Fig. 34.1 Colorectal cancer locations. Reproduced with permission from www.cruk.org/cancerstats. Accessed February 2018.
Colorectal surgery: in theatre
Colorectal surgery: on the ward
Colorectal surgery is the branch of surgery primarily concerned with the colon, rectum, and anus. Colorectal surgeons (along with upper GI surgeons) are the closest descendants of the ‘general’ surgeon, who would have previously operated on any acute surgical complaint (e.g. ruptured abdominal aortic aneurysm, testicular torsion) prior to the appearance of specialities. A large amount of colorectal surgery is centred on non-operative management, and it is a useful skill to try to gain a feel for when the acute abdomen can be managed conservatively.
• Colorectal cancer: PR bleeding (DD IBD, diverticulitis, dysentery, angiodysplasia, etc.).
• IBD: operations including strictureplasty.
• Hernias: inguinal, femoral, etc.
• Perianal pathology: haemorrhoids, fissure-in-ano, pilonidal sinus, fistulas, rectal prolapse.
• ‘Acute abdomen’ etc. including mesenteric ischaemia.
— Aetiology: volvulus, stricture, hernia, etc.
— Complications: hernia (including Richter’s hernia).
• Appendicectomy: US scanning.
• Colectomy: hemi, transverse, sigmoid, anterior resection (see Fig. 34.11).
• Abdominoperineal resection, Hartman’s procedure.
• Acute abdominal investigations: plain AXR (± erect CXR), CT abdomen/pelvis, MRCP/ERCP.
• Hernia repair including pantaloon.
• Examining the ‘acute’ abdomen.
This is the third commonest cancer, associated with:
• Familial syndromes (e.g. HNPCC/familial adenomatous polyposis).
• Neoplastic polyps (esp. >2 cm/villous > tubulovillous > tubulous).
Cancers may present with localizing symptoms, particularly left sided:
While right-sided present more insidiously with:
• constitutional symptoms (weight loss, lethargy, anorexia, sweats).
In general, weight loss (unintentional 10% loss in past 6 months) in the context of cancer should always trigger a suspicion of lymph node involvement of distant metastases. Remember to look out for colorectal cancer in the ED, presenting emergently as perforation, obstruction, or even appendicitis (caecal tumours in the elderly!).
CT, MRI (for rectal cancers), and PET are used to stage the colorectal cancer—look for lymphadenopathy and haematogenous spread to liver, lung, and bone (spine).
Surgery ± radio/chemotherapy can be used palliatively or curatively. The precise surgery depends on presentation and tumour location ± its extent.
Fig. 34.1 Colorectal cancer locations. Reproduced with permission from www.cruk.org/cancerstats. Accessed February 2018.
Colorectal cancer staging has moved on from the well-known Duke’s classification to the more universally accepted TNM as in most cancers. With TNM, it is not as easy to give a prognosis as the Duke’s system but the TNM is more precise and gives more information during decision-making on future management of the cancer (see Table 34.1).
Table 34.1 Colorectal cancer staging
| Primary tumour | Lymph node (LN) status | Metastasis | |||
| T0 | No evidence of primary tumour | N0 | No LN involved | M0 | No distant metastases |
| T1 | Tumour invades submucosa | N1 | 1–3 local LNs | M1a | Metastases confined to 1 site (e.g. lung, liver) |
| T2 | Tumour invades muscularis propria | N2 | 4 or more LNs | M1b | Metastases to >1 site |
| T3 | Tumour invades through muscularis propria into pericolonic tissue | ||||
| T4 | Tumour penetrates surface of peritoneum or invades adjacent organs | ||||
Ask the boss …
Consider the appropriateness of curative surgery in your patients after accounting for their comorbidities. When is symptomatic management (e.g. stenting) appropriate?
Honours
• Radiotherapy tattoos: may be identified for preoperative treatment for rectal cancer prior to surgery (as opposed to colon cancers). Since it lacks a mobile mesentery, we can target a fixed area of bowel beforehand. Radiotherapy is associated with higher rates of fistulization, VTE, and pathological fractures (from osteonecrosis).
• (Neo-)Adjuvant therapy: to improve the chances of curative surgery, neoadjuvant therapy can debulk the tumour size with preoperative radiotherapy for instance. Adjuvant therapy (e.g. radio/chemotherapy) is administered postoperatively to kill any metastatic disease that was not amenable to surgical resection.
All new colorectal cancer presentations must go through a local cancer MDT weekly meeting. Historically, any metastatic disease found at the time of diagnosis meant poor survival and contraindication to surgical treatment. While many colorectal cancers present as multiple metastases, single liver metastasis and subsequent liver resection can improve 5-year survival to ~40%.
Honours
As with most specialties there is a suspected colorectal cancer pathway known as the 2-week wait (2WW) pathway. GPs can refer patients via a fast-track system if they fit certain criteria known as red flags (e.g. rectal bleeding, change in bowel habits, or iron deficiency anaemia). Once referred, surgeons must expedite all reviews, investigate, and either (1) make a diagnosis of cancer and commence treatment within 62 days of referral or (2) remove the patient from the pathway after excluding malignancy.
IBD is primarily managed medically by gastroenterologists (see 
pp. 310–311), although surgical intervention (Table 34.2) may be necessary in the following cases:
(More common in *UC, **CD.)
• Perforation in UC (acute flare-ups), in CD secondary to strictures.
• Toxic megacolon (bowel >6 cm with shock, refractory to maximal medical management).*
• Obstruction secondary to strictures.**
• Fistulae/abscesses** presenting with intra-abdominal sepsis.
• Failure to respond to medical therapy (e.g. remains symptomatic, unacceptable side effects, exacerbations affecting growth in children, ongoing nutritional challenges).
• Pre-malignancy (high-grade dysplasia)/malignancy of colon.
Table 34.2 IBD surgical options
| UC | CD |
| • Pan-proctocolectomy (colon, rectum, anus) + end ileostomy | • Deal with complications, e.g. sepsis, obstruction with aim of preserving bowel |
| • Proctocolectomy leaving the anus for an ileoanal pouch later | • Crohn’s mass, abscess, symptomatic fistula |
| • Total abdominal colectomy (colon only) + ileostomy (leaving rectum/anus in the unwell) | • Strictureplasty |
Protrusion of a viscus from its body compartment to another through a normal or abnormal opening. (See Fig. 34.2.) This is one of the most common conditions referred to any general or colorectal surgeon. Most common types include:
• inguinal (direct vs indirect)
• recurrent (previously repaired).
Fig. 34.2 Anterior abdominal wall hernias. Reproduced with permission from Callaghan Chris, Emergencies in Clinical Surgery, 2008: Oxford University Press.
