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Hello, everyone. Welcome to the second session off. Mind the bleeps. Surgical Siris. Your first session was on the acute abdomen and an injection, too. So agree as next one. And this is our second session, which will be on growing lumps. And so, as mentioned in the last session where four F twos who wish to give you a serious off 16 lectures on how to essentially be a search left one. So we want to keep these lectures quite clinical over and a half about with a lot of pathophysiology on did surgical procedures. But rather what do you guys will see when your surgical F one in house manage common surgical presentations? Yeah. So the general former off the presentation will be and going through the disease is and the etiology is the very briefly last mean paths that pathology on with different presentations. We'll go through how to Clark for the different surgical presentations you might see, Teo, please, your seniors, we'll go through the investigations. You should order as juniors and investigations. You might be asked order on how to sort of get them through and accepted, for example, by radiology and then the initial management the acute management you'll have to you'll be expected to perform, and then the more sort of surgical senior management. And then it was, I want to talk about about complications off thesis, little procedures, complications you might come across and be asked to initially saw out. And then we'll go through some cases. This is me. When I was Frayer, four doctors were in London and I haven't tested teaching and hence my run this course on the key learning points for our sessions. Specifically, this session is identifying different differential diagnoses off the different lumps you won't see in the groin. Keep us off the history and examination that you will be expected to identify and clock. But I'm saying the search constipations that required. And then we're going to practice some of these skills you learning during the cases, We'll see. So when we go through the cases, just keep in mind as the last lecture that you are the search worth one and ask you anything about him previously, and I'm trying to still go through and be clocking and what investigations you might want to order. Let's start out with some brief and asked me off the groin. So the groin is essentially this and triangular and a song called Space and right by your hip bones. It starts by the A cyst and terrace period. I'll expire. Many kids inferior to the thigh on the medial to the pubic tubercle, so the groin contains quite a few important structures that are involved. A lot of the pathology is that you'll see and involved in wine or ligaments that runs from the ASIS to the pubic. Tubercle involves the inguinal canal on. This is sort of a tube like shape on which runs parallel, inferior to the and the inguinal ligament. Then you have the external iliac on D, which becomes the femoral artery, which, which ones under the ligament. The service major is a muscle that runs from the veterans, and attach is to the last to counter of the femur. That was a runs under the year in quite a ligament, and then you have a bunch of lymph nodes around the area as well that could result in lymphadenopathy, so embryology I'm always used to be a burden off my hand medical school life, but we won't go through too much embryology. But we will just briefly touching it because it's quite important to understand. And some of the pathology is off the growing. And so during development. About week 12, the go nuts reside in the tea and around the L2 region, off the numbers fine on they descend down to in meant to this great and on day. In order to do that, a part of the peritoneum creates an outpouching called the generic of the processes vaginalis this patch and goes through the abdominal wall. And for when the processes vaginalis protrudes through the abdominal wall, what creates a weakness? Usually, this this'll weakness disappears throughout development, but sometimes it can possessed. On. That is the source of quite a lot of issues that will see in a minute, so the procedure increase to rings, so the when it through through the innermost layer. But the trans dollars Fashir. It creates the internal ring on when it chews through the outermost layer, which is the external oblique. After neurosis, it creates the external brings. We still have to openings off the abdominal wall. So when going through your surgical clocking on, especially in terms of lumps and bumps. You want to ask about the onset off the lump? So is it Did it come on suddenly develops that suddenly? Or has it been there for a while and then gotten bigger? How long has it been that very important document? Whether that had it before, whether it's ah days. Well, us then and you want to ask about pain, so it's a painless lump or a painful. Then you go through a usual sokrati. Is history taking when you go through pain, so is the pain sudden? Is it severe? Come right out of 10. Does it radiate anywhere? So the radio up to the abdomen, down to the thigh or in two discretion. Do they have other associated systemic features? For example, fever, nausea, vomiting, right gorse have any rashes? And this is very important, particularly and asking about rashes in the genital area as well, and then ask about long term symptoms of the nose, any weight loss, you know, Sunday