Surgical anatomy
◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
#Hernia
#Surgery
◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
#Hernia
#Surgery
Richter Hernia
◼️It occurs when only a portion of the intestinal circumference is involved in the hernial sac.
◼️Here complete obstruction of the intestinal lumen is not present.
◼️Strangulation of a Richter's hernia is particularly noteworthy, because the clinical features mimics gastroenteritis, the local signs of strangulation are not obvious, the patient may not vomit and may even have a diarrhea, this causes delay in diagnosis and operation is delayed so that gangrene and perforation commonly takes place before operation.
◼️Richter's hernia usually complicates a femoral hernia or rarely obturator hernia.
#Hernia
#Surgery
◼️It occurs when only a portion of the intestinal circumference is involved in the hernial sac.
◼️Here complete obstruction of the intestinal lumen is not present.
◼️Strangulation of a Richter's hernia is particularly noteworthy, because the clinical features mimics gastroenteritis, the local signs of strangulation are not obvious, the patient may not vomit and may even have a diarrhea, this causes delay in diagnosis and operation is delayed so that gangrene and perforation commonly takes place before operation.
◼️Richter's hernia usually complicates a femoral hernia or rarely obturator hernia.
#Hernia
#Surgery
Clinical features of strangulated hernia:
◼️Sudden pain starting at the hernial site followed by generalized abdominal pain, this pain is colicky in nature and mainly around the umbilicus.
◼️Nausea and vomitting.
◼️ Recent increase in the size of the hernia.
◼️Extreme tenderness over the hernia.
◼️Tense hernial sac.
◼️Irreducible hernia.
◼️Absence of expansile cough impulse.
N.B sudden spontaneous cessation of pain must be viewed with caution as this may be a sign of perforation
#Hernia
#Surgery
◼️Sudden pain starting at the hernial site followed by generalized abdominal pain, this pain is colicky in nature and mainly around the umbilicus.
◼️Nausea and vomitting.
◼️ Recent increase in the size of the hernia.
◼️Extreme tenderness over the hernia.
◼️Tense hernial sac.
◼️Irreducible hernia.
◼️Absence of expansile cough impulse.
N.B sudden spontaneous cessation of pain must be viewed with caution as this may be a sign of perforation
#Hernia
#Surgery
Pathology Of Strangulated Hernia
◼️Constriction ring develops and impairs blood supply (thin black arrow)
◼️Venous return from the involved segment is affected first.
◼️Congestion develops with transudation of serous fluid into the hernial sac.
◼️Distension of the involved loop and edema results in furthur narrowing of the ring and compromising blood supply even more.
◼️Arterial supply then becomes more and more compromised.
◼️The viability of the bowel becomes affected resulting in translocation of bacteria through the wall leading to infection of the sac.
◼️If left unrelieved, gangrene develops (usually within 6 hours) first at the seat of constriction ring (thick black arrow) then at the antemesentric border(yellow arrow) perforation is expected in these sites.
◼️Because of these pathological events peritonitis spreads from the sac to the general peritoneal cavity.
#Hernia
#Surgery
◼️Constriction ring develops and impairs blood supply (thin black arrow)
◼️Venous return from the involved segment is affected first.
◼️Congestion develops with transudation of serous fluid into the hernial sac.
◼️Distension of the involved loop and edema results in furthur narrowing of the ring and compromising blood supply even more.
◼️Arterial supply then becomes more and more compromised.
◼️The viability of the bowel becomes affected resulting in translocation of bacteria through the wall leading to infection of the sac.
◼️If left unrelieved, gangrene develops (usually within 6 hours) first at the seat of constriction ring (thick black arrow) then at the antemesentric border(yellow arrow) perforation is expected in these sites.
◼️Because of these pathological events peritonitis spreads from the sac to the general peritoneal cavity.
#Hernia
#Surgery
Types of Hernias
◼️ Reducible.. Where the hernia can be reduced when the patient lies down or by the patient himself or by the surgeon, if the contents are intestine, then there is often a gurgling sound at time of reduction, and also the first part is usually more difficult to reduce than the last part, if the contents are omentum, then it will feel as a doughy mass, the last portion is more difficult to reduce than the first one.
◼️ Irreducible.. Refer to a hernia which do not return to the abdomen in absence of any other related symptoms it may occur because of adhesions between the sac and the contents or may occur due to overcrowdening of the sac with contents, such a hernia that doesnt reduce and doesnt produce any symptoms is highly suggestive of omentocele. Note that any degree of irreducibility predispose to strangulation.
◼️Obstructed.
◼️Strangulated.. Can proceed to gangrene within only 6 hours.
◼️Inflamed
What does incarcerated hernia mean?
