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Hi, everyone. Thank you very much for coming along to this, uh which is the seventh installment of Our Surgically Relevant Anatomy series. This is an SSC five project which is part of an undergraduate medical curriculum. Um And it's run by myself and Anton Diana and Aaca four medical students at the University of Edinburgh. Um We're delighted that you can join us this evening for teaching on anatomy relevant to general surgery. Now, just a bit of housekeeping as we begin. Um Firstly, please feel free to use the chat to ask any questions this will be monitored throughout the tutorial and we'd be delighted to do our best to answer any questions that you have throughout the teaching session. Um Please note that the session is recorded, so bear that in mind. Um As you're um asking any questions, um and the slides will be available via medal after the event as well as will a recording of the event, please be aware that the slides do contain sensitive content pertaining to um human and cadaveric tissue and images of surgery. But we will be showing a warning before um putting on any sensitive content. And um as part of this teaching series that we're doing, we're collating some feedback and some short polls at the start of the tutorial, as well as a post tutorial feedback form. This data is going to be used to conduct a study about the efficacy of this teaching approach um but will be completely anonymous. However, if you do not wish to participate, then please do not fill in um or complete the polls or the feedback form. Um And if you attend six out of the eight sessions, you'll be able to get free R CS student affiliate membership, which is normally worth 15 lbs. Also, I'd encourage you to follow E SSSS um medal and social media to see our future events. And for those that aren't familiar E SSS is Edinburgh Student Surgical Society. Uh just a couple of disclaimers whilst we have strived to use resources from reputable sites. This is a peer tutoring session and therefore may contain mistakes. All media shown is not owned by us and will be credited on each slide they feature on. Now just before we begin, we've got a couple of poll um that I'm gonna put in the chat. Um Please do fill these in. Um And this is just so you can gauge at the start of the tutorial versus at the end of the tutorial, your current um experience with the anatomy we're going to be covering in this tutorial. So I'm gonna put these in the chart. Now, that's all the poll in the chat just now. So I'll give you a minute or so to fill those in. Um, these polls are just ranked 1 to 5 with one being not very prepared. Five being very prepared and please answer in relation to each other questions. Yeah, great. You'll have time to continue filling in those polls throughout the tutorial as you wish. And we'll continue to put polls in relevant to the anatomy we cover throughout the session. Um But for now, we're going to crack on with the teaching. Um These tutorials follow a choose your own adventure style format wherein we will be covering the relevant um anatomy of three key general surgery operations. Um So you can see here on why Hepaticojejunostomy, abdominal hernia repair and hiatus, hernia repair. Uh Within that the learning objectives are to be able to identify the relevant anatomy of um pertaining to these three operations and then to apply a knowledge of the anatomy to then um evaluate the best decisions in surgical operations and the choose your own a bunch of formats. Um applying this knowledge to be able to make decisions in real time throughout the operation. And there will be poles which as a group you can anonymously answer and that will help us decide how we will proceed at different points in the operation and just to cover briefly our agenda. So I'm gonna start with a brief introduction to the specialty of general surgery, uh highlight the common specialty cases and then we'll proceed through the three key cases that we'll be covering this evening. Finally, we'll have some MC Qs to round off and a summary and a further chance to answer any questions. Firstly, an introduction to general surgery. Uh general surgery is an excellent specialty. It's one of the largest surgical specialties in the UK, um and makes up to a quarter of consultant surgeons. That's a, a hefty amount and it encompasses both elective and emergency surgeries such as in A&E patient. Arriving with acute abdominal pain, often general surgeons will end up um evaluating and managing these patients. And it also includes a lot of laparoscopic or keyhole surgery within general surgery because it's so broad. There are a lot of subspecialties that most um senior trainees and then consultants will end up subspecialized in. And these include breast surgery, lower gastrointestinal surgery, endocrine surgery, upper gastrointestinal surgery and transplant surgery. In terms of the common specialty cases, uh common operations include appendectomies, hernia repair and cholecystectomies, and we'll be covering several of these today. Um But there's a whole wide range of surgeries, including those um of the gi tract all the way through from the esophagus to the anus breast conditions, varying types of transplantation of the abdominal organs, trauma to the abdomen and thorax, certain skin conditions and initial assessment of patients with peripheral vascular disease. Um A lot of colla collaboration with the vascular surgeons on that one and also childhood conditions. So there's a big um involvement of general surgeons in pediatric um surgery and that's another specialty area you can subspecialise in. So now I'm going to hand over to Anton who is going to be presenting our first case. Um Right. Thank you for that one. So, hi, everyone. My name's Anton. I'm the fifth year medical students. So we will be discussing the room why hepatical Junos surgery. And basically, I'm going to cover the anatomy involved in the surgery and ultimately walk through and an active scenario based upon kind of your decisions that will be put into the chat for you. So to just start off uh the learning objectives for this surgery, uh as as follows, uh basically, we're gonna cover about the bi structure and learn about the pa of and also the symptoms that are associated with this. We're then going to move on, talk about the anatomy of the biil system and some parts of the small intestines. And then ultimately, it's going to be the surgical procedure we'll discuss and then go through our patient vignette. So to just ensure that everyone here has a rough idea of what will be involved, I will kind of give some background information on the system and obviously what's what's involved in. So to just start the pillory system is comprised of three organs. Uh these being the liver, the gallbladder and the pancreas. So the liver is basically the organ which creates a bile that then travels through the entire system. It's created here in the hepatocytes with this image from teach me anatomy and it then basically gets produced in hepatocytes, travels through these we kind of capillaries and then come down the bile ducts, uh which then descends towards the gallbladder. Uh The gallbladder is in the next organ that's involved. Um Basically, that helps to store bile, which is produced by the liver and is then released when it's stimu stimulated by the hormone CCK, which basically causes the gallbladder to contract as well as also stimulate some pancreatic secretions, which leads us on to the final organ being the uh pancreas, sorry. Uh basically, as well as it's a well known function of producing insulin and other stuff. Basically, pancreas also has a role in digestion. It creates pancreatic juices and enzymes which then get released and basically join up with the bile duct before being released into the small intestines. Uh So now that basically the background information is out the way I'm just gonna kind of focus more on be structure and obviously, it's path of physiology. So overall, the cause of BRIC can be divided into two broad categories as being either benign causes or malignant causes. Uh So, benign causes can basically occur due to a plethora of reasons. Uh with the most common cause of uh benign bi structure being actually erogenic, which means that it's actually caused by healthcare professionals and surgeons themselves. Uh And it can account for roughly about 80% of all benign bi structures according to a study. Uh So obviously, it makes up quite a big amount of the workload of this kind of this type. And the most common procedure that actually causes this is actually a cystectomy. So you think that going in and dealing with the gallbladder and getting rid of the pain is going to be all well and good and be and it does provide symptomatic relief. But again, it has been associated with kind of benign structure which then can lead to further operations in the future. So it's a good complication to be wary of about that kind of surgery. Uh and then just the other benign causes uh include infection, chronic pancreatitis and primary sclerosing cholangitis along with kind of any other inflammation of the pancreas tract. In terms of the malignant category, the most common cause of structures are cancers of the head of pancreas and a Cholangio carcinoma. We could go into this for days and kind of cover all the different types of cancer that can lead to this, but I'd bother you too much and I feel like it's not kind of worth our time at the moment. Uh but kind of moving on in terms of RIC, but just going to kind of cover the clinical features. So basically a significant amount of patients that do present with RIC are actually asymptomatic. So, which can make diagnosis very difficult. These patients usually have subclinical disease and they may have like just kind of mild derangement and the liver function tests which people won't really can investigate too much. So it can go undiagnosed for years uh before that eventually shows up and symptoms. Uh But on the other hand, patients do often present with symptoms. Uh these being symptoms such as jaundice that we can clearly see here in the eye um of uh pale stools that I would want to include a photo of because when might put you off your dinner at this time at night, uh putative. So obviously, with an obstructive