t!e isease tissue & alt!oug! le*els o% gastric aci secretion are not a&nor#ally !ig!$ aci is still a prere<uisite & !ence operations !a*e &een co##only use to lo'er aci secretion+ a @illroth / gastrectomy (9astroduodenostomy

he lower half of the stomach is removed including the ulcer that is usually situated on the lesser curve & the cut stomach anastomosed to the first part of
the duodenum

b @illroth // gastrectomy (9astro&e&unostomy - Use %or t!e high # lesser cur"e gastric ulcer '!ere gastro uo enosto#y is tec!nically i%%icult c Aagotomy+ ,yloroplasty # Ulcer e5cision

Co#plications o% Peptic Ulcer Surgery

A. 4arly !omplications
0uodenal stump lea%age+ gastric retention+ and hemorrhage may de"elop in the immediate postoperati"e period.

@. 'ate !omplications
i 0umping syndromeSy#pto#s o% t!e u#ping syn ro#e are note to so#e e/tent &y #ost patients '!o !a*e
an operation t!at i#pairs t!e a&ility o% t!e sto#ac! to regulate its rate o% e#ptying+ (it!in se*eral #ont!s$ !o'e*er$ u#ping is a clinical pro&le# in only 1-2; o% patients+ Sy#pto#s %all into t'o categories7 car io*ascular an gastrointestinal+ S!ortly a%ter eating$ t!e patient #ay e/perience palpitations$ s'eating$ 'ea2ness$ yspnea$ %lus!ing$ nausea$ a& o#inal cra#ps$ &elc!ing$ *o#iting$ iarr!ea$ an $ rarely$ syncope+ .!e egree o% se*erity *aries 'i ely$ an not all sy#pto#s are reporte &y all patients+ )n se*ere cases$ t!e patient #ust lie o'n %or 3B-8B #inutes until t!e isco#%ort passes+ Diet t!erapy to re uce 4e4unal os#olality is success%ul in all &ut a %e' cases+ .!e iet s!oul &e lo' in car&o!y rate an !ig! in %at an protein content+ Sugars an car&o!y rates are least 'ell tolerate 3 so#e patients are especially sensiti*e to #il2+ Meals s!oul &e ta2en ry$ 'it! %lui s restricte to &et'een #eals+ .!is ietary regi#en or inarily su%%ices$ &ut antic!olinergic rugs #ay &e o% !elp in so#e patients3 ot!ers !a*e reporte i#pro*e#ent 'it! supple#ental pectin in t!e iet$ an t!e use o% so#atostatin analogues o%%ers so#e pro#ise+

9arly & =ate u#pin

4arly /ncidence 3elation to meals 0uration of attac% 3elief Aggra"ated by ,recipitating factor ,athogenesis 'ate

$a&or symptoms

7reatment

:-1B; :; 2n Hour a%ter #eal "l#ost i##e iate 3B-8B#ins 3B-8B#ins =ying o'n -oo More %oo 9/ercise -oo $ especially car&o!y rate-ric! & "s early u#ping 'et -ainting & s'eating a%ter eating ue .!is is reacti"e hypoglycaemia+ .!e to %oo o% !ig! os#otic potential car&o!y rate loa in t!e s#all &o'el &eing u#pe in t!e 4e4unu# causes a rise in t!e plas#a glucose$ lea ing to se<uestration o% %lui '!ic! in turn$ causes insulin le*els to %ro# t!e circulation into t!e ,). rise$ causing a 2C !ypoglycae#ia+ causing oligaemia 9pigastric %ullness$ s'eating$ lig!t.re#or$ %aintness$ prostration !ea e ness$ tac!ycar ia$ colic$ so#eti#es iarr!oea iii. i. 0ietary manipulation D S#all$ ry #eals & a*oi %lui s 'it! a !ig! car&o!y rate content ii. So#atostatin analogue D (creotide3 .B4 D ,allstones$ oes not treat iarr!oea3 Acarbose #ay !elp to re uce t!e early !yperglycae#ic sti#ulus to insulin secretion+ 3e"isional surgery C "ntrecto#y 'it! 6ou/-en-E reconstruction

ii) 6ecurrent ulceration - Manage as ot!er peptic ulcers 0#arginal ulcer$ sto#al ulcer$ anasto#otic ulcer)6ecurrent ulcers %or# in a&out 1B; o% uo enal

ulcer patients treate &y *agoto#y an pyloroplasty or parietal cell *agoto#y3 an in 2-3; a%ter *agoto#y an antrecto#y or su&total gastrecto#y+ .!ese %igures 'ere accu#ulate &e%ore t!e e#ergence o% e%%ecti*e treat#ent against H pylori$ !o'e*er$ an are li2ely to &e lo'er 'it! current #anage#ent+ 6ecurrent ulcers nearly al'ays e*elop i##e iately a 4acent to t!e anasto#osis on t!e intestinal si e+ !B, - Diarr!oea$ %oul &reat! & #ay *o#it %or#e %aeces ,athogenesis - Se*ere conta#ination o% t!e 4e4unu# 'it! colonic &acteria $5 - Correct e!y ration & #alnutrition & o re*isional surgery

iii)

%istula &et'een t!e sto#ac! an colon+ Most e/a#ples !a*e resulte %ro# recurrent peptic ulcer a%ter an operation t!at inclu e a gastro4e4unal anasto#osis+

,astro4e4unocolic an gastrocolic %istula" eeply ero ing ulcer #ay occasionally pro uce a

Se*ere iarr!ea an 'eig!t loss are t!e presenting sy#pto#s in o*er FB; o% cases+ "& o#inal pain typical o% recurrent peptic ulcer o%ten prece es t!e onset o% t!e iarr!ea+ 1o'el #o*e#ents nu#&er G-12 or #ore a ay3 t!ey are 'atery an o%ten contain particles o% un igeste %oo +

.!e egree o% #alnutrition ranges %ro# #il to *ery se*ere+ =a&oratory stu ies re*eal lo' seru# proteins an #ani%estations o% %lui an electrolyte epletion+ "ppropriate tests #ay re%lect e%iciencies in &ot! 'ater-solu&le an %at-solu&le *ita#ins+ "n upper gastrointestinal series re*eals t!e #arginal ulcer in only :B; o% patients an t!e %istula in only 1:;+ 1ariu# ene#a un%ailingly e#onstrates t!e %istulous tract+ )nitial treat#ent s!oul replenis! %lui an electrolyte e%icits+ .!e in*ol*e colon an ulcerate gastro4e4unal seg#ent s!oul &e e/cise an colonic continuity reesta&lis!e + 5agoto#y$ partial gastrecto#y$ or &ot! are re<uire to treat t!e ulcer iat!esis an pre*ent anot!er recurrent ulcer+ 6esults are e/cellent in &enign isease+ )n general$ t!e outloo2 %or patients 'it! a #alignant %istula is poor+

i*) *)

S#all sto#ac! syn ro#e - 9arly satiety ue to reduced stomach si1e or loss of receptive rela8ation 1ilious *o#iting - Pre*ente &y !ou8 en : diversion after gastrectomy3 )n gastroenterosto#y -

follo-ing vagotomy - Heals 'it! ti#e+ 3yloroplasty

*i)

Post-*agoto#y Diarr!oea - "&out :-1B; o% patients '!o !a*e !a truncal *agoto#y re<uire treat#ent 'it! anti iarr!eal agents at so#e ti#e$ an per!aps 1; are seriously trou&le &y t!is co#plication+ .!e iarr!ea #ay &e episo ic$ in '!ic! case t!e onset is unpre icta&le a%ter sy#pto#-%ree inter*als o% 'ee2s to #ont!s+ "n attac2 #ay consist o% only one or t'o 'atery #o*e#ents or$ in se*ere cases$ #ay last %or a %e' ays+ Ot!er patients #ay continually pro uce 3-: loose stools per ay+ Most cases o% post-*agoto#y iarr!ea can &e treate satis%actorily 'it! constipating agents+ *ii) Malignant trans%or#ation - 9astrectomy or "agotomy 0except /ig" selective vagotomy) 2
drainage are in epen ent ris2 %actors %or t!e e*elop#ent o% gastric cancer as 4ile re2lux gastritis5 intestinal metaplasia & gastric cancer are lin2e +

*iii) "l2aline gastritis6e%lu/ o% uo enal 4uices into t!e sto#ac! is an in*aria&le an usually innocuous situation
a%ter operations t!at inter%ere 'it! pyloric %unction$ &ut in so#e patients$ it #ay cause #ar2e gastritis+ .!e principal sy#pto# is postpran ial pain$ an t!e iagnosis rests on en oscopic an &iopsy e#onstration o% an e e#atous in%la#e gastric #ucosa+ Since a #inor egree o% gastritis is %oun in #ost patients a%ter 1illrot! )) gastrecto#y$ t!e en oscopic %in ings are to so#e egree nonspeci%ic+ Persistent se*ere pain is an in ication %or surgical reconstruction+ 6ou/-en-E gastro4e4unosto#y 'it! a 8B-c# e%%erent 4e4unal li#& is t!e treat#ent o% c!oice+

i/)

"ne#ia)ron e%iciency ane#ia e*elops in a&out 3B; o% patients 'it!in : years a%ter partial gastrecto#y+ )t

is cause &y %ailure to a&sor& %oo iron &oun in an organic #olecule+ 1e%ore t!is iagnosis is accepte $ t!e patient s!oul &e c!ec2e %or &loo loss$ #arginal ulcer$ or an unsuspecte tu#or+ )norganic iron%errous sul%ate or %errous gluconateis in icate %or treat#ent an is a&sor&e nor#ally a%ter gastrecto#y+ 5ita#in 112 e%iciency an #egalo&lastic ane#ia appear in a %e' cases a%ter gastrecto#y+