Examine hernias with the patient standing up as well as supine. Assess the defect where the hernia arises and try to reduce the hernia back to the abdomen through the defect. Note the difference between direct (arising medial to the inferior epigastric artery) and indirect hernias (arising lateral to the inferior epigastric artery and enter the inguinal canal at the deep ring). Establishing whether a hernia is femoral is crucial as this carries a higher risk of strangulation (constriction and loss of blood supply to the contents of hernia) due to the narrower neck of the femoral canal.
Top tip
• Differentiating femoral hernias from inguinal is done by looking at the position relative to pubic tubercle—femoral hernias are inferolateral and inguinal are superomedial.
• GPs may send in elderly patients with a query hernia but in fact the diagnosis may be ‘divarication of recti’ muscles due to age-related muscular weakness. There is no treatment required here besides reassurance.
Straightforward hernias do not require investigation prior to operation if the diagnosis is obvious from the history and clinical examination. Imaging for anatomical delineation is reserved for unusual hernias (e.g. spigelian) and complex incisional hernias.
• Dynamic US: first-line imaging for assessing difficult hernias.
• CT scan: useful for incisional and complex abdominal wall defects.
• MRI: good for assessing groin hernias where US has not been clear and still high degree of suspicion.
• Herniogram: contrast injected into peritoneum and X-rayss taken to assess its spread into possible sites of herniation. This technique has largely been superseded by cross-sectional imaging.
Hernias are most commonly repaired openly with a mesh traditionally. Laparoscopic repair has become much more common in the past decade; yet, studies have concluded little difference between both techniques. In fact, there may be a slightly higher risk of complications overall with laparoscopic repair.
Honours
• • Recurrent groin hernias where the initial operation was open (if the initial operation was laparoscopic then open should be attempted for the re-do).
Encompasses diverticulosis (without inflammation) and diverticulitis (with inflammation from infection). It is a condition where outpouchings exist in the colonic wall at weak points where blood vessels traverse. This is usually confined to the sigmoid colon although diverticula can occur throughout the colon. Acute diverticulitis ± abscess may present with:
If a patient has acute left-sided tenderness or any signs of peritonism, this should prompt hospital admission or at the very least urgent outpatient imaging to exclude acute diverticulitis and its complications which may need urgent treatment. Complications to keep in mind:
With the symptoms being relatively vague and many in common with colorectal malignancy, the priority is to exclude cancer.
• Colonoscopy should be first line if the patient is fit, but it is contraindicated in acute episodes of diverticulitis (risk of perforation).
• CT cologram/‘virtual colonoscopy’ is carried out with oral contrast, bowel preparation, and CO2 insufflation in the CT scanner. It is indicated where colonoscopy has failed due to acute angulation, stricturing, or narrowing at the affected areas which the scope cannot pass.
• CT abdomen ± pelvis will confirm the diagnosis, but it will not exclude underlying polyps or cancers, so is reserved for acute episodes.
• If a CT scan occurred during the acute episode which has now settled, they should be reviewed in clinic at 6–8 weeks and colonoscopy arranged to exclude any underlying cancers or polyps.
Avoidance of constipation should be advised to avoid flare-ups. There is no evidence for dietary restrictions at present.
Definition
An abnormal tract or connection between two epithelialized surfaces. In diverticulosis, the most common site is colovesical (between the colon and urinary bladder).
Where young patients (<60s) have presented with multiple episodes of diverticulitis, careful consideration can be given to sigmoid colectomy. Symptomatic strictures may also prompt a discussion for surgical management. If severe diverticulosis is confined to this area, removing the sigmoid colon will avoid future problems but is of course not without risk as a major operation. Patients may also develop symptomatic colovesical fistulae and present with recurrent UTI, pneumaturia (gas in the urine), or in extreme cases pass feculent matter in the urine. Operations can be difficult as there has usually been chronic inflammation and possibly previous localized perforation making tissue planes difficult to see let alone dissect. Options include sigmoid colectomy and primary anastomosis, Hartman’s, or simple proximal diversion with stoma. A urologist will be present to protectively stent the ureters and repair in case of damage intraoperatively.
The anorectal junction forms a distinct angle due to the puborectalis muscle. The anus is lined by squamous epithelium, while the rectum is lined by columnar epithelium.
This transitional area is known as the mucocutaneous junction representing the fusion of the embryological hindgut and the ectoderm. The internal sphincter is a continuation of the inferior aspect of the circular smooth muscle of the rectum, whereas the external sphincter is derived from striated muscle surrounding the anal canal. Both muscles function to assist defaecation and continence. The autonomic afferents from the pelvic splanchnic nerves of S2–S3 are responsible for the sensation of rectal distension. The pudendal nerve supplies the levator ani muscles and the external sphincter. The internal sphincter receives innovation from both sympathetic and parasympathetic fibres with the parasympathetic nerves being responsible for keeping high intra-anal pressure and closure of the anal canal. (See Table 34.3.)
Table 34.3 Anatomical differences above and below the anorectal junction
| Above the junction | Below the junction |
|
• Rectum has autonomic sensation • Arterial blood supply from mesenteric vessels |
• Anal skin has somatic sensation • Arterial supply from iliac vessels |
Ensure adequate privacy and dignity for the patient with a chaperone. Obtain verbal consent for the examination after a full explanation.
• Lie the patient in the fetal position (hip and knee flexed to 90°) on their side.
• Equipment: glove, lubrication, light.
• Inspection: part buttocks carefully and inspect skin of anal verge. Look for excoriation/rashes/stool/mucus/pus/blood/scarring/external openings/swellings—haemorrhoids/warts/polyps/prolapse/fissure. Ask patient to cough to examine contraction of sphincter and to bear down looking for prolapse.
• Palpation: after placing lubricating gel, place pulp of index finger of right hand over the anus. Assess perianal skin circumferentially for scarring, openings, induration (sepsis/malignancy). Note resting tone of sphincter where 
tone may signify a fissure/local sepsis.
• Examine each quadrant carefully for masses, pain, tenderness, and feel for the smooth rectal mucosa. Assess mass if identified—ulcerated, within or outside wall, mobile fixed, position according to clock face. Note the contents—faeces, blood, mucus. Assess the squeeze pressure. Other areas to examine include pouch of Douglas, cervix, prostate (surface, smooth, enlarged, irregular).
• Check gloved finger at the end.
Illuminated tube total 20 cm in length inserted into the rectum for inspection. Rounded obturator, a lens, and a bellow for insufflation. No bowel preparation required; position as per DRE. Use insufflation to separate rectal walls and negotiate Houston’s valves to rectosigmoid junction depending on faecal amount present. Biopsies can be taken.
