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Yeah. Okay. Good evening, everyone. I'm just going to give a few people a chance to join. Get everything set up to be with you in one second. Okay, So hello. And welcome back to the mind bleep surgical sessions. Um, this week we're doing a session about stoma is quite a short session. Uh, but actually, I think it will be really useful because stones or something that I remember as a student I was quite afraid of. And, uh, the facts and figures about them are not always obvious. It can be a little intimidating to examine. And so we're going to go through everything you need to know about stoners as a surgical junior on the awards this week. So this is just a quick welcome back to the course reminder that it's designed by junior trainings for junior training. So we are really looking for your feedback. Any questions? You can always give us an email at our email address for mind the bleep. Um And this week we just got a quick message from our sponsors. So this is COPD me, uh, there an easy CPD portfolio building up. They basically replace the GMCSF. The service creates the interface and we have a special code vitamin bleep, so that if you sign up, it's just 8 lbs for a year, and that's a 50% discount. Um, so they're specifically designed for those who need COPD portfolios with GMC or NM. See you, kay Registration numbers. So do sign up to that. If that's something you're interested in, this is me again. Hello? I'm academic f Y. Two very excited to talk to you this week about stoners. So the key things are going to be addressing this week, are we gonna We're gonna do a little bit of anatomy and we're gonna talk about some of the common surgical incisions. Uh, we'll go through the abdominal wall and then we will move on to understanding a little bit more about stones themselves. So, as every week we'll go through a case, and this week you're the second one I take when you get referred. A patient, a 75 year old gentleman with hypochelemia, hyponatremia, hypocalcaemia and hypophosphatemia. And you might be wondering, quite rightly so. Why this gentleman with electrolyte abnormalities is being referred to surgeons. Well, he actually has a background of having a heart procedure for a large bowel obstruction secondary to bowel cancer, and this was two years ago. So if we move on to our key surgical questions that were asking all are situations. Uh, we want to check about nausea and vomiting, and this gentleman does have some, uh, some nausea. He still has it. And actually he had two episodes of vomiting last night, projectile vomiting quite severe. He has this sort of vague abdominal pain, which moves around the abdomen, but it's sort of nowhere specific at any one time, and it's more just like Crampy. His bowel habit is obviously a stone, Um, and we'll move on to talking about that in a little bit. But he's not jaundiced, and he hasn't had any constitutional symptoms. So this week I'm using something called Mental Meter, and it would be great if you guys could go to www dot menti dot com and use the code here. Or you can scan the bar codes. And by doing that, we're going to have access to some questions which are here. So I'll just give everyone one minute to get onto the presentation on Manti dot com and then we'll start going through the questions. Okay. Well, people have started answering the questions. Thanks very much. So I'm going to crack on. So, uh oh, we've got lots of things. This is quite exciting for me. This is the first time I've used it. Wow, this is quite cool. Okay, so what is the Heartland procedure? Just crack on an answer like you're doing so just send in your last answers now, and I'm gonna hit to show the correct one. Um Oh, cool. Yes. So well done to those of you who answered left hemicolectomy with end colostomy formation. That is the full name. Further. Well, I guess it's a sort of slang term apartments procedure. Okay, So back to the presentation, and we'll keep doing those as we go through. So keep that page up because I'm moving on to the next question later. So right at the start of the presentation, I thought given we were talking about Stoma is we could go through a few surgical words as well to get banded about, but no one ever really stops and tells you what they actually mean. And then you can't make a surgical by one. You sort of like, What does this actually mean? So a stoma is just any artificial whole made into a hollow organ. And that means that it could be an internal stoma, an external stoma. So the ones that we all classically think of, I guess our ileostomy and colostomy is, But you can actually have an internal stoma, something like a gadget gastrojejunostomy that would still qualify as a stoma. And so moving on to the surgical words I was just alluding to so ostomy means to make a whole limb. Uh, whereas ostomy is cutting into ectomy is taking anything out. So, like an appendicectomy, um, an example of autumn is a stir, not a me cutting into the sternum to access the thorax and placed the is a town we use for reforming or reshaping something. And that can be anything from a vessel, Uh, for example, a balloon angioplasty. And that's we're reshaping it because we're busting the Lumen back open. But it could also be something like a rhinoplasty on a nose job. Okay, so some classic stone in terms, I thought we just break down the sort of the name ology there must be a better word for that, but I