jaundice picture, quite a lot of people get really, really itchy. Uh obviously, you're going to be told that this happens, but some things that you can maybe look out for in patients is actually this from just a constant scratching. So they can be have exploration marks on their arms. So it's maybe something to just kind of keep an eye on if you're doing a general observation of a patient, especially if they're maybe talking about itchiness and have jaundice could be a good, good idea to just kind of keep this out, especially if you've got ay or other things like that they may have. So they might have kind of those fatty kind of sts that kind of like float on top of the water and then the dark urine that we can see here just from kind of the all the bilirubin that hasn't been processed and kind of goes into the urine leading to the skull as well as kind of these symptoms of obstructive jaundice. We should also be wary of systemic features. So as we know, we have the benign and malignant causes. So it's just always good to just make sure that you cover that if you see patients with these kind of symptoms, that I just kind of keep in the back of your mind, cancer. So I feel like fatigue or losing weight, nausea, vomiting, fever could also point to other things such as infections. So pancreatitis, stuff like that. So it's always good to just kind of make sure that you cover systemic features. Uh But now that I've kind of covered the path of physiology of this, just gonna kind of move on to what we're actually all here for is more about the anatomy. So to start off, uh I'm just going to cover the anatomy of the tree. Obviously, I've mentioned the organs that are involved, but it's not kind of time to take a deeper look. So we have more uh four main sections of the diary tree that's been the common hepatic duct that we can see here. So this basically arises from kind of the liver, from those kind of bile ducts are carrying all that bile down towards gallbladder. And basically, they join up together and create this common hepatic duct. We then have the cystic duct, which is obviously, we've got the gallbladder here and the cystic duct acts as obviously, we know that bile gets put into the gallbladder. It also has to come out and this is through the cystic duct. So this thing connects with the common hepatic uh to then create the common bile duct where hopefully, if there's no issues, bile should. And uh we then have the pancreatic duct which arises from the pancreas. Uh and then basically connects to the belly tree uh to basically become the ampule of failure, which then is the opening that goes into the duodenum. And this is where obviously bile gets released in to help with that fat digestion. So no time to kind of show more of a complete anatomy, which is very, very good resource for if you want to revise. But as we can see, it's chopped off the top of here, but we could probably appreciate here that this is the common hepatic. So we have two joining bits that come into this tube here. We then have the cystic duct that comes all the way from the gallbladder and then creates a common bile duct, it travels down and then we have the pancreas here which then joins up at this point. And this is in the, we also have an additional opening at the top here, but I'll just won't cover that at the moment. This is kind of the main area where the bail gets released from as along with the pancreatic secretions. So never nine uh another piece of relevant anatomy. So we've covered, the tree is now kind of time to learn about other structures are nearby that can be very helpful in terms of the surgery. So that's one as the ligament of treats. Uh I may have pronounced that wrong but kill me. But basically, this is a suspensory ligament which originates from the diaphragm as we can see here. So it comes all the way from the diaphragm and connects to the small intestines and that ligament, it's actually a really, really useful landmark, especially within the surgery. As basically, this connects onto the small intestines here and it marks the end of the duodenum and the beginning of the Jejunum, which is obviously very difficult to see if you're looking at just the small intestines itself because let's be honest, they kind of look the same inside as well. But this is a good landmark for known roughly when it's transitioning and it's used for surgery as for that exact reason. So it's just something that you should be aware of, but moving on, just going to cover a bit of the small intestines. Now, you've got your three sections be the duodenum, the Jejunum and the ilium and obviously the main function of the small intestine is for food breakdown the digestion to absorb all the nutrients for the food that we eat and also can remove any unnecessary components. So, acting as a tract for it where it joins up to the large intestines also provides barrier function. So again, if we eat something that might have bacteria on it, if maybe it manages to get through the stomach acid also provides another layer of protection as it can't pass through the intestine. So it stays localized within the tract and also it has an immune function. So that has many immune cells that are connected in the small intestines and they do a big job, but I'm just gonna kind of skip past that, you know, it's not really too important to the anatomy. It's just handy to know that it has that kind of function. So moving on to kind of the main part that I want to talk about the small intestine that's been the Jeju. It's roughly about 2.5 m long. So it's a very, very lengthy section within your um abdomen. It's involved in sugar, amino acid and fatty acid absorption. It also helps to absorb folic acid vit A and D uh his blood supply as by the superior mesenteric artery. Again, that is obviously going to be other collaterals and involved the um small intestines. As we can see, it's a very vascular organ. Um However, if we want to kind of have a better idea of how it's distinguishable especially if you're looking at it close up. Um It's distinct from the due to its longer vasa recta, which I know might seem hard to look at just now. But basically, the vasa recta are straight arteries that basically project from these kind of curved to collaterals. So as we can kind of appreciate here, we can see that this artery here is a fair, well not artery but small vessels are very, very, very long, kind of one compared to here where they kind of seem to be a bit shorter. So that's one way that we can distinguish between uh the and the E but again, it's quite hard to see this in your life. But it's always a good thing just to keep in mind if you get kind of ask these kind of questions, I'm moving on. So now can I give you a quick rundown of the anatomy? I'm just going to move on more about the room, why he called Junos. So basically, the process involves the tree, the and the duodenum. So basically, you go into you surgically dissect the bile duct above kind of the area where the structure is. So if it's lower down in the bile duct, you'll just go a little bit higher up. It's quite common to go to the common hepatic area just because most kind of structures can occur down low due to obviously the length. Uh So it's quite common to maybe come up at this part. But we then create a real from the jejunum. But we'll talk about more. But basically, they kind of, as we can see here, we've got stomach, the duodenum and a little bit of the jejunum. And then here we have. So basically, we cut off the Jejunum into kind of two sections. One being connected to the stomach, the other one being the remaining of the small intestines. And this is the one that's connected to the rest of the small intestines and it's connected up to the hepatic the system, sorry, uh to basically allow for the bile to flow into the section uh into that real limb and where it joins up with the Jejunum connected to the stomach where it will then release food here and then the bile will do its job in digesting the food. And as we see here, you connect it to the dissected build up and then you create that anastomosis between the rule and the dissected part of the small intestine. So just to cover quite a few of the complications. So basically, complications with any surgery can be bleeding, um especially the other one can be bile leaking. We are cutting into the system, we have kind of creating an opening. So if this as a close fully, it can cause bile to leak out, which can cause irritation to kind of other structures around. Again, for other surgeries, infection as a risk. Obviously, again, as we're cutting into the system. It's gonna cause inflammation just with any other part of the body narrowing of the bile duct. Gait is another possible kind of risk factor as any surgery that happens as we know what the genic causes from cholecystectomy. This is no different. This can cause again, stricture and narrowing. It can make it pull into the bile in the abdomen and liver failure is a very rare complication but just always handy to keep in mind. But moving on, we have got our patient vignette. So we've got a mixy. He presented to GP uh with jaundice, the arteria and basal itchiness. He had a past medical history of gallstones and he actually underwent a cholecystectomy six weeks ago and he's also got hypertension and his drug history as Aydin for his. So just kind of moving on just before we stop going to the changing room. So getting ready, going into surgery, gonna get ready, gonna get all scrubbed in and get involved in this and you're basically presented to the theater. So you walk in after getting changed and then where do you meet the team? So we have the consultant surgeon, the specialty trainee, the anesthetist is going to be doing all that hard work, make sure the patient's a OK for the surgery, the theater nurse is always there to help you and also the scrub nurse that's always willing to give you a hand. So just a content one before we start. So from here on out, we are going to be showing kind of uh images of surgery. Um So it may be a little bit woozy things that you've not seen before. So it's ok. Um If you do feel woozy, but if you don't know like images or are a bit kind of freak about blood, uh feel free to pop out if you grab a drink snack. And if you're able, and basically, if you're going to