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Housekeeping Please: • Use the chat to ask any questions. • Note that the session is recorded. • Slides will be available via MedAll after the event. • Be aware that slides do contain sensitive content. • Fill out our short questionnaire - the data will be used to conduct a study about the efficacy of our teaching approach but will be completely anonymous. • Attend 6/8 sessions to get free RCSEd student affiliate membership (worth £15) • Follow ESSS’ MedAll & social media to see our future events Disclaimers: • and therefore may contain mistakes.rces from reputable sites, this is a peer tutoring session • All media shown is not owned by us and will be credited on each slide they feature on.Lesson Objectives + Agenda Learning Objectives: 1. Roux en Y hepaticojejunostomy 2. Abdominal Hernia repair 3. Hiatus hernia repair Agenda: 1. Intro to specialty 2. Common Specialty Cases 3. Case 1: Roux en Y hepaticojejunostomy 4. Case 2: Abdominal Hernia repair 5. Case 3: Hiatus hernia repair 6. MCQs 7. Summary 8. Q&AIntro to specialty One of the largest surgical specialties, makes up to 25% of consultant surgeons. Both elective and emergency surgery (e.g., acute abdominal pain). Includes laparoscopic surgery. Sub-specialties: • Breast surgery – assessment of breast symptoms, breast cancer surgery and breast reconstructive surgery where a plastic surgeon is not needed • Lower gastrointestinal surgery – for the diseases of the colon, rectum and anal canal, and particularly cancer of the bowel • Upper gastrointestinal – this includes the oesophagus, stomach, liver and pancreas and also incorporates weight-loss surgery • Transplant surgery – renal (kidney), hepatic (liver) and pancreatic transplantations https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/general-surgeryCommon Specialty Cases Common operations including appendectomies, hernia repair, and cholecystectomies. Involves a wide range of surgeries, including: • Surgical conditions of the gastrointestinal tract from the oesophagus to the anus • Breast conditions • Kidney, pancreas and liver transplantation • Trauma to the abdomen and thorax • Certain skin conditions • Initial assessment of patients with peripheral vascular disease • Childhood conditions https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/general-surgeryLearning Objectives ● Biliary Stricture ○ Pathophysiology ○ Symptoms ● Anatomy ○ Biliary system ○ Jejunum ● Surgery Procedure ● Patient VignetteBackground information Biliary System: 3 organs Liver: Creates bile in hepatocytes Travels through bile ducts Reaches the Gallbladder. Gallbladder: Storage site for Bile. Releases Bile when stimulated. Helps with fat digestion Pancreas: Produces pancreatic juices and enzymes Joins bile duct. Helps with digestion of food. Complete Anatomy Credits: TeachmeanatomyPathophysiology Biliary Stricture: Can have benign or malignant causes. Benign causes; Iatrogenic, Infection, Chronic pancreatitis, PSC. Malignant causes; Pancreatic head cancer and CholangiocarcinomaPathophysiology Clinical features: Asymptomatic Jaundice Pale stools Pruritus Steatorrhoea Credits: Teachmesurgery Dark urine Systemic features: Fatigue, weight loss, nausea, vomiting, fever. Credits: PCDS Credits: StatpearlsRelevant anatomy Biliary tree: 4 main sections - Common hepatic duct, Cystic duct, common bile duct, Pancreatic Duct. Connect to create biliary tree. Ampulla of vater - Opening into duodenum Releases Bile into this space Helps fat digestion. Credits: TeachmeanatomyRelevant anatomy Complete Anatomy Relevant anatomy Ligament of treitz - Originates from diaphragm Connects to small intestine - Marks end of duodenum and beginning of Jejunum Important anatomical landmark. Complete Anatomy Relevant anatomy Small Intestine: 3 sections Duodenum, Jejunum and Ileum. Function: Food breakdown and Digestion Nutrient absorption Remove unnecessary components. Barrier protection Immune Function. Complete AnatomyRelevant anatomy Jejunum: 2.5m long Involved in - Sugar, amino acid and fatty acid absorption. Absorbs Folic acid and Vitamin A & D Blood Supply - Supplied by the Superior Mesenteric Artery. Distinguishable from Ileum due to longer Vasa Recta. Credits: TeachmeanatomyRoux en Y HepaticoJejunostomy Process: Involves the Biliary tree, jejunum and duodenum. Surgically dissect the bile duct above stricture area. Create roux limb from the Jejunum. Connect