/)

Pro2inetic agents 0eg$ #etoclopra#i e) are o%ten !elp%ul$ &ut so#e cases are re%ractory to any t!erapy e/cept a co#pletion gastrecto#y an 6ou/-en-E esop!ago4e4unosto#y 0ie$ total gastrecto#y)+

C!ronic gastroparesisC!ronic elaye gastric e#ptying is seen occasionally a%ter gastric surgery+

,astrecto#y causes3 #eight loss Bone disease - Principally in 'o#en 45 to osteomalacia Gallstones -ollo'ing truncal *agoto#y$ t!e &iliary tree$ as 'ell as t!e sto#ac!$ is ener*ate $ lea ing to stasis & !ence stone %or#ation+ Blind loop syndrome 1acterial o*ergro't! H #ala&sorption

/i) Ot!ers3

Upper ,) 1lee ing - OHCM

)ntestinal O&struction
Surgery Page 8K

Inter2erence wit" t"e normal caudal progression o2 intestinal contents

Classi%ication
a DunctionalBAdynamic - 64sent peristalsis e+g+ paralytic ileus or 3eristalsis present in a non-propulsive form Causes3 i) Congenital - Pre#aturity - Mucosal enJy#e e%iciency - Neuro*ascular e%ects e+g+ Hirschsprung9s disease ii) "c<uire - Peritonitis - 6etroperitoneal lesions - .hronic intestinal o&struction - Si#ple !an ling o% t!e gut e+g+ laparoto#y - Drugs e+g+ Opiates( ;etoclopromide - Syste#ic causes - <lectrolyte imbalance (=>7( =.a47)( ?epticaemia( )o8aemia - Neuro*ascular e%ects e+g+ ;esenteric arterial thrombosis CAP3 .!ere is no pain 6on projectile *o#iting H constipation 1o'el soun s are absent b $echanicalB0ynamic - (!ere peristalsis is 'or2ing against a mechanical obstruction ; i) Intraluminal - Congenital * Meconiu# plug * )#per%orate anus - "c<uire * -aecal )#paction * (or#s 0"scaris lu#&ricoi es$ .ape'or#s) especially a2ter anti!el#int!ic a #inistration * ,allstone ileus * 1eJoars * )atrogenic e+g+ gauJes ii) Extraluminal * Intramural; - Congenital * "tresia * Hirsc!sprung>s isease * Di*erticulitis * Congenital Hypertrop!ic Pyloric stenosis - "c<uire * "c<uire #egacolon * )ntussusception * Strictures 0post irra iation) * Stenosis * .u#ours

* <8tramural; - " !esions 0Post laparoto#y) - Hernias - Malrotation - ?igmoid or .aecal :olvulus - 9/trinsic #asses e+g+ ly#p!o#as

Surgery Page K8

.ypes o% O&struction
$ccording to duration a Acute obstruction - Usually occurs in small 4owel o4struction 'it! su en onset o% severe colic/y central a4dominal pain5 distension 2 early vomiting 2 constipation; )% *o#itus is 4ilious stained$ t!e o&struction is distal to t!e 2nd part o% t!e uo enu#+ DeH2O H "l2alosis & para o/ical aci uria b !hronic obstruction - Usually in large 4owel o4struction 'it! lo-er abdominal colic 2 constipation( follo-ed by distension. Body has adapted to deH4O etc; @ -t loss present. c Acute on chronic - .!ere is a short history of distension , vomiting against a bac/ground of pain , constipation d .ubacute obstruction - Incomplete03artial obstruction usually cause &y ad"esions %ollo'ing laparoto#y $ccording to Blood supply a .imple - Blood supply is intact b .trangulated - Strangulate &o'el causes loss o% &loo Aplas#a li2e %lui $ gut &eco#es gangrenous 'it! lea2age o% contents into peritoneal ca*ity L 3eritonitis3 .o/ins #ay &e a&sor&e into t!e circulation L )o8aemia Causes3 1E - Mesenteric in%arction 2E 9/ternal3 - )ntraperitoneal " !esionsA1an s Hernial rings )nterrupte &loo %lo'3 - 5ol*ulus )ntussusception )ncrease intralu#inal pressure - .losed loop obstruction CAP3 )he patient is more ill than you -ould e8pect @lood in stool - )n icati*e o% an isc!e#ic process at t!e le*el o% o&struction ,eritonism - " sy#pto# co#ple/ #ar2e &y vomiting; s"arper5 constant localised pain5 and s"ocassociate 'it! in%la##ation o% any o% t!e a& o#inal *iscera in '!ic! t!e peritoneu# is in*ol*e + - .en erness 'it! rigi ity -e*er & M(CC - M ?@$ "#ylase or =DH

Pat!op!ysiology
)nitially$ peristalsis is increased pro5imal to the obstruction to o*erco#e t!e o&struction$ 'it! t!e length of time it re#ains *igorous &eing proportional to t!e distance of obstruction+ )% t!e o&struction is not relie*e $ t!e &o'el &egins to dilate$ causing a re uction in peristaltic strengt!$ ulti#ately resulting in flaccidity # paralysis+ .!is is a protecti"e phenomenon to pre*ent *ascular a#age 2C to increase intralu#inal pressure+ .!e distension pro5imal to an obstruction is pro uce &y3 i 9as8 * Nitrogen 0<*%) & H2S %ro# &acterial action 0O2 & CO2 is rea&sor&e ) * "erop!agy i DluidsA28!rs3 * Sali*a - 1-1+:= * ,astric 4uice - 1+:-2= * 1ile - 1= * Pancreatic 4uices - 1+:= * Succus entericus 0S#all )ntestinal 4uice) - 3= ii Daeces ii :ypertrophy of the muscles of the gut if the obstruction is long standing 0istal to obstruction - .!e &o'el e/!i&its normal peristalsis 2 absorption until it &eco#es e#pty$ '!en it contracts , 4ecomes immo4ile1

Surgery Page K:

SAS
!ardinal symptoms8 i) Colic-y a4dominal pain ii) 64dominal !istension iii) Constipation - initially stool #ay &e re uce in <uantity progressing to constipation * 64solute &*4stipation) - No %aeces or %latus passes * !elative - -latus &ut no %aeces especially i% obstruction is high iv) 7omiting &-ith relief ) 8 * De!y ration - #ost co##only in small bo-el obstruction * Signs o% S!oc2 - Nurine output 0" ults- 3B-:B#lsA!r3 C!il ren- B+:-1#lA?gA!r)$ Mpulses$ N1P * Hypoc!lorae#ic #eta&olic al2alosis 'it! Para o/ical aci uria * Hypo2alae#ia (thers -lui & electrolyte e%iciencies ue to3 - 6e uce oral inta2e - De%ecti*e intestinal a&sorption - Se<uestration into lu#en o% &o'el 0 Osmotic flo-) - 5o#iting "nore/ia .mall @owel (bstruction8 CAP3 - ,ro5imal8 * Pain is higher in t!e a& o#en 0may be absent in long standing cases e.g. long standing atresia in children) * Mini#al istension * Pro%use early "omiting 'it! rapi e!y ration * 3ittle evidence of fluid levels on $A! - 0istal8 * Pain is at t!e centre o% t!e a& o#en * !entral a& o#inal istension * Aomiting is delayed * Multiple central fluid levels are seen on $A! 'arge @owel (bstruction8 CAP * Pain is #ore constant * )% t!e ileocaecal *al*e is3 - !ompetent - Pain #ay &e %elt o*er a isten e caecu# - Closed loop *4struction - /ncompetent - 'ross abdominal distension H %aecal *o#itus i% c!ronic * 5o#iting is late or absent * "cti*e 'tin%ling' &o'el soun s 2C to presence o% large air poc%ets

OA9
3ising pulse PA" Aisible peristaltic #o*e#ents i% dynamic ,eneralise a& o#inal ten erness & rigi ity H #ass 3esonant on percussion 0( -(7 o !9E or Enema evacuation i% you inten to o an A63 as t!is 'ill sti#ulate ,). contractions+