Short illuminated tube for inspecting anal canals. Used for managing haemorrhoids where banding or injection can be applied.
• MRI scan: identification of fistula tracts, localized sepsis.
• MRI scan: staging of rectal/anal lesions.
• Endoanal US: staging of rectal lesions.
• Proctography (MRI): assists in diagnosing obstructed defaecation.
• Endoanal ultrasound: assesses sphincter damage during childbirth.
• Anorectal physiology: assesses anal pressures/volumes and sensation.
Are engorgements of the venous plexuses within the anal canal.
Anal cushions are submucosal fibrovascular structures with arteriovenous communications involving the haemorrhoidal arteries, typically found in three classical positions at 3, 7, and 11 o’clock. Straining and passing hard stools 
the descent of the anal cushions following degeneration of the connective tissue matrix. Compromise of the venous return causes congestion and subsequent inflammation with the risk of trauma.
4.4%.
Poor fibre intake, constipation, and raised intra-abdominal pressure (e.g. pregnancy, pelvic tumours, etc.).
External haemorrhoids originate from the inferior haemorrhoidal plexus below the dentate line supplied by somatic pain drivers. Internal haemorrhoids originate from superior haemorrhoidal plexus above the dentate line with an insensate columnar epithelial. (See Table 34.4.)
On defaecation, little bright red bleeding usually on the tissue paper or in the pan, mucus/faecal discharge, pruritus ani, prolapse, and acute thrombosis.
Assessments (1) to exclude malignancy via endoscopy, (2) of evacuation difficulties including anorectal physiology in incontinence. Proctoscopy confirms diagnosis.
Table 34.4 Classification of internal haemorrhoids
| Degree | Signs |
| First | Bleeding but no prolapse |
| Second | Prolapsing but spontaneously reducible |
| Third | Prolapsing requiring manual reduction |
| Fourth | Chronic, irreducible prolapse |
Dietary advice, water intake, avoidance of straining and constipation. Topical creams (i.e. local anaesthetics and steroids) for symptomatic relief.
Success rate up to 80% where bands can be positioned at the base of the internal haemorrhoid at least 1 cm above the dentate line to minimize discomfort.
Risks: bleeding pain and pelvic sepsis.
Using 5% phenol in almond oil into the anorectal junction. This causes intravascular thrombosis followed by fibrosis. Success rate is lower than rubber band ligation and may require repeated injections.
Risk: iatrogenic prostatitis.
Staged (if bulky) vs total excision.
Risks: anal stenosis, pain (metronidazole may help), bleeding (up to 6 weeks), pelvic sepsis, incontinence.
This method uses a proctoscope (incorporating a Doppler) to identify and disrupt the superior haemorrhoidal artery (located together with mucosal plication) less postoperative pain than traditional haemorrhoidectomy.
Restores relationship of the haemorrhoids to the anal canal while disrupting the superior rectal artery markedly reduced pain/discharge and faster return to normal function. However, there is an in postoperative faecal urgency, more significant risks of rectal perforation or severe sepsis.
Is a linear split in the anal mucosa pain on defaecation.
Most cases are idiopathic, or commonly associated with constipation/repeated diarrhoea. Fissures can also be associated with other conditions such as CD, sarcoid, TB, or drugs such as nicorandil. A majority of fissures are posterior, with anterior fissures more commonly found in postpartum.
Self-remitting severe sharp pain on defaecation ± fresh rectal bleeding (noted on wiping). Other symptoms are mucus discharge and perianal itching.
Internal anal sphincter tone and visible mucosal split. Simple fissures heal within a few days, while others persisting for >6 weeks turn chronic, with induration, a sentinel pile (associated skin tag) and visible fibres of the internal anal sphincter. Sepsis can be associated with fissures developing into superficial fistulae. Fissures identified at other sites around the anal circumference or with atypical features should be assessed urgently (often under anaesthetic) to exclude sexually transmitted or malignant ulcers.
Honours
• Malignancy: squamous/basal cell carcinoma.
Conservative measures such as treatment of constipation, analgesia, and local anaesthetic ointment. A regular bowel habit with the passage of soft stool is central to all treatment pathways with the assistance of both an fibre and fluid intake and stool softeners. Medical therapies reduce anal tone and stimulate healing by the blood flow. Both topical glyceryl trinitrate and diltiazem for 6 weeks report healing rates of 65–70% (but warn of the risk of headaches due to cranial venous dilatation). Botulinum toxin can be injected into the internal anal sphincter providing relaxation for 3 months. Surgical intervention is a last resort. The commonest form is the lateral sphincterotomy with higher healing rates of 90% reported, although a risk of minor incontinence is documented in 20–30%. The procedure involves developing a plane in the inter-sphincteric space followed by a controlled partial division of the internal sphincter fibres.
Treatment of anal fissure
• Topical ointment: glyceryl trinitrate/diltiazem.
This is an intussusception of the full thickness of the rectum through the anal verge. Most commonly occurs in elderly females likely secondary to pelvic floor weakness and pudendal neuropathy. There is a clear association with incontinence and constipation.
Swelling around the anal verge which may either reduce spontaneously or require manual reduction. This is often associated with pain and fresh rectal bleeding together with symptoms of incontinence/tenesmus and constipation. In adults, associations are made with parity and connective tissue disorders together with neurological abnormalities. In children, the commonest association is with cystic fibrosis, chronic constipation, and Hirschsprung’s disease.
Surrounds distinguish a full thickness rectal prolapse from a mucosal prolapse or prolapse of haemorrhoidal disease. One important distinction is the concentric folds demonstrated on a full thickness prolapse, compared with the radial markings of a mucosal prolapse.
A coexisting genital prolapse can be identified in 10–20% of cases.
Pelvic floor disorders require a MDT approach including urogynaecologists, radiologists, physiologists, gastroenterologists, and physiotherapists. This warrants an endoscopy to exclude neoplasms, IBD, and solitary rectal ulceration through biopsy. Evacuatory disturbance can be investigated with colonic transit studies to distinguish between a more global picture (pancolonic slow transit constipation) rather than localized to the anorectum (pelvic outlet obstruction), also confirmed by defaecography.
Conservative measures (bulking agents and fibre intake). Surgery via either an abdominal or perineal approach ± resection.
Delorme’s procedure strips the excess rectal mucosa and plication of the prolapsed muscle wall without any resection. It is tolerated well in the frail under spinal anaesthesia. Yet there is a high recurrence rate >25%. Altemeier’s procedure involves opening the peritoneal cavity via the prolapse, performing a resection of the rectosigmoid and coloanal anastomosis. Lower recurrence rate but higher risk of anastomotic dehiscence localized sepsis.