don't know it. Colostomy is colon and make a hole in it. And I'll the ostomy is that Valium and make a hole in it. So they're actually quite simple. And you can see here in the diagrams on the right Some examples of both of them, um, which actually will deal with just next so that that's a colostomy on the top there, and then I'll the ostomy on the bottom. So if we're thinking about stoners were thinking about, if we're thinking in terms of the sort of classical ileostomy and colostomy sort of steamers, we are taking a hollow internal organ and we're bringing it out to the surface, which means means traverse the layers of the abdominal wall in order to do that. And this is a It's a classic surgical question. It comes up in more or less any surgical exam you're ever going to do. So it's it's worth really focusing on it and getting it into your head. So if we start from the skin and work our way internally on the exterior surface, you have campers, fatty layer of fascia and then beneath that you have the tougher Scarpa's Fasher, okay? And if you move inside, you've got your external obliques hands in pockets, and then you have your internal obliques going upwards. This way, hands on chest. Then you have your transverse abdominis muscle going straight across and finally inside that you have the preperitoneal fat before you. Then get the parietal layer of the peritoneum. And remember, the visceral peritoneum is closely adhered to the surface of the organs. Um, our diagram on the right here is just sort of, uh, showing the breakdown of the planes as you dissect downwards. Now, some common abdominal incisions. Okay, so they are labeled 1 to 10 here, and I think it's good if we just spend a little second going through what each of the incisions is for. So number one is conscious incision, and you can see that sort of it's just below the right costal margin. And because of that, it's going to give us excellent access to the liver. So lots of more minor open liver surgeries, particularly it's the right lobe of the liver. If you're looking to access the left lobe, it comes quite far over to the midline and then you'd actually be looking at more like something like a rooftop incision or Gables incision, and that's classically used in liver transplant, where you need really good access to be, uh, to the large vessels and to the liver itself. And you can also do a cool thing called a Mercedes Benz extension, which is when you go straight up from the top of the Gable decision. UH, number two. That's a throwback abdominal incision, and that is classically well, classically be on the right side, actually, in order to access the esophagus. The mediastinal portion of the esophagus during an esophagectomy three is your midline incision. That's your classical general surgery. Incision really gives you very good access to the bowel and many other viscera. Number four Rutherford Morrison That gives you nice access to the external iliac vessels, which is very useful for during a renal transplantation, where you anastomose the transplanted kidney to the external iliac vessels. Van and still incision is going to be your classical incision for a cesarean section and, uh, number seven there is lands number eight. McBurney's 10 number nine is a paramedian decision is not really done. So much anymore. It causes more bleeding. And number 10 is, um, a cavity. And that is what you use for, uh, femoral hernias in order to reduce them. Great. So just reminding every one of our abdominal anatomy, and you can see there that there effectively, where you make an incision is is in order to access the underlying organ there, Um and so just reminding everyone of where our abdominal viscera are. And that's very useful for when we're thinking about citing a stoma. So depending on what part of the colon needs to be brought out, you can think about where the stoma is going to be positioned. But there are some classical places for stones to be positioned, and we will discuss those now. So the probably the most common type of stone where actually is an end colostomy, Okay. And this is when the colon is brought out to the surface. Uh, rectal stump is left in situ, which is switching back together. Uh, so colostomies are relatively flushed in the skin. They will stick out a little bit, but much less so than an ileostomy, which is quite obviously spouted. Um, they are because of the types of operation that are done and because normally you only form an end colostomy when you're removing part of the left colon because the blood supply is not as good. It means that you normally find and then colostomy in the left iliac fossa. If you're receptive the right hand side of the bowel, unless the conditions are very unfavorable. For example, in nasty fecal peritonitis from diverticulitis, you can generally anastomose the small about to the distal segment of where you've receptive. Um so end colostomies will produce more solid contents than ileostomies. And patients tend to have more properly formed bowel motions. Uh, certainly compared to a ileostomies an end Ileostomy is where the ileum is brought out, and and that represents the the most distal point of the bowel from there on words. So I ileostomies are spouted. And that's because the enzymatic content and the pH of an ileostomy is much higher. And you can actually see in this ileostomy and the image here that there there is a bit of irritation of the skin around the site of the stoma