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Anatomy 4.7 Nov 22, 2011

Anatomy 4.7

 

Nov 22, 2011

Surgical Correlation-Abdomen

Dr. Zorba Bnn Bautista

 
 

OUTLINE

 

MOST COMMON COMPLAINT IN THE ABDOMINAL AREA

I. Abdomen II. Case 1 III. Case 2

Pain o PPoint of maximal pain.

IV. Meckel’s Diverticulum

V. Case 3 VI. Case 4

o QQuality (stabbing, burning, squeezing) o RRadiation( steady in one area? Or a shooting pain in other

 

parts of the body?)

   

o S Severity (starts the way it is now, starts with less pain,

a temple of surprises because a patient can come to you with many complaints and could cause tons of sickness

slowly increasing) o T Timing (occur spontaneously, after eating, etc)

4 Quadrants of the Abdomen

Anatomy 4.7 Nov 22, 2011 Surgical Correlation-Abdomen OUTLINE MOST COMMON COMPLAINT IN THE ABDOMINAL AREA I.

Figure 1. Specific organs found at the 4 quadrants of the abdomen

o Most common manner of describing abdominal areas clinically

o Areas point to specific organs or organ systems, aiding in narrowing down the diagnosis or working impression o Ex. Right lower quadrant pain Young individual- appendicitis Ureters- symptom/ stone in ureters

Right ovaries

9 Regions of the Abdomen o Less commonly used o Frequent among Surgeons/ Ob-Gyn’s o Further narrows down involved organ systems o Ex. Sinisikmura ako, Doc- epigastric area; Masakit puson ko- neither the left or right lower quadrant but in the hypogastric area

ESSENTIALS OF CLINICAL DIAGNOSIS

Understanding the main complaint Complete history of the condition o Onset → Course → Aggravating Factors o Past History/ Other medical conditions o Family history o Menstrual history (Important in Women) Physical Examination APPLICATION OF KNOWLEDGE OF ANATOMY & PHYSIOLOGY

Fullness/ Enlargement

F

T

Feces

Tae

Flatus

‘Tot

Fetus

Tao

Fatal Masses

Tumor

Masses

o Size

o Location

Blood supply o Upper viscera (stomach, liver, pancreas, spleen): Celiac Trunk o Small and large intestines: Superior Mesenteric Artery o More distal portion of large intestine: Inferior Mesenteric Artery The lymphatics follow the course of the arteries.

o Consistency (hard, soft, w/ or w/o fluid)

  • Stony hard like your knuckle: stone, malignant tumor

  • firm benign tumor

o Tenderness signs of infection or abscess formation

Ballotment is it movable? if you palpate the abdomen, and bounces back to your fingers- its movable- meaning its attach or

it

not fixed to anything underneath.

II. CASE # 1
II. CASE # 1

PATIENT HISTORY

MT/ 16y/o F

CC: Abdominal Pain

HPI:

o 12 Hrs PTA

 

Epigastric Pain

No Vomiting/ Fever

o 8 Hrs PTA

 

Localized to RLQ area

Past Med Hx & Family Hx unremarkable

Menstrual Hx:

o Presently menstruating (1 st day) o Menarche: 12y/o o Regular menses o Denies any Hx of sexual contact

Group 3| Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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PERTINENT PE FINDINGS

BP= 100/80 (normal); CR=110bpm (increased); afebrile Pale palpebral conjunctivae Abdomen: Flat, soft but with voluntary guarding o (+) direct & rebound tenderness over ALL quadrants o tenderness: when direct pressure is applied, there is pain o rebound: when the pressure is released, the internal organs will return to their original position o rebound tenderness indicates peritoneal irritation (+) R pararectal tenderness o when a finger is inserted inside the rectum, and tenderness is felt inside Pulses thready o pulses that can be compressed; a scarcely perceptible and commonly rapid pulse that feels like a

fine mobile thread under a palpating finger

IMPRESSIONS

Acute Appendicitis

acute inflammation of the appendix usually caused by hyperplasia of lymphatic follicles (in young people) that occlude the lumen or obstruction resulting from a fecalith (in older people), a concretion that forms around a center of fecal matter. (Moore) probably ruptured because there is tenderness in all quadrants if is not ruptured, then there should only be pain in the right upper quadrant

PLAN

Exploratory Laparotomy

Midline incision: less infection and less probability of the wound to open

Appendectomy

surgical removal of the appendix through a transverse incision along the McBurney point. (site of maximal pain and tenderness indicates actual location)

Laparoscopic appendectomy o standard procedure to remove appendix. o Peritoneal cavity is first inflated with carbon dioxide to distend abdominal wall laparoscope is passed through small incision in the anterolateral abdominal wall 2 small incisions required for surgical instrument to pass through to access the appendix and related vessels Other possible incisions:

Rocky Davis (vertical incision) -can hide scar under the strap of panties

McBurney’s Incision o McBurney’s Point -line drawn from the ASIS to the umbilicus. -serve as a guide as to where you will make an incision.

