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Bowel Obstruction and Hernias - SLIME teaching 2013

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???.

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Bowel Obstruction and Hernias - SLIME teaching 2013

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  1. Bowel Obstruction and Hernias- SLIME teaching 2013 Richard Marks – FY1 Orthopaedics @ Warwick

  2. Aims • Hernias • What are they? • Anatomy • Presentation • Complications • Bowel Obstruction • Types • Complications • Investigation • Management

  3. 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” ?

  4. What are the types?

  5. 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?

  6. The inguinal canal • Split it into the four “walls” • - Anterior • - Posterior • - Roof • - Floor • Where are the deep &superficial rings?

  7. Femoral a. Anatomy...yay... Deep/internal ring

  8. The Femoral Canal • Anteriorly: inguinal lig. • Medial: lacunarlig. • Lateral: Femoral vein + illopsoas • Posterior: pectineallig. + pectineus

  9. Inguinal or Femoral? The key to remember is: • Femoral = inferior and lateral to the pubic tubercle • Inguinal = Superior and medical to the tubercle

  10. 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?

  11. 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?

  12. So how to investigate?

  13. Management • Conservative... • Medical... Inguinal? Strangulated? • Surgical...

  14. Bowel Obstruction

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

  16. 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

  17. Small or Large bowel obstruction?

  18. Small or Large?

  19. Small versus Large?

  20. “Pseudo-obstruction” • ... So don’t worry too much about it!

  21. 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

  22. On the spot... • What type of hernia is this likely to be, and why? • How would you investigate this man? • What is the initial management in the acute setting? • And the long term management?

  23. More 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?

  24. Please explain... • Please take a few minutes to explain to Mr Hunt that he needs a CT scan...

  25. 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...

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

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