HERNIA

IB CSL SURGERY

PERINEUM & HERNIA
Dr J Ho

Surgery

Mon 30-09-02
HERNIA

HISTORY

C/O Swelling

Duration

Reducibility: mass absent when supine, present on standing/ straining

Unilateral or bilateral - inguinal/ femoral often assoc. with ab weakness (\ bilateral in 30%)

Pain - usu. no pain; only if complication like strangulation

Extension to scrotum - dragging discomfort; if yes, 99% indicates indirect inguinal hernia

Predisposing factors - chronic cough, constipation (cause ab pressure); large intra ab mass/ ascites/ preg (constant intra ab pressure)

Previous operation - Hx appendectomy (usu. don't cut ab wall m, may cut m's cutting ilioinguinal nerve - which supplies ab wall) - causing R direct hernia (indirect usu. congenital)

PHYSICAL EXAMINATION

Exposure - privacy (umbilicus to mid-thigh)
Position - standing and supine (esp. for groin - inguinal/ femoral - hernia)

LOOK

Swelling

Cough impulse - demonstrate to Pt, ask Pt to cough twice (each time, look at one side, then other); viewing cough impulse is more reliable than palpating (esp. if inexperienced)

Unilateral or bilateral - often only notice one side, even if bilateral - therefore MUST check both sides

Extension to scrotum

DIAG: right indirect hernia, pushes penis to other side

Also umbilicus hernia

Cirrhosis - ascites - hernia x 2

FEEL

Cough impulse: feel both sides

Reduction (by Pt): (1) Disappear with lying? (2) Pt reduce himself (best knows direction of reduction) (3) DO NOT attempt to reduce it yourself (4) If exam + Pt cannot, ask examiner

If umbilical/ incisional hernia - stop here ® continue for femoral/ inguinal

Neck of hernia: differentiates between inguinal and femoral hernias. Pubic tubercle = landmark (most lateral part of pubic bone felt)

Inguinal: neck above and medial to pubic tubercle (differentiate between direct and indirect)

Hasselbach's triangle - only covered by transversalis fascia (where direct hernia comes out) - direct because comes direct from posterior ab wall

Indirect: comes out at internal ring (mid-point between ASIS and pubic tubercle (mid-inguinal point), one finger's-breadth above) along with cord (inguinal canal, if severe can go to scrotum); note if small internal ring, may come out very slowly

Femoral: neck below and lateral to pubic tubercle (if femoral - finish exam here)

Occlusion test (inguinal): thumb on internal ring (occlude ring), ask Pt to cough/ stand up: (1) Indirect hernia - can be controlled (2) Direct hernia - hand on internal ring, but hernia can still come out

Can the remove thumb and ask Pt to cough again, if comes out, demonstrates indirect hernia

GROIN LN

HISTORY

Duration

Pain

Enlargement - progressive, static

Symptoms of anus, LL, perineum, buttock (regional)
Therefore need to ask for mass, cut in these areas - local (groin), regional, generalised lymphadenopathy (lymphoma, lymphocytic leukaemia)
Therefore, lumps or LN elsewhere (neck, axilla)
LN - usually secondary pathology (not painful)
Acute lymphadenitis - painful

EXAMINATION

Exposure: umbilicus to mid-thigh
Position - supine

LOOK

Swelling - side c/o, other side
Overlying skin - erythema (usu. accompanies acute lymphadenitis)

FEEL

Local

Number

Size - usu. spherical so describe diameter, if range, state range

Discrete/ matted - matted = fused together (TB infection, malignancy usu. secondary)

Consistency - soft, firm, hard (soft = path; firm = either; hard = malignancy); rubbery = lymphoma

Tenderness - if tender indicates acute infection (acute lymphadenitis), assoc. erythema, skin swelling

Mobility - mobile = benign; matted/ fixed/ hard = malignant

Group of notes involved - indicates primary problem

DIAG: Groups of groin LN

Deep - along femoral vein then iliac vein

Usu. feel superficial

Medial - along medial side of groin crease/ sapheno-femoral junction, drains external genitalia, anus

Lateral - to sapheno-femoral junction along groin crease, lat upper thigh, buttock, back

Vertical - along saphenous vein, drains through saphenofemoral junction into femoral, drains LL (except buttock)

