Surgical abdomen

1. Surgical abdomen Preparation for Finals – Case-based Learning Tutor name

2. TuBS attendance • https://tutorialbooking.com/

3. Session overview • Common surgical conditions for the OSCE • How to present your findings • Overview of clinical signs/surgical scars • Case presentations and viva questions

4. What is the purpose of an OSCE? “This station tests a student’s ability to perform an appropriate focussed physical examination, demonstrating consideration for the patient, and to report back succinctly describing the relevant findings. It also tests a student’s clinical judgement i.e. the ability to decide the differential diagnosis, choose investigations and formulate a management plan.”

5. Common surgical conditions in the OSCE • Hernias • Stomas • Surgical scars

6. Presenting your findings • What were you asked to do? • What were your key positive findings? • What were the important negative findings? • What does this mean? • How would you complete your examination, and what investigations would you do?

7. Example case presentation • I was asked to examine the abdomen of this ___ year old ___ • On examination this patient has a mass in the right groin. • It is medial to and above the pubic tubercle, and did not reappear after being reduced when the deep ring was occluded. Bowel sounds were auscultated over the mass. • I therefore think this is a direct inguinal hernia. • My differential would include an indirect inguinal hernia and a femoral hernia.

8. Completing your examination • Examine the contralateral groin • Transilluminate the mass • Full GI examination in particular look for causes of raised intra-abdominal pressure

9. Investigations Bedside ECGs, urine dip, spirometry Bloods and urine Biochemistry, haematology, M,C&S Imaging Plain XR, CT, MRI, US, echo Other Biopsy

10. Clinical signs Practise presenting!

18. Abdominal scars • Present what you see, described the scar if you do not know the name • Give a differential diagnosis

19. Presentation of a surgical scar • Describe: this is a xxx incision which is consistent with a previous xxx such as a xxx • Age - old or new? • Healing - well healed, hypertrophic or keloid? • Complications - infected or dehisced? Evidence of incisional hernia?

20. Scar 1

21. Scar 1 • Mercedes-Benz incision • Major upper GI or HPB surgery • E.g. liver transplant , Whipples procedure

22. Scar 2

23. Scar 2 • Midline laparotomy • Major intra-abdominal surgery

24. Scar 3

25. Scar 3 • Laparoscopy ports • 1 port = diagnostic laparoscopy

26. Scar 4

27. Scar 4 • Rutherford-Morrison incision • Renal transplant

28. Scar 5

29. Scar 5 • Loin incision • Renal surgery • E.g. nephrectomy

30. Scar 6

31. Scar 6 • Pfannenstiel incision • Open gynae surgery • E.g. C-section

32. Scar 7

33. Scar 7 • Suprainguinal incision • Open mesh repair of inguinal hernia

34. Scar 8

35. Scar 8 • Lanz incision • Appendicectomy • Lanz now favoured as hidden in skin creases compared to Gridiron which is more oblique

36. Scar 9

37. Scar 9 • Kocher’s incision • Open cholecystectomy

38. Scar 10

39. Scar 10 • Laparoscopy ports • Laparoscopic cholecystectomy

40. Case 1

41. Please present your findings.

42. Case 1 - general • Middle aged man, with walking stick • Very slim • No lymphadenopathy

43. Case 1 - abdomen

44. Case 1 – more abdo • Abdo soft, non tender • No palpable masses • Bowel sounds normal • Legs normal Please present your findings.

45. Case 2

46. Case 2 - general 45 Year old male, on examination…. Looks well at rest, average BMI. Face – Pale conjunctivae Legs – Nil of note

47. Case 2 - abdomen • Palpable mass in LIF – 8x6, smooth • Tender • Bruit present overlying it • No other masses • No other organomegaly, non-palpable bladder • Bowel sounds present, normal

48. Case 3

49. Case 2 Case 3 - observation 65 Year old male, on examination…. Looks well at rest, high BMI.

50. Case 3 - abdomen • Abdomen soft • Liver edge palpable 3 cm below costal margin • No spleen/kidneys/bladder • Bowel sounds present Please present your findings.