night sweats or long term low grade fevers with any surgical procedure, especially general surgery, and you want to ask what they opened their bowels have been constipated. No one talked about urinary symptoms so any sort of urinary pathology. So whether it's UTI on a renal, stones can often be non specific on it can radiate into the chlorine a swell that pain. So ask whether they've had any luck symptoms. So any problems and passing urine and it dysuria And he he material anyone else about that past medical history. Always really important document, whether they've had previous surgery when it comes to the groin, always document whether the whether appendix is intact where they hadn't pen, dissect me in the past, Ask about any history off catheterization and buy a catherization. I mean, whether had a a vascular catheterization. So have they had a recent angiogram, for example, where they've had a catheter into the family on artery or family vascular system? Then you want to ask about sexual history. So are they. Do they have sex with men or women? Do they have protected sex? Have they had any histories of ST I see and then ask about immune suppression? Do they have an active counselor or are they taking the suppression for any other reason? And that is very important. In terms of, for example, we lived in a pretty and infections. So if your examination, if the patient's acutely unwell and you want to always go through your 80 if you're worried about how to examine the patient or house document, your examination just always go through 80. It's very full proof. When it comes to groin lumps, you always want to examine the patient standing up, and this way you get a better view, and you can also get to them to cough and examine the cough reflex. This is important and hernias because the increased in trapped Oh no rational push the hernia out on you and then you can assess whether it's a reduce. It'll come then you want to, um, very carefully examine where exactly this lump is. So where is it in relation to the pubic? Typical on the ASIS on being wine? Elliptical doesn't be quite difficult to palpate, especially and overweight patients. And but the best way to do is to try and palpate the femoral artery on day superior to the femoral artery, you should feel the inguinal ligament. So where is the lump in relation to the inguinal ligament, and can you feel the inguinal canal as well? Then you want to assess the size, shape, consistency, borders and, as mentioned, your reducibility off the lump, and especially whether you can feel the the upper border off the lump. So in hernias, because the upper board will be intraabdominal, you will not be able to feel the upper border. Where is in, for example, a lymph node. She'll be able to feel an egg shaped and either tender or robbery round lump. Anyone ask the patient to cost? This could be either standing up lying down to see whether the lump patoot. You can also feel the lump while the patient is coughing to feel whether it's it's a choose out well and always remember to examine the genitalia. So any scrotal pathology and including infections and portion can radiates up to the abdomen as well. You also want to look for rashes and discharge anything that could indicate that the patient has an infection off their genitalia. Did you want some of the lymph nodes so the lymph nodes may not be palpable in the inguinal region, but you want to examine the lymph nodes and both sides on be a next NSAID lymph node? Examination of the other areas as well. Terms INVESTIGATION. You want to go through the usual bedside investigations, so I always do urine dipstick for any growing pathology, full infection and or hematuria in women of childbearing age. Do a pregnancy test always, always, always on. Then. Obviously, during this day in age wants your cave in 19 swab specifically to prepare them for theater. That will be necessary. But was it because it's a high risk? And two other patients in the world if there are acutely, um, well, you can do a quick Phoebe G to assess her electrolytes, their hemoglobin, the lactate that whether acidotic I like that it's very useful in abdominal pathology specifically when it comes to hernias. If you're worried about having you being strangulated, well, come on toe and what that means in a couple of slides. But elected will help guide that diagnosis. They won't do your routine bloods, full blood count used any allergies and CRP that's funny. And in function market, you want to send off urine cultures and blood coaches for you. If you're worried about infection, if they have any groin pain, urine culture is probably useful. And whether you're suspecting your infection a lot, then you want to do operative blood in surgery, so I always make sure they have a valid group and safe and a lot of trust. This requires two groups and saves within, you know, 48 or 72 hours to make sure that's on the system and do a crossing is well, if you notice any rashes or you're worried about ST I see do skin swabs or test for ST I specifically as well. So in terms of imaging, if you're but I'm sure what's going on. But the patient is constipated. There, in severe pain, they might have had an abdominal X ray, which shows that distended, well, loops of bowel. You want to do a CT, abdomen and pelvis to assess for about obstruction. If you have a good history of ballast reaction, normal rejects your