CLASSICAL APPENDECTOMY INCISION

Appendectomy Procedure Find the taenia. Then, follow the taenia proximally, this will lead

you to the appendix. Appendix is completely covered with longitudinal muscle where the 3 taenia converge, normally less than a centimeter in thickness, same color with small bowel

Mesoappendix: mesentery of the appendix, The short mesentery of the appendix lying behind the terminal ileum, blood vessel are present

Structures you will pass as you make an incision: (1) skin, (2) subcutaneous: Camper’s fascia (Fatty layer), Scarpa’s fascia

(membranous layer), (3) external oblique aponeurosis (inferomedial) (4) internal oblique, (5) preperitoneal fat (sometimes present, sometimes not), (6) peritoneum Incision should be done along the orientation of the muscle fibers so as not to weaken the muscle. PERITONEUM: needs to be sutured so small and large intestines will not adhere to the muscles above it. INTERNAL OBLIQUE: do not suture because you will strangulate the muscle and it will hurt as the patient moves post-op; the muscle fibers will co-uptake by themselves EXTERNAL OBLIQUE: completely suture, should be tightened just enough for the muscle fibers to co-uptake SUBCUTANEOUS TISSUE: it depends whether the patient has many fats or not, nevertheless, *Dr. Zorba sutures all patients, whether fat or thin usually in the Scarpa’s. (HAHA! Infrnez, kuhang kuha!) DO NOT go to the root of the appendicial artery because the ileocolic valve might be injured.

PERTINENT PE FINDINGS  BP= 100/80 (normal ); CR=110bpm (increased ); afebrile  Pale palpebral conjunctivae

Figure 2. Appendectomy Procedure

PERTINENT PE FINDINGS  BP= 100/80 (normal ); CR=110bpm (increased ); afebrile  Pale palpebral conjunctivae

Figure 3. Port Placement for Laparoscopy Apparatus

*no need to cut a muscle layer, you just simply go through them (only split open the layers)

*bipolar coagulated instrument- closes blood vessels; creates heat and electric current that could injure the ileocolic. Note: Appendicial arteries carry a lot of pressure

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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FINDINGS

RUPTURED ECTOPIC PREGNANCY 1.5 Liters of Blood and blood clots Slightly inflamed appendix R fallopian tube w/ rupture at midpoint; (+) areas of necrosis and persistent bleeding

PROCEDURE DONE

Exploratory Laparotomy Evacuation of hemoperitoneum R Salphingo-oophorectomy Appendectomy

III. CASE # 2
III. CASE # 2

PATIENT HISTORY

G.S. 23M from Pasig City CC: Abdominal Pain

History of the Present Illness o 6 days PTA

Abdominal pain

Self-Med: Novaluzid

o 4 days PTA

Persistent Vomiting

Cx: UTI

Rx: Co-Trimoxazole

o 2 days PTA

Vomiting

Abdominal Distension

Admitted

Dx: Ileus

o AM PTA

Transferred to PCGH

ADMITTED

ROS : Unremarkable FAMILY HISTORY: Unremarkable PAST MEDICAL HISTORY: Unremarkable

PERTINENT PE FINDINGS

BP: 110/70 (normal) CR:112 (increased) RR: 24 (increased due to the distended stomach; the patient’s breathing is shallow, short and thus he needs to increase the frequency)

T: 38.2°C (febrile) Pinkish Conjunctivae, Anicteric Sclerae Clear and equal breath sounds Tachycardic; distinct heart sounds Abd: Distended; Absent BS; Firm but w/o guarding; (+) Direct and Rebound tenderness all quadrants No deformities, full and equal pulses Admitting Impression Acute Abdomen prob.2° to Acute Appendicitis, probably ruptured (neglected?)

PLAN

Exploratory Laparotomy Possible Appendectomy

FINDINGS

≈ 400ml sero- sanguinous peritoneal fluid; non-foul (not contaminated with intestinal bacteria)

Dilated bowel loops w/ areas of gangrene Constricting band noted at distal ileum adherent to posterior wall 3.5cm long Meckel’s Diverticulum w/ 1.5cm base noted 50cm proximal to ileo-cecal valve Firm congested appendix with fecalith near base 2 landmaks in measuring lesions In the small intestines: (1) ileocecal valve, (2) ligament of Trietz

OPERATION PERFORMED

Exploratory laparotomy;

Segmental ileal resectioning with EEA Appendectomy

IV. MECKEL’S DIVERTICULUM/ILEAL DIVERTICULUM

a remnant of the proximal part of the embryonic omphaloenteric duct (yolk stalk), the diverticulum usually appears as a finger-like pouch (Moore) An inflamed ileal diverticulum may produce pain similar to that produced by appendicitis (Moore) True diverticulum has all three layers of bowel: muscularis, mucosa, submucosa; outpouchings of the mucosa through a weakness in the muscularis False diverticulum outpouchings in the mucosa thru the weaknessof the muscularis; has only two layers: mucosa and serosa

EPIDEMIOLOGY

Most common congenital GI anomaly 2% of general Population 3:2 male to female ratio True diverticulum Within 100cm of ICV 60% contain heterotopic mucosa