Laparoscopic vs open technique. A rectopexy involves mobilization and straightening of the rectum with fixation onto the sacrum with sutures or mesh ± resection. Lower recurrence rates but a higher incidence of defaecatory disorder.
Is a condition affecting the natal cleft usually attributed with hirsute young adults (more in males). It refers to a mass of hairs found within the natal cleft region subcutaneous abscesses and sinuses containing hair. An acquired disease resulting from a foreign body reaction caused by the frictional forces in the natal cleft region infection abscess.
Is usually twofold either following formation of an acute abscess requiring either antibiotics or incision and drainage, or secondly with a chronic sinus (midline openings communicating by a granulation tissue lined track containing loose hair follicles). Differentials include hydradenitis suppurativa and complex fistula-in-ano.
Incision and drainage of the cavity. The wound is left open and packed with regular dressings and healing rates of ~60% are described. In cases of recurrent disease, rotational flap techniques have been adopted with encouraging results.
Anal sepsis presents either in the form of an acute abscess or as chronic pain and discharge from an anal fistula. Multiple conditions are associated with anal sepsis including inflammatory bowel conditions such as CD, TB, skin conditions such as hydradenitis suppurativa, trauma or as a sign of malignancy, and a male predominance. Infection of the anal glands in the intersphincteric space is the likely cause of this disorder, where the spread of infection may occur in three directions: vertically (commonest perianal abscess), horizontally, and circumferentially. Following acute inflammation, infected fluid from the abscess traverses the wall of the anorectal canal along the anal ducts to emerge from the mucocutaneous junction generating internal + external openings with granulated tract. Endoscopic procedures such as proctoscopy and sigmoidoscopy should be performed in the outpatient clinic. The main areas to be identified as part of the assessment are the locations of the internal and external openings, the path of the primary tract, potential further tracts, and other associated disease. Assessment is complemented by an examination under anaesthesia allowing the probing of openings to confirm tracts. The mainstay of imaging for fistula-in-ano is the MRI scan given its high soft tissue resolution.
Honours
See Fig. 34.3.
• Intersphincteric: tract medial to external sphincter.
• Transsphincteric: the primary tract crosses the external sphincter, with the external opening located lateral to the pigmented perianal skin.
• Extrasphincteric: often related to pelvic sepsis or after surgical intervention, with the tract lying away from the sphincter complex.
• Suprasphincteric: a high tract passing over the levator muscle.
• Superficial (submucosal): limited to superficial tissue often with a skin bridge between openings.
Fig. 34.3 Park's classification of types of anal fistulae. Reproduced with permission from MacKay, G.J. Colorectal Surgery, 2010: Oxford University Press.
Fig. 34.4 Goodsall’s rule. Reproduced with permission from MacKay, G.J. Colorectal Surgery, 2010: Oxford University Press.
Goodsall's rule is applied to the examination of anal fistula (Fig. 34.4). It states that:
• if the external opening of a fistula lies posterior to a line drawn from 9 to 3 o’clock, then it tracks around the anus laterally and opens into the midline posteriorly
• if the external opening lies anterior to this line, then it opens directly into the anal canal.
Superficial and intersphincteric fistulae can often be laid open giving them the best chance for resolution. Treatment for transsphincteric and suprasphincteric fistulae can be more complicated, often requiring multiple procedures, focusing on preserving as much sphincter function as possible. In such cases, a loosely tied thread or seton can be placed through the tract. This serves the purpose of a marker of the exact position of the tract in relation to the sphincter, while allowing drainage of acute sepsis and local wound healing. This technique can be used as part of a staged fistulotomy aiming to reduce the amount of division of sphincter fibres. Over the years, other techniques such as core fistulectomy, injection of fibrin glue, insertion of collagen plugs, and more recently laser treatment have been introduced with variable results.
You will have a chance to see some technically difficult procedures so it is wise to revise the relevant anatomy and parts of the procedure to keep up. You should have a quick read through the patient’s notes and know what procedure you are going to be observing/assisting with before entering theatre. Ask the doctors to take you through any relevant imaging (e.g. CT).
This will hopefully allow you to better understand and engage when you happen to observe/assist in these procedures during your surgical placements. It would be particularly useful to familiarize/refresh your knowledge of basic abdominal anatomy, e.g. anterior abdominal wall layers and rectus sheath (see Fig. 34.5 and Fig. 34.6):
2. Superficial fascia comprising of (i) an outer fatty Camper’s layer which overlies a (ii) fibrous layer (Scarpa’s fascia).
3. A musculo-aponeurotic plane consisting of rectus abdominis, external oblique, internal oblique, and transversus abdominis.
Fig. 34.5 Layers of rectus sheath. Reproduced with permission from Harold Ellis, Clinical Anatomy 13e, Wiley, 2013, figure 42, p66.
Fig. 34.6 Colonic vascular supply. Reproduced with permission from MacKay, G.J. Colorectal Surgery, 2010: Oxford University Press.
Appendicitis.
Supine + strapped to bed for tilting patient.
Establish pneumoperitoneum using Hasson’s open technique: carefully dissecting down to the linea alba and the cicatrix. Carefully incise 5 mm at this junction longitudinally and insert a blunt umbilical port under direct vision. Inset laparoscopic camera into abdomen. Insert ports into suprapubic and LIF allowing triangulation of instruments under direct vision and avoiding inferior epigastric artery. Identify appendix and apex of taeniae coli on caecum. Dissect mesoappendix and ligate appendicular artery safely. Skeletalize base of appendix using diathermy and then apply two endoloops to base and one above. Resect appendix above the second endoloop and place it in bag for removal from abdomen. Washout and close.
Unilateral inguinal hernia.
Supine.
The principle of any hernia repair is to dissect out and define the hernial sac and defect, reduce the contents of the hernia sac, and complete a sound repair to reduce the risk of an incisional hernia. Incision is 1 cm above inguinal canal from level of superficial ring to two-thirds of length of inguinal canal. Incise Scarpa’s and Camper’s fasciae and ligate vessels encountered securely. Identify arching fibres of external oblique fascia and incise fascia 1 cm proximal to superficial ring and clip the external oblique. Self-retaining retractor to maintain wound open with ilioinguinal nerve preserved and protected. Insert finger down to pubic tubercle and hook finger to draw spermatic cord upwards—hold with rubber sling or hernia ring. Incise external spermatic fascia to identify hernial sac (of indirect hernia), open sac, explore contents, and proceed. Identify direct hernia (deficit in posterior wall/transversalis fascia) in relation to inferior epigastric vessels within Hesselbach’s (inguinal) triangle (see Figs 34.7–34.9 and Tables 34.5–34.7)
Fig. 34.7 Mesh repair of inguinal hernia—standard steps. Reproduced with permission from McLatchie GR and Leaper DJ. Oxford Specialist Handbook of Operative Surgery 2nd edition. 2006. Oxford: Oxford University Press, p.369, Figure 11.1.