-See below, I have quoted it.🌚
#Hernia
#Surgery
◼️ Reducible.. Where the hernia can be reduced when the patient lies down or by the patient himself or by the surgeon, if the contents are intestine, then there is often a gurgling sound at time of reduction, and also the first part is usually more difficult to reduce than the last part, if the contents are omentum, then it will feel as a doughy mass, the last portion is more difficult to reduce than the first one.
◼️ Irreducible.. Refer to a hernia which do not return to the abdomen in absence of any other related symptoms it may occur because of adhesions between the sac and the contents or may occur due to overcrowdening of the sac with contents, such a hernia that doesnt reduce and doesnt produce any symptoms is highly suggestive of omentocele. Note that any degree of irreducibility predispose to strangulation.
◼️Obstructed.
◼️Strangulated.. Can proceed to gangrene within only 6 hours.
◼️Inflamed
What does incarcerated hernia mean?
-See below, I have quoted it.🌚
#Hernia
#Surgery
"Removing a colorectal polyp is Removing a future cancer".
Almost all colorectal cancers arise on top of a pre-existing adenomatous polyps, any adenomatous polyp may turn to a cancer, but the risk is not the same in all of them, a polyp with significant malignant potential is larger than 2 cm, have a predominantly villous architecture and has dysplastic cells, and ofcoures, the more polyps are present, the more likely cancer will occur.
#Surgery
Almost all colorectal cancers arise on top of a pre-existing adenomatous polyps, any adenomatous polyp may turn to a cancer, but the risk is not the same in all of them, a polyp with significant malignant potential is larger than 2 cm, have a predominantly villous architecture and has dysplastic cells, and ofcoures, the more polyps are present, the more likely cancer will occur.
#Surgery
Clinical features of colorectal cancer
◼️It depend upon the site of carcinoma.
◼️On the left side, tumors tend to be of annular variety, such as that they narrow the lumen and cause early intestinal obstruction, this presents with lower colicky abdominal pain and the colics are widely seperated, along with other features such as distension.
◼️The above figure demonstrate the nature of this manifestation, this is a specimen of the descending colon and shows a constricting lesion which was revealed to be an adenocarcinoma, left sided tumors also present with early fresh per rectal bleeding.
◼️If the tumor is rectal, bleeding, mucus discharge and tenesmus will manifest.
◼️If tumor is right sided, this present with anaemia due to occult bleeding, and a change in bowel habit, intestinal obstruction here is a late feature, because right sided tumors tend to be fungating and slow growing.
◼️In a minority of patients perforation causing peritonitis, fistuale, and local abscess may occur.
#Surgery
◼️It depend upon the site of carcinoma.
◼️On the left side, tumors tend to be of annular variety, such as that they narrow the lumen and cause early intestinal obstruction, this presents with lower colicky abdominal pain and the colics are widely seperated, along with other features such as distension.
◼️The above figure demonstrate the nature of this manifestation, this is a specimen of the descending colon and shows a constricting lesion which was revealed to be an adenocarcinoma, left sided tumors also present with early fresh per rectal bleeding.
◼️If the tumor is rectal, bleeding, mucus discharge and tenesmus will manifest.
◼️If tumor is right sided, this present with anaemia due to occult bleeding, and a change in bowel habit, intestinal obstruction here is a late feature, because right sided tumors tend to be fungating and slow growing.
◼️In a minority of patients perforation causing peritonitis, fistuale, and local abscess may occur.
#Surgery
Investigations used for colorectal cancer
◼️The goal is to confirm the diagnosis and obtain staging.
◼️In order to confirm the diagnosis, the investigation of choice is colonoscopy, in contrast to barium enema it is more sensitive and specific and biopsies can be obtained, and polyps removed.
◼️When colonoscopy is incomplete or could not be done due to a high risk of complications, a CT colonography is appropriate, it is also called 'the virtual colonoscopy' whereby a computer software is used to produce a 3D image of the colon (figure above shows a comparsion between CT colonography and real colonoscopy).
◼️After diagnosis is confirmed, CT of chest, abdomen and pelvis is done for staging, if the cancer is rectal, endoanal ultrasonography or pelvic MRI is used for local staging, during staging a particular focus is paid to the liver as this is the commonest site of metastasis.
◼️Carcinoembryonic antigen (CEA) is not useful for diagnosis but valuable in follow up to monitor recurrence
#Surgery
◼️The goal is to confirm the diagnosis and obtain staging.
◼️In order to confirm the diagnosis, the investigation of choice is colonoscopy, in contrast to barium enema it is more sensitive and specific and biopsies can be obtained, and polyps removed.
◼️When colonoscopy is incomplete or could not be done due to a high risk of complications, a CT colonography is appropriate, it is also called 'the virtual colonoscopy' whereby a computer software is used to produce a 3D image of the colon (figure above shows a comparsion between CT colonography and real colonoscopy).
