1. B OWEL O BSTRUCTION AND H ERNIAS - SLIME TEACHING 2013 Richard Marks – FY1 Orthopaedics @ Warwick

2. A IMS Hernias What are they? Anatomy Presentation Complications Bowel Obstruction Types Complications Investigation Management

3. “A hernia is the protrusion of a viscus or part of a viscus outside the cavity which normally contains it” So what is a hernia???

4. W HAT ARE THE TYPES ?

5. C ASE 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. T HE INGUINAL CANAL Split it into the four “walls” - Anterior - Posterior - Roof - Floor Where are the deep & superficial rings?

7. A NATOMY... YAY...

8. T HE F EMORAL C ANAL Anteriorly: inguinal lig. Medial: lacunar lig. Lateral: Femoral vein + illopsoas Posterior: pectineal lig. + pectineus

9. I NGUINAL OR F EMORAL ? The key to remember is: Femoral = inferior and lateral to the pubic tubercle Inguinal = Superior and medical to the tubercle

10. D IRECT OR I NDIRECT I NGUINAL H ERNIA ? 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. W HY 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. S O HOW TO INVESTIGATE ? Vomiting, painful, stuck? FBC, U&E, CRP G&S Glucose, amylase Erect CXR – perf? AXR – exclude obstruction Painless, reducable?Vomiting, painful, stuck? Painless, reducable? ?USS Pre-op investigations

13. M ANAGEMENT Medical... Conservative... Surgical...

14. B OWEL O BSTRUCTION

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

16. W HAT 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. S MALL OR L ARGE BOWEL OBSTRUCTION ?

18. S MALL OR L ARGE ?

19. S MALL VERSUS L ARGE ?

20. “P SEUDO - OBSTRUCTION ”... So don’t worry too much about it!

22. C LINICAL F INALS... 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

23. O N THE SPOT... 1) What type of hernia is this likely to be, and why? 2) How would you investigate this man? 3) What is the initial management in the acute setting? 4) And the long term management?

24. M ORE 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?

25. P LEASE EXPLAIN... Please take a few minutes to explain to Mr Hunt that he needs a CT scan...

26. A LMOST 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...

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