Session 7 Abdo wall hernias and other bowel disorders

• Abdominal wall - layers

  • Skin
  • Superficial fascia - Camper’s fascia (fatty layer)
  • Superficial fascia - Scarpa’s fascia (membranous layer)
  • Muscles
  • External oblique
  • Internal oblique
  • Transversus abdominus
  • Transversalis fascia
  • Extraperitoneal fascia
  • Peritoneum
• Abdominal wall - muscles?

  • External oblique
  • Internal oblique
  • Transversus abdominis
  • Rectus abdominis & pyramidalis
• a tendinous sheath formed by a unique layering of the aponeuroses of the ext & int obliques and the transversus abdominis; encloses the upper part of the rectus abdominal muscle & also contains blood vessels and nerves. - rectus sheath
• Diastasis recti?

  • acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but with no fascia defect
  • due to thinning and widening of the linea alba and weakness of the associated abdominal musculature.
  • frequent in pregnancy and regresses spontaneously after childbirth.
• if possible, surgical incisions should in the direction of lines of cleavage (collagen fibers in the dermis run in parallel rows).

  an incision along a cleavage line will heal as a narrow scar & one that crosses the lines will heal as wide or heaped-up scars. - langer lines
• Midline incision - Almost bloodless, No muscle fibres divided, Nerves at lower risk of injury, Very quick to make, Good access to upper abdomen.

  • Disadvantage: Heals with a midline scar
• For open appendicectomy: Lanz incision is transverse and the Gridiron is oblique (follows ext. oblique).
• Label these scars

  A) Gridion

  B) lanz

  C) pfannestiel

  D) rutherford-morrison

  E) transverse

  F) midline

  G) paramedian

  H) pararectal

  I) kocher rooftop

  
• A hernia is an abnormal protrusion of the contents of a cavity through a weakness in the wall of that cavity, taking with it the accompanying serosal linings.
• Causes of hernia?

  • Weakness in the walls - aging
  • Weakness due to structures entering/leaving abdomen
  • Developmental failures
  • Trauma
  • Intra-abdominal pressure - ascites, pregnancy
  • Malnutrition or obesity
• Indirect vs direct inguinal hernias?

  • Direct hernia: acquired weakness in the abdominal wall, protrudes through Hesselbach's triangle.
  • Indirect hernia: congenital weakness in the inguinal canal, protrudes through the deep inguinal ring.
• Indirect inguinal hernia: more common in men than in women, occurs because some part, or all, of the embryonic processus vaginalis remains open or patent.
• Inguinal (Hasselbach’s) Triangle?

  • Latera l- inferior epigastric artery
  • Medial - rectus abdominis muscle
  • Inferior - inguinal ligament
• Para umbilical hernias?

  • occur through a defect in the abdominal wall adjacent to the umbilicus.
  • Weakening of the tissues around the umbilicus
  • Common in obesity and multiparous women
• type of incisional hernia that allows protrusion of abdominal contents through the abdominal wall defect created during ostomy formation. - para-stomal hernia
• Primary Constipation: disordered regulation of colonic and anorectal neuromuscular functions/ disordered brain-gut neuroenteric function.
• Secondary Constipation: results from another disease or medication
• Rome IV Criteria?

  2 or more of the following for more than one month:

  • fewer than 3 stools per week
  • history of excessive stool retention
  • history of painful or hard bowel movements
  • history of large-diameter stools
  • presence of a large faecal mass in the rectum.
• Causes of constipation due to medications?

  CONsTIBation

  • Calcium-channel blockers
  • Opiates
  • NSAIDs
  • Tricyclic Antidepressants
  • Iron supplements
  • Beta-blockers
  • Antihistamines
• Hirschsprung’s disease “Hereditary Aganglionic Megacolon” - Developmental failure of Auerbach and Meissner plexus
• Anti-Tissue Transglutaminase IgA If raised, indicates Coeliac disease.
• coeliac disease is characterized by

  • inflammatory small bowel enteropathy
  • gastrointestinal or systemic symptoms
  • presence of coeliac-specific antibodies
• Three types of coeliac disease?

  • Potential (no villous atrophy)
  • non-responsive
  • Refractory
• Genes HLA-DQ2, HLA-DQ8 - coeliac disease
• Dermatitis Herpetiformis - caused due to coeliac disease
• Investigations for Coeliac Disease

  • IgA tissue Transglutaminase IgA-tTG - must have been eating gluten for 6 weeks prior
  • FBC
  • Small Bowel Endoscopy
  • Small Bowel Biopsy - Gold Standard
  • Skin Biopsy if suspected Dermatitis Herpetiformis
• Excessive colonic bacteria colonising the small intestine - Small Intestinal Bacterial Overgrowth.
• Red Flag Symptoms - Gastrointestinal system

  • Unexplained Appetite Loss
  • Unexplained Weight Loss
  • Anal Mass or Ulceration
  • Anaemia
  • Abdominal or rectal Mass
  • Rectal Bleeding
  • Change in Bowel Habit