formation. So, because of simply where they're really, um, is anatomically, they're much more commonly in the right iliac fossa. But they produce much more liquid content, and they are harder to manage and they are higher output. And patients have to be, uh, more careful about their hydration status. And that's something that will sort of deal with a little bit later as well. So another type of, uh, ileostomy is a diversion ileostomy uh, and it looks exactly the same, except it will be seen with the for the Stoma. And this is because the diversion ileostomy is performed. Two. It's either to rest in the anastomosis bowel segment of a delicate anastomosis. Or it might be because, for example, in ulcerative colitis, there is a lot of inflammation in the colon and as a method of trying to preserve the colon. What surgeons can do is bring out a diversion ileostomy and rest that segment of bowel until it has recovered a bit more and the patient can be started on sort of more stable medical therapies and optimize before any further surgeries. This is another type of stomach a urostomy, and that's when the ureters brought out to the abdominal wall. Uh, and that's usually because of something like bladder cancer where the ureters are not affected and therefore the ureters can be brought out the abdominal wall and the bladder removed. So But, I mean, just because of the size of the ureters, these stones are going to be a lot smaller, and obviously they're gonna have year in in the bag. Uh, yes. If the ureters are not long enough, then we may need what's called an ileal conduit where some of the island has resected. Uh, and it is used to fashion uh, a well fashion segment that can then be, uh, an estimation to the ureters and brought out of the skin. Now, another type of stoma is a mucus fistula, and this is seen just below the end colostomy in the diagram here. So your end colostomy is passing all of the bowel contents into the bag. And the mucus fistula is there as a sort of way of venting, uh, mucus. And it can prevent this thing called a rectal stump Blow out. Now you can imagine in the rectal stump when it's closed off. Normally, that's fine as long as there's no inflammation there. But if there is inflammation, then the segment of bowel doesn't have the same kind of drainage effectively as it as it once was, and and the same amount of normal Paracelsus so it can build up. And you can get this nasty thing called a rectal stump blow out. And therefore, if there's lots of inflammation, mucus fistula is quite often indicated, and you'll see a few of those. And it can be quite confusing because you have two things in the left lower quadrant or the left iliac fossa. It's difficult to know how to interpret, but don't be caught out by that one in a sort of a ski scenario. And then we've got, uh, two different things a loop colostomy or a double barreled colostomy. I'm sorry I should say that this could be a colostomy or an ally ostomy, but what it means is a loop. Colostomy is when an incision is made in sort of like half of the bowel wall, and the two bowel segments are not completely separated. The two segments joined together, as you can see here are then anastomosed to the abdominal wall, and why this is done is because it makes it a lot easier to reverse the stoma operation. So generally it's indicated, and we think that the stoma is going to be quite temporary and that we want to, um, sort of reduce the operative load of the patient. It's a much smaller operation can be done through the small stone incision. A double barreled colostomy, or ileostomy is when the bowel is completely separated, and then the two ends our brought out together and switch it to the skin separately. So in both cases you get a double Lumen, but in the loop colostomy, there will be a sort of shared wall, as it were. So that is, that's another thing that you can be caught out with. And there's such thing as a Lupus slash double barreled. I'll ileocolostomy where you bring out the ileum in A in order to divert bowel contents and potentially rest it a downstream anastomosis or the downstream bowel. And then you have the colostomy brought out to the surface right next to it, so that is such a thing as well. Now, indications for stone formation. The main ones really are malignancy and bowel obstruction to rest bowel anastomosis when there's a lot of intraabdominal inflammation and it would threaten the anastomosis or or threaten any attempted anastomosis. So generally that's when you bring the bowel out. But other things such as IBD now Crohn's. We try desperately not to not to touch the abdomen of someone with Crohn's, because there there's so pro inflammatory that it causes terrible damage. But unfortunately, sometimes there's no way and it has to be done. Operative colitis. If someone's bleeding out, the definitive management is going to be a subtotal colectomy. And so, for ulcerative colitis, there are quite a few surgical indications, and it's something like a diversion. Ileostomy can be really, it can revolutionize some people's lives because they have such bad bowel inflammation so much bleeding that, uh, that it's the It's the only way to allow the colon to recover, and I've seen it myself on the ward, and it is amazing the effects it can have. Um, other more minor indications for stone information can be things like incontinence and genetic defects, so on to examination of stones. And I've included this section