the new roux limb to the dissected bile duct. Create anastomosis been roux limb and dissected jejunum. Credits: Laparoscopic surgery infoComplications The complications of RYHJ include: ● Bleeding ● Bile leaking ● Infection ● Inflammation of the bile duct ● Narrowing of the bile duct ● Pooling of bile in the abdomen ● Liver failure Credits: Laparoscopic surgery infoPatient Vignette Mr Cole McStectmy 75 PC: Presented to GP with Jaundice, Steatorrhoea and pruritus PMHx: Gallstones, underwent Cholecystectomy 6 weeks ago, HTN DHx: AmlodipineThe Team Consultant Surgeon Anaesthetist Scrub Nurse Specialty Trainee Theatre NurseContent Warning! Before the procedure starts, the scrub nurse lets you know that you might see some things you haven’t seen before. It’s ok to feel woozy! But if you do, feel free to pop out of theatre and grab a drink/snack if you are able or, if the faint is imminent, take a seat on the floor (better than falling into the patient!) The Laparoscopic Surgery has began, with the consultant entering the abdomen. They proceed to remove the adhesions that are near the planned surgery site. They turn round to you and ask: ‘what is the most likely reason for these adhesion to be present in this patient?’ > Infection > Previous Surgery > Radiation Credits: Dr. R. K. Mishra Youtube channell Infection The SpR scoffs. ‘Whilst Infection can be a possible cause of adhesions within the abdominal cavity, this patient has no prior infection history that we know of. We do know that they have had previous surgery in this area which would make that the mostly likely explanation.’Previous Surgery The consultant smiles and nods her head. ‘That is correct! We know that the patient has had previous Surgery in the abdomen and that surgery/trauma can cause adhesions due to damage and inflammation. Due to this we can assume this is the most likely cause.’Radiation The questioningly.ou but the patient has no history of this. It would be extremely unlikely that is the cause unless he has an X-rataking some snapshots.’ikes Credits: Dr. R. K. Mishra Youtube channel Liver The Adhesions are now clear and you and the consultant have an unobstructed view. Before the consultant continues any further they ask you: ‘what is the structure that my robotic arm currently next to?’ > Portal Vein > Common Hepatic Artery > Bile Duct Portal Vein The SpR scoffs. ‘You need to brush up on some anatomy lectures. The portal vein is located behind bile duct. We cannot visualise any other structure in front, thus we can confidently say this is the bile duct.’Common Hepatic Artery The SpR looks at you questioningly. ‘No, That is incorrect. The common hepatic artery is a vtrunk. It does not come directly down from the liver like this structure. Due to it being the most anterior structure, we can confidently say it is the bile duct.’Bile Duct The consultant smiles and nods her head. ‘That is correct! We can see that this structure looks as if it is descending directly from the liver. You remember your anatomy well, as you knew that the bile duct is the most anterior vessel which comes from the liver.’Credits: Dr. R. K. Mishra Youtube channel The consultant has now finished working with the bile duct at the moment. They are starting to prepare for the next part of the surgery. When they are moving they suddenly stop and they ask you: ‘What structure are we able to visualise at the moment?’ > Ligament of Treitz > Ligamentum Flavum > Pancreas Credits: Dr. R. K. Mishra Youtube channelLigament of Treitz The consultant smiles and nods her head. ‘That is correct! We can currently see the Ligament of Treitz. This is our important landmark as it marks the change from the duodenum and jejunum. We now know that the small intestine beyond this is the Jejunum so we can proceed!’ Ligamentum Flavum The SpR scoffs. ‘Hmedical schools even teach anatomyere? Do anymore? I guess i will instead then. The Ligamentum flavum is found near the spinal canathe ligament of treitz is a suspensory ligament connecting from the diaphragm to the small intestines, which this structure looks like it is doing.’Pancreas The SpR looks at you questioningly. ‘No, That is incorrect. The pancreas is a retroperitoneal orperitoneal thus would betra extremely surprised that the pancreas is here. We are actually looking at the ligament of treitz which is osurgery. ’k for this The consultant has now grabbed the Jejunum and started to create another incision. Whilst doing so they ask: ‘what is the structure that i am currently cutting through?’ > Omentum > Mesentery > Vasa Recta Credits: Dr. R. K. Mishra Youtube channelOmentum The SpR scoffs. ‘No, that is wrong. The omentum is a structure that drapes over the intestines. The structure we are cutting through at the moment is attached directly to the inteswhat the Mesentery does. ’ This isMesentery The consultant smiles and nods her head. ‘That is correct! We are currently creating a hole through the mesentery. The mesentery is a structure which anchors the intestines to the abdominal wall as well as housing other structures such as nerves, blood vessels and fat.’Vasa Recta The questioningly.ou ‘Although you are not fully wrong, this what nlooking for.r we were Thblood vessels which arise fromll terminal branches of arteries supplying the intestine. It is technically not an independent looking for was mesentery as this is a structure which anchors the Small intestine and houses these blood vessels’Credits: Dr. R. K. Mishra Youtube channel The Jejunum has now been separated and stapled. The consultant now ask you: ‘How much of the jejunum should i pull forward before creating the anastomoses between both sections?’ > 5 cm > 15 cm > 30 cm Credits: Dr. R. K. Mishra Youtube channel5 cm Thequestioningly.you ‘No that is incorrect. We need can reach the Bile duct which we are helping to bypass. 5cm would not be sufficient enough for this. 15 cm however would be enough to janastomose with.’uct and15 cm The consultant smiles and nods her head. ‘That is correct! We are trying to connect this roux limb we have made with the opening in the bile duct we made. 15 cm would provide us with enough length to reach this and avoids excess wasting of the jejunum.’30 cm The SpR scoffs. ‘No, that is wrong. 30 cm would be too excessive of a length. It would reach the Bile duct but we would be losing area for absorption on nutrients. 15cm would be more ideal as we can still reach the bile duct and proserve as much jejunum for food absorption as possible. ’ The surgeons then proceed to create openings into the roux limb and remaining jejunum. They then anastomose these sections together to create a passageway for food to enter the roux limb and be digested by bile. Credits: Dr. R. K. Mishra Youtube channel The Roux limb is then moved towards the bile duct, when again another opening is created in the roux limb to allow for a connection between the bile duct and the roux limb. Credits: Dr. R. K. Mishra Youtube channel The surgeons then proceed finish up suturing these openings together and they have now finished the surgery. They congratulate you on seeing your first operation on general surgery and say you can now scrub out! When you begin to do this a thought comes to your mind. Credits: Dr. R. K. Mishra Youtube channelhttps://www.istockphoto.com/photos/surgical-gown-gloves You choose… > Remove your GOWN first… > Remove your GLOVES first…Gown first You grab your gown first and pull to break the ties, bringing the sleeves forward over the gloves to turn the gown inside out. https://www.molnlycke.com/our-knowledge/surgical-gown-donning-guide/ Gloves first You begin to pull your gloves off first before realising that you now have no way of removing your blood-stained gown without getting your hands dirty. You make a mental note to remove your gown first next time… https://alliedusa.net/how-to-put-on-sterile-gloves-with-a-gown-6-steps/You successfully managed to leave after having a mini crisis of how to scrub out of theatre. A Consultant then appears from thin air and asks you if you would like to scrub into theatre as they want to get in on the action of teaching medical students. >>Jump right back into theatre for some more teaching! << The SpR scoffs. ‘No, this is likely incorrect. Although Meningitis is a possible complication, the which typically fit this clinical picture. There are no signs or mentions of photophobia,neck stiffness, fever or rash . It would be handy to rule thi● ouThe Biliary Tree is formed from 3 organs - Gallbladder, Liver, Pancreas the top of my di●ferStricture occurs for many reasons - Iatrogenic, Infection, cancer, ect. ● There are Multiple surgical interventions for this - RYHC, ERCP ● Ligament of Treitz is a key landmark for the Small intestines.Definition the cavity wall that normally contains it.cia through a weak point inTypes of abdominal hernia Adults: • Epigastric • Femoral • Incisional • Inguinal wall hernias; approx., 95% are male • Obturator • Richterilical • Spigelian • Umbilical Children • Infantile umbilical Licensed to TeachMeSeries LtdClinical features • Palpable, protruding lump. • Lump may be reducible. • Cough impulse – lump may protrude on coughing (due to raised intra-abdominal pressure). • Sensation of aching, dragging, or pulling. • Pain. https://wwl-hernia-repair/arepair.com/inguinaManagement Conservative Surgical Most appropriate for: Tension-free repair: • Mesh is placed over the faulty area of • Wider-necked hernias abdominal wall to prevent the abdominal • If surgery is contraindicated cavity contents from herniating. • Abdominal tissues grow into the mesh over time and add to the level of • Lower recurrence rate than tension https://scottishhernia.com/hernia-repair-surgery-in-glasgow/ Tension repair: • The muscles and tissues on either side of the faulty area of abdominal wall are stitched together. • Rarely undertaken. • repair.recurrence rate than tension-freeComplications of Abdominal hernias Incarceration – irreducible hernia, cannot be reduced back to its proper position. • Can lead to obstruction and strangulation. Obstruction – hernia blocks passage of faeces through bowel. • More common in femoral hernias. • Presents as bowel obstruction: vomiting, generalised abdominal pain, absolute constipation (not passing faeces or flatus).Complications of Abdominal hernias Strangulation – base of hernia becomes so tight that it compromises the blood supply to the bowel, leading to ischaemia. • A surgical emergency! • Presentation: considerable pain and ischaemia at site. https://www.upstate.edu/hernia/about-hernia/index.phpInguinal hernia: Pathophysiology Inguinal hernia - protrusion of abdominal contents through inguinal canal. Two types: Indirect Inguinal Hernia – hernia through the inguinal canal (via deep inguinal ring). • Most paediatric cases of inguinal hernias are indirect. TeachMeAnatomyInguinal hernia: Pathophysiology Inguinal hernia - protrusion of abdominal contents through inguinal canal. Two types: through the posterior wall of the inguinal canal (Hesselbach’s triangle). • More common in older patients. • Acquired due to weakening of abdominal wall or raised intra- lifting, chronic cough or heavy constipation. TeachMeAnatomyInguinal hernia: Clinical features • Groin lump that is superior and medial to the pubic tubercle. • The lump disappears when the patient lies down or when pressure is applied (reducible). • Ache and discomfort, aggravated by movement. • Rarely strangulates. O/E: • to the level of the deep inguinal ring (midway between ASIS andced pubic tubercle) and will remain reduced (unlike direct inguinal hernias). • Direct inguinal hernia: Irreducible when pressure is applied. Typically a clinical diagnosis. USS may be required if diagnostic uncertainty.Inguinal hernia: Management • Treat even if asymptomatic (as long as patient is medically fit)! • If patient is not fit for surgery → hernia truss. Surgery: mesh repair. • Unilateral inguinal hernias → open surgery. • Bilateral or recurrent inguinal hernias → laparoscopic. • Two main laparoscopic approaches are total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP) repair. • Also consider in those at risk of chronic pain or in females (due to greater risk of femoral hernia).Inguinal hernia: Types of Surgery Herniotomy – “removal of the hernial sac with ligation and excision of the patent processus vaginalis, most commonly performed in neonates/infants.” Herniorrhaphy – “herniotomy with suture repair of the posterior wall of the inguinal canal.” Hernioplasty – “herniotomy with reinforcement of the posterior wall of the inguinal canal with a synthetic mesh.” Most common technique is Lichtenstein tension-free mesh repair. Reference: TeachMeSurgeryInguinal hernia: Mesh Repair Indications: • Elective: Symptomatic inguinal hernia. • Emergency: Incarcerated or strangulated hernia. Contraindications: • Pregnancy (only undertake mesh repair if signs of acute incarceration, strangulation, or obstruction). • Small asymptomatic hernias (watchful waiting).Mesh repair: Pre-operative Anaesthesia: general, regional, or local. Position: supine. Considerations: Consider a urinary catheter.Mesh repair: Intra-operative (1) 1. deep inguinal ring level, running parallel but superior to inguinal ligament. 2. Dissect until visualize external oblique aponeurosis. 