Surgery Page KK

 A63 - Supine , Erect; i) "&nor#al 9as patterns 0gas in t!e fundus of stomach & throughout the large bo-el is normal) is &est seen on .upine A63. - .mall @owel O&struction -!entral gas s!a o's & :* gas in the large bo-el & is F GHcm wide3 * .!e &e&unum is centrally place & i enti%ie &y pronounced "al"ulae conni"entes t!at completely cross the lumen - concertina effect (=i2e curtain gat!erings * .!e ileum !as -( c!aracteristics - 'arge @owel O&struction - ,as is pro5imal to t!e &loc2 0e+g+ in caecu#) &ut not in the rectum * .!e =arge &o'el !as few peripheral loops # haustral (scalloped patterned folds t!at do not cross all the lumen9s -idth & is F5cm wide+ ii) On 4rect A63 loo2 %or horiIontal Dluid le"els - JG con%ir# intestinal o&struction in adults 0J5 - in children)+ .!e %lui le*els #ust &e J2.5cm in !eig!t3 ;ay be a4sent in proximal small bo-el obstruction. @arium enema - 9specially in colonic lesions3 )t is therapeutic in intussusception &ut carries t!e anger o% lea%age into t!e peritoneu# i% gut is gangrenous "& o#inal UAS /AU - De#onstrates ureteric calculi '!ic! #ay lea to inflammation 2 paralytic ileus C. scanAM6) $5 !onser"ati"e (initial management before surgery 8 )n ications3 DunctionalBAdynamic causes /ncomplete s#all &o'el o&struction =arge &o'el o&struction t!at is not >close loop o&struction> i -@$ i "luid 2 <lectrolyte therapy to correct N?@$ NCa2@ & NNa@ - )5 NS clears aci uria ii Becompression &y passage o% a3 - N,. - -latus tu&e - 9ne#a - especially large &o'el o&struction t!at is -(7 'closed loop obstruction' i 0( -(7 gi*e Analgesics as t!ey #ay #as2 eterioration o% t!e o&struction e+g+ per%oration i ,OM 3units .urgery - 'aparotomy8 )n ications3 * 9*i ence o% isc!e#ia or in%la##ation - Intussusception , Malrotation * >!losed loop obstruction' - 'arge &o'el o&struction 'it! ten erness o*er a grossly dilated caecum (JKcm $ '!ic! occurs '!en t!e ileocaecal *al*e re#ains competent espite &o'el istension+ "lso 7olvulus1 Has a high ris% o% perforation Usually occurs in3 - Malignancy e+g+ Hepatic %le/ure tu#ours - -ollo'ing 1illrot! )) 0,astro4e4unosto#y) * -aile conser*ati*e #anage#ent * Hernias * " !esions - )n ications %or surgery3 - Strangulation - Peritonitis - P ain - )n%ection * Unresecta&le Ca colon to relie*e t!e o&struction

)/

5ol*ulus
" *ol*ulus is a twisting or a5ial rotation o% a portion o% &o'el a&out its #esentery+ (!en co#plete$ it %or#s a closed loop of obstruction 'it! resultant isc!e#ia 2C to *ascular occlusion+ May in*ol*e .mall intestines+ !aecum or .igmoid colon 7ypes 1E - 9+g+ 5ol*ulus neonatoru#$ .aecal 2 ?igmoid *ol*ulus - 2C to3 - Congenital #alrotation o% t!e gut - Anticloc%wise rotation o% gut along t!e a/is o% superior mesenteric artery - "&nor#al #esenteric attac!#ents - Congenital &an s 2E - Occurs secon ary to actual rotation o% a piece o% &o'el aroun an acLuired adhesion or stoma - More common

5ol*ulus o% t!e s#all intestine

1C or 2C & usually occurs in t!e lower ileum. Pre isposing %actors3 Consu#ption o% a large *olu#e o% *egeta&le #atter 2C to a !esions

Caecal *ol*ulus
Occurs as part of "ol"ulus neonatorum or de no"o & is usually a cloc%wise t'ist+ DJ$ (B48 -eatures o% )ntestinal o&struction " palpa&le ty#panic s'elling in t!e midline or left side o% t!e a& o#en - )n 25% cases /58 "O6 - ,as %ille ileum H a distended caecum 1ariu# ene#a - "&sence o% &ariu# in t!e caecu# & a bird bea% deformity $5 .urgery8 Deco#press t!e caecu# 'it! a nee le t!en re uce t!e *ol*ulus -i/ t!e caecu# to t!e 6)- 0 caecope5y) &Aor a caecostomy )% t!e caecu# is ischemic or gangrenous$ a right hemicolectomy s!oul &e per%or#e +

Sig#oi 5ol*ulus
!ommonest spontaneous type & cause o% large bowel o&struction Pea2 age - J1*yrs8 9specially el erly patients su%%ering %ro# psychiatric # chronic neurological diseases suc! as stro%e or multiple sclerosis+ "lso$ cardio"ascular disease and diabetes. ,redisposing causes8

:igh residue diet - %ananas are ric" in serotonin w"ic" relaxes t"e gut AcLuired megacolon e.g. $%5 !ia4etes !hronic constipation

PP 6otation nearly al'ays occurs in an anticloc%wise irection+ !B, 6cute in t!e young & c"ronic in t!e elderly 0>ol ?a#&a gentle#an>) Acute colic%y abdominal pain$ al#ost in*aria&ly associate 'it! early progressi*e abdominal distension H !iccoug! & 'retc!ing Intermittent large &o'el o&struction %ollo'e &y t!e passage o% large <uantities o% %latus & %aeces Constipation is absolute ((bstipation 5o#iting occurs late (B4 )ensely distended( tympanitic 9drum li/e9 a& o#en+ .!e rectum is empty o% stool+ 1o'el soun s are o%ten increased Signs o% peritoneal in2lammation suc! as re&oun ten erness or guar ing suggest t!at colonic in2arction or gangrene "as occurred1 Signs o% e!y ration #ay &e apparent i% presentation !as &een elaye /5 A63 - Massi*e colonic istension - .!e c!aracteristic appearance is t!at o% a grossly enlarge $ gas-%ille sig#oi colon arising %ro# t!e pel*is an e*iating to t!e left or right flan% 'it! 2 fluid le"els+ .!e ape/ o% t!e loop is positione !ig! in t!e a& o#en+ .!ree ense cur*e lines$ representing t!e 'alls o% t!e enlarge loop$ con*erge to'ar s t!e stenosis o*er t!e le%t part o% t!e sacru# - >/n"erted U' sign. :austral mar%ings are usually lost. $5 a -on-operati"e8 4ndoscopic deflation - Care%ul sig#oi oscopy an t!e passage o% a %latus tu&e *ia t!e sig#oi oscope+ -ollo'ing a success%ul e%lation$ t!e %latus tu&e s!oul &e le%t in place %or at least ;Khrs to re uce t!e li2eli!oo o% an early recurrence+ !B/ - i% t!ere is e*i ence o% strangulation or per2oration1 )% eco#pression is success%ul$ goo -ris2 young patients s!oul &e sc!e ule %or electi"e resection as soon as t!e colon can &e prepare $ &ecause t!e recurrence rate a%ter eco#pression alone is 5*% within 2yrs+ -o operation is in icate a%ter en oscopic eco#pression o% t!e first episode o% sig#oi *ol*ulus in elderly patients or t!ose 'it! se"ere disease of other organ systems. b .urgery8 :artmann procedure - Pri#ary resection wit"out anasto#osis 02-stage procedure)-.!e isease &o'el is re#o*e $ t!e pro/i#al en o% t!e colon is &roug!t out as a te#porary colosto#y$ an t!e istal colonic stu#p is close + )ntestinal continuity is restore in a second operation a2ter ;w-s1 &locally( %5 anastomosis performed due to poor tolerance of a stoma by patients) 4mergency operation is per%or#e i%3 * atte#pts to eco#press t!e &o'el per rectu# are unsuccess%ul+ * strangulation or per2oration is suspecte rognosis - Mortality - ;*%

Co#poun 5ol*ulusA)leosig#oi 2notting

.!e long pel*ic #esocolon allo's t!e ileum to twist around t"e sigmoid colon+ resulting in gangrene o% eit!er or &ot! seg#ents o% &o'el+ .!e patient presents 'it! acute intestinal o4struction &ut distension is co#parati*ely mild. A63 - Disten e ileal loops in a isten e sig#oi colon+ Has a H*% mortality

)ntussusception
.!is occurs '!en one portion o% t!e gut &eco#es in*aginate 'it!in an i##e iately a 4acent seg#ent$ it is the proximal over t"e distal 4owel1

7ypes8 )leoileal )leo-ileo-colic /leocolic - 6eonates !olocolic - $dults Aetiology8 Pre isposing %actorsAcon itions3 ) iopat!ic - /leocolic more common3 Pea2 age - G-<months - Hyperplasia of 3eyer9s patches in the terminal ileum 2C to weaning+ U3/ e+g+ a eno*irus or rota*irus #ay &e t!e initiating %actor )n older children8 - Mec2el>s i*erticulu# - 4 ft pro8imal to the ileocaecal junction( 4C long( in 4D of 4yr olds - P olyp - Duplication - Henoc!-Sc!olein purpura - "ppen icitis Adults - !olocolic more common; - Polyp 0e+g+ PeutJ-Qeg!er>s syn ro#e) Su&#ucosal lipo#a - .u#our !B, .olic/y abdominal pain - "n ot!er'ise %it & 'ell male child of H months e*elops sudden onset o% screa#ing associate 'it! ra'ing up o% t!e legs3 .!e attac2s last %or a %e' #inutes$ recur e*ery 15 minutes & &eco#e progressi*ely se*ere+ During attac2s t!e c!il !as facial pallor '!ile &et'een episo es !e is listless 2 dra-n !efle8 vomiting following pain - 1eco#es conspicuous 'it! ti#e '3edcurrant &elly stool' ue to e/u ation o% mucus 2 blood ue to *ascular co#pro#ise L )sc!e#ia H per%oration L 7enderness on palpation (B4 .!e a& o#en is not distended .ausage shaped lump 'it! conca*ity to'ar s t!e u#&ilicus t!at hardens on palpation 0@*e in only 5*-H*%) -eeling o% emptiness in t!e 3/D 0the sign of !ance) 0348 1loo -staine #ucus #ay &e %oun on %inger Occasionally in e/tensi*e ileocolic or colocolic intussusception$ t!e ape/ #ay &e palpa&le or e*en protru e %ro# t!e anus

005 "cute enterocolitis HSP 6ectal prolapse /5 A63 - s#all or large &o'el o&struction 'it! an a4sent caecal gas s"adow in ileoileal or ileocolic cases @arium enema - #ay &e use to iagnose t!e presence o% an ileocolic or colocolic %or# (t"e claw sign) &ut 'oul be negati"e %or the ileoileal *ariant in t!e presence o% a competent ileocaecal *al*e

$5 a -on-op8 :ydrostatic or ,neumatic reduction - %arium enema at a !eig!t i% 1m or air under controlled pressure respectively is pus!e into t!e patient ,3 & re uction is con%ir#e &y *isualisation o% contrast or air enters t!e ter#inal ileu# &y /-ray !B/3 * Presence o% o&struction * Peritonis# * Prolonge !istory 0 J;Khrs ) b .urgery8 )n icate i% /schemia ? perforation is suspecte 0tenderness on palpation) 6e uction is ac!ie*e &y ta/is3 sLueeIing the most distal part of the mass in a cephalad direction + 0o not pull+ .!e *ia&ility o% all t!e &o'el s!oul &e c!ec2e care%ully+ )n t!e presence o% an irreducible or gangrenous intussusception$ t!e #ass s!oul &e e/cise in situ & an anastomosis or temporary end stoma created.

