1 / 43

Abdominal cases for SURGICAL FINALS

Abdominal cases for SURGICAL FINALS. Dr. Anika Kaura & Dr. Upama Banerjee. Approach to the surgical abdomen. Surgeons want it SHORT and SIMPLE Use your normal schema for examination but be prepared to be INTERRUPTED! And to move on quickly from one aspect of examination to another

lulu
Télécharger la présentation

Abdominal cases for SURGICAL FINALS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Abdominal cases for SURGICAL FINALS Dr. Anika Kaura & Dr. Upama Banerjee

  2. Approach to the surgical abdomen • Surgeons want it SHORT and SIMPLE • Use your normal schema for examination but be prepared to be INTERRUPTED! And to move on quickly from one aspect of examination to another • Don’t bore them with all the negatives! • Mention the positives and only a few RELEVANT negatives • E.g. I have examined the abdominal system of this gentleman who did not complain of any pain. The most obvious finding was a well healed rooftop incision. There were no peripheral stigmata nor abdominal masses on palpation and bowel sounds were present

  3. Scars

  4. Abdo Scars Kochers Gable/Rooftop – join up R subcostal and L LANZ GRIDIRON/Mcburneys incision Loin Vascular scars Pfannenstiels

  5. STOMAS • “surgically created communication between the bowel and the skin” • OPTIONS : ileostomy / colostomy / ileal conduit • EXAMINATION • Site of the bag • Contents- liquid/solid • Output • Bowel flush/spouted • Bowel healthy? • Feel for parastoma hernias • Offer to digitate the stoma • ALWAYS OFFET TO INSEPCT PERINEUM FOR AN ANUS!!! • Beware of drain bags appearing like stoma bags

  6. Stoma complications

  7. STOMA summary 3 Ss and 3 Cs • Site • Size • Skin • Contents • Condition- of stoma, and for which they have it • Complications Important to know about stoma care and role of stoma nurses, especially psychological impact

  8. Which operation?!Cancers… Right hemi-colectomy Extended right hemi-colectomy Sigmoid-colectomy Left hemi-colectomy (rarely transverse colectomy)

  9. Which operation?!Cancers… ANTERIOR RESECTION ABDOMINO- PERINEAL RESECTION • Rectal cancers: HIGH OR LOW

  10. Ulcerative Colitis • Pan Procto-colectomy • Subtotal colectomy + rectal treatment • J POUCH FORMATION • (ileo-anal pouch)

  11. Perforated Diverticula Hartmans

  12. What to consider o/e SCAR RIGHT/LEFT STOMAS MUST ASK TO EXAMINE THE PERINEUM

  13. Ileostomy NO ANUS? ANUS? ANTERIOR RESECTION END ILEOSTOMY

  14. Ileostomy NO ANUS? ANUS? ANTERIOR RESECTION END ILEOSTOMY HIGH RECTAL CANCER RESECTION PAN-PROCTOCOLECTOMY

  15. Colostomy NO ANUS? ANUS? HARTMANS ABDOMINO-PERINEAL RESECTION

  16. Colostomy NO ANUS? ANUS? HARTMANS ABDOMINO-PERINEAL RESECTION PERFORATED DIVERTICULA LOW RECTAL CANCER

  17. CASE 1 • Present the findings • Get ready for some viva questions

  18. What do you want to know about the stoma?? • Single lumen • Bowel flush with the skin • Solid contents • Anus present • No excoriations/parastomal hernia

  19. Questions • Differential for midline laparotomy and left sided stoma • Hartmanns- sigmoid colectomy and end colsotomy (reversible) • Anterior resection with reversible end colostomy (unlikely as elective so primary anastamosis) • Abdomino perineal resection- permanent end colostomy and NO anus • Loop colostomy- two lumens- either to defunction distal bowel (rare) or as palliative measure for distal Ca • Could always be ILEOSTOMY but just in a funny place!