faint, just have a, we sit down and again, you don't have to look at the images if you're a bit squeamish, but that's ok. So moving on the laparoscopic surgery has begun with the consultant entering the abdomen, they proceed to remove these adhesions so that we can see uh as they are near the plan surgery site, they turn around and ask you what is the most likely reason for these adhesions to be present within this patient? Is it infection? Is it previous surgery or is it radiation? I'll just give you a couple of minutes to a uh answer the questions. So I'll call it there. So we've got 88% of people voted have voted for previous surgery, which is correct. So the consultant smiles and nods her head. Uh that's correct. We know that the patient had the previous surgery in the abdomen duties, a cholecystectomy that he had and basically surgery and trauma can cause adhesion due to damage. And inflammation that occurred during surgery. So we can assume this is the most likely cause compared to infection and radiation. We have no kind of history of infection that we know of. So it's not kind of one that they really jumped to right away. And again, we have no history of the radiation which can cause adhesions. But again, no history, it's not really going to be top of, of differentials, but we know he's had surgery. Therefore, I can't we remove. So we move on. Um Basically, now the adhesions are clear. Uh They've managed to kind of open up and expose all the surgical site. Er, and basically the consultant, uh you know, have an of view as it says before the consultant continues any further, they ask you what is the structure that might, robotic arm is currently next to? So it is a robotic arm because it's done through a robot. And I put a nice big arrow to kind of point to the structure that I wanted. So it's either the portal vein, the common hepatic artery or is it the bile duct? Just give it a couple of more seconds? Seems so tied at 40% on two answers. If one other person wants to vote, maybe sway it in 11 way or the other. Ok. And we'll call it there. So 41% of people have voted for the bile duct, which is, oh, correct. So basically we can see that this is a structure that looks as if it's descending directly from the level. Uh Basically, we know uh you remember your anatomy very well as you know that the bile duct is the most anterior vessel which comes from the liver. So that's one way that we can tell uh between differentiate between the portal vein and the bile duct is that the bile duct actually sets more anterior than the portal vein. So the portal vein will usually set behind and kind of the common hepatic artery wouldn't really be shown as that way. It doesn't descend directly from the liver. It kind of comes off the celiac trunk and kind of goes more perpendicular to the level. Therefore, it wouldn't come directly from the level. I know I haven't covered that, but it's just kind of a little bit of anatomy to keep in mind that it comes from celiac trunk. The portal vein sets more uh posteriorly and the bile duct sets more anteriorly oh two seconds, made a boo boo there. Anyway, so we move on. So may I know that this is build up because the consultant cuts in at, as we see here in the opening there is bile that's been released from the structure. So she can appreciate bio is kind of usually more of a yellow green color. This looks to be a yellow or green fluid that's coming out. Um So we can appreciate that this is probably that is most likely bile, which seems to be from coming from the structure that we cut. So moving on the consultants now finish working with the bile duct. So they create the opening in the bile duct and then they kind of leave it as is for a bit. They just kind of put a wee bit of gauze over it, cover it up while they go and do other things in the abdomen. So they basically start to prepare for the next part of the surgery. And when they're moving, they suddenly stop and ask you what structure are we able to visualize at the moment? Which is this structure here? And they give you the options of the ligament of trees, the ligament flavum or is it the pancreas just have a couple of more seconds? Uh and I will call it there. So 54% have went with 0 50% now went off the ligament of trees, which is correct. So we can see the ligament of treats. Uh Basically, this is an important landmark. Obviously, it didn't show it connected to the diaphragm, but we could appreciate that any kind of ligament that descends down into the abdominal cavity and seems to be quite superficial as probably going to be the ligament of treats. Uh Basically, this connects on to the small intestine, gives us that again, the differentiation to duodenum and jejunum. And now we know that basically the small intestines, it's more lateral to this. And beyond this point is the jejunum, which is where we create the, the real limb. In terms of the other answers, ligamentum flavum. It's actually located within the spinal cord. So the consultant would be quite worried uh if that was the answer and the pancreas, uh 15% voted for. Um You couldn't see the pancreas cell, the pancreas rather than being quite a superficial organ is actually mostly retroperitoneal, which means it's behind the peritoneum. So you're not really going to see it at that uh kind of so anteriorly, you would have to kind of go digging a wee bit down deeper to see most of it. Again, the head of the pancreas is kind of a structure that kind of breaks out rule for being retroperitoneal, but we couldn't see it there. Therefore, it would be the pancreas is the answer. But over nine, for some reason, it keeps connecting to that. So that is not bad. I would just click on. So basically, the consultants now grab the jejunum after spotting that ligament of streets and starts to create another incision and Wales doing. So uh they ask you, what is the structure that I'm currently cutting through? Is it the omentum the Mery or is it the vasa ect got a couple of more seconds. And I think that's all the responses. So 53% of people have went with the omentum, which is incorrect. So people will be see probably thinking so yellow structure, we know that the omentum is from the abdominal cavity. Why is it not the answer? But the spr and says 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 intestines and looks to be anchoring it. This is what the mesentery does. So basically the mesentery as a structure that connects to the intestines helps to anchor it to the abdominal wall and kind of keep it in place. It also houses other kind of structures such as nerves, blood vessels and fat, which 28% of you kind of may have thought that we were cutting through because the vasa ect that is located within these um as it says here, not fully wrong, the vas ect as a group of small blood vessels which arise from the terminal branches of arteries, supplying intestines. It's certainly, but it's technically not an independent structure rather than just more a name given to these kind of blood vessels. Uh So basically, the answer that I was wanting was a mesentery because that is the main structure that we are kind of looking at there. So again, we move on after the special restaurants that I told you off, basically, the consult now gets the, gets the intestines and starts to divide it into two parts. So they use this, that basically is a giant stapler and kind of cuts the in half, which we can appreciate here as you can see, does this and creates two separate limbs. But now the Jejunum has been separated and staple consultant. I ask you how much of the Jejunum should I pull forward before creating the anastomosis between both sections? Is it five centimeters, 15 centimeters or 30 centimeters? Again? I know it's a bit of a tough question but just feel free to have a guess if you're right, you're right. If you're wrong, you're wrong. Just have a couple of more seconds just for the last year. Responses to come in and I will call it there. So I got 13 responses with 61% voting for 15 centimeters, which is correct. So basically, we're trying to connect the rule li we've made an opening. Uh Basically, we're trying to connect this real with the opening we've made within the bile duct. Basically, 15 centimeters is a decent length. And this would provide us with enough to basically reach the uh the bile duct and basically avoid excess wasting of the. I know there's 2.5 m worth of it, but we kind of want to keep every section that we can. So it can kind of get involved in nr absorption in terms of the other answers. Five centimeters is a bit too small, um be a bit kind of a tight pool. Although the can have plenty of length, you kind of want to give the bio enough time to just kind of like flow through and basically 30 centimeters is a bit too big. Can waste a little bit too much of the, although 30 centimeters at 2.5 m doesn't sound like a lot. We still want to make sure that the patient has enough. Uh Basically, we're not wasting any absorption space for the patient. If maybe the duodenum isn't really going to be working because it's not going to be connected with the enzymes that we use, er, that your body produces. So we kind of want to make sure that they've got enough space for the absorption. So basically, the surgeon then proceed to create the openings in the limb and the remaining jejunum, as we can see here, they cut, cut these open and they basically, and ask the moses by creating these two openings to allow the food to get released into this area and then allow the bile to kind of slow down and digest uh the rule, but then pull up is then connected towards the bile duct. Um as you can see here, not really quite hard to see the opening, but as there from what was made earlier, and basically, you can allow that connect between them and then the surgeon proceeds, they kind of finish such on these together and that should I finish the surgery? So they close up, they usually put in a wee drain and that's about it. So they then congratulate you on seeing your first operation in general surgery. And so you can now scrub out when you begin to do this. But a thought comes to your mind, you're thinking, how do I actually scrub out? Do you remove your gown first or do you remove your gloves first? When scrubbing out? Just let last few responses come in right now. We'll call it there. So 