Surgery Page 71

Hirsc!sprung>s Disease 0.ongenital aganglionic megacolon)

)nci ence - 1)5*** &irt!s3 M7- - ;)1 "ssociate 'it!3 )ND - 25% 0own's syndrome - G% "6Ms

Causes
a !ongenital (commonest - -ailure o% #igration o% ganglion cells %ro# t!e neural crest to t!e gut 0usually "ind gut) - nor#al inner*ation is cranio-caudal t!us a%%ects t!e gut 0istally M ,ro5imally b AcLuired8 - 5ascular causes e+g+ 3ost op 45 to 3ull through operation( -ith damage to the mesenteric vessels Non-*ascular e+g+ )B( Biabetes

Pat!ological "nato#y
.!e histological hallmar/ o% Hirsc!sprung>s isease is Aganglinosis in the submucosal ple5us of $eissner an :ypoganglionosis # 's%ip-area' Aganglionosis 0#ay e/ist or coe/ist) in the intermyenteric ple5us of Auerbach. .!is lea s to unopposed autonomic nervous system %unctioning '!ic! causes3 * 6e uce or a&sent peristaltic acti*ity * )ncrease intestinal sp!incter tone .!e pathological hallmar/ is3 .!ere is #ar2e distension # hypertrophy o% gut pro5imal to t!e aganglionic seg#ent .!ere is funnelling (coning o% t!e gut between t!e t'o - transition Ione !onstricted or collapsed gut at # distal to t!e aganglionic portion

"nato#ical Distri&ution
K5% - =e%t colon 2% - .otal colonic aganglionosis Ultra short segment disease- "ganglionosis only at dentate line

CAP

C!ronic constipation since &irt! 0#p to < days constipation in an e8clusively breast feeding baby could be normal) Delaye passage o% #econiu# "& o#inal istension -ailure to t!ri*e -ecrotiIing enterocolitis - Bloody diarr"oea( "ever( ?epsis( Bile stained vomitus( ?hoc/

OA9

"& o#inal istension 0348 - )ncrease intestinal sp!incter tone - 9#pty rectu# - -ollo'e &y e/plosi*e passage o% stool & %latus PP Do D69 after @arium meal to pre*ent sti#ulating ,). contractions Mec!anical intestinal o&struction e+g+ ;econium plug syndrome /ntestinal neuronal dysplasia (/-0 8 - )nci ence o% N5% that of :irschsprung's disease. )t is esti#ate t!at 25% o% c!il ren 'it! Hirsc!sprung>s isease !a*e concomitant neuronal intestinal ysplasia$ '!ic! #ay e/plain '!y so#e patients continue to !a*e sy#pto#s %ollo'ing e%initi*e surgery+ - -eatures3 - Ectopic ganglion cells - Hyperplasia of the submucosal and intermyenteric ple8uses - H Hypertrophic nerve trun/s and aberrant neurofibrils i enti%ie &y acetylcholinesterase stain - !B, - $ long-standing "istory o2 constipation ( often dating from early infancy. - /5 - ON"DPH # O=DH in intermyenteric ple/us Hypoganglionosis - 'anglion cells are reduced by a factor of => 2 nerve 2i4res by a factor of 5 Hollo' *isceral #yopat!y e+g+ Besmosis of the colon - a&nor#al connecti*e tissue o% t!e colon+ Meta&olic isor ers Con itions a%%ecting stool co#position Muscular or neurological isor ers Me ications a #inistere to t!e #ot!er

DD/

Surgery Page 72

)/
1ariu# #eal3 - Massi*e istension o% pro/i#al colon - -unnelling 0coning) o% transition Jone - S!o's narro'ingAconstricte rectu# 6epeat after 2;:rs to #onitor %lo' o% contrast+ 6ectal &iopsy3 - .uction biopsy - "or neonates - Done up to 5cm a&o*e t!e entate line - Dull thic%ness biopsy - Un er ," for older c"ildren - Done from 2cm a&o*e t!e entate line "norectal #ano#etry - .o rBo /-0 - M resting anal pressure P25mm:g - )nsert &alloon & ilate it a&o*e intestinal sp!incter - .!e sp!incter nor#ally s!oul rela/ - rectosp"incteric in"i4itory re2lex is Absent8 Sp!incter rela/ation #ay occur 'it!out peristaltic 'a*es & instea t!ere is !ig! pressure seg#ental contractions 2C to nor#al s#oot! #uscle re%le/ acti*ity

M/ ,reop8 Manage %lui & electrolyte i#&alances )nsert a so%t rectal tu&e & gi*e patient so%t ene#as - ;.5mlB%g warm -. & irrigate ,). until patient settles+ !onser"ati"e surgery8 'e"elling colostomy - Colostomy in the normal colon or Ileostomy in total colonic aganglionosis )n ications3 - .o decompress nor#al gut to allo- normal gro-th 2 development until '!en e%initi*e #anage#ent can &e institute + - "*oi - -(7 eli#inate ris2 o% enterocolitis G Serial &iopsies are ta2en & su&#itte in %roJen section to eter#ine t!e e/tent o% t!e isease intra-op o% t!e3 i) Un ilate seg#ent 0most affected)3 - $bsent ganglion cells - Increased acetyl cholinesterase activity on !istoc!e#ical staining ue to lac2 o% consu#ption &y t!e ganglion cells ii) Ma/i#ally ilate seg#ent - Presence o% hypertrophic nerve bundles i) Nor#al gut - Nor#al anato#y 0efiniti"e surgery8 a 'eft colon disease - !esect aganglionated gut t!en anastomose normal gut at the dentate line i .oa"e procedure8 ;ucosectomy o% t!e rectal cu%% up to t!e entate line .!e anasto#osis o% nor#al gut at t!e entate line - 0#o i%ie &y 1oley) .!ere is ris2 o% cu%% a&scess so al'ays rain t!e cu%%+

Original Soa*e proce ure ii

1oley #o i%ication

.wenson's operation - 9n -to-9n anasto#osis at t!e entate line

ii 0uhamel-9rob princen procedure8 9n o% nor#al gut anasto#ose to t!e si e o% rectal cu%% at t!e entate line .!ere is ris2 o% faecaloma %or#ing in t!e aganglionate rectal cu%% - 'ester-$artin #o i%ication ta2es care o% t!is co#plication

Du!a#el Proce ure

=ester-Martin #o i%ication

6esultant co##on c!a#&er

b 7otal colonic aganglionosis - Martin?s procedure8 So#e colon is le%t %or a&sorption o% 'ater & storage o% %aeces+ )leu# is anasto#ose at t!e entate line & a side to side anasto#osis o% ileu# to re#aining colon+ .!e ileu# 'ill pro*i e peristalsis+

c Ultra short segment disease - Su4mucosal myomectomy

"ppen icitis

"cute "ppen icitis

"cute in%la##ation o% t!e *er#i%or# appen i/ $ost common acute surgical con ition o% a& o#en

"nato#y
.!e *er#i%or# appen i/ is a fi5ed "estigial narro' &lin e tu&e usually a&out G-;Q (1.H-1*cm long t!at e/ten s %ro# t!e caecu# in t!e 6)- at t!e ter#ination o% t!e 3 taenia coli & represents an atrophied terminal part of the caecum+ $ )t !as much lymphoid wall tissue$ nor#ally co##unicates 'it! t!e ca*ity o% t!e caecu#$ Aariation in sites8

)nci ence
2-H%8 )nci ence is decreasing ue to t!e use o% antibiotics # impro"ed hygiene Hig!est in t!e Grd - ;th eca es 01:-3:yrs) 1e%ore pu&erty & R3Byrs - MS .eenagers & young a ults - M7- - G)2

6is2 -actors
" olescent #ales -a#ilial ten ency - 1BG )ntra-a& o#inal tu#ours Purgati*e a&use