because it's something that I just had absolutely no idea how to do in Florida, and it's actually really easy, and it's quite a quite a thoughtful thing in a way, like people will ignore doing the Stoma exam, and it's just not very thorough. It's not hard to do, and it doesn't take it long. So hopefully, after we go through this, you guys will all feel much more common, confident examining stoners, knowing sort of how to how to interpret things that you might see. So your first step is always going to be performing the normal examination. And if you see a stoma when you're talking through this exam, be it in your office case scenario, be at whatever. Just note that the stoma is there and know where it is, because it's most likely that the stoma is over. Whatever structure is being brought out. So you know, if it's in the right iliac fossa, it is likely to be a highly, um, the next thing to do is consent, because, remember, patients may be very self conscious about they're about. They're stoma, and it's a very personal thing. So please maintain dignity. Gain consent for the exam before you start to look at the stoma more closely. Now, normally, the bag that's on this image here is not a terribly good representation because normally the bags of skin colored and you have to pull back a sort of skin colored flat in order to look into the bag to see what's called the effluent or the fecal contents. Uh, now that the bag is designed to hide the effluent. And if you've never examined a stone before, it's going to be really obvious, because you're not going to know how to examine the bag. So get some gloves, and I really encourage you after this talk to go out and try and find the stones on the ward and ask patients if they wouldn't mind you examining them. And then you can look for some of these things. So stoma bags, as I was saying there, often skin colored, they need the flat to be lifted in order to see them. And you have this pad, which you can cut to size and stick down over the stoma. Now it's important that the sticky pad is fitted properly. Otherwise you get things like leak from the stoma, which patients find incredibly distressing, as you can imagine, and it can be quite embarrassing as well. Um uh, cut the size and in order to remove the stoma if that ever comes up. If you ever get asked to do that in a Noski, which I actually was in medical school, uh, there is a special spray. Uh, it's like a cool spray, and it just lets the the sticky pad their come off really easily so you can look extra swish if you're in your skin and you say, And if I was to examine the stoma properly, I would like to remove the stone with the spray that I can see here on the bedside, etcetera, etcetera. Number four is looking at the stoma itself. So at the bottom here, we've got a nice, healthy spouted ileostomy with a bit of contents with a bit of effluent just in the loop in there and then above it. We've got some not quite so healthy looking stoners, so the one on the left at the top there, that is what we called dusky. That's the correct descriptive term, and you can see it's a bit patchy. It doesn't look nice and red and pink, healthy and moist. It looks a bit a bit dry and a bit dark and that is, that is a bad sign, and that is a sign of ischemia. And even more of a sign for ischemia is the one on the right, so you can see that's actually a double barreled, probably colostomy, and you can see one room in there and the second Lumen. And that's actually that's a necrotic looking stone. And that is a That's a bad sign indeed. Um, so things were looking for, because I sort of alluded to are the color of the stomach and the consistency of the bowel in there. You know, bowel is a living tissue. It should be moist, pink and, well, perfused. We all know how good the blood supply is to the bowel because of the need for absorption, so it should be reflecting bowel itself. You want to make sure if you have an ileostomy that's spouted and when you're looking at the stone, where it's very good to comment on whether or not it is spouted, and then you want to comment on the quality of the effluent, So is it runny? Is it particularly offensive? What the color is like checking with the patient how different it is to their normal effluent. And then it's really nice touch. During your examination. You can just check the surrounding skin because all patients care for their stones in the best way, and they may have some sort of surrounding irritative dermatitis. Um, and it's great if you can just pick up on any signs like that. And then finally, you just don't need to complete the exam. So that's thanking the patient. Always recommend as a top tip in house keys, offering to help the patient get dressed. It just shows a real kind of humility and summarizing the findings to the examine you. And then you do your sort of a star stuff. Explain their extra testing investigations. Why you want to get those so back to our case with our 75 year old gentleman, and now we know he has a stoma, Uh, and he's got these electrolyte abnormalities. So on your examination, his abdomen is soft and nontender. He's very dehydrated. Actually, he's got quite sunken skin and dry mucous membranes. He's got a stoma in the left arm back fossa, and it's pink, moist and very healthy. However, it contains yellow liquid feces, and he's already he admits to you, He's already had to change the bag three times today, which is definitely not normal