3. Split fibres of external oblique aponeurosis to level of 4. Identify ilioinguinal nerve. • Protect function of motor innervation of the transverse abdominis and internal oblique muscles. 6. Dissect hernial sac free from spermatic cord, and pass tape around spermatic cord.Mesh repair: Intra-operative (2) 1. •erDirect inguinal hernia – push sac back into extra-peritoneal space and plicate posterior wall over it using non-absorbable sutures. • inguinal ring to inspect and empty contents. Transfix sac at its base. 2. Cut mesh into shape and size of inguinal canal. Place mesh to pubic tubercle. Make slit at lateral end to create two ‘tails’. 3. Suture inferior edge of mesh along inguinal ligament. Suture superior edge of mesh onto internal oblique muscle. 4. Recreate deep inguinal ring by suturing the ‘tail ends’ of 5. Close wound with absorbable sutures.to contents of cord.Lichtenstein Tension-Free Hernia Repair https://www.surgicalcore.org/popup/418667Mesh repair: Post-operative • Patients discharged on day of operation (unless early complications). • Unilateral inguinal hernias: Can return to manual work after 2-3 weeks. • Bilateral and recurrent inguinal hernias: Can return to manual work after 1-2 weeks.Complications of Inguinal hernia repair Early complications: Late complications: • Wound infection. • Bleeding. • Chronic infection of mesh. • Formation of haematoma or • Chronic pain (secondary to seroma (fluid). damage to ilioinguinal nerve). • Damage to vas deferens. • Recurrence of hernia (0-2%). • Ischaemic orchitis or testicular atrophy. • Damage to ilioinguinal nerve. • Damage to femoral vessel.Relevant anatomy: Inguinal Canal Inguinal canal runs superior and parallel to inguinal ligament, extends in an inferior-medial direction. Runs between deep inguinal ring (where it connects to the peritoneal cavity) and the superficial inguinal ring where it connects to the scrotum. Complete Anatomy TeachMeAnatomyRelevant anatomy: Inguinal Canal Superficial inguinal ring: end of inguinal canal, approx., 1cm superolateral to pubic crest. • Triangle-shaped opening. • Created by invagination of external oblique. • Contains intercrural fibres. Complete Anatomy TeachMeAnatomyRelevant anatomy: Inguinal Canal Deep inguinal ring: opening of inguinal canal, lies halfway between the pubic tubercle and the anterior superior lilac spine (ASIS) (midpoint of inguinal ligament), lateral to epigastric vessels. • Created by invagination of transversalis fascia. Complete Anatomy TeachMeAnatomyRelevant anatomy: Borders of Inguinal Canal • Anterior: aponeurosis of external and internal oblique muscles. • Posterior: transversalis fascia and conjoint tendon. • Superior: transversalis fascia, internal oblique and transverse abdominus. • Inferior: inguinal and lacunar ligaments. TeachMeAnatomy TeachMeAnatomyRelevant anatomy: Contents of Inguinal Canal • Il•oiFunction: sensory innervation of genitalia, motor innervation of the transverse abdominis and internal oblique muscles (risk of damage during repair!). • nerve (both sexes).he genitofemoral • Function: • Males: supplies cremaster muscles and anterior scrotal skin. • mons pubis and labia majora. • Males: Spermatic cord uses inguinal canal to pass through abdominal wall from its origin in peritoneal cavity, into scrotum. Complete AnatomyRelevant anatomy: Contents of Inguinal Canal • Ilioinguinal nerve (both sexes). • genitalia, motor innervation of the transverse abdominis and internal oblique muscles (risk of damage during repair!). • nerve (both sexes).he genitofemoral • Function: • Males: supplies cremaster muscles and anterior scrotal • Females: Supplies skin of mons pubis and labia majora. • Females: Round ligament originates its uterine horn attachment, passes through deep inguinal ring and inguinal canal to its attachment to the labia majora. Complete AnatomyRelevant anatomy: Inguinal Canal Embryology Processus vaginalis – a pouch of peritoneum extending from the abdominal cavity through the inguinal canal. • Allows testes to descend from abdominal cavity inguinal canal scrotum. Gubernaculum is a fibrous cord of tissue which guides the inferior part of gonad (testes/ovaries) to location of future scrotum/labia. Normal development: Deep inguinal ring closes after testes descend, and the processus vaginalis degenerates. TeachMeAnatomyRelevant anatomy: Indirect Inguinal Hernia • Patent processus vaginalis resulting in tract between abdominal