Pat!ogenesis
=u#en obstruction 2C to3 Daecaliths &most common) - Co#pose o%3 - )nspissate %aecal #aterial - Calciu# p!osp!ates - 1acteria - 9pit!elial e&ris =y#p!oi !yperplasia -ilarial 'or#s )nspissate &ariu# 5egeta&le$ %ruit see s an ot!er %oreign &o ies Strictures .u#our especially carcino#a o% t!e caecu# Once o&struction occurs$ continuous mucous secretion # inflammatory e5udation increases intralu#inal pressure$ obstructing lymphatic drainage. (edema # mucosal ulceration e*elop 'it! bacterial translocation to the submucosa+ 6esolution #ay occur at t!is point eit!er spontaneously or in response to anti&iotic t!erapy+ )% t!e con ition progresses$ %urt!er istension o% t!e appen i/ #ay cause "enous obstruction # ischemia o% t!e appen i/ 'all L ischemic necrosis M gangrenous appendicitis L perforation M a) )n neonates 0 ue to a poorly developed omentum)$ t!e elderly 0omentum shrin/s in si1e) & t!e immunocompromised$ t!e con ition is not controlle L %ree &acterial conta#ination o% t!e peritoneal ca*ity L 9eneralised peritonitis+

&) )n t!e rest$ the greater omentum 2 loops of small bo-el &eco#e a !erent to t!e inflamed appendi8$ 'alling o%% t!e sprea o% peritoneal conta#ination$ resulting in a phlegmonous mass & e*entually #ay %or# a paracaecal abscess 6arely appen iceal in%la##ation resolves lea*ing a isten e #ucous-%ille organ - mucocele o% t!e appen i/+ ,eritonitis occurs as a result o%3 -ree #igration o% &acteria t!roug! %ran2 per%oration o% a gangrenous appendi8 Delaye per%oration o% an appendi8 abscess

! Impaired ability to prevent invasion$ &roug!t a&out &y impro"ed hygiene 0so less e/posure to gut pat!ogens)

Surgery Page 7F

SAS
.ymptoms8 Sy#pto# appearance 0 <5%)3 i) .rescendo $bdominal pain - "s in%la##ation &egins$ t!ere is perium4ilical colic%y abdominal pain 0t!is is visceral pain t!at is re%erre to t!e midgut $@-$=>) &ut once t!e parietal peritoneum &eco#es in%la#e $ t!e pain s!i%ts to t!e 3/D 0localise parietal pain) & &eco#es more constant. Pain lessened -ith fle8ion of thigh &ut e8acerbated by coughing or sudden movement. i) $nore8ia - Patient is not !ungry ii) ;ild 6ausea 2 :omiting 0at t!e pea2 o% t!e pain 2C to peritoneal irritation) i) (bstipation - )na&ility to pass stool # flatus 0Constipation Inability to pass stool only) i) H Mil Diarr!oea (B48 "%ter Hhrs - 3ow grade fever 037+:-3G+:CC) & slight tachycardia -urre tongue @ -etor oris 3/D 3 i ,ointing sign - Patient points to '!ere t!e pain &egan & '!ere it #o*e i !utaneous hyperesthesia at 71*-12 i Ma/i#al tenderness at Q$c@urney's pointQ - Birect and referred i 3ebound tenderness - as2 t!e patient to coug! or gently percuss o*er t!e point o% #a/i#u# ten erness ii $uscle guarding - :oluntary and involuntary iii 3o"sing's sign - Pain #ore in t!e 6)- t!an in t!e =)- '!en t!e =)- is percusse i" ,soas sign - Occasionally$ an in%la#e appen i/ lies on t!e psoas #uscle 0usual %or retro-caecal ones) & t!e patient o%ten a young a ult 'ill lie motionless 'it! t!e right hip fle5ed %or pain relie% (3 hypere5tension of the hip &oint 0"emoral stretch test) #ay in uce a& o#inal pain+ " (bturator sign - )% an in%la#e appen i/ is in contact 'it! t!e obturator internus 0pel*ic ones)$ t!ere 'ill &e pain in t!e !ypogastriu# 'it! internal rotation of fle5ed right thigh D69 ten er on t!e rig!t 5aginal e/a#ination to rAo salpingitis etc+ 0 7ve cervical e8citation) 5ariations in t!e clinical picture3 - 3etrocaecal appendi5 - 3igidity is o%ten absent ue to istension o% t!e caecu# 'it! gas pre*enting t!e pressure e/erte &y t!e !an %ro# reac!ing t!e in%la#e structure+ Ho'e*er$ deep tenderness is o%ten present in t!e loin$ 'it! rigidity o% t!e Luadratus lumborum+ "lso ,soas spasm - ,el"ic appendi5 - -( a& o#inal rigidity8 .uprapubic tenderness+ D69 - ten erness in t!e rectovesical pouch or in the pouch of Bouglas( especially on t!e rig!t si e+ "lso$ H Diarr!oea$ .enes#us$ -re<uency - /nfants - (atery iarr!oea & *o#iting7 "ppen icitis #ay &e a co#plication o% si#ple gastroenteritis !hildren - 7he boy 'it! *ague a& o#inal pain '!o 'ill not eat !is fa"ourite food & "omits. - 4lderly - Gangrene 2 perforation occur #uc! #ore %re<uently+ .!e shoc%ed+ confused octogenarian '!o is not in pain - ,regnancy - "ppen icitis is not co##oner in pregnancy$ &ut mortality is higher$ especially %ro# 2*w%s gestation+ "s pregnancy progresses$ t!e appen i/ #igrates$ so pain is o%ten less 'ell localiJe $ & signs o% peritonis# less o&*ious+ ,erforation is commoner

DD/

)/
C1C @ 9S6 - OR@! - 11-15P1*<B' 0A=5 .omplicated appendicitis)3 15% neutrophils UA9AC Urinalysis "O6 Pregnancy test

SS" score o% P1 is strongly pre icti*e o% acute appen icitis

)n patients 'it! an e<ui*ocal score 0:-K)3 "& o#inalAPel*ic UAS Contrast en!ance C. scan o% a& o#en )nci ental %in ing o% a %aecolit! is a relati*e in ication %or prophylactic appendicectomy

Surgery Page G1

M/
,re-op8 )5/A $etronidaIole = cefuro5ime 1-3 oses 1hr pre-op - reduces -ound infections "ntipyretics %or !yperpyre/ia in c!il ren

i) Surgical "ppen icecto#y3

S2in & Su&cutaneous tissue - an arterial t'ig %ro# t!e superficial circumfle8 iliac artery usually re<uires ligation
>

9/ternal o&li<ue - cut along t!e line o% t!e incision

>

)nternal o&li<ue - split

>

.rans*ersus "& o#inis - split

>

Peritoneu#

a 7rans"erse or s%in crease ('anI incision Centre on midcla"icular-midinguinal line+ 2cm &elo' t!e u#&ilicus+ PP 9/posure is &etter & e/tension '!en nee e is easier especially '!en t!e iagnosis is in ou&t$ particularly in t!e presence o% intestinal o&struction+

b 9ridiron incision - Centre on $c@urney's point at rig!t angles to line 4oining "S)S & u#&ilicus PP Di%%icult to e/ten $ #ore i%%icult to close & pro*i es poorer access to t!e pel*is & peritoneal ca*ity+

c 3utherford $orison's incision - Use%ul i% t!e appen i/ is para- or retrocaecal # fi5ed+ )t is essentially an obliLue muscle-cutting incision 'it! its lo'er en o*er $c@urney's point # e5tending obliLuely upwards # laterally as necessary 0)t is possi&le to con*ert t!e ,ri iron incision to a 6ut!er%or Morison &y cutting the internal obliEue 2 transversus muscles in t!e line o% t!e incision) Unclear diagnosis - .!e iagnosis can &e #a e 'it! certainty &e%ore treat#ent is ren ere 0e+g+$ patients %oun to !a*e gynaecologic isor ers can &e treate appropriately) .!e operation is tec!nically easier in obese patients '!en one laparoscopically 6eco##en e %or females of child bearing age .!e postoperati*e !ospital stay a*erages 1 day less t!an a%ter open appen ecto#y & 3ecuperation an return to nor#al acti*ity is faster. ,ostoperati"e complications 0e+g+$ ileus$ 'oun in%ection) are less common &ut increases ris- of intraabdominal abscesses. PP .!e stu#p o% t!e appen i/ is buried &y purse stitc" or B met"od3 .!e stu#p is > irty> - contains conta#ination .o pre*ent it %ro# &ursting ue to &ac2 pressures %ro# t!e rest o% t!e colon Cexcept w"en; ,angrenous -ria&le

ii) =aparoscopic appen icecto#y3

Surgery Page G2

Co#plications

i) Pro&le#s encountere

uring "ppen icecto#y

Nor#al "ppen i/ 01B-1:; rate accepta&le) .!e appen i/ cannot &e %oun "n appen icular tu#our is %oun "n appen icular a&scess is %oun & t!e appen i/ cannot &e re#o*e ii) Per%oration 0 oes not appear to cause later in%ertility in girls) - 6is2 %actors3 )##unosuppression 9/tre#es o% age Dia&etes #ellitus Pregnancy -aecolit! o&struction o% t!e appen i/ lu#en " %ree-lying pel*ic appen i/ Pre*ious a& o#inal surgery t!at li#its t!e a&ility o% t!e greater o#entu# to 'all o%% t!e sprea o% peritoneal conta#ination+

iii) ,angrene i*) "ppen i/ #ass - .!is results '!en the greater omentum 2 loops of small bo-el &eco#e a !erent to t!e
inflamed appendi8$ 'alling o%% t!e sprea o% peritoneal conta#ination+ /5 - UAS$ Contrast-en!ance C. scan 358 "ppen icecto#y is deferred until t!e in%la##ation su&si es as t!e appendi8 is readily friable & surgery #ay lea to fistula formation. TT!onser"ati"e *sc"ner-Sc"erren regimen8 (@47743 7( (,43A74U - 5itals ;hrly - N1M & "nti&iotics 0 cefuro8ime 2 metronida1ole I: ) - Maintain %lui s - 6ecor t!e patient>s con ition & t!e e/tent o% t!e #ass - mar/ the limits of the mass on the abdominal -all using a pencil Clinical i#pro*e#ent is usually e*i ent 'it!in 2;-;Khrs - -ailure o% t!e #ass to resol*e s!oul raise suspicion o% a !arcinoma or !rohn's disease. Stop i%3 Patient gets #ore to/ic 0MPain$ .CC$ Pulse$ (CC) )ncreasing or sprea ing a& o#inal pain )ncreasing siJe o% #ass Appendicectomy is one a%ter an inter*al o% H-Kw%s *) "ppen i/ a&scess - .!is results i% an appendix mass 2ails to resolve1 .B. - 9nlarge#ent o% t!e #ass or i% t!e patient gets #ore to/ic 0MPain$ .CC$ Pulse$ (CC) 358 !onser"ati"e - 9specially in children - 6nti4iotics 0rainage - Surgical or percutaneous 0un er ra iological gui ance) Elective appendicectomy is one in H-Kw%s

