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B OWEL O BSTRUCTION AND H ERNIAS - SLIME TEACHING 2013 Richard Marks FY1 Orthopaedics @ Warwick Slide 2 A IMS Hernias What are they? Anatomy Presentation Complications Bowel Obstruction Types Complications Investigation Management Slide 3 A hernia is the protrusion of a viscus or part of a viscus outside the cavity which normally contains it So what is a hernia??? Slide 4 W HAT ARE THE TYPES ? Slide 5 C ASE 1 A 54 year old builder attends your GP clinic with a testicular mass. Its painful, mildly tender to palpation. Differentials? What if hes vomiting? Slide 6 T HE INGUINAL CANAL Split it into the four walls - Anterior - Posterior - Roof - Floor Where are the deep & superficial rings? Slide 7 A NATOMY... YAY... Slide 8 T HE F EMORAL C ANAL Anteriorly: inguinal lig. Medial: lacunar lig. Lateral: Femoral vein + illopsoas Posterior: pectineal lig. + pectineus Slide 9 I NGUINAL OR F EMORAL ? The key to remember is: Femoral = inferior and lateral to the pubic tubercle Inguinal = Superior and medical to the tubercle Slide 10 D IRECT OR I NDIRECT I NGUINAL H ERNIA ? 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? Slide 11 W HY 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? Slide 12 S O HOW TO INVESTIGATE ? Vomiting, painful, stuck? FBC, U&E, CRP G&S Glucose, amylase Erect CXR perf? AXR exclude obstruction Painless, reducable?Vomiting, painful, stuck? Painless, reducable? ?USS Pre-op investigations Slide 13 M ANAGEMENT Medical... Conservative... Surgical... Slide 14 B OWEL O BSTRUCTION Slide 15 C AUSES Intra-luminal: Faecal impaction Gallstone ileus Intramural Cancers Strictures IBD, diverticulitis Extraluminal Adhesions Hernias Volvulus Foreign body... TB (developing world) Slide 16 W HAT 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 Slide 17 S MALL OR L ARGE BOWEL OBSTRUCTION ? Slide 18 S MALL OR L ARGE ? Slide 19 S MALL VERSUS L ARGE ? Slide 20 P SEUDO - OBSTRUCTION ... So dont worry too much about it! Slide 21 Slide 22 C LINICAL F INALS... 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 its 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 Slide 23 O N 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? Slide 24 M ORE QUESTIONS... 5) What are the borders of the inguinal canal? - Floor? - Anterior? - Roof? - Posterior? 6) Risk factors for hernias? 7) Remind me again... What is a hernia? 8) What are the main complications of hernias? Slide 25 P LEASE EXPLAIN... Please take a few minutes to explain to Mr Hunt that he needs a CT scan... Slide 26 A LMOST THERE... As theres no orthopaedic session by SLIME, make sure you at least skim the basics on #NOFs...... And dont suggest exercise tolerance test as a pre-op investigation in a hip fracture like a few 2009 cohort guys did... Slide 27 F INALLY... Good luck!! (They let me pass, so youll be absolutely fine!) http://radiologymasterclass.co.uk