cavity and scrotum, along which bowel can herniate. • Tract begins at deep ring along with spermatic cord, and travels laterally to the inferior epigastric vessels. • Travel along inguinal canal to superficial ring. • May descend all the way to scrotum. Complete Anatomy TeachMeAnatomyRelevant anatomy: Direct Inguinal Hernia • Hernia protrudes through Hesselbach’s triangle and into inguinal canal. This is directly through posterior wall of inguinal canal, and medial to inferior epigastric vessels in Hesselbach’s triangle. TeachMeAnatomyRelevant anatomy: Direct Inguinal Hernia • triangle (RIP mnemonic –’s courtesy of Zero to Finals): • Medial: R – Rectus abdominis (lateral border). • Supero-lateral: I – Inferior epigastric vessels. • Inferior: Poupart’s ligament (inguinal ligament). • Hesselbach’s triangle does not contain any structures of TeachMeAnatomy clinical importance.Patient Vignette Mr Ian Guinal, 79M: PC: 10-day hx of a ‘lump’ in his left groin, aches, disappears when patient lies down at night. PMHx: Postnasal drip & asthma (chronic cough); anxiety. DHx: Salbutamol inhaler (daily), Beclometasone inhaler (as needed), Cholecalciferol, Sertraline. SHx: BMI 36; Smokes 2 packs a day (for 40 years); Now retired; Previously a professional powerlifter for Scotland; Lives alone with his cat. O/E: Unilateral L groin lump, separate from the testes (has not entered the scrotum), disappears when patient lies down. When pressed to level of deep inguinal ring the hernia remains reduced (indirect). Dx: Indirect inguinal hernia. Mx: Lichtenstein tension-free mesh repair.Credits: Incision Youtube Channel Mesh repair case - IncisionCredits: Incision Youtube Channel Inferior epigastric vessel Once the subcutaneous tissue has been incised, and an inferior epigastric vessel is identified. The consultant, scalpel in hand, turns to you to ask: ‘In what position would you expect an indirect inguinal hernia to be in relation to the inferior epigastric vessels?’ > Medial > LateralMedial The SpR scoffs. ‘Wrong! It is a direct inguinal hernia whiepigastric vessels, whereas anrior indirect inguinal hernia will pass laterally to the vessels.’Lateral The consultant shead. and nods her ‘Thtravels laterally to the inferior epigastric vessels, when passing from the deep inguinal ring to the distinguish it from a direct hernia which travels medially to the vessels.’’Credits: Incision Youtube Channel Mesh repair case - Dissection to external oblique aponeurosis External oblique inguinal ring aponeurosis Inguinal ligamentCredits: Incision Youtube Channel Mesh repair case - Ilioinguinal nerve As the surgeon dissects down through the external oblique aponeurosis, she is careful to avoid injury to the ilioinguinal nerve which runs beneath. ‘Which of the following is not a function of the ilioinguinal nerve?’ > Sensory innervation of genitalia > Supplies cremaster muscles and anterior scrotal skin > Motor innervation of the transverse abdominis and internal oblique musclesSensory innervation of genitalia The SpR scoffs. ‘Wrong! The ilioinguinal nerve does indeed supply sensory innervation of the genitalia.’Supplies cremaster muscles and anterior scrotal skin The consultant smiles and nods her head. ‘Correct. Instead it is the genital branch of the genitofemoral nerve which supplies the cremaster muscles and anterior scrotal skin. This nerve can also be found within the inguinal canal.’Motor innervation of the transverse abdominis and internal oblique muscles The SpR looks at you questioningly. ‘Incorrect! Motor innervation of the transverse abdominis and internal oblique muscles is a function of the ilioinguinal nerve.’Credits: Incision Youtube Channel Mesh repair case - Hernia sac dissection from spermatic cord Indirect inguinal hernia TrafasciaalisCredits: Incision Youtube Channel Spermatic cordCredits: Incision Youtube Channel Hernia sacCredits: Incision Youtube Channel As the hernial sac is pushed into the deep inguinal ring to invert it into the abdominal cavity, the SpR turns to you in suspense and asks… ‘How would this stage of the operation be different if we were repairing a direct inguinal hernia?’Credits: https://emedicine.medscape.com/article/1534281-technique?form=fpf Mesh repair case - Suturing in the meshSummary - Inguinal hernia repair Direct Inguinal Hernia • triangle).hrough the posterior wall of the inguinal canal (Hesselbach’s • Irreducible when pressure is applied. • Pass medially