57% of people have voted to remove the gloves first, which is incorrect. You begin to put off your gloves first before realizing that you now have no way of removing your very blood stained gown that you've had been scrubbed in with without getting your hands study. So you make a mental note to basically remove your gloves first. Uh, you make a mental note to remove your gloves first next time. What is wrong? Basically, you want to remove the gown if you pull the gown off with your gloves, uh, basically, you can then rip it off and roll the gloves up into it. Therefore, you're keeping your hands clean. You're not transferring any kind of patient fluids. And basically, then that is you. But so that's me. I finished. Uh, there's been a wee error here, which if you give me two seconds. Yeah. So we'll now move on to the abdominal hernia repair and I will hand you over. That's great. Thanks Anton. Just checking. You can see my side's. Ok. Yup. Perfect. So, now that you've, uh, seen your first case in general surgery, you're very keen to continue on and learn about abdominal hernia repair, which is gonna be our next, um, next surgery that we're gonna be seeing. Now, just a, a red definition to begin with a hernia is a protrusion or a, pushing through of an organ or the fascia around an organ through a weak point in a cavity wall that normally would contain the organ. And there are lots of different types of abdominal hernia that I've listed here. Um There are many types of hernia more common in adults. Um such as epigastric femoral incisional inguinal obturator, periumbilical, Richter, spigelian, and umbilical. And then there are a few uh which are more particular to Children. Um but the vast majority of abdominal hernias, um over 75% of abdominal wall hernias are inguinal hernias. So that is what we're going to be focusing on this evening. And approximately 95% of patients um presenting with inguinal hernias are biological males. Hence, um will be focusing more so on male anatomy throughout this tutorial. Although I will highlight some female anatomy specifics as well. Now, just some clinical features of abdominal hernias in general. Um if a patient presents with a palpable protruding lump, which may or may not be reducible, um This just means when you push it in or that the lump can be pushed in. Um it may stay there or a cough impulse, which means um when a patient coughs, which increases the pressure in the abdomen, this pushes the lump out. Um because if part of the abdominal wall is weaker, there's no integrity to hold the organ of fascia in. So it'll just pop out. Uh There may be a sensation of aching, dragging or pulling and there may be pain associated with it. Although this is less common. Now, some general management of abdominal hernias before we go specifically on to inguinal hernias. Um if a patient has a wider neck hernia, so if the diameter of the weakness in the abdominal wall is wider, or if surgery is contraindicated, conservative management may be more appropriate. However, generally, surgical management would be um gone forward with. And in general these days, the majority of surgical approach is via a tension free repair using a mesh which is placed over the weak area of the abdominal wall. And this prevents the um abdominal organ or fascia from herniating and protruding outwards. And over time, the tissues grow into this mesh which reinforces the structure um that you're adding to keep it in place. You can also get a tension repair which is where the muscles and tissues themselves around the faulty area are stitched together. Um but this is rarely undertaken. Now, as there's higher recurrence rates compared to using mesh. And this just highlights the tension free repair with a mesh. You can see the mesh is inserted over the weakness which is highlighted by a circle um and put in place to reinforce the area. Now, some complications of abdominal hernias, there are two main ones to be aware of. Um firstly, incarceration. Um I mentioned before, some hernias can be reduced or pushed in. But if a hernia gets to the point where it cannot be pushed into its normal position, so it's stuck in its abnormal position. This can lead to obstruction and strangulation, which I'll talk about now. So, obstruction, um if you're dealing with the gut and the intestinal system, if there's a blockage, this can block um the feces throughout the bowel. Um And obviously, this is not a good thing. Uh This is more common in femoral hernias just due to their um anatomical location in relation to the bowel. Um And it would typically present as a bowel obstruction would present. So, with vomiting, generalized abdominal pain, sometimes it can be hard to localize and constipation. So, because the blockage is so great patients will not be passing feces or passing women and both these um complications, incarceration, str um, obstruction can lead to strangulation and this is a surgical emergency. So this is where the base of the hernia becomes so tight that it cuts off the blood supply to the bowel leading to ischemia and necrosis of the area. Um And this would present with considerable pain and ischemia at the site and this is very concerning and you want to deal with it quickly because you do not want the area of bowel to die. Um, because then that would create um the need to either anatomize parts of bowel or the main distoma. So, moving specifically on to inguinal hernias, um, an inguinal hernia is a protrusion of abdominal contents through the inguinal canal. And there are two main types, there are direct and indirect inguinal hernias. This just highlights um the normal inguinal area will go into the anatomy in more detail in a moment. But in indirect inguinal hernias, the hernia passes through the inguinal ring by the inguinal canal, by the deep inguinal ring. And most of the cases in Children of inguinal hernias are of this type. However, the other type is a direct inguinal hernia, which is where the hernia passes through the posterior wall of the inguinal canal known as Hesselbach triangle. And we'll talk about the boundaries of that in a bit. And this is more common in older patients and is more acquired due to raised um intraabdominal pressure such as um in pregnancy with heavy lifting, with a chronic cough, such as if a patient has CO PD um or with constipation and clinical features of inguinal hernia. So you'll get the lump will appear superior and medial to the pubic tubercle, which is the prominence of your pubic area, which I highlighted a bit. Um The lump generally will be reducible it will disappear when the patient lies down or when pressure is applied, there may be ache and discomfort which is particularly aggravated if the patient moves and comparatively inguinal hernias more rarely strangulate. Key differentiators on examination. In indirect inguinal hernias can be reduced to the level of the deep inguinal ring, um which is midway between the anterior superior iliac spine and pubic tubercle and will remain reduced. Whereas a direct inguinal hernia is irreducible. And typically this is a clinical diagnosis. Although if there's uncertainty, an ultrasound scan may be used. So, in terms of management, um you treat even if the patient is asymptomatic and that's because you want to make sure that complications such as um obstruction leading to strangulation do not occur, the consequences are too great. So make sure you treat it. If a patient is not fit for surgery, you can use something called a hernia truss, which is almost like an extra um pair of reinforced underwear, it almost looks like a, a harness that people use when they go rock climbing. And that's just um worn by the patient and provides material support to keep the hernia in place. Although some patients do not like it for cosmetic reasons. However, if a patient is fit for surgery, we go for a mesh repair approach. If the inguinal hernia is in on one side, it's generally an open surgery approach. Whereas if it's a bilateral or recurrent hernia, it's a laparoscopic or Keyhole surgery approach. And these two main approaches are highlighted here. The um laparoscopic approach is also considered more in those at risk of chronic pain or in females just due to the greater risk of a femoral hernia as a complication. More detail in terms of the types of um inguinal hernia surgery. You've got a herniotomy and these are all referenced directly from teach me surgery. This is a removal of the hernia sac with ligation and excision of the patent processor vaginalis. And this is most commonly performed in neonatal infants. You've got a hernia roughy, which is a herniotomy, but with suture repair of the posterior wall of the inguinal canal and you have a hernioplasty which is a herniotomy with reinforcement of the posterior wall of the inguinal canal with a s um synthetic mesh. I've just seen a question in the chat, what's an incarceration? So, um if I just go back a moment, an incarceration is a complication that can occur with hernias as you can see here where, um so just here where you cannot push the hernia back into its proper, proper position at all, um It's protruding too much. I hope that makes sense. Um So just going back to the surgical approaches, but the most common technique and the one we'll be discussing this evening is the Lichtenstein tension free mesh repair. The indications for this electively are symptomatic inguinal hernia. Although as I mentioned, even if the patient's asymptomatic. You do want to pursue, um, a correction of it and in an emergency if the hernia is incarcerated or strangulated, but this is contraindicated in pregnancy, um, uh, except in the um, acute complicated scenarios or if there's very small, a asymptomatic hernias, you wouldn't completely discharge the patient, but you'd, um, check up on them and undergo watchful waiting in terms of the mesh repair operation. This can be done ov under general regional or local anesthesia, depending on um the patient's risk factors, how long or complicated they think the surgery is going to be and the patient will typically be in a supine position. And as with a lot of surgeries, do consider a urinary catheter intraoperatively. Um apologies. This is quite text dense, but as we go through the patient case, hopefully this will become more clear, but you create an incision along the