for him. But there's no blood in there. Um, and he's had He's had this bit of extra extra skin redness while he's had this this extra discharge from his stoma. So what do you guys think the diagnosis is? And we'll go back to our but two are presentation. Yeah. So what? I'm sorry. Not just what's the diagnosis, but this is a bit of a two step question. So what's actually the most likely cause of the presentation? So you need to get the diagnosis, and then you need to think about what's causing that pathology. Just give you a minute to answer that. Okay, so this is a This is quite a hard question. I can see people are thinking about it. So I'm going to go ahead and give you the answer, and I'm gonna talk to you and explain why. So the answer is a compiler back to get any infection, okay? And we'll talk through them a little bit. So this gentleman has a high output stoma. Okay. It's one of the known complications of stones that we're going to go through just now. Um, but something like parasternal cellulitis that I mean, that's just basically saying that the skin is a little bit inflamed. It wouldn't give you high output through the stoma. Short bowel syndrome would give you a high output stoma, but you need to have reception to the degree that you only have, like, less than a meter of small bowel left. In order to get short bowel syndrome, this gentleman has only had a tiny little bit of, uh, well, he's just had a left Hemi. So it's not actually enough to cause short bowel syndrome. So it wouldn't be that intraabdominal sepsis doesn't really fit because he doesn't have an acute abdomen, and he's not really unwell enough taking codeine for back pain. That would give you the opposite. That actually, uh, increase the thickness of the secretions. And therefore the answer is, compile it back to genital infection because it gives you diarrhea. This sort of crampy abdominal pain, a bit of nausea and vomiting as well, and is one of the reasons that well, intraabdominal infections, like just try to sort of sort of infections are one of the reasons that people with stones can represent a later date with high output rather than straight after the operation. Okay, so back to the presentation. So we'll deal with the stone. More complications now. And the first one we're talking about is high output. Stoner, as our gentleman in the case had just there, so you can see that's a very full stoma bag. And remember, stone bags can become full of gas as well, so you can actually see in this diagram quite now this is this is much more like the stone bags that you have in the NHS. The skin colored there are. You can see the little flap that you have to pull back here in order to get access to this sort of clear plastic window that lets you look in to see the quality of the effluent. Um so it high output stones are going to be most common with ileostomies in general, and they're defined as greater than 1.5 liters a day. Now you can imagine that if we're supposed to drink two liters of water a day, just as normal human beings and then a person with the Stone has an extra 1.5 liters of output, it can be very difficult to replace the fluid losses. And so it's really important to assess the fluid status accurately in these in these patients because of the the ileostomy content, because the OxyContin is so high and electrolytes the sorry that the ileal secretions are so high and electrolytes they get gross electrolyte abnormalities hyponatremia, dehydration, hypophosphatemia. And that puts these patients particularly at risk of refilling syndrome as well. So the risk factors for having a high output stoma are short bowel syndrome, any any infections of the stomach or bowel. As we were saying in the question, Any prokinetic medications that increase or decrease the transit time, uh, any other kind of sort of about inflammation, something like IBD were thinking that, um, the way to treat them is step wise. You start by fluid restricting, Um, because hypotonic fluids such as water are just going to exacerbate the electrolyte abnormalities, and they won't replace the free water deficit. So you actually need to fluid restrict the patients and then start them on IV fluid, replacement and, uh, electrolyte rehydration as well. Um, if that's still not enough. Then you can get the patient to try some ST Mark's solution, which is basically like a diet or a light or an oral rehydration, uh, salt solution that we have in the UK here. It's hypotonic and you drink it orally, and it can help reduce the output from stoners. And it's used a lot of the centers around London where I work, and then your other options after that are to step up to medications like you know, Paramygina and codeine, which is a well known constipating medications and can reduce the gut transit time. Uh, kind of increases gut transit time, which allows greater water reabsorption something else that can happen in stone or obstruction, and that will present, as you can see on the right here with features of small bowel obstruction. Um, so that would be nausea and vomiting, you know, output through a stone and know output of gas pain and distention risk factors for that are gonna be intraabdominal condition. So you've got your IBDs and strictures that might occur in the band and then become obstructed, uh, diverticulitis and the volvulus, an incarcerated parasternal hernia, or after any abdominal surgery and that could actually be an alias After that