IB CSL SURGERY
ABDOMEN / PERINEUM-HERNIA BEDSIDE
Dr NG Patil
Thu 03-10-02
Abdomen
- RUQ ® GB
- RLQ ® appendix
- LUQ ® pancreas, stomach
- LLQ ® sigmoid colon
Pain
- Site
- Onset
- Duration
- Severity
- Character/ pattern
- Radiation
- Exacerbating/ Relieving
- Associated factors - eg. Vomiting for duration = obstruction?
Murphy's sign ® inability to take a deep breath with palpation beneath the R costal margin
If tenderness present on superficial palpation, DO NOT process to deep palpation ®
say "Tenderness on superficial palpation \ not able to perform deep palpation satisfactorily"
If Pt tenses rectus abdominus muscle
- Pt to squeeze your hand (distraction)
- Talk to Pt about Hx (distraction)
- Flex knees (while supine)
Note
- Peritonitis - inflammation of the peritoneum, which may be due to chemical irritation or
bacterial invasion
- Pernitonism - a condition of shock simulating peritonitis, but without inflammation of the peritoneum
Palpate ALL areas of abdomen - eg. May miss Spigelian hernia (DDx = lipoma)
- Any point along the transversus abdominus aponeurosis (Spigelian fascia) - most occur at/ just cranial to line connecting 2 ASIS's
- Hernial sac pierces the TA + IO m's - may expand between the obliques; hernia rarely penetrates the dense EO aponeurosis
-
in middle-aged women
- Pain often non-specific (classical exacerbation with Valsalva manoeuvre rarely manifests)
- Spigelion hernias difficult to detect in all but thin patients
- Role of imaging uncertain (US + CT unreliable) + MRI accuracy unknown
- Surgical repair strongly advised as the neck of the sac is usually narrow
\ risk strangulation
- Persistently painful groin "lipomas" should be explored surgically, irrespective of another ready explanation for the clinical findings
Normal abdomen with gallstones
- GB not enlarged
- No lump
- Tx/ Mx already
- No organomegaly \ no peritonism
- Operation to prevent further problems
\
-ve P/E ¹ no disease
Hernia
- Protrusion of viscous through normal/ abnormal opening in abdominal cavity
- Normal - umbilicus (umbilical)
- Abnormal - surgical incision (incisional)
- Sites
- Groin - inguinal
- Incisional
- No deep fascia at abdomen as it needs to expand (eg. with breathing, food)
- Corset not good - hernia may be trapped between body and corset
Ca Breast
- Say "our Pt" or "my Pt"; not "this Pt"
- Bilateral mammogram: comparison, metastasis
- Modified radical mastectomy: axillary resection, all breast fibrous/ fatty tissue, retain pec major
- Dx for ca: histological grade, staging (TNM), cytogenetic (pendulous breast), sex (male more danger than female ca br), receptors
- Bony metastases: localised (radiation), multiple (different modalities)
- Pathological #: malignant, osteomyelitis, osteoporosis
- Tx of pathological + normal # = same (outcome different)
- Prophylactic masectomy: only if strong familial/ genetic Hx
- Reconstruction: saline, muscle flap (breast shape)
- Breaking bad news (1) Personality (2) Hope (3) General info ("Pt's with ca br…") rather than making the Pt the picture
Reading CT - 6 C's
- Confirm belongs to Pt (CT of? Eg. brain)
- Contrast/ non-
- Cuts - level
- Correlation of anatomical structure (very imp with abdomen)
- Comments - factual (eg. hypo/ hyperdense region, SOL)
- Conclusion - may not have one (eg. do not know nature of lesion)
Ca UB
- Resection/ Excision/ Radiation
® surveillance cystoscopy
Clot in urine - shape (eg. if from kidney, must travel down ureter \ cylindrical shape
Clot from which kidney? Cystoscopy, angiogram
Scar - nylon stitch ® stitch granuloma