Fig. 34.8 Hesselbach’s (inguinal) triangle (green). Reproduced from Häggström, Mikael (2014). ‘Medical gallery of Mikael Häggström 2014’. WikiJournal of Medicine 1 (2). Public Domain.
Fig. 34.9 Contents and coverings of inguinal ligament. Reproduced with permission from Agarwal, Anil, Oxford Handbook of Operative Surgery 3e, 2017: Oxford University Press.
Table 34.5 Extension of layers from abdominal wall to spermatic cord
| Abdominal wall | Spermatic cord/testicle |
| Skin | Scrotum |
| Superficial fascia | Dartos fascia and muscle |
| External oblique aponeurosis | External spermatic fascia |
| Internal oblique muscle | Cremaster muscle |
| Transversalis fascia | Internal spermatic fascia |
| Peritoneum | (Processus) Tunica vaginalis |
Table 34.6 Contents of the inguinal canal: rules of 3 Male—spermatic cord/female—round ligament (see also Fig. 34.11)
| 3 arteries | To the vas, testicle, cremaster |
| 3 fascial layers | Cremaster, external + internal spermatic |
| 3 other structures | Vas deferens, pampiniform venous plexus, genital branch of the genitofemoral nerve (L1/L2) |
Table 34.7 Boundaries of the inguinal canal—2 MALTs
| Roof (2 Muscles) | Muscle: internal oblique + transverse abdominus |
| Anterior | Aponeurosis: external + internal oblique |
| Floor (Lower) | Ligaments: inguinal + lacunar |
| PosTerior | Transversalis fascia + conjoint Tendon |
Ascending colon/proximal transverse colon cancer/ascending colon diverticulitis complications/caecal volvulus.
Supine, strapped for tilting. Establish pneumoperitoneum.
Commence lateral to medial/medial to lateral mobilization of ascending colon. Identify right colic and right branch of middle colic and ligate arteries. Resect tumour through resection at terminal ileum and proximal transverse colon and perform ileocolic anastomosis through extension of umbilical wound (see Fig. 34.10 and Fig. 34.11).
Fig. 34.10 Anterior resection. Reproduced with permission from McLatchie, G, and Leaper, D. Operative Surgery 2nd edition, Oxford University Press: 2006.
Fig. 34.11 Options for colectomies. A = right colectomy, B = left colectomy, C = transverse colectomy, D = abdominoperineal resection (APE), E = total colectomy, F = Hartmann’s procedure. Reproduced with permission from McLatchie, G, and Leaper, D. Operative Surgery 2nd edition, Oxford University Press: 2006.
Tumour or diverticular complications of rectum or sigmoid colon.
Lloyd Davis.
Establish pneumoperitoneum. At the sacral promontory identify and ligate the inferior mesenteric artery, while identifying and protecting the left ureter and gonadal vessels. Continue with medial to lateral and lateral to medial dissection of rectal total mesenteric excision (TME) to reach beyond distal margin. Resect specimen distally with laparoscopic stapler. Extend suprapubic port to Pfannenstiel incision and retrieve specimen into wound and resect proximal margin. Mobilize splenic flexure if require extra length to reach tension-free anastomosis. Circular stapler from rectum and introduce anvil proximally to perform stapled anastomosis. Air leak test to check anastomosis integrity. Perform loop ileostomy to defunction anastomosis. (See Fig. 34.10.)
See Table 34.8 for indications.
Table 34.8 Indications of stoma (Greek for ‘mouth/opening’)
| Type | Loop (temporary) vs end (permanent) |
| Feeding | Percutaneous endoscopic gastro-/jejunostomy |
| Decompression | Obstruction (e.g. colorectal cancer) |
| Diversion | IBD, ischaemia, fistulae, bowel perforation, trauma, protecting distal bowel anastomosis (temporary) |
| Exteriorization | Bowel perforation, low rectal cancers, permanent stomas (abdominoperineal resection), low bowel perforations |
Scars, skin folds, creases, bony prominences, umbilicus, belt/waistline, previous radiation sites
Loop (two lumens (proximal and distal limbs), defunctioning loop colostomy for bowel rest—elective reversal in months–years) vs end (one lumen, e.g. end colostomy, Hartmann’s procedure—permanent usually but reconstructive options available). Double-barrelled stoma (Paul–Mikulicz) looks like a loop stoma (but severed into two separate lumens) and has only one functioning lumen excreting faeces.
This is failure of a surgical joint between two hollow viscera resulting in leakage of luminal content.
Ranges from 2% to 25% following colorectal surgery and has an associated mortality as high as ~40%.1 Typically occurring 5–7 days postoperatively, signs and symptoms can vary from subtle, tachycardia, low-grade pyrexia, prolonged ileus, to a septic patient with a rigid peritonitic abdomen with faecal matter present in surgical drains.
Poor nutrition, steroid use, perioperative blood transfusions, and importantly, the level of the anastomosis—with risk of AL ≤7 cm from the anal verge.
Intra-abdominal abscess, enterocutaneous fistula, and global peritonitis.
High level of suspicion of an AL is required, with a low threshold to order a CT abdomen/pelvis; or take the patient urgently back to theatre for washout and proximal faecal diversion in the form of an ileostomy or colostomy. Air leak test can identify anastomotic leaks intraoperatively, and right-sided anastomoses have a lower AL risk than left ones (~1 vs 5%).
This is failure of wound healing resulting in partial or complete re-opening of a surgical incision (see Table 34.9 for risk factors).
Estimated at 0.5–3.4% of abdominopelvic surgeries and associated with a 40% mortality rate.2
Can be categorized as pre-, peri-, and postoperative. Initial signs can be abdominal pain and pink wound discharge (blood-tinged peritoneal exudate); preceding complete wound dehiscence where abdominal viscera may protrude through the wound or be visible.
If stable, urgent return to theatre for closure with tension sutures.
Honours
See Table 34.9.
This is disruption in normal peristalsis of the alimentary canal following surgery. It is considered an expected physiological response after handling bowel, lasting for hours (stomach/small bowel) and days for the colon.