Other

Other LN (neck, axilla)

Abdomen (liver, spleen) - lymphoma ® hepatosplenomegaly

DRE - leave to last

Acute abrasion/ lesion/ discoloration (eg. malignant melanoma)

Don't just concentrate on LN ® Just tells you there's something wrong with its drainage region
RECTAL EXAMINATION

HISTORY

Local

Anal pain

Nature
Continuous/ intermittent
PR bleeding (commonest complaint with anal problems)
Other bowel symptoms (change in habits)

Anal swelling

Constant (anal swelling)/ after straining (prolapse)
[Disappear - spontaneous reduction; manual reduction (more severe prolapse)]
Pain
PR bleeding/ discharge
Other bowel symptoms

IMPORTANT

Anal fissure - pain with bleeding

Haemorrhoids - bleeding with no pain
Instruments

Gloves - protection against communicable disease
Jelly - lubrication
Tissue/ Gauze - wipe Pt

RECTAL EXAMINATION

Prep

Left lateral (Simm's) - most common; buttocks near end of bed; pillow under buttocks (esp. important for protoscopy)
Prone Jack-knife ( prone); need special bed, Pt kneels, face down; inspection easier
Exposure: umbilicus to mid-thigh
Privacy
MUST wear 2 gloves

LOOK

Spread buttocks

Perineum - scar, fistular opening

Perianal - fissure, external haemorrhoid (surrounding pigmented area)

Anal fissure - 6 o'clock (posterior midline) (80% at this site); looks like a crack; if see sphincter, it is a chronic fissure

90% males posterior midline

70% females posterior midline fissure, 30% anterior midline fissure

If anterior midline, underlying bowel pathology (eg. Crohn's disease)

FEEL

Lubricated gloved finger
Warm Pt, touch perianal region, press downwards to dilated external anal sphincter
Direction: towards umbilicus
Examine as cylinder (don't miss any places)
Know the length of your finger
Male - feel urethra, must do PR/ prostate/ bimanual (everything) before WD finger

Rectal Lesion

Intraluminal (mucosa)/ extraluminal (prostate)

Level (upper + lower borders): how many cm above anal bridge (anal opening) - upper border may be beyond reach of finger; state height of lesion (upper - lower)

Size and % circumference: fingers-breadth (size), circumferential (whole circumference)

Shape - ulcer, polypoid growth, plaque-like lesion

Consistency: soft, firm, hard

Mobility: arising from rectal lumen, free (not invading to surrounding organ), Male: fixed in anterior (prostate), fixed in posterior (sacrum), fixed lateral (pelvic side wall), Female: anterior (cervix and vagina)

Bimanual rectal-abdominal examination

RVP (rectovesicular pouch) - male - part of peritoneal cavity, feel redundant sigmoid colon? Malignant deposits from intra ab malignancy
POD (Pouch of Douglas/ rectouterine pouch) - female - part of pelvic cavity - if ant lesion, bimanual rectal-vaginal - vagina invaded? (R rectum, L vagina) (rectovaginal septum thin)
Blood or colour of motion on glove - if Pt c/o tarry stool, look at colour of stool

PROCTOSCOPE

Look at anal canal - esp. internal haemorrhoids (cannot palpate unless thrombosed) \ need protoscopy for Dx

Golden Rules

Should be preceded by PR exam (narrow anus and cause damage; direction may not be towards umbilicus; may not do proctoscopy if large lesion found in PR exam)
Must have obturator fully in situ before inserting scope (sheath is sharp and metal) - otherwise, lesion/ perforate (a) With obturator - can advance scope (b) Without obturator - can only withdraw scope (c) If see something, WD, attach obturator and insert again

Equipment

Old model: sheath, obturator, no light (need 2nd person to hold light)
New: self-illuminating
Lumen of scope is narrower than lumen of anal canal
Therefore rotate scope (circumferential movt) to inspect all areas of anal canal
Direction - towards umbilicus (or as directed by PR exam)

Procedure

Insertion (with obturator fully in situ - hold thumb/ finger to prevent slipping out)
Removal of obturator
Inspection upon WD (no need to replace obturator)

DIAG

Pale red - anal mucosa

Anal papilla

Dentate line - redder than mucosa

Cherry-like substance below dentate line - internal haemorrhoids