skin crease from the groin to the pubic cubicle along the level of deep inguinal ring. Um then you dissect um through the layers until you can visualize the external oblique aosis. Then you split the fibers of the external oblique aponeurosis to the level of the superficial inguinal ring. At this point. You want to identify the ilioinguinal nerve and this is important because this, there's a risk of damaging this nerve during the operation. And you want to avoid this to protect the function of motor innervation of the transverse abdominis and the internal oblique muscles. Then you want to identify and inspect the con contents of the inguinal canal, dissect the hernia free from the spermatic cord and pass a tape around the spermatic cord to isolate it. Then the hernia sac relocation takes place and there's slightly different approaches for direct and indirect hernias. So if it's direct, you push the sac back into the extraperitoneal space and plicate the posterior wall over it or like push it over using nonabsorbable sutures. Whereas if it's indirect, you dissect the hernial sac down to the deep inguinal ring to inspect and empty the contents and then transfix the sac at its base. At this point, the mesh comes into the picture. So you want to cut it into the correct size and shape of the canal or the weakness um in the inguinal wall. And then you place the mesh along the posterior area of the inguinal canal and suture it in place. Um making a slit at the end to create two tails. Just to ensure it fits correctly, you suture along the various edges of um the mesh to the nearby structures. The inguinal ligament inferiorly and the internal oblique muscle superiorly, then you recreate the deep inguinal ring by suturing the tail ends around the spermatic cord and finally close the wound with absorbable sutures. And this just highlights the various steps that we'll be talking through during the patient's case postoperatively. Most patients can be discharged on the day of the operation um and the main consideration to counsel patients on is returning to manual work or heavy lifting. Um for example, if a patient likes doing weightlifting in the gym or if they're a, a builder by trade, for example, um caution them not to return to manual work after 2 to 3 weeks. If it was a unilateral hernia or after 1 to 2 weeks with a bilateral, just because with bilateral, the laparoscopic approach means the need to delay, heavy lifting is less in terms of complications. The early complications as with a lot of surgeries, you'd expect bleeding but also formation of a hematoma or seroma damage to the vas deferens, um ischemic orchitis or testicular atrophy or damage to the ilioinguinal nerve, as I mentioned or to a femoral vessel and later on infection can occur, there can be chronic infection of the mesh you insert because it is a foreign body. Um chronic pain. If you have damaged the ilioinguinal nerve uh or recurrence of the hernia, moving on to the relevant anatomy. So the inguinal canal, as you can see highlighted in the diagram on the right runs superior and parallel to the inguinal ligaments and extends in an inferior medial direction. So downwards and towards the middle, it runs between the deep inguinal ring where it connects to the peritoneal cavity and the superficial inguinal ring which connects to the scrotum and the ring. Um just highlighting more details about this and you can see it highlighted on the complete anatomy diagram as well as the teach me anatomy image here. This um marks the end of the inguinal canal and it's approximately one centimeter supralateral, so high up and lateral to the pubic crest. And it's a triangular shaped opening which is created by an invagination of the external oblique muscle. And it also contains intracrural fibers which maintain its structure. The deep inguinal ring um marks the opening inguinal canal um and is more um superior to the superficial inguinal ring. And this lies halfway between the pubic tubercle and the ass um and lateral to the epigastric vessels. And this is created by the imagination of the transversalis fascia in terms of the borders of the inguinal canal. I found this image from teach me anatomy helpful and you notice the key at the bottom highlights the different boundaries in different colors. Um The anterior border is the upper neurosis of the external and internal oblique muscles. The posterior wall is the transversalis fascia and chondroit tendon. The superior border is the transversalis fascia, internal oblique and transverse abdominis muscles. And the inferior boundary are the inguinal and lacunar ligaments. And this just highlights it from a slightly different perspective. In terms of the contents of the inguinal canal, you have the inguinal nerve, the genital branch of the genitofemoral nerve. And these are in both sexes and then specifically in males, the inguinal canal contains the spermatic cord. So in terms of the ilioinguinal nerve. As I mentioned, it provides motor innervation of the transverse abdominis and internal oblique muscles and also sensory innervation of the genitalia. So there's a risk of damaging these during the repair and also uh with the genital branch of the genitofemoral nerve. In males, this supplies the remata muscles and the anterior scrotal skin. And in females, this supplies the skin of the mons pubis and the labium majora. And in males uh mention the spermatic cord passes through the inguinal canal from the abdominal uh from its origin in the peritoneal cavity all the way into the scrotum. Whereas in females, the round ligament passes through the inguinal canal. It originates at its uterine horn attachment and it passes through to its attachment at the labia majora. Now, apologies if embryology is not your thing, but it's difficult to talk about inguinal hernias without covering a little bit of embryology as it helps to explain the anatomy. And also the pathophysiology of how inguinal hernias develop. Um And so the processor vaginalis is a pouch of the peritoneum which extends from the abdominal cavity through the inguinal canal. And during embryology, this allows the testes to descend from the abdominal cavity where it originates into the inguinal uh through the inguinal canal into the scrotum. The gubernaculum. Um as highlighted on this diagram on the right is a fibrous cord of tissue which helps guide the inferior part of the gonad, the testes in males or the ovaries in females to the location of the future scrotum or labia and in normal development, um, the deep inguinal ring closes after the testes descend and the process is vaginalis to generate. So it's um no longer open. However, in an indirect inguinal hernia, this processes vaginalis. This connection remains patent or open and this creates a tract or a, a passageway between the abdominal cavity and the scrotum along which the bowel can herniate and push through because normally there shouldn't be a hole there. But in this um pathological process, there is a hole, there's a weakness. Therefore, the bowel can herniate through. And this tract, as I mentioned, uh begins at the deep ring along the spermatic cord, travels laterally to the inferior epigastric vessels. And um it travels along the inguinal canal to the superficial ring and this hernia may descend all the way to the scrotum depending on how far the patency of the processors vaginalis um continues and it just highlights how an indirect hernia, the con the content may continue to descend all the way into the scrotum. Whereas in a direct inguinal hernia, the hernia protrudes through Hesselbach triangle, which I'll cover in a moment into the inguinal canal. And this is directly through the posterior wall of the inguinal canal and medial to the inferior epigastric vessels in Hesselbach triangle. So the boundaries of Hesselbach triangle as highlighted um in color on this image on the right. Um I found zero tins had a great mnemonic for this R IP. So the medial border of the R is the rectus abdominis muscle which forms the lateral border, the eye or the supra supra, lateral border is the inferior epigastric vessels. And the p or the inferior border are po parts ligament also known as the inguinal ligament. Um It's helpful to know Hessel back's triangle in terms of um categorizing or defining a direct inguinal hernia. However, it doesn't um contain structures of clinical importance regarding the the surgery and it doesn't change the management. Now, moving on to the patient case, the fun part. Um So we have Mr Ian Gule who's a 79 year old male. He has presented to you um with a 10 day history of a lump in his left groin which aches and disappears when he lies down at night. His past medical history is a postnasal drip and asthma um which gives him a chronic cough all the time. He finds it very annoying and he also has anxiety. The drugs he currently takes are a daily salbutamol inhaler and a betamethasone inhaler as needed for his asthma. He also takes chol uh cholecalciferol or Vitamin D because he lives in Scotland and there's not much sun and sertraline an SSRI for his anxiety, his social history, he is obese, he smokes two packs a day as he has done for 40 years. He now retired, but he used to be a professional powerlifter for Scotland and he lives alone with his cat on examination. Um, you identify a unilateral left groin lump, which is separate from the testes. Therefore, it's not entered the scrotum. And as the patient reports, this does disappear as he lie do. Has he lies down when pressed to the level of the deep inguinal ring, um, the hernia remains produced. Therefore, this tells you that it's an indirect hernia and that's the diagnosis. Therefore, you decide the most appropriate management, given that it's bothering him. It's not a very small asymptomatic hernia and he has no um contraindications to surgery is a Lichtenstein tension free mesh repair. Therefore, you begin by uh making your incision and once the subcutaneous tissue has been incised, an inferior epigastric vessel is I the consultant scalp 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? Would it be medial or lateral? So I'll give you a minute to fill in that form. That's great. So currently, majority of people, 85% saying that you would expect an indirect hernia, inguinal hernia to be lateral to the epigastric vessels. So we'll