POI is considered pathological when it extends beyond these periods and results in intolerance of oral intake, abdominal distension, and N&V.
Prolonged POI includes intra-abdominal sepsis, drugs (opioids), and electrolyte disturbances (K+/Mg2+). Longer duration of surgery and open technique (vs laparoscopy) POI risk too.
A NG tube should be passed if significant abdominal distension and repeated vomiting, with fluid resuscitation to match gastric output and fluid requirement. Parenteral nutrition should be considered if POI extends beyond 7–10 days. POI resolution is monitored through (1) reduced NG output, (2) abdominal distension, and (3) passing of flatus/stool.
Oliguria is defined as urine output <0.5 mL/kg/hour. Causes: categorized as (1) pre-, (2) renal, or (3) post-renal oliguria. Initial assessment should look to identify evidence of pre-renal causes—negative fluid balance or sustained periods of hypotension. Hypovolaemia may be caused due to fluid losses from haemorrhage, evaporation, and ‘third spacing’.
Fluid resuscitation guided by response to fluid challenges. Excessive fluid administration risks of complications (e.g. anastomotic leakage and bleeding). A common post-renal cause is a palpably distended bladder due to urinary retention. In the absence of pre/post-renal causes, intrinsic renal causes can be explored.
Fluid challenges, flush urinary catheter, stop nephrotoxics, urine dip ± MSU, U&E, renal US.
A low-grade fever is common in the first 24 hours following surgery due to the release of inflammatory mediators. Postoperative pyrexia can be indicative of a range of postoperative complications, which can be remembered as the 7 Cs:
• Collection (subphrenic/pelvic)
• Central venous line (infection)
Further clues as to the source of the pyrexia could be taken from associated signs and symptoms—respiratory or irritative urinary symptoms and wound discharge. Pre-existing comorbidities a higher risk of specific complications (e.g. COPD patient and pneumonia, or diabetics and wound infections). The nature and timing of onset of the pyrexia—intra-abdominal collections typically developing 4–10 days postoperatively and following a swinging pattern. Management: stabilize the patient with high-flow oxygen and IV fluids, septic screen including bloods ± cultures, ABG, CXR, urine dip ± MSU, wound/line swab, stool sample, CT, etc. Treatment: antibiotics, removal of infected lines/catheters or surgical wound clips to encourage draining of discharge and radiological/surgical drainage of abdominal collections.
• • Infection—mostly candidiasis and Staphylococcus aureus.
• • High output dehydration, hypovolaemia, and electrolyte disturbance.
• • Electrolyte disturbance (Na+, K+, Ca2+, Mg2+).
• • Peristomal contact/allergic dermatitis (from ileostomy contents).
• • Ischaemia/necrosis—dusky, dark, purple, and black appearance.
• • Bowel obstruction (from constipation or parastomal hernia).
• • Ileus (takes several days to resolve).
• • Prolapse (from high intra-abdominal pressure).
• • Retraction (from excess tension) peristomal dermatitis leakage.
• • Stomal stenosis/strictures (from chronic ischaemia).
• • Parastomal hernia (from chronic comorbidities such as diabetes and immunosuppression poor healing, high intra-abdominal pressure).
• • Peristomal pyoderma gangrenosum (from ulceration in IBD).
References
1. Murrell ZA, Stamos MJ (2006). Reoperation for anastomotic failure. Clin Colon Rectal Surg 19(4):213–6.
2. Shanmugam VK, Fernandez SJ, Evans KK, et al. (2015). Postoperative wound dehiscence: predictors and associations. Wound Repair Regen 23(2):184–90.
Is a surgical emergency and presents as peritonitis. Acute abdominal pain is commonly referred to the surgeons with a wide range of pathologies. Any viscus is susceptible to obstruction, inflammation, perforation, or ischaemia, and it is helpful to think about the differentials in terms of site of pain (i.e. organ involved) and these four mechanisms of pathology. (See Table 34.10.)
Table 34.10 Differentials for right lower quadrant pain
| Organ | Inflammation | Obstruction | Perforation (local/generalized) | Ischaemia |
| Appendix | Appendicitis | Appendicitis | ||
| Caecum | IBD | Bowel obstruction (with competent ileocaecal valve) | ||
| Bowel | IBD | LBO/SBO | Ulcers LBO/SBO | Mesenteric ischaemia |
| Tubo-ovarian | Salpingitis/oophoritis Cyst | Ectopic pregnancy | ||
| Ureter | UTI | Stone, tumour, clots | Iatrogenic (intraoperative) |
IBD, inflammatory bowel disease; LBO/SBO, large/small bowel obstruction; UTI, urinary tract infection.
Left-sided abdominal pain, bleeding, and diarrhoea from ischaemia to the splenic flexure or descending colon in the area supplied by the marginal artery. Essentially this is the part of the colon with the poorest blood supply. Pathology: low-flow states or other significant medical issues can precipitate this condition. Diagnosis: can be clinically suspected based on abdominal CT scan. There is no acute occlusion here as in acute mesenteric ischaemia but CT could show end-organ ischaemia or simply colitis. If CT is unclear, endoscopy and biopsy can confirm the diagnosis. Management: supportive with fluids and optimization of cardiovascular status. Surgery and resection will be rarely required if there is complete necrosis, if the patient is peritonitic and in extremis. These patients are usually high risk as vasculopaths. Most times patients will stabilize with conservative measures.
Occurs with blockage of the superior mesenteric artery (a principal arterial supply of the GI tract) with an embolus. Associated mortality rate of 70% due to high risk of bowel perforation secondary to absolute ischaemia.
Classically with severe diffuse abdominal pain disproportionate to clinical findings (Fig. 34.12), bloody bowel evacuation, and the presence of new-onset AF. A high index of suspicion should be adopted in older arteriopathic patients with cardiovascular comorbidities.
ABG—high lactate/metabolic acidosis. May also have high WCC, CRP and amylase in formal blood testing.
Fluid resuscitate, correct dysrhythmias, antibiotics, followed by prompt CT angiography (if patient is stable) or exploratory laparotomy (if unstable/peritonitic) for resection of necrotic bowel.
Fig. 34.12 Causes of abdominal pain according to each section. Reproduced with permission from Athanasios Kalantzis and Crispian Scully, Applied Medicine and Surgery in Dentistry (3 ed.) 2009, Oxford University Press.
Is the most common abdominal surgical emergency, resulting in 40,000 admissions annually in England1 and occurs after obstruction of the vermiform appendiceal lumen inflammation phlegmon/abscess or tissue necrosis/perforation.
Faecolith, lymphoid hyperplasia, and malignancy.