and CT abdomen. Pelvis Request. If the lump is tender, eyes in the head meal orifice it or fizzies, you sort of know 100% sure what the etiology of the lump is. You can request an ultrasound to assess whether it's or vascular origin, whether it's a hernia and that's full and nonacute presentations right, Let's go through some cases. So you're the surgical F one on take on. You are asked to see a 62 year old male with a painful groin lump. This lump is lasted one day. It was sudden onset of pain, and it's in the right side and when you palpate, you help. Eighth a painful, not painless, intermittent right sided mass. And prior to this, he's had a mask for about two months on. It's been painless up until now, but suddenly it became very painful. His bell's have no opened. I'm he's not cancellation the last day he has a past medical history of COPD. Andi had an appendectomy when he was a young Really, This is a photo of the lump you conceive. So you're affirmative is quite large. Then on examination, he is hemodynamically stable, but he does have a low grade fever. His abdomen elsewhere is soft. When you feel you can feel an irreducible painful area them a tous elongated mass which is superior to the final ligament. You make him cough, but you can't feel it. Cough impulse. You check his scrotum. There are no masses on on P. R. Has an empty rectum. Do you send off some bloods? You find that his inflammatory markers are raised on because you're worried about this patient not having opened his bowels and then being and quite a lot of pain you are from Don't know X ray. Initially on the season dilated bell loops. So your initial management while she waiting for someone to answer your escalation requests. It's to stabilize the patient so you want to manage his pain because it isn't quite a little pain. And so prescribing this pain relieved. Start with your usual paracetamol and you might want to prescribe some anti emetics if it's feeling nauseous, a swell prescribing some fluids and then you want to make sure what you were places, electrolytes. Patients with constipation may have electrolyte derangements anyone address requests and urgency to get abdomen pelvis on. Urgently referred to your surgical seniors as this patient is likely obstructed. You want to start some prophylactic antibiotics you to his race and plenty markets, and it's are usually guided by either your trust guidelines or by senior preference, so make sure you check your crest guidelines before asking. Your seniors just have that little extra edge and and ask them whether they would like specific antibiotics. So this presentation is a common presentation off a strangulated inguinal hernia. Hernias are often incentive findings that found on elective operations or and on scamps and two types of families. Open ears are found in the growing regions you have. Your femoral hernia is which are more inferior than the inguinal hernias. These are more commonly seen in females because of they're wider held pelvic structure, and they also have a higher risk of strangulation, just that more narrow family canal. So if you find Dagnall, Hanya and these from people undergo a speedy operation and inguinal hernia inguinal hernias ah, found in the either they could be the indirect or direct in the inguinal Canal. And if they are strangulated, they're usually indirect because indirect hangers for true through both the internal on the external ring, which means they have two points where they can be strangulated. Well, honey is are more common and men on family hangers as mentioned on low common in women, remember to always examine the scrotum. This is because inguinal hernias well's going through the Guadalcanal. They follow the spermatic cord and they can actually produce the way down to these questions. If you examine a patient with the scrotal lump, make sure you try and palpate for the upper border and see whether you can you can feel it and whether it's actually confined TV testicle, this gross, um, or whether it protrudes all the way up through the Inguinal Canal. So we have several levels of herniation you have reduced will hire years. When you examine the hernias mentioned, always try and reduces it. Push the hernia room, follow the the course of a hernia and see whether you can push it in. If the patient is in pain, irreducible hangers can be either obstructed, which means that the Lumen off the intestine is obstructed. But the blood supply is still intact to the intestine is no, no cruised. Then you have uncastrated Haniya's where additions have developed and and these are high risk of strangulation, which is when the blood supply is compromised. Any reduce will hang A requires urgent management, so the surgical management offhand yours is zero and your repair, and usually they are open mass repairs. But if they're recurrent hernias, you want to a lapse copy. Repair them a swell. The honey's can often patoot through the mash and become recurrent, especially if there's increased intraabdominal pressure. For example, do two obesity, or COPD, which requires a lot of coughing from patients. Right, so we're not gonna go into detail of the operation, but just to mention some of the complications that happened during intraabdominal surgery in general. But you might also see particularly in handle hernia surgeries, So the interruptive competent complications include bladder injury, bowel injury, a