Transcript Bowel Obstruction and Hernias

BOWEL OBSTRUCTION AND
HERNIAS
- SLIME TEACHING 2013
Richard Marks – FY1 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?
?USS
Pre-op investigations
Vomiting, painful,
stuck?
FBC, U&E, CRP
G&S
Glucose, amylase
Erect CXR – perf?
AXR – exclude obstruction
MANAGEMENT

Conservative...

Medical...

Surgical...
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 4cm 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