treatment is going to be conservative measures. Um, if it's a partial obstruction with any bowel obstruction, you're going to start via the drip and suck approach and then feeling that you're going to be straight onto your surgical management measures. Stone wall, hernia and dehiscent are they have the same risk factors. So they're grouped together here. Um, Stone Wall hernia itself is the most common long term complication of, uh, having a stone excited. Um, and there are some schools of thought that actually anyone with the stoma will develop Estonia a stone or hernia after long enough. And that's because you effectively create a defect in the bowel wall and you poke bowel through it, which has no tensile strength in itself. So after after years of things like a chronic cough, and that's why smoking is a risk factor or being overweight, increase increases intraabdominal pressure. Um, increased intraabdominal pressure over time. Which is what age is that a factor as well. Uh, they all increase your risk of eventually developing a stone wall hernia, and this will. This will generally present with a lump. But if that becomes an irreducible lump becomes hard and painful. Then you know thinking potentially is incarcerated, and that's going to be a bowel obstruction. So the measures for treating our well, broadly conservative leave it alone if it's not causing any problems or or surgical repair after 2018, there's a new school of thinking that perhaps we should be because of the pathology of stoma hernias, and that everyone is very likely to develop them over time. There's a thought that they should be, uh, implanted with primary mesh prevention, so you suture a pretty Meche to the bowel wall at the time of Operation Stone or Retraction. So this is actually the most common reason for re operation and occurs normally due to poor surgical techniques. So it means that not enough of the bowel was mobilized in order to give, like, sort of free movement of the bowel when it undergoes. It's normal parasynthesis, which leads the bowel and becoming retracted inside. But another cause, an important cause can be bowel ischemia, so it's important to rule out bowel ischemia. If you have a retracted stone and that is causing problems quite often, it won't cause any problems, but the issues can be and the issues. I've seen an award with it. When a colostomy becomes retracted, the patient becomes constipated. And then there is reduced output through the stone and the stomach. It will become blocked, and that can lead to symptoms. Bowel obstruction, as you can see, so investigations with stoners. I mean, it's not as big a part of some of the other surgical conditions. Obviously, if you're expecting any kind of intraabdominal pathology, you have an incarcerated parasternal hernia. You know you're going to need all your standard blood. You're going to need your CT in order to check that. If you're suspecting ischemic bowel, you can get CT angiograms, etcetera, etcetera. But, I mean, it's mostly, uh, it's mostly going to be, uh, clinical acumen with the legal status. So, yes, I was saying the key assessment points are are going to be your history, the quality of your stoner exam, uh, the effluent, and then any imaging as necessary when to escalate your Reg. Well, I mean, it's fairly. It's fairly simple with stones and and it's going to be quite obvious either they're not getting anything out through the stoma and they look obstructed. Or it's a patient who has the stoma, and they're complicated because it's a It's an abdomen that's previously undergone major surgery. Um, and it needs to be looked at promptly by a senior. So I just thought I'd show you how they actually create the stoners, and you can see it's very well illustrated the diagram here. So they create the defect in the abdominal wall, usually by, uh, passing a surgical instrument from the inside of the abdomen out through the abdominal wall and then creating an incision, pushing the bowel through and then suture into the abdominal wall. So that's how they do it. Okay, great. But sorry. I've actually taken longer than I thought I was going to there. But we will move on to the end of session questions, if that is all right with everyone. So click through to the next one. Great. So we've got I think we've got four questions here just to finish off the session. Four or five questions, uh, in the first one. I just want to know, based on everything we've talked about, which of these options do you think merits a stoma formation? Sorry, baby. One, I'll just give you a minute to answer that as well. Okay, just 10 seconds. Right. That's enough. And the answer is severe bleeding in ulcerative colitis. Okay, so that is a That is a classical reason, actually, for, uh, for formation of the stoma, it would usually be a subtotal colectomy, potentially with a new class fistula and a and an end ileostomy. The reason the others are incorrect is because uncomplicated diverticulitis is managed with antibiotics. Uh, sub acute bowel obstruction is not an emergency and should be managed conservatively. Uh, intraabdominal abscesses in IBD patients as we were saying, We if at all possible, we want to not touch the abdomen of the patient with friends. And those are the patients that are going to develop these intraabdominal abscess is not so much in you see. So for that reason, we manage them generally with a protracted course of antibiotics. Um, and Hirschprung's disease is new performer. Intellectual poultry procedure. Okay. Next question. 