vascular injury. So just make sure you remember you're on. Ask me is very simple. The blood is quite close to the the intestine, very rare for the patient. Experience any bad injury, But make sure you montedio urine output and make sure they don't have any hematuria or dysuria bowel injury. Eso Mitchell The patient is opening. Their 1000 is not in excessive pain after the surgery and then vascular injury. If you're worried about any basket injury, just check your routine blood. Is their hemoglobin stable? Are they hemodynamically stable? You can do a peripheral vascular assessment, Major. Do you feel the peripheral pulses? Postoperatively. Um, it's quite common to find postoperative complications after general surgery patient might have a hematoma, which you may be able to palpate to even see again. You want to check the hemoglobin, check the hemodynamically stable. Gonna check the hematoma. Doesn't compromise any of the vascular supply to the legs. Assess for your new retention. So this is independent of anybody. Injury. But patients can, quite commonly, after being catheterized after being on general anesthetic or just having a lot of insult to their abdomen experience. Um, your attention. So make sure you examine their output measure that are out cuts on, if in doubt, to do about a scam. And cast dries if you think that's necessary. And in a bladder scan, Um, it's quite difficult to know when to cast Dries or not, I would say, if the patients in discomfort and has sort of around 500 cast Millie's in their bladder is probably best to catheterize the patient on Let the seniors make a decision as to whether I went Oh, trial without the catheter wound. Infections quite common. So make sure you assess the wound. Is that complaining off pain accessibly or whether they're showing signs of infection and then the recurrence of hernia is also quite common involved in you. So it's going to the next case. You are asked to see a 56 year old male with a painless grow growing a lump. This gentleman was admitted with fresh PR bleeding. Initially, he's now complaining of a solitary firm, rubbery and nontender egg shapes. Left sided growing lump. It measures about 4.2 centimeters supporting to the patients, and he's also experienced some weight loss About 6 kg in the last month on D is experiencing some Bell symptoms, including tenesmus, diarrhea and, of course, PR bleeding. He doesn't have any background. History has been fitting well previously under assessment Patient Hemodynamically stable. He is, however, but cocks it. He can kind of see the weight loss, and it's thanks, um, and in terms of further examinations and you want to do for this patient. So when you examine this lump and it's it's rubbery and painless, you want to immediately think off lymphadenopathy. So it's very important to examine the rest of the little nose, especially on the other side. On dust, do a full note examination. This patient was also complaining of PR bleeding, so you want to do a PR examination to assess full on any current bleeding and because he has a left node in the groin. You also want to assess the scrotum, and you want to assess the Perineal area on D. See if you can identify any source of infection or malignancy. Do you do some routine bloods for him? His hemoglobin? A cent. Five. This is after one you know, red blood cells. So he's had quite a lot of blood loss. It might be an ongoing, and any mirrors? Well, his exam tree markets are normal, so this sort of makes you think that potentially feel of doxy is not infection. The other thing to mention is that a non tender lymph node is rarely less commonly infection on, but it does make your own suspicions point towards malignancy rather than inflammatory cause. So you do some further investigations because it's quite anemic. You want to send off iron studies. His surgical patients always send off your clotting in the group and safe send off a blood film because of the anemia on. Then, because of the left knee up, see, you probably want to send off some steam markets he has his PR beating, which hasn't been assessed by senior yet, and you probably want to examine him a little bit further. So whether you want to do a fact is a colonoscopy when an erect oscopy is probably, ah, senior preference. But you want to see whether what the PR beating is coming from. Now you do a flex sig with the help of your senior, and unfortunately, you identify um, a anal malignancy and anal mass, which is profusely bleeding. So when you identify a colorectal malignancy, you always on order a staging CT chest, abdomen, pelvis. It's well, as mentioned, any robbery. Nontender solitary lymph node is always suspicious off malignancy Taste. Three. You also see a patient, 72 year old female with a tender growing. She was initially admitted with chest pain. She went on to have a corner Androgel um, through her femoral artery yesterday. Since then, she's had a one day history of a mildly tender, erythematous soft lump in the right side of her groin. You examine her on, but she is humor dynamically stable. She's slightly fibro. You notice the right sided pulse Thomas about 5 to 6 centimeters below the wine a ligament. The superficial skin is intact and you don't notice any excessive, earthy, memorable, and it discharged from this lump. You do your bed, I tax your analysis shows no abnormal findings your routine bloods are normal on. Do you then