◼️After diagnosis is confirmed, CT of chest, abdomen and pelvis is done for staging, if the cancer is rectal, endoanal ultrasonography or pelvic MRI is used for local staging, during staging a particular focus is paid to the liver as this is the commonest site of metastasis.
◼️Carcinoembryonic antigen (CEA) is not useful for diagnosis but valuable in follow up to monitor recurrence
#Surgery
Modified Duke classification for colorectal cancer
Stage A = tumor within bowel wall.
Stage B= tumor extended through bowel wall.
Stage C= Lymph nodes are involved.
Stage D = Distant metastasis, usually to liver and less commonly to lungs.
#Intestinal
#Surgery
Stage A = tumor within bowel wall.
Stage B= tumor extended through bowel wall.
Stage C= Lymph nodes are involved.
Stage D = Distant metastasis, usually to liver and less commonly to lungs.
#Intestinal
#Surgery
Hereditary factors in colorectal cancer
◼️They can be broadly classified into disorders with polyposis and without polyposis.
◼️Those involving polyps include familial adenomatous polyposis, Peutz jeghers syndrome, juvenile polyposis and MUTY homolog associated polyposis (for more informations see previous posts)
◼️Hereditary non polyposis colorectal cancer (HNPCC) or Lynch syndrome, is a result of mutations affecting DNA repair genes (microsatellite instability, see before), a subset of patients with Lynch syndrome also are predisposed to (1) Endometrial cancer, (2) Ovarian cancer, (3) Small bowel cancer, (4) Pancreatic cancer, and (5) CNS tumors, this results from a different repair gene mutation.
◼️The diagnosis of Lynch syndrome first relies on Modified amesterdam criteria (see next Post).
◼️The above figure summarizes the pathophysiologic factors involved in the development of colorectal cancer.
#Intestinal
#Surgery
◼️They can be broadly classified into disorders with polyposis and without polyposis.
◼️Those involving polyps include familial adenomatous polyposis, Peutz jeghers syndrome, juvenile polyposis and MUTY homolog associated polyposis (for more informations see previous posts)
◼️Hereditary non polyposis colorectal cancer (HNPCC) or Lynch syndrome, is a result of mutations affecting DNA repair genes (microsatellite instability, see before), a subset of patients with Lynch syndrome also are predisposed to (1) Endometrial cancer, (2) Ovarian cancer, (3) Small bowel cancer, (4) Pancreatic cancer, and (5) CNS tumors, this results from a different repair gene mutation.
◼️The diagnosis of Lynch syndrome first relies on Modified amesterdam criteria (see next Post).
◼️The above figure summarizes the pathophysiologic factors involved in the development of colorectal cancer.
#Intestinal
#Surgery
◼️Colonic diverticula are acquired herniations that occur through the circular muscle coat of the colon at the site where blood vessels penetrate the colonic wall.
◼️They are most common in the sigmoid colon (90%).
◼️They may associate with gallstones and hiatus hernia (Saint Triad).
◼️Complications include diverticulitis, pericolic abscess, peritonitis, intestinal obstruction, hemorrhage, and fistula formation.
#Intestinal
#Surgery
◼️They are most common in the sigmoid colon (90%).
◼️They may associate with gallstones and hiatus hernia (Saint Triad).
◼️Complications include diverticulitis, pericolic abscess, peritonitis, intestinal obstruction, hemorrhage, and fistula formation.
#Intestinal
#Surgery
Corner stones of managing Intestinal obstruction :
(Suck and Drip)
-Gastrointestinal decompression.
-Fluid and electrolyte resuscitation.
-Relief of the obstruction.
#Intestinal
#Surgery
(Suck and Drip)
-Gastrointestinal decompression.
-Fluid and electrolyte resuscitation.
-Relief of the obstruction.
#Intestinal
#Surgery
Benefits of Gastrointestinal decompression in intestinal obstruction:
1)Relief the distension and thereby improve respiration.
2)Relief pain.
3)Makes operation easier to perform.
4)Prevent aspiration pneumonia upon induction of anaesthesia.
5)Minimize absorption of toxins following relief of the obstruction, this may occur when the obstruction is relieved and the fermented toxin filled proximal fluids are passed to the downstream healthy intestine which inturn absorb these toxins and cause postoperative toxaemia.
#Intestinal
#Surgery
1)Relief the distension and thereby improve respiration.
2)Relief pain.
3)Makes operation easier to perform.
4)Prevent aspiration pneumonia upon induction of anaesthesia.
5)Minimize absorption of toxins following relief of the obstruction, this may occur when the obstruction is relieved and the fermented toxin filled proximal fluids are passed to the downstream healthy intestine which inturn absorb these toxins and cause postoperative toxaemia.
#Intestinal
#Surgery
Parts of the intussusception:
-The intussusception itself is three parts
A) The outer tube or the sheath aka intussuscipiens.