*i) Pel*ic a&scess3

!B,8 Spi2ing pyre/ia se*eral ays %ollo'ing appen icitis Pel*ic pressure & isco#%ort =oose stool & tenes#us (B4 - D69 - Boggy mass in the rectovesical pouc" or t"e rectouterine pouc" (3ouch of Bouglas) /5 - Pel*ic UAS or C. scan $58 .ransrectal drainage un er ," Elective appendicectomy is one in H-Kw%s

*ii)

"ppen icular stu#p syn ro#e - S/S o2 acute appendicitis 2D to appendicectomy due to a retained

small appendix1

*iii) C!ronic appen icitis - $%

Surgery Page G3

 (oun in%ection )ntra-a& o#inal a&scess )leus 0especially if persisting A<-5days E 2ever) Pneu#onitis or collapse 5enous t!ro#&osis & e#&olis# Portal pye#ia 0pylep"le4itis) - Co#plication o% gangrenous appen icitis associate 'it! "ig" 2ever5 rigors , (aundice cause &y septicae#ia in t!e portal *enous syste# & lea s to t!e e*elop#ent o% intra"epatic a4scess1 -aecal %istula " !esi*e intestinal o&struction 6ig!t inguinal !ernia - more common follo-ing a gridiron incision due to injury to the ilio"ypogastric nerve

Post-op Co#plications

Sto#as
" sto#a is an arti2icial union #a e 4etween 2 conduits 0e+g+ a c!ole oc!o4e4unosto#y) or$ #ore co##only 4etween a conduit , t"e outside e+g+ a colosto#y 0Mout! & anus are natural sto#as)

a) )leosto#y - Protru e %ro# t!e s2in & e#it %lui #otions '!ic! contain acti*e enJy#es 0so
s2in nee s protecting)+ 4nd ileostomy - -ollo's proctocolectomy( typically %or ulcerative colitis 'oop ileostomy - Use instea o% a colosto#y %or defunctioning a lo- rectal anastomosis3 Ad"antage o*er loop colosto#y - Ease -ith -hich the bo-el can be brought to the surface 2 the a4sence o2 odour1 &) Caecosto#y - )n icate %or emergency situations &e%ore e%initi*e treat#ent is institute +

Colosto#y is an artificial opening #a e in t!e large &o'el to divert 2aeces , 2latus to t!e e/terior$ '!ere it can &e collecte in an e/ternal appliance+
&)

)n ications3
$o relieve an o4struction $o give a distal in(ury time to "eal $o rotect a distal Sx site

'oop colostomy - " loop o% colon is e/terioriJe $ opene & se'n to t!e s2in+ " ro un er t!e loop 0&ri ge) pre*ents retraction & #ay &e re#o*e a%ter 1d+ Use to protect a distal anastomosis or to relieve distal o4struction & #ost are #a e in t!e transverse colon &ut t!e sigmoid colon can also &e suita&le 4nd (7erminal !olostomy - .!e &o'el is i*i e 3 t!e pro/i#al en &roug!t out as a sto#a- Usually in t!e '/D8+ .!e istal en #ay &e3 - 6esecte e+g+ "P resection o% t!e rectu# - Close & le%t in t!e a& o#en - :artman's procedure - 9/terioriJe %or#ing a 'mucous fistula' 0ouble-barrelled (,aul-$i%ulicI colostomy - " colosto#y 'it! both ends of a colon e8teriori1ed+ )t #ay &e close using an enteroto#e+ 0i"ided 7emporary - in '!ic! e*ent it is su&se<uently close $ usually after ;-@w-s S 'oop colostomy - Usually %or pae iatrics & *ery sic2+ - 9asy to per%or# &ut #ore associate 'it! prolapse ,ermanent8 - :artman's colostomy

.ypes3

Duration3

Dunctioning colostomy - Bischarges stool from normal e8ternal orifice i.e. the anus; - 3oop colostomy 0efunctioning colostomy - ?tool is discharged through a stoma -

-unctionality3

Dou&le-&arrelle 0Paul-Mic2ulicJ) colosto#y - Di*i e colosto#y - Hart#an>s colosto#y

Surgery Page FB

Hart#an>s colosto#y

"nato#ic site3

"

7rans"erse+ descending+ sigmoid+ etc.

$anagement ,rinciples R ,atient counselling R Usual pre-op preparation for 9/7 R A"oid areas of prominences (A./. or .5 incisions (laparotomy R ,os t-op care8 Analgesia7 )nitially )5 eg+ Opiates 0pet!i ine .i A Ti in1st 8G!rs) or strong NS")DS t!en step o'n to oral NS")DS 0can co#&ine t'o t!en single) Dluid # 4lectrolyte balance7 gi*e 3lA or #aintain urine out o% B+:-1+B#lA2gA!r+ "ccount %or *o#iting an insensi&le losses 0up to KBB#lA ) an ?ANaACl le*els ,re"ention of !omplications7 proper aA&iotics$ !ae#ostasis 0S/ tec!+)$ p!ysio &occupational t!erapy+ .pecific $5 %or un erlying con ition 3ehab3 counseling epen ing on proce ure one

Co#plications - 2*% (=5% reFuire operative correction

Anaesthetic complications .toma-associated - /aemorr"age usually %ro# granulo#as aroun t!e #argin o% t!e colosto#y - Isc"emia , :ecrosis o2 t"e distal end - ue to tec!nical errors in constructing t!e sto#a+ - Obstruction by ad"esions - 9etraction - ue to tec!nical errors in constructing t!e sto#a+ - eristomal a4scess - Stenosis o2 t"e ori2ice - largely a*oi e &y #aturing t!e colosto#y at t!e operating ta&le as 'it! ileosto#y+ - ?toma (mucosal) rolapse most common complication - .hronic peristomal "ernia - e*elops &ecause t!e a& o#inal 'all aperture enlarges 'it! ti#e$ allo'ing colon$ o#entu#$ or s#all &o'el to !erniate a 4acent to t!e colosto#y+ - Gistulae - 3erforation - a*oi e &y putting a de ,eIIer catheter (a sel%-retaining cat!eter 'it! a &ul&ous e/tre#ity) an &y #aintaining t!e irrigation reser*oir at no greater t!an s!oul er !eig!t+ - Colostomy diarr"oea - usually an in%ecti*e enteritis & 'ill respon to Metroni aJole 2BB#g t s+ - =ess serious co#plications inclu e faecal impaction$ an s/in irritation. - syc"ological - 'angrene (revise) -@) Colosto#ies usually on>t gi*e electrolyte imbalances unli2e ileostomies

)ntestinal -istula
V3efer to :and-out) 4nterocutaneous DistulaW
S#all &o'el %istulae " %istula is an a4normal communication &et'een a "ollow viscus and some ot"er organ or structure5 inclu ing t!e s2in+
i) ii)