request an ultrasound Doppler, which shows a femoral artery. It's pseudo aneurysm. The reason why we choosed and all sound doctor in this case is because the lump is, pulse tells. This is quite uncommon to find a pulse. Thailand in the groin with any post high lump, you want to immediately think of a vascular cause. This patient has very recently had an insult to her family artery through the cardiac on drug, and so you immediately have to think that this might be ephemeral student aneurysm. So ephemeral pseudoaneurysms are usually I action IQ, and they come from catheterize a shin. The usually they can also be created through IV. Drug usage is quite common. Drug users may use the family artery when they're antecubital arteries or their arm. Arteries are or veins are, ah, defects on. They use the family vein and published in the femoral artery, which creates and families to down reason trauma. Whether his blunt trauma to the groin after, for example, right traffic accidents can cause the family sued artery. It's a studio on your eczema's well, when you find a vascular cause of a lump is really important to examine the lower limb, and you want to clearly document this is well and especially before any further intervention. So make sure you do have full that vessel examination examined the popliteal artery and the prayerful, and so our trees as well. I'm doing urological examination as well. You want to send off your routine bloods. Do a clotting on a group and safe, especially when it's the hemoglobin Go son Family Pseudoaneurysms is a duplex ultrasound, and if you have a pulse Thomas, it's definitely warranted to us. For foreign ultrasound Pseudoaneurysm Conga Infected This's is a surgical emergency and affected aneurysm of the artery can lead to a clot formation, and they can honestly lead thio and spread of infections systemically so this requires urgent or just sound. Otherwise, pseudoaneurysms can be managed with the watching wait approach, so if they're small around two centimeter less on that asymptomatic, you might do regular ultrasounds as an outpatient and observe on the patient may find that these two done is, um, actually resolves by itself if the aneurysm is large or symptomatic, or in fact is, as you can see in the photo A that often have a pump home with a disc with discharge now even bleeding, you want to do an urgent ultrasound, got guided and compassion and or thrombin injection to manage this pseudoaneurysm. If it's really large, you might also surgically manage it. This will be a referral to the basket of sergeants. So case full you are. See a 33 year old gentleman who's febrile and has a tender growing lump. He is admitted with fever over the fever and right lower quadrant pain for about 10 days. Yeah, his pain restricts. His movement, including walking has been limping for the last 10 days, is also noticed 5 kg of weight loss in the last two weeks until night sweats. In addition, he has no history of any true murmur any surgery or IV drug use. The only background he has is type one diabetes medicines, which is fairly poorly controlled in this this man do you examine him? He is hemodynamically stable fairly well, but is febrile that 8.1. Examine the right groin lump. You find that it's below the inguinal ligament. After careful examination, you also see that his hip is passively flexed for comfort, and when you try to extend it, he's in a lot of pain. So you want to now do a further, quite detailed examination off the hip joint. And this is because this patient is presenting with sort of fixed flexion and fairly painful dammit! Tree a lump of the groin so you want to do if you're full hip examination off buried sites, you always want to do a lumber spine and the examinations always examine the joint below in the buff, and then you want to do a lower limb. New Russell examination to make sure you document needs very clearly so your examination. You find that he has limited range of motion of the right hip, and he has a particular pain on hip extension hands where it's keeping it flexed. You order some better test, says your analysis comes back as normal. His bloods, his white cell count, is very raised. A 23 as is, is CRP as at 312 is using. These are normal on his bloods and urine cultures are pending on because you don't come back until about three days. You order a chest X ray, which shows no abnormal features, and it was ordered a hip X ray because this patient might have a fractured hip. But this is also completely normal. So, so far with found this patient with a tender right groin lump, he has ongoing fever, night sweats, weight loss, reduced range of motion on be raising bantry markers. Specifically, white cells are 23 which is very high. There's obviously an infection going on, and you want to start. Some empiric want to politics while, but we're waiting cultures. He's quite unwell with his with his infection to you want to start some broad spectrum antibiotics often has, and it's used, and this is a pyrexia of unknown source. But it is very likely to be somewhere in the hip, and this baffled worms a CT, abdomen and pelvis, so you get your CT abdomen pelvis on. Do you find that this patient has a large serous abscess, so it's abscesses are quite rare. They usually seen in a musical provide patients, patients with diabetes, CKD and all patients with Koreans disease or any intraabdominal inflammatory process