to inferior epigastric vessels. Indirect Inguinal Hernia • A hernia through the inguinal canal (via deep inguinal ring). • ring (midway between ASIS and pubic tubercle) and will remain reduceduinal (unlike direct inguinal hernias). • Pass laterally to inferior epigastric vessels.Mr Guinal is off for recovery and has been told to avoid any heavy lifting for 2-3 weeks. You look at the theatre list and see a hiatus hernia repair next - what do you do? >> Hit the books and let’s learn about hiatus hernia repair! << Pathophysiology Hiatus hernia: part of the stomach squeezes up into the chest through an opening ('hiatus') in the diaphragm. Exact cause unclear, but may be the result of the diaphragm becoming weak with age, or pressure on the abdomen. Risk factors: ● Increased age (>50) ● Overweight ● PregnancyRelevant anatomy https://app.pulsenotes.com/medicine/gastroenterology/notes/hiatus-herniaTypes of Hiatus Hernia https://app.pulsenotes.com/medicine/gastroenterology/notes/hiatus-herniaPatient Vignette Pt: Herr Nina Esophageberg, 72M PC: Heartburn, acid reflux, halitosis, dysphagia, bloated. PMHx: GORD, obesity, T2DM DHx: Gaviscon, omeprazole, metformin. SHx: Married, poor exercise and diet, tries to eat small, frequent meals (no effect). Profession: leather surgeon (a type of bookbinder).InvestigationsTreatment 1. First line - lifestyle modifications 2. Second line - PPIs and H2 antagonists 3. Third line - surgery a. Nissen Fundoplication b. Dor Fundoplication/ Toupet Fundoplication c. Gastropexy https://app.pulsenotes.com/medicine/gastroenterology/notes/hiatus-herniaStep-by-step diagram https://app.pulsenotes.com/medicine/gastroenterology/notes/hiatus-hernia Postoperative care https://www.mitralvalverepair.org/after-surgery https://www.stroke.org/en/health-topics/cardiac-rehab/what-is-cardiac-rehabilitationChoose your own adventure: hiatus hernia Hiatus Hernia - Nissen Fundoplication https://www.youtube.com/watch?v=htDF1JoDfmk The surgery has started and we’re in the abdomen! We’re looking up at the diaphragm and can visualise the esophageal hiatus. You see the surgeon placing a band around the stomach. Why? > A. To tie off the stomach and prevent the hernia sliding up through the hiatus. > B. As an anchor to pull the stomach down through the hiatusA. Tie off the stomach The SpR scoffs. “If we tied off the stomach now, the patient would be unable to consume food, and part of their stomach would still be herniated through the oesophageal move”.. Not the best B. Use as an anchor The consultant smiles and nods her head. “Absolutely. This band will give us traction to pull the herniated part of the stomach through the oesophageal hiatus have to tug on the stomach tissue itself and risk damage”. We’re ready to close the stomach wall! What type of stitch should the surgeon use? We’re a> A. To tie off the stomach and prevent the hernia sliding up through the hiatus. placing our posterior sutures! We’ve placed 3 sutures so far but thestomach down down the hiatus hiatus is still quite big. What do we do? > A. Continue suturing, you’re nearly there! > B. Place some anterior sutures. https://www.youtube.com/watch?v=htDF1JoDfmkA. Continue Suturing The SpR shakes his head. “Tricky point, but we place our sutures not approximated after 2-3 posteriortill sutures, we’ll place additional sutures anterior to the oesophagus. This is to avoid sigoesophageal body”f the distalB. Anterior sutures The consultant smiles and nods her head. Sutures are placed at 1cm intervals. If the hiatus is still not approximated after 2-3 posterior sutures, we’ll place additional sutures anterior to the oesophagus. This is to avoid sigmoid distortion of the distal oesophageal body” Transition Slide + key points + 2-3min break https://www.youtube.com/watch?v=htDF1JoDfmkhttps://www.youtube.com/watch?v=htDF1JoDfmk Transition Slide + key points + 2-3min break The surgeons are preparing to complete Nissen’s fundoplication procedure and wrap the stomach. How many degrees do you wrap the stomach around the gastro-oesophageal junction before suturing this into place? > A. 270 > B. 360 A. 270 degrees The SpR shakes his head. stomach should be wrapped 360he degrees around the oesophagus! 