Classi%ication "ccor ing to t!e sites of origin and termination - e+g+ jejunocutaneous or ileovesical fistulas. "ccor ing to tissue of origin8 Nor#al intestine "ssociate 'it! an a&nor#ality suc! as .rohn9s disease or radiation enteritis. iii Internal or External a /nternal fistulae - al#ost al'ays t!e result o% c"ronic in2lammation o2 t"e intestine+ Per%oration an a&scess %or#ation lea s to co##unication 'it! an a 4acent loop o% &o'el or *iscus+ - Ileoileal and ileocolonic fistulae are relati*ely !ar#less an o%ten asy#pto#atic obstruction or sepsis rat!er t!an t!e %istula itsel% are t!e usual reasons %or resection+ - Gistulae to t"e 4ladder or$ rarely$ to ot!er parts o% t!e urinary syste#$ lea to recurrent &outs o% urinary sepsis3 %or t!is reason t!ey usually re<uire resection+ - !uodenoc"oledoc"al fistulae$ a rare co#plication o% uo enal ulcer isease$ are o%ten asy#pto#atic$ &ut #ay lea to episo es o% &iliary sepsis+ b 45ternal fistulae inclu e duodenocutaneous or ileovaginal i" "ccor ing to amount o2 output a 'ow output fistulae - .!ese %istulae rain s#all a#ounts o% %lui - X2** m'Bday '!ic! o%ten !as t!e appearance o% mucous or infected material t!at oes not suggest an intestinal origin+ ersistence o% a lo' output %istula usually in icates t!e presence o%3 a foreign body$ typically !ea*y sutures or #es!$ or an intrinsic abnormality o% t!e intestine at t!e site o% origin+ b :igh output fistulae - .!ese %istulae rain large a#ounts o% %lui - J5** m'Bday '!ic! is eit!er %ro#3 t!e diversion o% a su&stantial part o% t!e intestinal contents or a *ery pro8imal origin$ an #any patients !a*e partial or co#plete o&struction or e/tensi*e suture line e!iscence+ Causes =ocal per%oration o% isease &o'el - Internal fistulae Surgery - $lmost all external fistulae - Surgical "oreign bodies - usually #es! use in t!e repair o% a %ascial e%ect - Surgical misadventures Spontaneous - Occur at the site of drainage of an abscess originating from a bo-el perforation .rau#a M/ Conser*ati*e i Dluid # electrolyte balance ii 'ocal s%in care - a collecting &ag s!oul &e use as a #eans %or protecting t!e s2in an <uantitating output+ iii /5 a Distulogram+ using a 'ater solu&le ra io-opa<ue #e iu#+ )% t!ere is no cavity$ @arium studies can t!en &e use 3 SiJe o% t!e lea2 "&sence o% istal o&struction Presence o% a tu#our 9/tent o% in%la##atory c!anges in t!e intestine itsel% b Ultrasound study c !7 scan i" 0ecrease "olume output if high8 a) Place#ent o% a nasogastric tube or i% long term use #ay &e in icate $ a gastrostomy tube. a) ,harmacological #eans o% ecreasing output inclu e t!e a #inistration o% /2 4loc-ers -ithout antacids an somatostatin analogues. " -utritional support "i !ontrol local sepsis - "&scess ca*ities #ust &e unroo%e or raine an placing a cat!eter a 4acent to or e*en in a %istula opening #ay &e use%ul+

Surgical inter*ention )he definitive treatment of fistulae t"at do not close spontaneously is surgical resection. a) )% 0irect closure see#s possi&le$ the suture line should be protected &y &ringing up a loop o% intact s#all intestine as a ?serosal patc"?+ .!is con ition #eets t!e nee o% pro*i ing a nor#al local en*iron#ent %or !ealing+ a) .egmental resection # Anastomosis - " seg#ent o% intestine is re#o*e 'it! anasto#osis$ t!e suture &o'el &eing place in an area not affected &y in%la##ation or ot!er a&nor#ality+ &) " @ypass #ay &e all t!at can &e acco#plis!e e+g+ 0uodenal fistulae - " 3ou5-en-Y li#& is anasto#ose o*er t!e %istula$ con*erting it to a per#anent internal %istula

Co#plications ! 6cute o4literative peritonitis

Hernias
" !ernia is a protrusion o% a "iscus or part of a "iscus t!roug! an opening in t!e 'alls o% it>s containing ca*ity+ !ommonest cause o% intestinal o&struction UU

.ypes
a /nternal - Invisible ;ore common in children .ongenital; i 0iaphragmatic hernias e+g+ 1oc! ale2 !ernias in t!e %ora#en o% 1oc! ale2 2C to %ailure to close o% t!e le2t posterior part of the diaphragm. i :iatus :ernia b 45ternal - ;ost common 3resent -ith a visible s-elling i) )nguinal !ernia - K*% i) )ncisional !ernia - H-1*% ii) -e#oral !ernia - 2-5% iii) U#&ilical !ernia - .ongenital

3ed - Co##on3 Rhite - Not unusual3 @lac% - 6are

"etiologyA6is2 %actors
1C 0Congenital)3
"n indirect inguinal hernia #ay occur in a congenital pre%or#e sac - t!e re#ains o% t!e processus "aginalis Umbilical hernia

2C3

- C!ronic coug! 0bronchiectasis( asthma)

"ny con ition t!at raises intra-abdominal pressure e+g+

Po'er%ul #uscular e%%ort Straining on #icturition Straining on e%ecation 0 chronic constipation ) )ntra-a& o#inal #alignancy Pregnancy .mo%ing - lea s to ac<uire collagen e%iciency (besity - -at3 - Separates #uscle &un les & layers - (ea2ens aponeuroses - Usually3 * Hiatus !ernia * Parau#&ilical !ernia * 0irect inguinal !ernia $ultiparity - Causes femoral hernias ue to stretc!ing o% t!e pel*ic liga#ents /atrogenic8 - )ncisional !ernias - 3eritoneal dialysis can cause t!e e*elop#ent o% a !ernia %ro# a previously occult -ea/ness or enlargement of a patent processus vaginalis. 7rauma

Co#position o% a Hernia
Mout! Nec23

i) .!e sac - .!is is a di"erticulum of peritoneum$ consisting o%3

- #ell defined - a narro' nec2 t!at coul lea to strangulation o% t!e &o'el * /ndirect inguinal !ernias * -e#oral !ernias * Parau#&ilical !ernias

- :ot -ell defined 0no actual nec2) * 0irect inguinal !ernias * )ncisional !ernias
1o y & %un us

ii) .!e co*erings o% t!e Sac - Deri*e %ro# layers o% t!e a& o#inal 'all t!roug! '!ic! t!e sac passes+

iii) Contents o% t!e Sac3

O#entu# S Omentocele )ntestine S <nterocele - $ore commonly small bowel$ &ut #ay &e large intestine or appen i/ " portion o% t!e circu#%erence o% t!e intestine S 3itchter's hernia - )n*ol*e t!e bowel wall only$ not lumen. " portion o% t!e bladder (or a diverticulum - #ay constitute part o% or &e t!e sole contents o% a3 - 0irect inguinal Hernia Sli ing inguinal !ernia -e#oral Hernia O*ary H t!e correspon ing %allopian tu&e " Mec2el>s i*erticulu# S a 'ittre's hernia -lui - as part o% ascites or as a resi uu# t!ereo%

Classi%ication

.!e !ernia eit!er re uces itsel% '!en t!e patient lies down or can &e re uce &y t!e patient or t!e surgeon )#parts an e5pansile impulse on coughing .!e intestine usually gurgles on re uction & t!e first portion is #ore difficult to re uce t!an t!e last .!e omentum in contrast$ is oug!y$ & t!e last portion is #ore difficult to re uce t!an t!e %irst+ ii) )rre uci&leAincarcerate - contents cannot &e returne &ut t!ere are no ot!er co#plications3 Usually ue to ad"esions bet-een the sac 2 it9s contents or %ro# overcrowding -ithin the sac Usually omentocele$ especially in femoral # umbilical hernias .!ere is a ris% of strangulation at any ti#e iii) O&structe - / rred ucib le hern ia containing intes tine '!ic! is obstru cted %ro# ' it!out or 'it!in &ut t!ere is no inter 2erence to th e blood supp ly to th e bow el. ! B, - Colic2y a& o#inal pain & ten erness 3 us ually goes on to strangu lation i*) Strangulate - 1loo supply o% &o'el is o&structe ren ering t!e contents isc!e#ic3 gangrene can occur 'it!in 5-Hhrs8 More co##on in femoral hernias &ecause o% t!e narrowness of the nec% & its rigid surrounds. *) )n%la#e - contents o% sac !a*e &eco#e in%la#e

i) 6e uci&le - contents can be returned to a& o#en

Pat!ology
.!e intestine is obstructed & it>s blood supply impaired+ )nitially only t!e "enous return is impeded$ t!e 'all o% t!e intestine &eco#es congested # bright red 'it! transudation o% serous %lui into t!e sac+ "s congestion increases$ t!e 'all o% t!e intestine &eco#es purple in colour+ .!e intestinal pressure increases$ distending the intestinal loop & impairing "enous return further+ "s *enous stasis increases$ t!e arterial supply becomes more # more impaired+ 1loo is e5tra"asated under the serosa & is effused into the lumen+ .!e %lui in t!e sac &eco#es &loo -staine & t!e s!ining serosa ull ue to a fibrinous+ stic%y e5udate. "t t!is stage$ t!e 'alls o% t!e intestine !a*e lost t!eir tone & &eco#e %ria&le+

@acterial transudation occurs 2C to t!e lowered intestinal "iability & t!e sac %lui &eco#es in%ecte + 9angrene co##ences at the rings of constriction+ '!ic! &eco#e eeply in ente & grey in colour$ t!en e*elops in t!e antimesenteric border$ t!e colour *arying %ro# &lac2 to green epen ing on t!e eco#position o% &loo in t!e su&serosa+ 7he mesentery in*ol*e &y t!e strangulation also &eco#es gangrenous+ )% t!e strangulation is unrelie"ed$ perforation o% t!e 'all o% t!e intestine occurs$ eit!er at t!e con"e5ity of the loop or at t!e seat of constriction+ ,eritonitis sprea s %ro# t!e sac to t!e peritoneal ca*ity+

CAP

-on-strangulated hernias - .oft & e/!i&it no pain .trangulated hernias - Su en pain$ at %irst situate o*er t!e !ernia$ %ollo'e &y generalise a& o#inal pain$ colic2y in c!aracter & o%ten locate #ainly at t!e umbilicus. -ausea # su&se<uent "omiting ensue+ Unless t!e strangulation is relie*e &y operation$ t!e spas# o% pain continue until peristaltic contractions cease 'it! t!e onset o% ischemia$ '!en paralytic ileus (often the result of peritonitis # septicaemia e*elop+ .pontaneous cessation of pain #ust &e *ie'e 'it! caution$ as t!is #ay &e a sign of perforation (B4 - .!e !ernia is tense+ e5tremely tender+ irreducible & t!ere is no expansile coug" impulse )ncrease in !ernia siJe