stop the leg. So this is correct. Well done. The consultant smiles and nods her head. That is correct. An indirect hernia travels laterally to the inferior epigastric vessels when passing from the deep inguinal ring to the superficial inguinal ring. This helps distinguish it from a direct inguinal hernia which would travel medially to the vessels so well done at this point. Um The consultant continues dissecting down through the layers and you can identify the superficial inguinal ring to the left here, the external oblique aponeurosis and the inguinal ring again. And as the surgeon dissects down through the external oblique a neurosis, 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. Is it sensory innervation of the genitalia. The supply supplying the cremaster muscles and anterior scrotal skin or motivation of the transverse abdominis and internal oblique muscles, which is not a function of the ilioinguinal nerve. So, currently, majority of people are saying that the ilioinguinal nerve is not responsible for motor innervation of the transverse abdominis and internal oblique muscles. So that is incorrect motor indication of these muscles is actually a function of the ilioinguinal nerves that is not correct. Um If we go for sensory innervation of the ge genitalia, that's also incorrect because the ilioinguinal nerve does indeed supply sensory of the genitalia. So, the correct tonsil, which is not a function of the ilioinguinal nerve is that it does not supply the cremaster muscles and anterior scrotal skin instead, a genital branch of the genito femoral nerve which supplies these muscles. And this nerve can also be found within the inguinal canal. But is not the same as the ileo inguinal nerve. So at this point, um we are dissecting through, we can see the transversalis fascia inferiorly. And now, at this point, we can locate the in indirect in inguinal hernia. If at this point, if the patient had a direct inguinal hernia, instead, we would see the hernia protruding and it would be covered by the transversalis fascia. Whereas here, they're more distinct and separate. And now we can er identify the spermatic cord as well. And um the spermatic cord is isolated by dissecting off the floor of the inguinal canal and it is retracted by placing a tape around it. At this point, the hernial sac is isolated and retracted isolated from the spermatic cord, which you can see. Now we've got a tape around on the left and the hernial sac needs to be completely isolated from its surroundings in order for the structures to be released. So now as the hernial sac is pushed into the deep inguinal ring to invert it into the abdominal cavity. The surgical re um with a glint in his eye turns to you and suspense and asks, how would this stage of the operation be different if we were repairing a direct inguinal hernia? And this, there's no pole for this, but this is if you want to just put in the chat and share your ideas. Um No problem if you're not sure. Just um give a few suggestions how potentially, you think this part of the operation might be different if it was a direct hernia rather than an indirect, I'll give it a minute or so for suggestions. Thanks, Kevin for your suggestion. Um You're not far off. So, in, as I've said, in an indirect inguinal hernia, you dissect the hernial sac down to the deep inguinal ring to inspect and empty the contents and transfix it to space. However, with a direct inguinal hernia, you actually push the sac back into the extraperitoneal space. So I guess um well, yeah, further back and you plicate, which just means to stretch the weakened tissues and fold the excess and tuck it back. Um uh You took it back and attached it um over the posterior wall using nonabsorbable sutures. Um So, yeah, well done. Thanks for your suggestions. So, at this point, the mesh is placed in the posterior wall of the inguinal canal and sutured in place. The deep inguinal ring is recreated by suturing the tail end of the mesh around the spermatic cord, lateral to the contents of the cord and the operation was successful. And Mister Ian G will hopefully be bothered by his inguinal hernia no more. So, just a recently to finish. Um and I focused here on the key differences between direct and indirect cos I think this would be a common thing to come up in exams and OSC. So, uh direct hernia is a hernia through the posterior wall of the inguinal canal or heel back triangle. It's irreducible when pressure is applied and it passes medially to the inferior epigastric vessels. Whereas a direct inguinal hernia is a hernia through the inguinal canal via the deep inguinal ring, they can be reduced to the level of the deep inguinal ring midway between the ace and the pubic tubercle and they'll remain reduced and they pass laterally to the inferior epigastric vessels. So now Mr Guo is off for recovery and has been told to avoid heavy lifting for 2 to 3 weeks. So, no more power lifting for Scotland for him. You look at the theater lift and see a hiatus, hernia repair next. So what do you do? You hit the books and let's learn about hiatus, hernia repair. Brilliant. So covering hiatus hernias will be me and Natasha and I'm sure Naasia is trying to share the slides right now. Brilliant. Yeah, we can see that. Ok. So let's start us off. Um Yeah. Yeah, we can see that. So. Hi, I'm all right. So, yeah, we're gonna be presenting hiatus, hernia repair and I'll just start us off with um Pathy. Can everyone hear me? All right, I'm just gonna can hear you fine. Nice. Ok. So what a hiatus hernia is, is one part of the stomach squeezed up through, like into the thoracic cavity or the chest area through the opening or a hiatus in the diaphragm and that like esophageal hiatus it's called um is always there. Um But sometimes when the diaphragm becomes weakened, either with age or with increased pressure in the abdomen, part of the stomach can squeeze up through it. Um And in the bottom left, I've included an image of like what a normal esophagus and um stomach should look like so that you can see the esophageal hiatus like the, the whole um in the diaphragm that lets the esophagus pass through and the bulk of the eso of the, of the stomach, its entirety should be below the diaphragm. Um With the like esophageal gastroesophageal junction sitting around at the level of the diaphragm or slightly below. But with the hiatus, hernia, part of the stomach is bulging up above the diaphragm. And there are four different types of um hiatus, hernias uh that not will go into in more detail when covering the um yeah, when covering the, the anatomy, in terms of risk factors, it's anything that can weaken the diaphragm really um or cause increased pressure on the abdomen to make that stomach bulge up. So increased age, your diaphragm becomes weaker, being overweight or pregnant or yeah, or pregnant would cause that increased pressure on the abdomen. But the exact cause as to why they happen, we haven't figured that out yet. It is unclear. Ok. Next slide, perfect. So now I'm just gonna go through a little bit more about the anatomy. So the anatomy involved in this condition is rather simple. Um As Diana said, there's an opening through the diaphragm where the esophagus travels through, um called the esophageal hiatus. And this is at the level t 10 below the diaphragm, the esophagus morphed into the stomach and the stomach is supposed to stay below the diaphragm. Um And this is an important fact to take note of because there is an abrupt transition from the mucosa of the esophagus when it's with its stratified squamous epithelium to the glandular mucosa of the stomach. Now, we're just gonna go through the different types of hiatus, hernia. So, there are four types. The first type is a sliding hiatus, hernia. So that is um a reducible and a limited herniation of both the stomach and the gastro oesophageal junction into the fourth thorax. And that is composes 90% of esophageal hernias. So, it's the most common. The majority are actually asymptomatic, but some symptoms could include heartburn, regurgitation, sour taste and increased coughing. And the complications of this are having barrett's esophagus. The second type of hiatus, hernia is the paraesophageal hiatus, hernia. And this is a herniation of all a part of the stomach through the esophageal hiatus into the thorax with an undisplaced gastroesophageal junction. And the majority are also asymptomatic due to the gastroesophageal junction being normal, but dysphagia could also occur. The third is the mixed hiatus, hernia and this is actually a combination of types one and two. So this can include something called a giant hernia, which is known as an interthoracic stomach. So, this is when the stomach actually goes completely above. And um, this has a rare risk of inducing gastric volvulus. The common symptoms are heartburn, reflux, feeling full after a normal size meal, bloating and retrosternal comfort, discomfort. And it can also present as a gastric outlet obstruction or gastric necrosis secondary to strangulation of the gastric volvulus. And um, a fun fact is this is the most common indication for surgical repair for a hernia. And the last one is the type four hernia. And this is the herniation of the stomach and other abdominal organs in um into the thorax. So this is including but not limited to the colon, spleen and pancreas. Those are some common ones um that join the stomach above the um the diaphragm and the symptoms are very similar to type three, including heartburn, reflux and bloating. And this also needs surgery. Lovely. Yeah, that was great. And we thought it'd be best to just dive straight into a case because then we can apply everything really to this case. So let's meet our patient. They called her es sober. They're 72 and they are male. Um So they're coming into their GP, let's say because they've been noticing some heartburn. So it's like some painful feelings in their chest, especially after eating some acid reflux halitosis with bad breath, dysphasia, so painful swallowing, um and bloating. So they they do have a past medical history of Gord, um, which is like the reflux disease. Um, so they put the symptoms down to that. They're also obese and have type two diabetes. And they're currently on Gaviscon omeprazole and Metformin that Gascon omeprazole for the Gord and then Metformin