  20. Hartmanns procedure • EMERGENCY PROCEDURE • Sigmoid colectomy with end colostomy (reversible) • Usual indications: acute diverticulits especially perf! And acute obstructing sigmoid Ca

  21. Diverticulitis • Outpouchings of mucosa through the bowel wall • Diverticulae/diverticulosis/diverticulits • Complications: diverticulitis, large PR Bleeds, perforation, abscess, fistulae, strictures leading to obstruction. • Investigations: basic to complicated: bloods, AXR, colonoscopy if well NOT if risk of perf, CT in acute

  22. Diverticulitis ACUTE Mx • Nil by mouth • IV fluids • Analgesia • ABx- cef and met • Most managed conservatively +/- elective sigmoid colectomy • Emergency surgery for perf/not improving ---- Hartmanns --- most will not have colostomy reversed!

  23. Hernias Scar related Groin - shorts v.common Complications of hernias

  24. Groin lumps – hernias • How to dd a femoral vs inguinal • More likely be to a inguinal hernia • Why?

  25. ABOVE & MEDIAL = INGUINAL BELOW & LATERAL = FEMORAL

  26. Inguinal Hernias Inguinal anatomy! Scrotal mass cannot get above it Dd in the exam by occluding the deep ring

  27. Hernias • ASIS  Pubic tubercle • What is this called? • What lies here? • ASIS  Pubic Symphysis • What is this called? • What lies here?

  28. Definitive Operative Hesselbachs triangle Lichenstein tension free mesh repair Gold standard still open

  29. Hesselbachs triangle:

  30. CASE 2 • Present the findings • Get ready for some viva questions

  31. What do you want to know about the fisutlae? • old/ current?? • Venepuncture marks • Palpable thrill • Audible murmur • multiple.--- prev failure of fistula • Thinks about complications

  32. The renal transplant patient • Approach to examination LOADS of signs and clues! • Iliac fossa scar and mass – uni/bilat • Nephrectomy scars?? • Previous renal replacement Tx- old AV fistulae, HD scars in neck, PD scars abdo • Immunosuppresion SEs- cushingoid features, gum hypertrophy, BCC/SCC • Evidence of underlying renal disease- diabetic? etc

  33. PRESENTATION • Example “I have just examine the abdominal system of this lady. The most obvious finding is scar in the RIF with a mass beneath consistent with a renal transplant without nephrectomy. She has an old AV fistula in the right arm and I can see well healed PD scars on the abdomen, indicating previous methods of renal replacement therapy. I notice some cushingoid features including striae and bruising on her legs. The transplant appears to still be working as the patient is euvolaemic and not uraemic; and there is no evidence of other current renal replacement therapy.”

  34. COMPLICATIONS of transplant • REJECTION- hyperacute/acute/chronic • IMMUNOSUPPRESION - increase opportunistic infection PCP CMV - increase risk of skin malignancies - PTLD • TOXICITY OF IMMUNOSUPPRESANTS - hepato and nephrotoxic - cushings disease - ciclopsorin- gum hypertrophy

  35. COMPLICATIONS of transplant • VASCULAR- thrombosis, RAS • Hypertension and increased risk of CV disease • URINARY- UTIs and vesicoureteric reflux • Chronic graft dysfunction +/- post transplant nephrectomy • Recurrence of the original disease • Psychological

  36. COMPLICATIONS of haemodialysis • FLUID BLANCE Hypotension vs pulmonary oedema • Hypokalaemia • Disequilibirum syndrome- cerebral oedema • Aluminium toxicity • Infection from vascular access • Stenosis/thrombosis of access site • Dialysis related amyloid AA

  37. Complications of av fistula • Failure to mature • Stenosis/thrombosis • Aneurysm/pseudoaneurysm • Infection • Venous hypertension • Steal phenomenon- distal tissue ischaemia • High output CF • Ishcaemic monomelic neuropathy

  38. Urology - haematauria Vascular scars

  39. Other topics to revise that we have touched on! • Bowel caner: screening programme, Dukes post op histology vs staging and grading • Different types of anastomsis, anastomitc leaks, complcations of a colectomy • Indications for dialysis; nephrectomy • CAPD and HD via tesio

  40. THE END • PLEASE DO THE FEEDBACK FORMS! • QUESTIONS?? • ANIKA- ak8009@ic.ac.uk • UPI- ub06@ic.ac.uk

More Related