270 degrees is a Toupet fundoplication!B. 360 degrees The consultant smiles and nods her head. “360 degrees is correct! We want to wrap the stomach around the lower end of the oesophagus to reduce the likelihood of the stomach sliding back up through the oesophageal hiatus and forming another hernia.”https://www.youtube.com/watch?v=SXvTpUojXeA https://www.researchgate.net/figure/Typical-360-degree-Nissen-fundoplication-with-exposure-and-closure-of-the-crura_fig11_301779978MCQ 1 Which of the following is the most common cause of benign Biliary stricture? 1) Laparoscopic cholecystectomy 2) Primary Sclerosing Cholangitis 3) Infection 4) PancreatitisMCQ 1 Which of the following is the most common cause of benign Biliary stricture? 1) Laparoscopic cholecystectomy 2) Primary Sclerosing Cholangitis 3) Infection 4) PancreatitisMCQ 2 Which of the following best describes the position of the Jejunum within the abdominal cavity? 1) Retroperitoneal 2) Extraperitoneal 3) IntraperitonealMCQ 2 Which of the following best describes the position of the Jejunum within the abdominal cavity? 1) Retroperitoneal 2) Extraperitoneal 3) IntraperitonealMCQ 3 Which of the following anatomical structures does not form the superior border of the inguinal canal? 1) Transversalis fascia 2) Inguinal ligament 3) Internal oblique 4) Transverse abdominisMCQ 3 Which of the following anatomical structures does not form the superior border of the inguinal canal? 1) Transversalis fascia 2) Inguinal ligament 3) Internal oblique 4) Transverse abdominisMCQ 4 Which of the following anatomical structures forms the inferior boundary of Hesselbach’s triangle? 1) Rectus abdominis 2) Inferior epigastric vessels 3) Poupart’s ligament 4) External oblique aponeurosisMCQ 4 Which of the following anatomical structures forms the inferior boundary of Hesselbach’s triangle? 1) Rectus abdominis 2) Inferior epigastric vessels 3) Poupart’s ligament 4) External oblique aponeurosisMCQ 5 What is the most commonly performed surgical procedure done to treat a hiatus hernia? 1) Dor fundoplication 2) Nissen fundoplication 3) Gastroesophageal fundoplication 4) Toupet fundoplicationMCQ 5 What is the most commonly performed surgical procedure done to treat a hiatus hernia? 1) Dor fundoplication 2) Nissen fundoplication 3) Gastroesophageal fundoplication 4) Toupet fundoplicationMCQ 6 Which of the following is NOT a risk factor for a hiatus hernia? 1. Obesity 2. Pregnancy 3. Increased age 4. GORD 5. SmokingMCQ 6 Which of the following is NOT a risk factor for a hiatus hernia? 1. Obesity 2. Pregnancy 3. Increased age 4. GORD 5. SmokingSummary Roux En Y Hepaticojejunostomy ● RYHC is a surgical management used in biliary stricture which can be caused by multiple reasons - Iatrogenic, infection, malignancy, autoimmune. ● Roux limb is created using the Jejunum. ● Ligament of Treitz is a key landmark to know what area of Small Intestine you are interacting with. ● The anastomosis must be done between the roux limb and remaining SI and also above the level of stricture. Direct Inguinal Hernia • A hernia through the posterior wall of the inguinal canal (Hesselbach’s triangle). • Irreducible when pressure is applied. • Pass medially to inferior epigastric vessels. Indirect Inguinal Hernia • Indirect inguinal hernias can be reduced to the level of the deep inguinal ring (midway between ASIS and pubic tubercle) and will remain reduced (unlike direct inguinal hernias). • Pass laterally to inferior epigastric vessels. Hiatus Hernia: • A hiatus hernia occurs when part of the stomach squeezes up into the chest through an opening ('hiatus') in the diaphragm. • There are 4 main types of hiatus hernias, the most common being the sliding hiatus hernia. • Risk factors for developing a hiatus hernia include increased age, obesity, and pregnancy. • Treatment includes a mix of lifestyle modifications, PPIs, and surgery. • The most common surgical procedure is the Nissen Fundoplication.Q&ACitations ‘The Unofficial Guide to Surgery: Core Operations’ Zero to Finals TeachMeSurgery TeachMeAnatomy CompleteAnatomy https://www.centerforherniarepair.com/inguinal-hernia-repair/ https://scottishhernia.com/hernia-repair-surgery-in-glasgow/ https://www.upstate.edu/hernia/about-hernia/index.php https://www.surgicalcore.org/popup/418667 Incision YouTube Channel https://emedicine.medscape.com/article/1534281-technique?form=fpf Toronto Notes https://www.youtube.com/watch?v=XznQUZu1e5c&t=19s https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash https://www.ncbi.nlm.nih.gov/books/NBK544252/figure/article-23802.image.f2/ https://www.laparoscopicsurgeryinfo.com/wp-content/uploads/2014/06/bileduct-profile-10a.jpg