going on. Um, the reason why is what it sells is the highest, because when you have a confined abscess, a confined space with with past forming the while it sells can usually go up very high. So whenever you see a really high white cell, think off potentially abscess formation and or lymphatic malignancies. So so Those abscesses are emergencies they can cause quite unwell patients, and they require drainage, since is either percutaneously or open drainage but also be treated with quite intense antibiotics. He want to target these antibiotics, too. The coaches that come back and you also want to coach there abscess fluid. So in literature is says, absence is described as a triad off fever, flank pain and lenders range off motion of the hip, so this is unfortunately rarely seen, as with most of the descriptions and let's sugar. But they will often have a flicks fixed flexion off the hip because of the pain of extension to the service. Muscle is one of your main hip extended in there for, and the the extensions of sort of the hip flexes never extension will be quite painful for the patient. Um, as mentioned it seem immunocompromised patients, patients, diabetes, CKD, HIV and any previous surgery, and you want to treat them with the entyvio six on drainage. So, just to mention description, it's very important to to examine the genitalia in any groin, lump or growing pain. Because and many of the testicular checks ology such a hydrocele back seals tumors on a particular torsion comports radiation of pain up to the groin. The other reason is that inguinal hernias mentioned camp itude down to the's gruesome on. Therefore, if the patient has a painful, obstructed hanya, but you can't really feel a growing lump, you want to examine these crazy, Um, well, be very wary of statement or shin, and it causes necrosis off the testicle, and it's really important and imposed Davis not to mess. So a bread flags went to be worried and went to escalates. The patient has a very painful swelling on. They also look septic or and very, very poorly. You always want to, and you want to ask like that and irreducible painful swelling that you think it's probably of Haniel origin. It is a surgical emergency and need to be asked last immediately. And he pulls tell swelling, and that will indicate a vascular source of the lumps that needs to be escalated to the bathroom. Surgeons on any recent interventions where that's recent operation or catherization or any other insults to the groin area is a red flag. So keep points for growing lumps. A. Our examination documentation off. This is key. So remember to properly describe the lump whether you can feel the upper border, whether it's reducible, whether it's painful or not on the consistency of it. Is it soft? Is it robbery Onda on Also, remember to examine the lymphadenopathy the lymph nodes widespread on D. Check your your your analysis on exam in this great on this Byetta. If you think that causes vascular, always do peripheral vascular examination. Examined the joint and full. If you think the has any mythology to the surrounding joint areas and and examine the joint above and below, don't forget other nonsurgical causes. Even though you're a surgical, a fun, you'll get a lot of rough hours that aren't surgical, and it would be very helpful to properly different shape between surgery. Course is not just because you're seeing it will be happy that they can. They have one less patient on their patient list border because it targets appropriate management for the patient and some of the other causes. Such a service abscess we lived in Oxy really need to be. Don't really investigators remember your postop complications and examining a patient POSTOP. Explain quite different from pre op. If you're unsure what what what's going on. Just do your full 80. Ask them if they've opened the bowels. Check whether their septic have any and abnormalities of their blood's other electrolytes. Okay, can you manage them with fluids on pain relief initially and then whether they have appropriate antibiotics prescribed, they haven't infectious process going on. Okay, that completes the lecture Ongoing Loves. So our next lecture in a week's time will be on appendicitis. We has mentioned will run 16 Total Free Search Webinars as part off mind oblique, and we hope that this is useful. We try to keep it very clinical and try to keep aimed at F ones and House of Manage things. Initially on the ward money by yourself, and it is very daunting to start out, especially in surgery. And as we didn't learn, I think we learned too much about how to manage surgery complications and surgical presentations. Ask as F ones on our own on the ward. We would be very grateful for your feedback so you can follow this. QR codes. Here. You'll get a certificate for participation when you fill up the feedback for and with the visit. Mind the bleeps websites for the webinar recording to get recording off this this and lecture on. We also provide Britain content off the lectures as well. If you don't want to ask me questions now, please don't have state. Oh, send us an email on webinars at mind. The beep dot com will be very happy to answer any questions you have, whether that's about the specific lectures or whether it's about a career in surgery or life as an F one, I hope you'll enjoy this last shot we will keep and this up on the screen for a little while longer.