Common Cases in Surgery: Understanding Abdominal Scars, Stomas, and Hernia Examinations, Lecture notes of Pathology

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OSCE-Aid Presents:

Common Cases: Surgery and Vascular

What to expect

Stable, chronic conditions in well

patients

Patients who have had previous surgery

and have scars or stomas

Medical conditions with surgical

sequelae

Surgical Stations

1) Abdominal Scars

2) Stoma examinations

3) Hernia examinations

4) Vascular examinations

Abdominal scars

Rooftop Kocher’s Transverse Lanz & Gridiron Vertical femoral Pfannelstiel Groin Paramedian/Battl e Laparoscopy ports

Important Scars

• Midline laprotomy – “the workhorse”
  • Exploratory – emergency or exploratory
  • Bowel pathology
    • Colonic or rectal resection - malignancy
    • Small bowel resection/stricturoplasty - malignancy/IBD
  • Open AAA repair

Important Scars

• Laproscopic ports : Umbilical (10mm for the camera) + 2-4 other small incisions - Most commonly: appendicectomy and cholecystectomy
• ALL bowel resections can be done laparoscopically: look for larger scars nearby
• Kochers (right)/Subcostal (left)
  • Open access to the biliary tract and spleen
  • Older patients who have had cholecystectomy

Likely Cases: Crohn’s

SIGNS

• Young, male, smoker
• Cachectic
• Pale (anaemia of chronic disease / iron deficiency / B deficiency)
• Evidence of multiple courses of steroids
• Clubbing
• Energy drinks e.g. ensure plus

Likely Cases: Crohn’s

SIGNS

• Oral ulcers / evidence of malnutrition e.g. glossitis
• Abdominal scars
  • Likely multiple, including laparotomy
  • May include previous stoma sites
• Stomas - ileostomy/colostomy
• Fistulae – enterocutaneous
• Anal fissures

Top questions: (1) What are the key differences between Crohn’s Disease and Ulcerative Colitis? Crohn’s Disease Ulcerative Colitis From the mouth to the anus Colon & Rectum Bowel wall thickened - ‘cobblestones’ Thin bowel wall ‘Patchy’ disease with skip lesions Continuous disease Ulcers can be deep – transmural Ulcers do not cross the muscularis mucosae (mucosal) Granulomas are common Granulomas are uncommon

Top questions: (2) What are the indications for surgery in Inflammatory Bowel Disease?

• Failure of medical management to control symptoms
• Abscess formation and fistulae
• Obstruction / strictures
• Toxic megacolon
• Sepsis
• Cancer
• Curative (only UC)

Stomas: What to Look For The Stoma

• Site
• Spouted or flush
• Pink/well perfused
• Skin bridge/rod
• Retracted
• Luminal stenosis
• Hernias

Stomas: What to Look For The contents of the bag (if clear)

• Liquid/Solid Stool/Gas
• Colour
• Volume
• Blood? “The stoma appears to be functioning well….”

Stomas: What to Look For Site Bag Contents Stoma Ileostomy RIF^ Liquid stool (green coloured) Spouted Colostomy LIF^ Solid stool (brown coloured) Flush with skin Urostomy RIF^ Urine^ Spouted

Present your findings: “I examined this gentleman’s stoma. It is situated in the right lower quadrant of the abdomen together with a midline laprotomy scar. There is a marked parastomal hernia but no surrounding cellulitis. The surrounding abdomen is soft. The stoma is raised from the skin and stoma bag contains liquid stool only. This is likely to be an ileostomy. To complete my examination, I would examine the perineum and perform a digital examination of the stoma.”