DR TOM HARDY SHO GENERAL SURGERY ???

85 yo male Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis 4/7 increasing RIF Over last 24 hours has developed Nausea and 1 x vomiting Starting to feel unwell PMH – HTN, AF, Angina

Differentials?? Appendicitis Bowel Obstruction due to  Hernia  Ca  Adhesions Perforation Renal Colic

Plan? Airway – is it patent? Breathing -  RR 24  O2 saturations 99% on 5litres O2 Circulation –  BP 95/54  P 102 Disability –  AVPU Everything else –  T 37.1  U/O ??  BM – 6.9

On examination Cardio –  I + II + O Respiratory -  Good air entry Abdo –  V tender RIF, small lump in R groin, red, tender, no cough impulse, non-reducible  Rest of abdomen soft, bowel sounds not present  PR – empty rectum

Initial Management Groups please Initial investigations/beside Scans/secondary investigations Other considerations

Initial Management 1 Bedside –  Vital signs  Bloods  FBC, LFT, U&E, CRP, Amy, G&S/X-match  ABG  BM  Catheterise/NG Tube  IVI  NBM

ABG pH7.25 pO28.5 pCO23.8 Glu6.4 Hb11.2 Lac2.5 BE-6.5 HCO3-14.5

Initial Management 1 Scans  AXR?  CXR?  CT abdo/pelvis

Extras Inform theatres Inform anaesthetist Booking and consenting ECG

Bloods Hb 10.2TP 75Ur 12.7 MCV 94.2Alb 36Cre 147 WCC 17.8Bi 7Na 138 Neut 14.1ALT 20K 3.6 CRP 215Alk Phos 98

Hernias! Definition -  Protrusion of a tissue through the wall of the cavity which normally contains it

Reducible –  you can put it back in Irreducible –  you can’t Incarcerated –  you can’t put it back in Strangulated –  blood supply cut off

1) Risk factors for developing hernia  Smoking, chronic cough, female, heavy lifting, previous surgery 2) Hernia develops, initially reducible and of no concern 3) If increases in size, may become irreducible 4) Part of bowel/tissue gets trapped leading to irritation, swelling, oedema 5) Increasing size leads to further issues which may compromise blood supply 6) Hernia becomes strangulated, can lead to necrosis as no blood supply and peritonism

Types of Hernia Inguinal  Direct vs Indirect Femoral Incisional – ummm...through an incision Richter’s Hernia – one side of bowel wall, may not be an obstruction Umbilical/paraumbilical Littre’s hernia

Up-to-date webite, viewed 3/1/12, &search=femoral hernia&utdPopup=true

Up-to-date webiste, hernia&utdPopup=true, viewed 3/1/12, hernia anatomy

Surface Anatomy A: Inferior epigastric artery B: Femoral nerve C: Femoral artery D: Femoral vein E is the most important … THE PUBIC TUBERCLE

Examination of a Hernia Examine standing and sitting How do you assess a lump?? SCRoTum  3 x S – Size, Shape, Surface  3 x C – Cough impulse, Colour, Consistency  Reducibility  3 x T – Tenderness, Transillumination, Temperature  External genetalia!!!

IPE Questions 1 This gentleman has a swelling in his groin, please take a history... Risk factors Features of a hernia Differential diagnosis  Don’t forget lymphadenopathy

IPE Questions 2 Examination... Hernia or Abdomen?? Probably Hernia first, if time/to finish abdomen

IPE Questions What is a hernia? How to differentiate between direct and indirect How to differentiate between inguinal and femoral How would you identify the deep inguinal ring? Treatment options Complications of hernia surgery

Communication in Surgery Happy PR not PV! Sad Get out of my theatre Hmmmm Good job Angry Your only fit for psych