B) The middle tube or the returning tube.
C) The inner tube or the entering tube aka intussusceptum.
-The apex is the advancing part.
-The neck is the junction between the proximal tube of bowel and the intussusception mass it self.
#Intestinal
#Surgery
-The intussusception itself is three parts
A) The outer tube or the sheath aka intussuscipiens.
B) The middle tube or the returning tube.
C) The inner tube or the entering tube aka intussusceptum.
-The apex is the advancing part.
-The neck is the junction between the proximal tube of bowel and the intussusception mass it self.
#Intestinal
#Surgery
Postoperative complication of appendicectomy
¶ Wound infection (most common)
¶ Intra abdominal abscess.
¶ Paralytic ileus (significant if it last more than 72 hours).
¶ Portal pyaemia (With gangrenous appendicitis).
¶ Respiratory complications (pneumonitis/Collapse).
¶ Venous thromboembolism.
¶ Right inguinal hernia (Said to be more common with Gridiron incision due to injury of the Rt iliohypogastric nerve).
¶ Adhesive intestinal obstruction (most common late complication).
¶ Faecal fistula (more when the stitch at appendix base is taken too deeply or when edema of caecal wall is extensive, also may follow cases of crohns disease).
#Appendix
#Surgery
¶ Wound infection (most common)
¶ Intra abdominal abscess.
¶ Paralytic ileus (significant if it last more than 72 hours).
¶ Portal pyaemia (With gangrenous appendicitis).
¶ Respiratory complications (pneumonitis/Collapse).
¶ Venous thromboembolism.
¶ Right inguinal hernia (Said to be more common with Gridiron incision due to injury of the Rt iliohypogastric nerve).
¶ Adhesive intestinal obstruction (most common late complication).
¶ Faecal fistula (more when the stitch at appendix base is taken too deeply or when edema of caecal wall is extensive, also may follow cases of crohns disease).
#Appendix
#Surgery
Acute appendicitis Vs mesentric adenitis
◼️ Pain = Both present with colicky abdominal pain, but in mesentric adenitis pain is interspersed with periods of complete freedom from pain.
◼️Tenderness= in acute appendicitis tenderness is classically in the Rt iliac fossa, in mesentric adenitis tenderness is maximal along the line of the mesentry with shifting tenderness (put the patient on the left side, the point of maximum tenderness will move to the left side as the inflamed lymph nodes gravitate to the left).
◼️Lymphadenopathy = Mesentric adenitis may be accompained by cervical nodes enlargement.
◼️ History = A history of respiratory tract infection is present in 25% of those with mesentric adenitis.
#Appendix
#Surgery
◼️ Pain = Both present with colicky abdominal pain, but in mesentric adenitis pain is interspersed with periods of complete freedom from pain.
◼️Tenderness= in acute appendicitis tenderness is classically in the Rt iliac fossa, in mesentric adenitis tenderness is maximal along the line of the mesentry with shifting tenderness (put the patient on the left side, the point of maximum tenderness will move to the left side as the inflamed lymph nodes gravitate to the left).
◼️Lymphadenopathy = Mesentric adenitis may be accompained by cervical nodes enlargement.
◼️ History = A history of respiratory tract infection is present in 25% of those with mesentric adenitis.
#Appendix
#Surgery
Gynaecological causes that are frequently mistaken for appendicitis :
¶ Pelvic inflammatory disease
Here you will find a history of dysmenorrhea, offensive vaginal discharge and burning micturition, cervical tenderness will help, its always a good idea to consult a gynaecologist when in doubt.
¶ Torsion/Hemorrhage of ovarian cyst
This is challenging as it presents very closely as appendicitis, but the pain start in the same place and remain in the same place, its helpful to do pelvic ultrasound.
¶ Ectopic pregnancy
Can be excluded by pelvic ultrasound and pregnancy test, a history of missed menstrual cycle is helpful.
¶ Endometriosis.
¶Mittelschmerz pain
-This one is due to rupture of a follicular cyst, pain classically happen midcycle.
#Appendix
#Surgery
¶ Pelvic inflammatory disease
Here you will find a history of dysmenorrhea, offensive vaginal discharge and burning micturition, cervical tenderness will help, its always a good idea to consult a gynaecologist when in doubt.
¶ Torsion/Hemorrhage of ovarian cyst
This is challenging as it presents very closely as appendicitis, but the pain start in the same place and remain in the same place, its helpful to do pelvic ultrasound.
¶ Ectopic pregnancy
Can be excluded by pelvic ultrasound and pregnancy test, a history of missed menstrual cycle is helpful.
¶ Endometriosis.
¶Mittelschmerz pain
-This one is due to rupture of a follicular cyst, pain classically happen midcycle.
#Appendix
#Surgery