Age 10–19 years.
Classically a short history of initially intermittent, diffuse periumbilical pain, which migrates and evolves into a constant localized right lower quadrant pain days later, associated with N&V and anorexia.
Guarding and rebound tenderness at McBurney’s point (one-third of the way between umbilicus and anterior superior iliac spine (ASIS)). (See Fig. 34.13.)
Fig. 34.13 McBurney’s point. Reproduced from https://commons.wikimedia.org/w/index.php?curid=1211886 licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
• Rovsing’s sign (palpating left lower quadrant induces pain in right lower quadrant).
• Iliopsoas sign (pain on hip extension in retrocaecal appendix).
• Obturator (Cope’s) sign (pain on hip internal rotation in pelvic appendicitis).
• Dunphy’s sign (pain on movement and coughing).
The most common appendix tip location is retrocaecal.
WCC (neutrophilia/left shift), urine pregnancy test (rule out ectopic pregnancy), and US in atypical cases where other differentials may be likely (e.g. ovarian pathology). Diagnosis: can be guided by scoring systems (Alvarado) and investigations, but the diagnosis is fundamentally clinical.
Prompt antibiotics and laparoscopic appendicectomy with washout ± drain insertion if complicated appendicitis.
Top tips
• • Younger patients: Be aware of those presenting with RIF pain as a sign of terminal ileitis (CD) as opposed to appendicitis.
• • Males: any male with abdominal pain requires a testicular exam
• • Child bearing age: always do a urinary pregnancy test to rule out an ectopic pregnancy!
• • Older patients: at the other end of the age scale, right-sided colonic tumours may present as RIF pain mimicking appendicitis (or even causing it) and patients over the age of 50 should be investigated with an urgent CT scan prior to operation.
This is the presence of diverticulum (outpouching of the bowel wall) most commonly present in the sigmoid colon and is present in half the population ≥50 years. Diverticulitis occurs when faecal matter and bacteria congregate within these outpouchings resulting in inflammation.
Age, low-fibre diet (western diet), smoking, and obesity. Presentation: left lower quadrant pain, low-grade fever, less commonly PR bleeding, tender on PR.
Conservatively with fluids and antibiotics. CT can (1) confirm the diagnosis, (2) see if it is amenable for radiological drainage of abscesses, and (3) identify any complications (e.g. perforation or fistulas). Extent of perforations can be classified using the Hinchey classification. Surgical management is required in one-third of patients who fail to respond to conservative treatment/perforation with faecal peritonitis—commonly a Hartmann’s procedure with a colostomy. (See Fig. 34.14.)
Fig. 34.14 Hartmann’s procedure. Reproduced with permission from McLatchie, G, and Leaper, D. Operative Surgery 2nd edition, Oxford University Press: 2006.
Is the mechanical blockage of the colon preventing the passage of colonic content gross dilation bowel perforation (if untreated). It is less common than small bowel obstruction (SBO), only accounting for 20% of bowel obstructions.
90% accounted for by colonic malignancy and diverticulitis. Other causes are volvulus (sigmoid/caecal), faecal impaction (especially in the elderly and secondary to opioids) and hernias. (See Fig. 34.15.)
Fig. 34.15 AXR of caecal volvulus (left) and sigmoid volvulus (right). Reproduced with permission from Thomas, William E.G., et al, Oxford Textbook of Fundamentals of Surgery, 2016 Oxford University Press.
Initial colicky abdominal pain which becomes constant. Absolute constipation is where there is no passing of stool or flatus. Worsening pain on movement may imply bowel ischaemia/perforation. Vomiting is initially gastric bilious faecal. In LBO, vomiting is a late sign but vice versa in SBO. Examination: tympanitic abdomen, palpable abdominal mass, visible hernia, localized tenderness (ischaemic bowel segment), tinkling bowel sounds, PR rectal mass/empty.
Lactate (to assess level of ischaemia); AXR/CXR—free air (pneumoperitoneum secondary to perforation), level of bowel dilatation, volvulus, concurrent small bowel loops suggests incompetent ileocaecal value; CT to demonstrate the level and cause of LBO.
Varies according to the cause and associated complications (ischaemia/perforation). Treatments range from conservative ‘drip and suck’ (keep patient nil by mouth, IV fluids plus NG tube) to surgery.
1. Simpson J, Samaraweera AP, Sara RK, et al. (2008). Acute appendicitis – a benign disease? Ann R Coll Surg Engl 90(4):313–6.
Typical OSCE histories orientate around PR bleeding, change in bowel habit, and abdominal pain. Generally speaking you cover most of the same questions but ask increasingly focused questions depending on the actor’s responses. Key focused questions:
• PR bleeding: blood on toilet paper/in toilet/around stool/mixed in stool. Was the blood fresh/clots/melaena? Amount of blood (teaspoons/cups)/frequency?
• Change of bowel habit: weight loss, anorexia, symptoms of anaemia (lethargy, sob, palpitations), tenesmus, family history.
• Familiarize yourself with common abdominal scars and what previous surgeries they represent (see Fig. 34.16). They may act as clues to what other clinical signs you may expect to find during the examination (e.g. laparotomy scar associated with a reversed stoma scar). Remember that one of the key differentiating features between a surgical abdominal examination vs a medical one is the addition of vascular clinical signs (abdominal aortic aneurysm and aortic/renal bruits). So if you find you finish your examination station with time to spare, just quickly consider whether you felt for an expansile and pulsatile mass (Table 34.11), and whether you only listened for bowel sounds instead of renal/femoral bruits. Common signs presenting in the surgical abdomen examination include hernia, stoma, hepato-/splenomegaly, and renal transplant (palpable mass in right lower quadrant).
