Colorectal Surgery- THE GUIDE
by Morag Sime and Chloe Hymers
Hernias
Definition: - A hernia is the protrusion of a viscus or part of a viscus outside the cavity which
normally contains it.
Types of hernia:
o Direct inguinal – medial to inferior epigastric artery
o Indirect inguinal – lateral to inferior epigastric artery
o Femoral- inferior and lateral to pubic tubercle
o Paraumbilical- midline
o Umbilical- only occurs in children
o Spigelian- linea semilunaris weakness ie lateral borders of rectus sheath
o Incisional – at scar
o Parastomal – around stoma
o Divarication of Recti – not a true hernia, weakness of the linea alba
Anatomy:
Examination:
Size, site, reducibility, tenderness, overlying skin, cough impulses.
Examine standing and lying
Risk Factors:
o
Age
o
Increased abdominal pressure- pregnancy, obesity, constipation, chronic cough
o
Occupational- heavy lifting
o
Congenital causes
o
Poor scar healing
Complications:
o
Incarcerated- irreducible. Mainly due to inflammation causing scarring around area. No
necessarily an acute problem
o
Strangulated- Compromised blood supply due to compression of blood vessels. Emergency
surgery.
o
Obstructed- compromised bowel transit. Symptoms of obstruction. Emergency treatment.
Investigations:
o
Bloods
o
USS abdomen
o
CXR, AXR
o
?CT
Management:
o
Dependent on presentation
o
Conservative:
o
Reassurance
o
Watch and wait
o
Truss
o
Treat cause – cough, constipation, weight loss, stop smoking, stop heavy lifting
o
Medical - analgesia
o
Surgical
o
Mesh repair
o
+/- Bowel resection
Bowel Obstruction
Cardinal signs:
o
Abdominal pain
o
Distention
o
Vomiting
o
Absolute constipation
Small bowel obstruction tends to have more vomiting and less distention (be aware of quicker
dehydration) . Large bowel vica versa.
Causes:
•
•
•
Intraluminal
–
Faecal impaction – large bowel
–
Gallstone Ileus – small bowel
Intramural
–
Cancer- both
–
Diverticular strictures- large bowel
–
IBD strictures- both
Extraluminal
–
Adhesions- both
–
Hernias- both
–
Volvulus- large bowel
–
Other cancers (ie gynae, nephrological, omental) – both
Most common causes:

Cancer

Hernias

Adhesions
Investigations:
o
PR
o
Bloods
o
AXR, erect CXR
o
?CT
Management:
o
Drip and suck ie
o
Iv fluids
o
NG tube
o
NBM
o
Catheter
o
Analgesia
o
Antiemetics
Types of surgery
Right hemicolectomy
Left hemicolectomy
Sigmoid colectomy
Anterior resection
Abdominoperoneal resection
Hartmanns procedure
Stomas
What to look at when examining a stoma:
o
Site
o
shape
o
colour (should be pink, if not get help)
o
surrounding skin
o
output (colour, consistency and volume)
o
number of lumens
o
hernias
Colostomy:
o
usually left sided (not a hard and fast rule)
o
usually one lumen ie end
o
flush with the skin
o
Stool like output
Ileostomy:
o
usually right sided (not a hard and fast rule)
o
may be biluminal (ie loop)
o
spouted as contents irritable to skin
o
more green, fluid like output
Complications:
o
Hernias
o
Necrosis
o
Retraction
o
Stenosis
o
Prolapse
o
Ulceration of the surrounding skin
o
Dehydration if high output
o
Psychological problems ie change in body image, sexual dysfunction