)nguinal Hernias
Surgical anato#y

Abdominal incision - ,fannenstiel incision i) S2in ii) Su&cutaneous tissue iii) Super%icial %ascia a) Ca#per>s - -atty &) Scarpa>s - Me#&ranous i*) 6ectus s!eat! - "poneurosis o% e/ternal o&li<ue #uscle *) 6ectus a& o#inis *i) Pyra#i alis #uscle *ii) .rans*ersalis %ascia *iii) 9/tra-peritoneal 0su&serous) %ascia 0areola tissue)APre-peritoneal %at i/) Peritoneu#

.!e .uperficialB45ternal inguinal ring is a triangular aperture in t!e aponeurosis of the e5ternal obliLue+ .!e ring is &oun e &y a superomedial 2 an inferolateral crus 4oine &y t!e criss-cross intercrural fibres+ Nor#ally t!e ring 'ill not a #it t!e tip o% t!e little %inger+ .!e 0eepB/nternal inguinal ring is a U-s!ape condensation of the trans"ersalis fascia abo"e the inguinal (,oupart's ligament$ #i 'ay &et'een t!e sy#p!ysis pu&is & t!e "S)S+ .!e trans*ersalis %ascia is t!e %ascial en*elope o% t!e a& o#en & t!e co#petency o% t!e eep inguinal ring epen s on t!e integrity o% t!is %ascia+ .!e inferior epigastric "essels lie medial to t!e ring+ )t is e%ine as &eing t!e inguinal ligament's mid-point 11B2 cm abo"e t!e femoral pulse 0'!ic! crosses t!e #i -inguinal point) .!e inguinal canal is irecte downwards # medially %ro# t!e deep to the superficial inguinal ring+ 1oun aries3 - Dloor - )nguinal liga#ent$ cooper>s+ - 3oof - -i&res o% trans*ersus & internal o&li<ue - Dront - 9/ternal o&li<ue aponeurosis @ )nternal o&li<ue %or t!e lateral 1A2 - @ac% - =aterally$ trans*ersalis %ascia3 #e ially$ con4oine ten on 0internal o&li<ue & trans*ersus a& o#inis) Contents3 - 9ncase in cre#asteric %ascia3 * Sper#atic cor A6oun liga#ent 0in %e#ales) * .esticular *essels * ,enital &ranc! o% t!e genito%e#oral ner*e * )lioinguinal ner*e - Sper#atic %ascia 0)nternal - .rans*ersalis %ascia3 9/ternal - 9/ternal o&li<ue "poneurosis) "n inguinal !ernia can &e i%%erentiate %ro# a femoral !ernia &y ascertaining t!e relation o% t!e nec% of the sac to t!e medial end of the inguinal ligament # the pubic tubercle$ i+e+ in t!e case o% an inguinal hernia+ t!e nec% is abo"e # medial$ '!ile t!at o% a femoral hernia is below # lateral. Digital control o% t!e internal ring #ay !elp in istinguis!ing &et'een an indirect # a direct inguinal !ernia - .!e !ernia is re uce & t!e internal ring occlu e 'it! 2 fingers3 .!e patient is as2e to coug! - i% t!e !ernia is restrained$ it is indirect$ i% it pops out$ it is direct+

a) )n irect 0O&li<ue) )nguinal Hernia

Incidence $ost common o% all %or#s o% !ernia3 Most co##on in t!e young *-1*yrs - More co##on on t!e right si e in males ue to t!e later descent of the right testis & a !ig!er inci ence o% %ailure o% closure o% t!e processus *aginalis+ Adults8 - H5% o% inguinal !ernias are indirect 55% are right si e 3 1ilateral in 12; at"ogenesis - 7ra"els down the canal on t!e outer 0lateral # anterior) si e o% t!e sper#atic cor + .!e nec2 is lateral to t!e in%erior epigastric *essels

$ypes;

i @ubonocele - .!e !ernia is li#ite to t!e inguinal canal ii Dunicular - .!e processus *aginalis is close 4ust a&o*e t!e epi i y#is+ .!e contents o% t!e sac can &e %elt separately %ro# t!e testis '!ic! lies &elo' t!e !ernia iii !omplete (scrotal - t!e testis appears to lie 'it!in t!e lo'er part o% t!e !ernia+ 6arely present at &irt!+ C/ ; Pain in t!e groin or pain re%erre to t!e testicle '!en per%or#ing !ea*y 'or2 or ta2ing strenuous e/ercise+ )n large !ernias$ t!ere is a sensation o% 'eig!t & ragging on t!e #esentery & t!is #ay pro uce epigastric pain */E; .!e clinician e/a#ines t!e patient %ro# t!e %ront 'it! t!e patient stan ing 'it! t!e legs apart & also '!en lying o'n to c!ec2 %or re uci&ility+ 9/a#ination using %inger & t!u#& across t!e nec2 o% t!e scrotu# 'ill !elp to istinguis! &et'een a s'elling o% inguinal origin & one t!at is entirely intrascrotal+ (!en as2e to coug!$ a s#all transient &ulging #ay &e seen & %elt toget!er 'it! an e/pansile i#pulse+ (!en t!e sac is still li#ite to t!e inguinal canal$ t!e &ulge #ay &e &etter seen &y o&ser*ing t!e inguinal region %ro# t!e si e or e*en loo2ing o'n t!e a& o#inal 'all '!ile stan ing &e!in t!e rele*ant s!oul er o% t!e patient+ )n in%ants$ t!e s'elling appears '!en t!e c!il cries3 it can &e translucent in in%ancy & early c!il !oo &ut ne*er in an a ult )n girls t!e o*ary #ay prolapse into t!e sac 0058 Psoas a&scess Male3 - " *aginal !y rocele - "n encyste !y rocele o% t!e cor - " lipo#a o% t!e cor - Sper#atocele - " %e#oral !ernia - "n inco#plete escen e testis in t!e inguinal canal+ "n inguinal !ernia is o%ten associate 'it! t!is con ition -e#ales3 - " !y rocele o% t!e canal o% Nuc2 - most common !!x " %e#oral !ernia

Surgery Page 1BB

&) Direct Hernia

/ncidence - G5% o% inguinal !ernias3 Most co##on in t!e older males. Romen practically ne"er e*elop a irect inguinal !ernia 3is% factors8 S#o2ing Occupations t!at in*ol*e straining & !ea*y li%ting Da#age to t!e ilioinguinal ner"e 0pre*ious appen icecto#y) - ue to resulting 'ea2ness o% t!e con4oine ten on+ ,athogenesis - " irect inguinal !ernia is always acLuired+ .!e sac passes t!roug! a wea%ness or defect o% t!e trans"ersalis fascia in the posterior wall o% t!e inguinal canal usually in t!e :esselbach's triangle+ .!e !ernia usually e#erges medial to t!e in%erior epigastric *essels e5cept in t!e saddle-bag type or pantaloon type$ '!ic! !as &ot! a lateral & #e ial co#ponent & lie behind t!e spermatic cord+ .!ey reduce easily & rarely strangulate.

$5 Manage causati*e %actors I /nguinal herniotomy - Dissect out & open t!e !ernial sac$ re uce any contents & t!en trans%i/ t!e nec2 o% t!e sac & re#o*e any re#ain er+ 6eco##en e %or /nfants$ a olescents & young a ults3 I :erniotomy # 3epair (:erniorrhaphy 8 i) 9/cision o% t!e !ernial sac3 plus i) 6epair o% t!e stretc!e internal inguinal ring 2 the transversalis fascia; & .houldice operation - .!is in*ol*es #ultilayere tension-%ree suturing in*ol*ing &ot! t!e anterior & posterior 'alls o% t!e inguinal canal &et'een t!e internal o&li<ue aponeurosis arc! & t!e inguinal liga#ent using #ono%ila#ent #aterials$ polypropylene$ polya#i e or 'ire iii -urt!er rein%orce#ent o% t!e posterior 'all o% t!e inguinal canal - (ii # (iii #ust &e ac!ie*e 'it!out tension resulting in t!e 'oun + $esh techniLues e.g. 'ichtenstein tension-free hernioplasty in*ol*es place#ent o% a #es! - synt!etic e+g+ Dacron or Patient>s o'n tissues e+g+ %ascia lata$ e/ternal o&li<ue aponeurosis) as an e/tra la#ina$ anterior to t!e posterior 'all & o*erlapping it generously in all irections$ inclu ing #e ially o*er t!e pu&ic tu&ercle+

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-e#oral Hernia
Anatomy8 1oun aries o% t!e %e#oral ring3 - "nteriorly & Me ially - .!e inguinal liga#ent =aterally - .!e %e#oral *ein - Posteriorly - .!e pectineal liga#ent Contents3 - -at - Clo<uet>s no e /ncidence - Occur #ore o%ten in women ,athogenesis .!e nec2 o% t!e !ernia is %elt below # lateral to the pubic tubercle 0inguinal !ernias are a&o*e & #e ial to t!is point)+ 1o'el enters t!e %e#oral canal$ presenting 'it! a #ass in t!e upper medial thigh or abo"e the inguinal ligament '!ere it points o'n t!e leg$ unli2e an inguinal !ernia '!ic! points to t!e groin+ .!ey are li2ely to &e irreducible & to strangulate.