for the diabetes a bit about their social history. They're married, they've got like a poor exercise and diet but they try to eat small, frequent meals. Um which is what you should do for, for GERD. It's like the first line management to no effect, however, has not improved their symptoms. Um And they are a leather surgeon which is a type of book binder. Um So let's say you're the GP and you want some further investigations. So you send them out for a chest X ray and that's usually like the first line investigation you would do um for like a non resolving um gourd. Um Even though they're on a PPI like the omeprazole and they're, they're doing your lifestyle advice. So, on the chest x-ray, between those two arrows, you can see what's called the air fluid level and that's characteristic um of a hiatus hernia. So there you know that something's wrong but say if the X ray was a bit unclear because these are a bit hard to see. Um You could also do some like gi contrast series like that's called the Barium Esopha um Barium Esophagram where you swallow a drink containing barium, take an X ray and then you can see where the barium settles. And there you can see that is a hiatus hernia. So most of the barium is swallowing is, is settling in the stomach. The part of the stomach is um herniating up from the diaphragm. So you can see the stomach kind of divided into two places if, if that makes sense as well as those two investigations, those are the two main ones. But again, if it's not really clear, you can consider endoscopy. So actually going in with a scope through the mouth and just having a look at what's down there, um, doing a bunch of other scans like CT S or MRI S to maybe see it in more detail or maybe seeing a different cause for this patient's symptoms or you can do, um, what's called esophageal manometry, which is measuring the pressure differences in the esophagus and the stomach or like, or just in the esophagus to see where the pressures are different. And I'm sure you can tell that there, there'd be a very different, um, pressure in that bit of herniated stomach right above the diaphragm and the rest of the esophagus were further down into the stomach. Um, yeah, and that's it for investigations. Now we're gonna move on to some treatments. So the first line of treatment of a hiatus, hernia depends on the type. Um, and also any associated complications. So, as a general rule. Asymptomatic type one hiatus, hernias do not require any intervention aside from lifestyle modifications. So these lifestyle modifications, which you can see to the right, they, um, include, um, smoking cessation, weight loss, elevating the head off the bed with pillows, no meals, um, three hours before bed and eating small, frequent meals, avoiding alcohol, coffee, mint, and fatty foods and some of the other foods that are, um, are on the right and then the second line. Um So patients with symptomatic type one hiatus, hernias require management of gastroesophageal reflux disease, um which is the heartburn and um this includes proton ha giving them protein pump inhibitors. Um and in highly selected cases, surgery. So, proton pump inhibitors and also um h two antagonists are medications that are given to neutralize the acid in the stomach and decrease these painful symptoms of heartburn after eating the third line treatment. So, in patients with paraesophageal hernias, so type 2 to 4 surgical intervention is typically recommended if they're symptomatic or if they develop complications, um such as the gastric volvulus, I was talking about before or strangulation or any necrosis. So, um the first type of surgery is a NS and F duplication and this is a laparoscopic hiatus, hernia repair where the fundus of the stomach is wrapped around the gastroesophageal junction and sutured in place. And this is the most common type of hernia surgery for hiatus hernias. The second type is the d fundoplication and the TPA fundoplication which are partial fundoplications. And then the third surgery is a gastropexy. So this is suturing the stomach to the anterior abdominal wall to reduce the risk of gastric reherniation. And this is indicated if the treatment in the treatment of more severe hernias, for example, the mixed hernias, um such as like type four or type three. So now I'm gonna go through the steps for the most common surgical intervention use, which is a nice infant application. Um So first, the anesthesist gives the patient propofol and sevofluran to induce the anesthesia. So the patient goes to sleep. Um the surgeon then makes 4 to 5 small incisions in the abdomen and inserts a laparoscope. So that's a small tool that's quite long, that has a camera at the very end. And um in the other incisions, they insert um other tools um that all have different names. Um And some of them are called Y hands and they use the camera and I images and the um tiny operating tools to pull the herniated portion of the stomach downwards. So, in the Neeson procedure, they also wrap the upper stomach around the lower esophagus in a 360 degree wrap to keep all the structures in place. So the stomach doesn't slide up again. So after this is complete, um they can also put some mesh as well to help with the um with the healing and the bleeding as well. Um after this is finished, uh the surgeon closes the incision with stitches and um and then the patient is closed up. Um So now I'm just gonna talk about operative care. So as an inpatient hernia spends less than 24 hours in intensive care unless a complication occurs. And then as an outpatient hernia has uh outpatient care involving lifestyle modifications such as um keeping a healthy diet, gentle exercise, such as walking. And he's also advised to avoid heavy lifting and strenuous activities for about 4 to 6 weeks. Um Good thing, binding books doesn't require any lifting whatsoever. Nice. And now we're part of um we're going into our choose your own adventure series. So consider this, you're like warning that we're gonna be showing some operation pictures to anyone who is, who is squeamish or doesn't want to look at them, maybe tune out for this part. But otherwise, yeah, let's get ready for, for the case. Great. Ok, so this patient hernia um is going into to have a like the nis infant application to the most common um hiatus, hernia repair surgery and the surgery started, we're now in the abdomen. So just to orientate ourselves, um we're looking up at the diaphragm. Um So this whole, yeah, this whole big area here is a diaphragm and that triangle that you can see there just about is the esophageal hiatus. So that's the whole of the stomach's coming down on and the big bit that you can see at the left. Yeah, that's the stomach uh that we can see coming through that hole. Um Yeah, into the like abdominal cavity. So we can visualize the esophageal hiatus. And then um as you're watching the surgery, you're seeing the surgeon place this white band around the stomach. Why are they doing that? So the pole is gonna be launched in a bit. So is it a to tie off the stomach and prevent the hernia from sliding up through the hiatus or to use the band as an anchor to pull the stomach down through the hiatus? If you just click A or A or B and I'll just wait for some responses. Great. You can see some answers coming in already. Um We'll just wait a couple more seconds. Cool. So we've got, we've got a couple of answers and majority is going for b um I feel what might be the best thing to do. Just go, go through both right and wrong answers. So we can see the, yeah, both of them. So actually, if you go back one slide. Um The Taia. Yeah. So for those who said tie off the stomach, um, if we turn off the stomach now, um like you can imagine the esophagus ending right there. So like the food wouldn't actually be able to go all the way down to the stomach. It would be, it would be quite bad. Um And that wouldn't really help fix anything. The, the stomach would also be still herniated through the esophageal hiatus. So do not tie off the stomach. Now. Um, and then going on to the, um, we're actually using it as an anchor. Um Oh, yeah, next slide, please. Yeah. Nice. So we're, we're using it as an anchor. So by having that, um, that white band we can use in the laparoscopic instruments to have some traction and pull that herniated part of the stomach through the esophageal hiatus where it shouldn't be above that hiatus all the way down again into the abdominal like cavity. And that way, we've got that like soft band to pull on and we don't use the laparoscopic tools directly on the stomach tissue and risk damaging or perforating it, which could be complications of the surgery. Great. Let's go to the next slide and brilliant. So you can see that. Um, well, the like part of the esophagus and the stomach is pulled through the esophageal hiatus and now we're trying to close the hiatus up. So that, that whole, the hiatus had widened just because the stomach hadn't made its way through. And now we're just trying to approximate it or close it. So we're approximating the hiatus and we've placed three posterior sutures. Um, but the hiatus is still quite big. So we don't want it that, that big still. What should we do? Is it a continue suturing? We're nearly there just place a couple more or b place some anterior sutures rather than the posterior ones. And again, we'll launch the pool and if you click A or B depending on what you think we should do. Yeah, I can see some, some response already. That's great. And so far for this one, I've got like a 0% and 100%. Everyone can see me going for B um So yeah, literally everyone seems to be going for b so if we just go um straight for bi think, um Yeah, and to your sutures, this is really advanced knowledge, guys, so well done. Um So in terms of how we suture, the um esophageal hiatus uh backs shot. So sutures are placed at one centimeter intervals and we'll start off with the posterior suture, we'll place 2 to 3 posterior sutures. Um And if the hiatus is still quite big, so not approximated, then we'll place the sutures anteriorly because if we kept on placing just posterior sutures, uh would create something called sigmoid distortion of, of the like esophagus. So I've included like an image of like a normal esophagus um joining up to the stomach. If you can imagine the like posterior