42 year old lady presents with lethargy and weakness. She has an ileostomy with a two liter daily out. Put her sodium was 126 and her IgE. EFR is down at 53. What's the first step in management of this patient? So I'm talking. I'm talking here about the A to eat approach. Okay, so we'll go through the answer now. Okay, So that's great. Well done to the majority of you. So the answer is normal. Saline IV. Um and that's because we can't. We can't replace the losses with oral fluids. Saint marks. Solution itself is a is a hypotonic solution that you take orally, but it's a bit further down the management. It's not there, Right? In our acute resuscitation phrase, the hyponatremia is not that severe. 126 isn't that bad. Really. So it's not going to be the first thing that we think about replacing and, you know, it might be causing some of her symptoms, but that will get better with actually. I mean, the normal saline will correct the hyponatremia as well. So I suppose they're both sort of right hold nephrotoxic. Yeah, that's true. But it's not going to be the first thing we do right there. And hypertonic Saline IV is only indicated for a severe hyponatremia, something like less than 100 115 or 100 I don't actually know. You'd have to check guidelines for that, but, uh, with the hypertonic saline orally that generally we're using. So that was a bit of a trick question for that answer. Next one. So a consultant asked you to identify a stoma. The stone has two bowel movements which share a wall centrally, and it's located in the left lower quadrant of the abdomen. What type of stoma would we call this? Okay, so well done to the majority of you again. The correct answer. There is a loop colostomy because they share that central warrant in the left lower quadrant. Uh, double barrel colostomy is close, but unfortunately, the bowel has to be completely resected. And the two segments of bounds separated to be a double barreled one. Uh huh. Great. A 47 year old man develops leak from around his long term colostomy. Which of these options is not a recognized cause of leak? Okay, great. So the answer that is local skin irritation is not a cause of it. It's not working. Local skin irritation is not a cause of leak from around the colostomy because it doesn't. It doesn't affect the way the bag sticks to the skin or anything like that. Whereas a poorly fitted bag Stoma retraction. I change in the shape of the donor site. Poor technique where the bag isn't being transfixed properly, Uh, and things like stone wall hernia, where the shape of the offices can again be distorted. Uh, those would all be reasons for leak developing, so we didn't go through that explicitly, but I just wanted to test it. Sort of bit of lateral thinking based off some of the stuff we've been talking about. Okay, last question now, And this is a tough one. So a 68 year old lady undergoes an emergency bowel resection and stone formation. Four days later, the ileostomy appears dusky. What is the most likely cause? Remember, it's an ileostomy. Okay, I'm just going to give you a few seconds more, so get the answers in. Okay, So the answer here is, in fact, stretching of the bowel when forming a stoma. And that is because stretching the bowel compromises the blood supply to the bowel and therefore leads to it becoming dusky as we were saying earlier. Ischemia is a recognized cause of, uh, dusty, dusky, uh, ileostomy appearance. So an incarcerated Paris stone or hernia will it would be the incarcerated part that started becoming dusky thrombus affecting the inferior mesenteric artery seems like a good answer. But unfortunately, the inferior mesenteric artery doesn't actually supply the Eylea. Um, it's the superior mesenteric artery that supplies the the small bowel and the inferior mesenteric artery and the supplies from two thirds of the way along the transverse colon. So that's the reason that's not correct. High output stoma know. Once I identified and sternal dehiscence well, that that's just the stoma coming away from the from the abdominal wall and isn't itself a cause of the stone becoming dusky. Now it's ischemia may cause the stoma to de his, but unfortunately doesn't like the other way around. Um, cool. So they were quite hard questions, actually. Just wanted to really push you guys because it's a It's a shorter session. Um, as ever. Our surgical website Webinars. You can find the sign up on the website to get links to to join every week, and we have started putting articles online so that you have a written source of information to support your learning for the session. Um, we are stuff we're working on at the moment. We are trying to improve the webinars. However we can. And we're trying to generate a model that we can run with in the future. So we really do want to hear any feedback you have. You get a survey. Um, please. Sorry. The next session is not on gallstone disease. The next session will also not be happening. Next Monday will instead be happening on Tuesday. I do apologize for the inconvenience and we will change the Facebook settings on the webinar. Please do Scan the QR code to get your feedback survey and certificate for attending the session. Uh, this session, we'll go onto YouTube. And as ever, any questions always give us a shout, Uh, pleasure to be teaching again. And I hope to see some of you for the next session. Thanks very much.