Table 34.11 Examining a lump or bump
| Finding | Examples |
| Site | Local anatomy |
| Size | Width × length × depth |
| Shape | Round/oval |
| Surface | Smooth/lumpy |
| Surrounding skin | Erythema, bruise, sinus/fistula, lacerations/abrasions |
| Consistency | Soft/firm/hard/irregular |
| Compressibility | Yes (e.g. saphena varix or varicose veins)/no |
| Colour | Erythema, pigmentation |
| Tenderness | On palpation |
| Transillumination | Using pen torch (e.g. cyst/lipoma) |
| Tethering | E.g. to skin |
| Fluctuance | Yes with a fluid thrill (e.g. cyst/abscess)/no |
| Fixity/mobility | E.g. to deep structures like underlying muscles |
| Pulsatility | Yes (e.g. aneurysm)/no |
| Percussion | Resonant vs dull (e.g. in cystic and solid lesions) |
| Reducibility | Yes/no (e.g. reducible vs strangulated hernias) |
| Auscultation | ?Bruit (e.g. aneurysm) |
| Edges | Smooth/nodular/defined borders/hard (e.g. cancer/bone) |
| Distal examination | Nerves, lymph nodes, pulses and capillary refill |
Fig. 34.16 Incisions of the neck, chest, and abdomen. A. Carotid incision B. Thyroidectomy incision C. Tracheotomy incision D. Subclavicular incision E. Sternotomy incision F. Infra-areolar incision G. Inframammary incision (either side) H. Clamshell incision I. Kocher/subcostal incision J. Mercedes Benz incision K. Paramedian incision (either side) L. Chevron incision M. Epigastric/upper midline incision O. McBurney's/Gridiron incision (right side only—for appendectomy) P. Rockey-Davis/Lanz incision (right side only—for appendectomy) Q. Supraumbilical incision R. Infraumbilical incision S. Pararectus incision T. Mayland incision U. Pfannenstiel/Kerr/pubic incision V. Gibson incision (either side, but conventionally left) W. Midline incision X. Inguinal incision Y. Femoral incision Z. Turner–Warwick's incision. Reproduced from Wikimedia commons, available under Creative Commons Public Domain.
A stoma is a surgically created opening in a hollow viscus into the external environment. Stomas in exams are very common since it is a common procedure in colorectal surgery.
Introduce yourself, wash your hands, and put on gloves. Lie the patient down at 45° and explain what you will be doing.
• Site: colostomy usually in LIF vs ileostomy in RIF (but stomas can be anywhere—see Fig. 34.17).
• Sprout: ileostomy/urostomy are sprouted to avoid contact dermatitis (from alkaline/caustic content). Colostomy is flushed to the skin.
• Content: green/brown soft/liquid output in ileostomy. Formed faecal matter in colostomy. Urostomy contains urine.
• Number of lumens: single (end) vs double (loop).
• Output: ileostomy (500–1000 mL/day) > colostomy (<300 mL/day).
• Complications: retraction (obstruction), prolapsed (high output), infarction, parastomal hernia (risk of bowel strangulation), haemorrhage, excoriations, skin changes.
Fig. 34.17 Sites of stoma Reproduced from Lammon, Carol, et al, Clinical Nursing Skills, 1995, with permission from Elsevier.
Having removed the stoma bag:
• Palpate for stoma tenderness.
• Ask the patient to cough and palpate for parastomal hernia.
• Look at your finger tip to rule out blood, pus, and mucus.
To rule out obstruction (high-pitched tinkling) and ileus (absent).
Hernia is defined as a protrusion of (part of) a viscus through the walls of its containing cavity into an abnormal position. (See Fig. 34.18 and Table 34.12.)
Fig. 34.18 Composition of a hernia. Reproduced with permission from Francis, David M.A., et al, Textbook of Surgery 3e, 2008, Wiley.
Table. 34.12 Classification of hernias
| Reducible | Contents can be returned to the abdomen |
| Irreducible | Contents cannot be returned to the abdomen |
| Obstructed | Bowel in hernia is obstructed but not ischaemic |
| Strangulated | Bowel in hernia is ischaemic gangrene perforation peritonitis |
| Incarcerated | Bowel in hernial sac is blocked with faeces/adhesions |
| Reduction-en-mass | Reduction of the hernial sac together with its contents with the bowel still remaining incarcerated (rare form of acute bowel obstruction) |
Congenital (patent processes vaginalis), acquired (surgical incisions) defects in the abdominal wall or due to intra-abdominal pressure (cough, straining, ascites). Hernias can present in clinic as a relatively asymptomatic lump or can present in the ED with pain and distension due to complications:
The sac is a diverticulum of peritoneum, consisting of the mouth, neck, body, and fundus. It is covered by layers of the abdominal wall. Content normally consists of the omentum or bowel.
These are the commonest hernia (prevalence of 4% >45 years and accounting for 75% of all anterior abdominal wall hernias). These usually appear in clinical exams so take every opportunity to examine these on the ward, in clinic, or in the ED. (See Table 34.13.)
Table. 34.13 Types of inguinal hernias
| Dual/pantaloon/saddlebag | Concurrent direct and indirect inguinal hernias |
| Sliding (hernia-en-glissade) | Retroperitoneal organ is part of hernial sac |
| Richter | Partial circumference of the bowel is obstructed ± strangulated |
| Maydl | ‘W’ hernia: hernial sac contains two loops of bowel with another loop of bowel being intra-abdominal |
| Littre | Meckel’s diverticulum in hernial sac |
| Amyand | Appendix in hernial sac |
The deep inguinal ring is at the midpoint of the inguinal ligament (halfway between ASIS and pubic tubercle). The superficial ring is just lateral to the pubic crest. Do not get confused with mid-inguinal point (halfway between ASIS and the pubic symphysis) which is the location of the femoral pulse. (See Fig. 34.19 and Fig. 34.20.)
Fig. 34.19 Anatomical landmarks of the inguinal canal. Image reproduced from GeekyMedics.com, illustrated by Mr Robert Pearson.
Fig. 34.20 Differentiating direct and indirect inguinal hernias. Image reproduced from GeekyMedics.com, illustrated by Mr Robert Pearson.
1. Introduction: introduce yourself, wash your hands, gain consent.
2. Inspection: look for vomiting bowls and lie the patient down before standing the patient up to repeat the examination. Look for abdominal/groin lumps and ask the patient to cough (cough impulse).
3. Palpation: for scrotal contents + hernia orifices. Describe the lump and feel for a cough impulse. Gently reduce the lump and check for reducibility.
4. Percuss: for bowel in the hernial sac and examine the abdomen
• Direct inguinal hernias occur through a defect in the posterior wall (transversalis fascia) of the inguinal canal at Hesselbach's triangle.
• Indirect inguinal hernias traverse via the inguinal canal—through the deep and out of the superficial ring (and often into the scrotum—i.e. inguinoscrotal)
• To differentiate between the two, reduce the lump, cover the deep ring, and ask the patient to cough.
• If the hernia returns, it is a direct inguinal hernia, and indirect if it does not.
• However, the true origin of a hernia can only be confirmed after surgery.
The femoral canal lies medial to the femoral vein and acts as a space for physiological expansion of the femoral vein. Femoral hernias can occur by passing through the femoral ring through the canal and out of the saphenous opening. Femoral hernias are more common in women due to the wider pelvic shape. The tightness of the femoral ring makes femoral hernias higher risk for strangulation than inguinal hernias (providing a more pressing need to operate) but may be managed conservatively with monitoring.