Tuesday, May 18, 2010

Post 12: Hernia

1. Wash Hands, Intro and consent.

2. Expose and general inspection, and ask; Where have u noticed the lump or swelling?

3. Inspection: Look carefully for scar both sides. Ask the patient to cough, look for visible cough impulse. Ask patient to lift head off bed to increase intraabdo pressure.

4. Palpate: Both sides. Let me know if it is sore. Look at the patient's face as well. Check size, and neck of the hernia. and for 3 Ts - Tenderness, temperature and tension - signs of strangulation. Ask the patient to cough, to feel for cough impulse.

also palpate for pubic tubercle, and ASIS.

palpate the bola.

5. Reduce: Can you push the lump back yourself normally? Can you do that now? If cant, ask permission, do u mind I have a try? Try patient supine if so far the examination is done standing.

Differentiating direct and indirect inguinal hernia. Reduce the hernia, and use two fingers to occlude the internal ring (which is midpoint ASIS-Pubic Tubercle) ask the patient to cough. If didnt come out, its indirect. If come out still, its direct.

6. Auscultate for bowel sound.

7. Shine light the scrotum as well.

8. Would like to have a complete GI exam to look for any cause of increase intraabdo pressure. which is hepatomegaly, splenomegaly, bladder distension, ascites, prostatism. and USS abdo. and CT abdo

Anatomy of inguinal hernia. - Mneumonic - MALT from wikipedia.

Start writing A first of the MALT. Coz A stands for anterior - so it is the anterior wall. and A = aponeurosis of..? if anterior must be damn superficial, and so its the EXTERNAL oblique. Thats how i remember.

So done A. Aponeurosis of External Oblique.

Now L? Ligament. Inguinal Ligament.

so left M and T. Thats the two hardest one but then i somehow remember that the first two MA is oblique muscles, so actually M according to wikipedia stands for Muscles - Internal Oblique and Transverus abdominis, but i choose to remember internal oblique only.

And the T is Transversalis fascia. I choose not to remember conjoint tendon adn all other shit.

So MALT - Muscle (Roof), Aponeurosis of external oblique (Anterior), Ligament Inguinal (Floor), Transversalis Fascia (Posterior). I dont have to remember the which is which for posterior or roof coz just naturally, A=anterior and Ligament has to be the floor. and the other two just sink in nicely. For me.

Now the other anatomical thing that i hate the most is the hasselbachs triangle. So medial to the internal ring, is where the inferior epigastric artery travels past.

and medial to my great body is my impressive six pack rectus abdominis.

And so the triangle of this hasselbachs, is inferior epigastric laterally, rectus sheath medial, and the inferior border would be the inguinal canal.

Hernia coming out from this circle would be due to weakness of the deepest muscle in this post, ie, the posterior wall, ie...the T...ie...Transversalis fascia.

If this helps...

And so, the other types of hernia; femoral. Easily incarcerated with high risk of strangulation. urgent repair.

Types of surgery; Open and put a mesh, Open and suture it closed, and laparoscopic.

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