Gastro LOCAS Scars, Stomas and Hernias

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Gastro LOCAS Scars, Stomas and Hernias

• Matt Wickham

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Agenda

• What is LOCAS?
• Overview of Gastro Examination
• Scars
• Hernias
• Stomas
• Tips
• Questions
• Useful Information

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LOCAS
Matts Tip Number 1 Relax, its not like the
OSCE

• 2 Days
• Medicine and Surgery
• Specialties (OG/Paeds/Psych/Community)
• 6 stations per day
• 12 minutes per station
• 8 mins for Hx or Examination
• 4 mins for summary and questions
• Supposed to have 3 examination and 3 Hx stations
  per day.

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GASTRO EXAMINATION

• Wash hands
• Introduce yourself
• Check patient details
• Consent
• Exposure and position of pt.
• INSPECTION from End of Bed
• Is the patient comfortable?
• Comment on anything obvious eg. Scars, Lumps,
  Swellings, Stoma etc.

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GASTRO EXAMINATION

• INSPECTION cont.
• Hands nails
• Eyes
• Mouth tongue
• Cervical Lymph Nodes esp. Virchows
• Chest
• Abdomen
• Ask pt to take deep breath and cough

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GASTRO EXAMINATION

• PALPATION of abdomen
• Get on level with abdomen
• Superficial and deep palpation
• Describe any mass if present
• Organomegaly?
• PERCUSS for Liver and Spleen
• Shifting dullness?
• Hernias?
• Dont forget AAA

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GASTRO EXAMINATION

• AUSCULTATION
• Bowel sounds / Bruits
• Then SAY
• I would like to do a rectal examination,
  external genitalia examination and dipstick the
  urine
• Cover the patient and thank them
• Present findings to examiner SUMMARISE

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Scars
Subcostal (Kochers)/ Cholesystectomy
Midline / Gastroduodenal, Pancreatic, Splenic
surgery, AAA
Nephrectomy
Paramedian / Laparotomy
Classical Caesarian section/ Hysterectomy
Gridiron/ Appendicectomy
Inguinal Hernia repair
Pfannenstiel/ Caesarian section
Rutherford Morrison (hockey stick) Kidney
transplants
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Hernias
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Hernias

• Definition The protrusion of an organ or
  tissue out of the body cavity in which it
  normally lies
• Types of hernia
• Inguinal (Direct/Indirect) Femoral
• Umbilical Epigastric
• Hiatus Parastomal
• Obtruator Spigelian
• Inscisional

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Anatomy of Inguinal Canal

• Canal is roughly 4cm long in adults
• Lies parallel to and immediately above inguinal
  ligament
• Extends from the deep inguinal ring, downward and
  medially to superficial inguinal ring

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Anatomy of Inguinal Canal

• Deep (Internal) Ring
• Oval shaped
• Lies 1.25cm above inguinal ligament at midpoint
  of ASIS and Pubic Symphysis (MID-INGUINAL POINT)
• Inferior epigastric vessels lie medially to it
• Superficial (External) Ring
• Triangular shaped
• Lies 1.5cm above and 1.5cm medial to pubic
  tubercle
• Inferior epigastric vessels lie laterally to it

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Hasselbachs Triangle
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Anatomy of Inguinal Canal

• Anterior Wall Aponeurosis of the external
  oblique muscle (Lat 1/3 reinforced by internal
  oblique)
• Posterior Wall Fascia transversalis (Medial 1/3
  reinforced by conjoint tendon)
• Superior Wall Arching lowest fibres of internal
  oblique and transversus abdominus muscles
• Inferior Wall Inguinal Ligament (Lacunar
  ligament medially)

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Contents

• In Women Ilioinguinal nerve and round ligament
  of uterus
• In Men Ilioinguinal nerve and spermatic cord
• Spermatic cord

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Examination

• Introduction and inspection as normal
• Expose pt (In LOCAS the pt will wear underwear)
• Ask pt to stand
• Palpation
• Define the swelling
• Location
• Size
• Shape
• Colour
• Consistency
• Tenderness
• Cough impulse

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Examination

• Ask pt to lie down
• Ask pt to reduce the hernia if poss. (Watch how
  they do this!)
• Place two fingers over deep ring
• Ask pt to cough again
• See what happens
• Nothing Indirect hernia
• Lump re-appears Direct Hernia
• Auscultate lump for potential bowel sounds

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Inguinal Hernias

• Commonest type
• Either Indirect (80) or Direct (20)
• Direct hernias will lie within Hasselbachs
  triangle
• Indirect hernias originate through the deep ring
  which is lateral to the inferior epigastric
  arteries and therefore do NOT fully lie in
  Hasselbachs triangle
• Indirect hernias may protrude into scrotum,
  direct will not.
• If still not sure? Lateral more likely, indirect
• Medial more likely, direct

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Differential Diagnosis of Groin Swelling
Matts Tip Number 2 I cannot convince myself

• Above Inguinal Ligament
• Inguinal Hernia
• Undescended testis
• Hydrocele
• Lipoma
• Iliac Lymph Node
• Below Inguinal Ligament
• Femoral Hernia
• Femoral aneurysm
• Saphena Varix
• Lymph Node
• Psoas Abcess

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Complications

• Hernia may strangulate (Emergency)
• From surgery
• Bleeding/haematoma formation
• Bruising
• Infection
• Urinary retention
• Infarcted testis
• Pain (persistent in up to 5)
• Recurrence rate lt1
• Anaesthetic complications (Infection, DVT/PE etc)

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Stomas
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Stomas

• What is a Stoma?
• A surgically created opening

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Reasons for stoma formation

• Carcinoma - Bowel or Bladder
• Diverticulitis
• Inflammatory Diseases - Ulcerative colitis /
  Crohns Disease
• Familial Polyposis
• Trauma - e.g. Stab / Gunshot wounds
• Neurological Damage - e.g. Multiple Sclerosis
• Incontinence
• Congenital Disorders

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TYPES OF SURGERY RESULTING IN STOMA FORMATION

• Anterior Resection with Loop Ileostomy
• Abdomino Perineal Resection
• Hartmanns Procedure
• Double Barrelled Colostomy
• Pan-Proctocolectomy
• Sub-total colectomy with end ileostomy
• Ileo-anal Pouch
• Ileal Conduit
• Mitrofanoff

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End Colostomy
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Loop Colostomy
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Ileostomy
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Colostomy Vs Ileostomy
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Urostomy
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STOMA COMPLICATIONS
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Retraction
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Prolapse
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Muco-cutaneous separation
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Matt Tip Number 3 Examine the contents of the
bag!
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Cases from Last Year

• Inguinal hernia
• Inscisional hernia
• Diaphragmatic hernia
• Stomas
• Ileostomy
• Colostomy
• Urostomy
• AAA
• Splenomegaly
• Polycystic Kidneys
• Kidney Transplant AV fistula
• Insulin dependent DM

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Tips

• Be FLEXIBLE!
• Play the game.
• Confidence
• Take a moment to think before answering
• Give structured answers

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USEFUL RESOURCES

• PasTest books
• Surgical Finals 2nd Ed
• Medical Finals 2nd Ed
• Dr Clarke Website
• www.askdoctorclarke.com
• Hospital is Best Resource!

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Questions?