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
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
Scars
Abdo Scars
Kochers
Gable/Rooftop – join up R subcostal and L
LANZ
GRIDIRON/Mcburneys incision
Loin
Vascular scars
Pfannenstiels
STOMAS
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

“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
Stoma complications
EARLY
LATE
• Haemorrhage at site
•Obstruction
•High output
•Dermatitis
•Stoma ischaemia
•Intussusception
•Stoma retraction
•Prolapse
•Obstruction secondary
•Parastomal hernias
to adhesions
•Stenosis
•Fisutlae
•Psychological
•Failure/re-positioning
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
Which operation?!
Cancers…
Right hemi-colectomy
Extended right hemi-colectomy
Sigmoid-colectomy
Left hemi-colectomy
(rarely transverse colectomy)
Which operation?!
Cancers…
Rectal cancers:
HIGH
ANTERIOR
RESECTION
OR LOW
ABDOMINOPERINEAL
RESECTION
Ulcerative Colitis
Pan Procto-colectomy
Subtotal colectomy + rectal treatment
J POUCH FORMATION
(ileo-anal pouch)
Perforated Diverticula
Hartmans
What to consider o/e
SCAR
RIGHT/LEFT STOMAS
MUST ASK TO EXAMINE THE
PERINEUM
Ileostomy
ANUS?
ANTERIOR
RESECTION
NO
ANUS?
END
ILEOSTOMY
Ileostomy
ANUS?
ANTERIOR
RESECTION
HIGH RECTAL
CANCER
RESECTION
NO
ANUS?
END
ILEOSTOMY
PANPROCTOCOLECTOMY
Colostomy
ANUS?
HARTMANS
NO
ANUS?
ABDOMINOPERINEAL
RESECTION
Colostomy
ANUS?
HARTMANS
NO
ANUS?
ABDOMINOPERINEAL
RESECTION
PERFORATED
DIVERTICULA
LOW RECTAL
CANCER
CASE 1
Present the findings
Get ready for some viva questions
What do you want to know about
the stoma??
Single lumen
Bowel flush with the skin
Solid contents
Anus present
No excoriations/parastomal hernia
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!
Hartmanns procedure
EMERGENCY PROCEDURE
Sigmoid colectomy with end colostomy
(reversible)
Usual indications: acute diverticulits
especially perf! And acute obstructing
sigmoid Ca
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
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!
Hernias
Scar related
Groin - shorts v.common
Complications of hernias
Groin lumps – hernias
– How to dd a femoral vs inguinal
– More likely be to a inguinal hernia
Why?
ABOVE &
MEDIAL =
INGUINAL
BELOW &
LATERAL
=
FEMORAL
Inguinal Hernias
Inguinal anatomy!
Scrotal mass cannot get above it
Dd in the exam by occluding the deep ring
Hernias
ASIS  Pubic tubercle
What is this called?
What lies here?
ASIS  Pubic Symphysis
What is this called?
What lies here?
Definitive
Operative
Hesselbachs triangle
Lichenstein tension free mesh repair
Gold standard still open
Hesselbachs triangle:
CASE 2
Present the findings
Get ready for some viva questions
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
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
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.”
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
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
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
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
Urology - haematauria
Vascular scars
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
THE END
PLEASE DO THE FEEDBACK FORMS!
QUESTIONS??
ANIKA- ak8009@ic.ac.uk
UPI- ub06@ic.ac.uk