sutures being placed, the esophagus would like slowly go more towards the front and create like a sigmoid area. Um And again, that could contribute to reflux, it can contribute to dysphasia um which would not be good. So we're trying to keep it as like straight as possible or as close to like the it's normal anatomy as possible. So, yeah, really well done guys. Uh Next slide, please. And that's just the image of the sutures being placed. So we've got our posterior sutures, our anterior sutures. And after so we want to um the like esophageal height is like approximated, we don't want it tight um because we, we do still want the esophagus to be able to like expand and have the food like perosis through to the stomach. But we just want it close enough shot again that the stomach isn't liable to go back through and herniate through that again. Nice. Next slide. And now we've added the mesh bit. That's the white part that you can see. Um again, that's just to provide more stability and make sure the, the esophageal hia stays closed and the stomach doesn't go back through it again. And we're preparing to complete nissen and duplication and wrap the stomach around. How many degrees are we wrapping the stomach around that gastroesophageal junction before suturing it into place? And is it a 202 170 or B3 160? So I'll, I'll give it some time as well. We've got some already cool. So it's like a a third to two thirds split with most people going for B3 160. So, yeah, let's, let's look at that slide. Um For those that said 270. No, that's not quite right, the stomach, um, in the nissen for duplication, the stomach is wrapped 360 degrees around to like completely around the esophagus. But the 270 is a type of, is a type of surgery that's called the tupa application. But in this one, the most common one done, uh, the Nissan one, it's 360 degrees around. So, just fun facts. So, remember, um, exactly. And we, we just wrap the stomach around the lower end of the esophagus just to reduce the likelihood of that stomach sliding back up um through the esophageal hiatus and just keep on herniating like it did before. So it kind of created a stopper if you will. Yeah. And I think we just have one final slide so you can see there the stomach is wrapped around um on the esophagus and then just sutures into place and that's it. Great. Thank you very much. Thank you. Great. So, for our final few minutes, we have some MC Qs. We're going to work through just a few to try and refresh uh and recap your knowledge on what we've covered. Um So for our first couple, I'll hand over to Anton who's covering er, questions from our first case? Thank you. So, can I start off with the first question? Um Basically, which of the following is the most common cause of benign biliary stricture? Is it a laparoscopic cholecystectomy? Is it the primary sclerosing cholangitis. Is it infection or is it pancreatitis? Got a few votes coming in now and we'll call it now. So we had 50% of people voting for the laparoscopic cholecystectomy, which is if you can move on to your next slide, correct? So, as I mentioned that basically estrogenic causes are the most common cause of the benign belly stricture. And out of all these, the estrogenic cause would be the laparos, laparoscopic sorry cholecystectomy. Then if we move on to the next question, um which of the following best describes the position of the jejunum within the abdominal cavity. Is it one retroperitoneal to extraperitoneal or free intraperitoneal? You have a couple of more seconds and we'll call it there and 70% of people of intraperitoneal, which is correct. So, retroperitoneal is more kind of your organs like the pancreas, kidneys, stuff extraperitoneal. No, the kind of small intestines are actually found behind the omentum kind of in the mess as peritoneum. And then obviously, I would dangerously intraperitoneal as the answer. So I will hand you over great. So our next two questions are relating to the inguinal hernia case. So, question three, which of the following anatomical structures does not form the superior border of the inguinal canal. It, the transversalis fascia, the inguinal ligament, the internal oblique or the transverse abdominis and stop it there. So currently, we have a majority going for transversalis fascia fascia. Uh Unfortunately, that's incorrect. So the transversalis fascia, the internal oblique and the transverse abdominis are all part part of the superior border of the inguinal canal. However, the inguinal, along with the lacunar ligaments form the inferior border of the inguinal canal. Question four, which of the following anatomical structures forms the inferior boundary of Hesselbach triangle? Remember Hesselbach triangle is relevant for direct inguinal hernias. Is it the rectus abdominis? The inferior epigastric vessels, poop parts ligament or the external oblique aponeurosis? Currently, there's a split between two and three. Does someone else want to vote to swear it either way? I'll stop it there. So, the correct answer uh is po parts ligament so well done for the third of you that put that uh the po parts ligament is also known as the inguinal ligament. Um And to remember this um recall the helpful R IP mnemonic that zero to finals um helpful referred to where R is the rectus abdominis muscle. Um I are the inferior epigastric vessels and P are the poo parts ligament. Um And these are the borders of Hesselbach triangle with the pou parts ligament being the inferior border of Hesselbach triangle. Whereas Rectus abdominis um forms the medial border and the inferior gastric vessels form a supralateral border. So I'll hand over to Natasha and Diana. Yeah. So this is question five. What's the most commonly performed surgical procedure to treat a hiatus hernia? So, you've got four options there and I'll give you some time to have a read through and just like which one is most common? Ok. Yeah. Uh response are coming through and the grand majority is saying um an ent for application and oh, things are changing but majority is still missing from modification, which is correct. So, yeah, Nissen is the, is the most common one to treat your hiatus hernia, well done guys. And now the sixth and final M CQ, which one is not a risk factor for hiatus, hernia. Ok. We seem to be getting a more even split with this one um with some slight with yes, a slight majority saying Gord is, is not a risk factor. So if we go over to the next slide, that's absolutely correct. So, Gord, you can think of it as like a symptom of a hiatus hernia or the hernia is causing the gord to manifest. It's not a risk factor to developing it. Um That was a bit mean because our patient had gord. But yeah, think of it as more of like a symptom of the hernia. Lovely, great. So uh last but not least we're just gonna do a brief summary of each of our cases. So, Anton, do you want to go for the real life? Uh Yeah. So basically room I is a surgical management that issues structure and this can be caused by multiple different reasons. It's recovered such as GIC infection, malignancy, autoimmune. Uh Basically, the key point is that the real limb is created using the jejunum rather than any other structures, the small intestines. And to find this, you want to use ligament of treats, which is a key landmark to let you know what area you're interacting with. And basically the anastomosis must be done between the rule and the remaining si and also above the level of the stricture and the bile duct. Because if you do it below the stricture, you're not gonna get any bile flowing through. So you want to make sure that you do it above that structure. So you're getting that good flow in and that's it. Great. Thanks Anton. Um So with regards to direct inguinal hernias, just remember that this is a hernia through the posterior wall of the inguinal canal or Hassleback triangle. It's irreducible when pressure is applied and it passes medially to the inferior epigastric vessels. Whereas an indirect inguinal hernia is a hernia through the inguinal canal via the deep inguinal ring. They can be reduced to the level of the deep inguinal ring and will remain reduced unlike direct inguinal hernias, and they pass laterally to the inferior epigastric vessels and finally, for hiatus, hernia. So here are some take home messages for the hiatus hernia. So a hiatus hernia occurs when part of the stomach squeezes up into the chest during an opening, which is called the hiatus. In the diaphragm. There are four main main types of hiatus hernias. The most common being the sliding hiatus, hernia. The risk factors for developing hiatus, hernia include increased age, obesity and pregnancy treatment for hiatus. Hernias includes a mix of lifestyle modifications, PPIs and surgical procedures. And the most common surgical procedure is the knees and fundoplication. Uh Thanks Natasha. So I hope you all enjoyed that. Um, our session this evening and learn some more about general surgery and also anatomy relevant to general surgery. Please do, um, put questions in the chat now, if you have um any remaining and we'll do our best to answer them. Um And on our sides, we've also just included some citations that you're welcome to refer back to the recording of this event on the slides will be uploaded to Medal. Um And next week, please do tune in for the final session which is going to be on trauma and orthopedics, which will be at the same time on Thursday. Um For those of you that are happy to fill in our feedback form, I'll just put this in the chat. Now, please do fill this in. Um It's really helpful for us to gain feedback on this um approach to teaching anatomy, the choose your own adventure style. Um All feedback is anonymous, but if you do not wish it to be used for our student research project, please refrain from contributing. Um And if you would like a certificate of attendance, this will be given upon completion of the feedback form. Uh just a reminder that, um, if you've currently attended five sessions, you only need to attend one more to get to six of the eight sessions and then you will get free R CS membership. Um, but that is all for this evening. So, um, I'm going to stop the recording shortly. But if you have questions, please do feel free to put them in the chat and we'll stick around for a couple more minutes. Have a good evening, everyone.