1. Hernias & bowel obstruction Richard Griffiths FY1 Surgery

2. Introduction • Aims/objectives • Hernias • Bowel obstruction • Clinical case example • Quiz

3. Aims + objectives • Aim • To give an overview of hernias and bowel obstruction relative to finals examinations • Objectives • Key features • Causes • Investigations • Management

4. Hernias • Definition of a hernia • A hernia is the protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position • Inguinal • Direct • Indirect • Femoral • Incisional • Others

5. Anatomy • Inguinal hernia – Above and medical to pubic tubercle • Anterior – External oblique + internal oblique for lateral 1/3 • Posterior – Transversalis fascia + conjoint tendon • Roof – Arching fibres of internal oblique + transversus • Floor – Inguinal ligament • Femoral hernias – Below and lateral to pubic tubercle • Anterior – Inguinal ligament • Posterior – Pectineal ligament • Laterally – Femoral vein • Medially – Lacunar ligament

6. Terminology • Reducible • Irreducible • Incarcerated • Strangulated • Obstructed • Richter’s

7. Risk factors • Chronic cough • Chronic constipation • Straining on passing urine • Heavy lifting • Obesity • Age • Previous surgery • Males = Inguinal herniae • Females = Femoral herniae

8. Symptoms and signs • Lump • Painful/painless • On and off for long time/Sudden onset • Presents on coughing/straining • Reduces on lying flat • Pain • Dragging sensation in scrotum • Complications

9. Differentials • Different type of hernia • Lymph node • Hydrocele • Abscess • Femoral aneurysm • Saphenavarix

10. Investigations • Bedside – Observations • Bloods – FBC, U+Es, LFTs, amylase, G+S • Imaging – USS

11. Management • Conservative • Manually reduced by patient • Stop smoking, avoid heavy lifting/straining • Truss • Large defect • Patient not fit for surgery • ??Medical – analgesia, anti-emetics • Surgical – Hernia repair • All femoral herniae • Herniorrhaphy – laparoscopic or open • Suture repair • Mesh repair • Obstructed/strangulated bowel dealt with accordingly

12. Bowel Obstruction • Small bowel obstruction • Large bowel obstruction

13. Causes • Small bowel obstruction • In the lumen • Impacted faeces • Foreign body • Large polyp • In the wall • Tumours • Infarction • Stricture – Crohn’s • Outside the wall • Adhesions • Volvulus • Strangulated hernia • Extrinsic compression

14. Causes • Large bowel obstruction • Carcinoma of colon • Diverticular disease • Volvulus

15. 4 Cardinal features • Pain • Abdominal distension • Absolute constipation • Vomiting

16. Investigations • Bedside – Observations • Bloods: • FBC, U+Es, LFTs, amylase, G+S • Blood gas • Imaging: • AxR, erect CxR • CT with contrast

17. Management • Conservative – “drip + suck” • NBM • IVI fluids • NG tube • Analgesia • Anti-emetics • Surgical • Depends on cause • Adhesiolysis • Hernia repair • Bowel resection

18. Conclusions • Hernias • Anatomy • Difference between incarcerated and strangulated • Examination • Bowel obstruction • 4 cardinal features • Causes • Management

19. Clinical case 1 • 80 year old male • Painful lump in groin – irreducible • Present lying and standing • Previous history of lump that comes and goes • What else do you want to know?

20. Questions • Risk factors for herniae? • Boundaries of the inguinal canal? • What is an incarcerated hernia? • What are the features of a strangulated hernia? • Four cardinal features of obstruction? • Major causes of obstruction? • Initial management of obstruction?

21. Thank you Questions