60% Gastric mucosa

CLINICALLY PRESENTATION

Usualy asymptomatic 4% complication rate More than half are < 10 years old Common Presentations Bleeding (>50%) - pediatric Intestinal obstruction - adult Diverticulitis (≈ 20%)

PATHOPHYSIOLOGY

Results from failure of complete obliteration of Omphalo- mesenteric (Vitelline) duct May or may not have a fibrous band to the umbilicus(Vitelline duct) or to the root of the mesentery (L Vitelline Artery) Bleeeding o Heterotopic Gastric Mucosa o Ulceration of adjacent ileal mucosa Intestinal Obstruction:

o Volvulus of the intestine around a fibrous band to the umbilicus o Entrapment by mesodiverticular band o Intussusception

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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o Stricture formation of a chronic diverticulitis Diverticulitis:

o Obstruction of a narrow-based Meckel’s diverticulum o Diagnosis:

o Largely clinical Imaging:

o Enteroclysis (75% yield) o CT scan very low yield o Radionuclide scans detect ectopic gastric mucosa o Angiography may show extravasation into small intestine

TREATMENT

Surgical Segmental ileal resection Wedge resection/ Diverticulectomy Incidental resection controversial Pro’s – presence of bands narrow base

V. CASE # 3
V. CASE # 3

PATIENT HISTORY

NS; 43y/o F

CC: RUQ pain HPI: Intermittent crampy RUQ pain occurring within an hour after meals. Waxes and wanes within a 2 hour period then resolves. Symptoms started 2wks ago.

PERTINENT PE FINDINGS

Abdomen: flabby, NABS, soft (+) direct ROQ tenderness No Murphy’s Sign

Murphy’s Sign -performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to breathe in. Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive.

Abdominal Ultrasound: Distended GB; Non-thickened wall; Multiple High-level echoes w/ posterior acoustic shadows (seen as the soundwaves during an ultrasound comes in contact with hard, solid structures, as in gall stones or cholelithiasis, and kidney stones; if the soundwaves comes in contact with soft tissues only, what is seen in the ultrasound are static projections)

IMPRESSION AND PLAN

Impression: Chronic Calculous Cholecystitis (Inflammation of the gallbladder) Plan: Cholecystectomy - removal of the gallbladder (right hepatic artery must be located 1 st before ligation of the cystic artery)

o Stricture formation of a chronic diverticulitis  Diverticulitis: o Obstruction of a narrow- based Meckel’scostal margin on the right side at the mid - clavicular line (the approximate location of the gallbladder) . The patient is then instructed to breathe in. Normally, during inspiration, the abdominal contents are pushed downward as th e diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive.  Abdominal Ultrasound: Distended GB; Non-thickened wall; Multiple High-level echoes w/ posterior acoustic shadows (seen as the soundwaves during an ultrasound comes in contact with hard, solid structures, as in gall stones or cholelithiasis, and kidney stones; if the soundwaves comes in contact with soft tissues only, what is seen in the ultrasound are static projections) IMPRESSION AND PLAN  Impression: Chronic Calculous Cholecystitis ( Inflammation of the gallbladder)  Plan: Cholecystectomy - removal of the gallbladder (right hepatic artery must be located 1 before ligation of the cystic artery) Figure 4. Laparoscopic and Open Cholecystectomies Figure 5. Types of Incisions: (1.)classical cholecystectomy), (2) laparoscopic cholecystectomy, (3) single incision laparoscopic surgery VI. CASE # 4 PATIENT HISTORY  EA, 38M, Pasig City  CHIEF COMPLAINT: HEMATOCHEZIA (fresh blood in the stool)  HISTORY OF THE PRESENT ILLNESS: 1 DAY PTA o Bloody stools (2 episodes)  Day of admission o 1 episode o Hematochezia o Sudden weakness  ADMITTED  On Admission:  o BP: 70/50 (increased) o CR: 120’s ( increased) o RR: 20 o Afebrile o Abd: non surgical, no masses o Double line o NGT, FC o Blood works o Hgb: 86 ( decreased) o Hct: .25 (decreased) o Had an episode of hematocheia (fresh blood in stool) on admission o VS the same o Transfusion of 3 units PRBC o 5 liters of crystalloids in 24h o Kept on NPO w antacids  2 HD o No hematochezia Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo Page 4 of 5 " id="pdf-obj-3-108" src="pdf-obj-3-108.jpg">

Figure 4. Laparoscopic and Open Cholecystectomies

o Stricture formation of a chronic diverticulitis  Diverticulitis: o Obstruction of a narrow- based Meckel’scostal margin on the right side at the mid - clavicular line (the approximate location of the gallbladder) . The patient is then instructed to breathe in. Normally, during inspiration, the abdominal contents are pushed downward as th e diaphragm moves down. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive.  Abdominal Ultrasound: Distended GB; Non-thickened wall; Multiple High-level echoes w/ posterior acoustic shadows (seen as the soundwaves during an ultrasound comes in contact with hard, solid structures, as in gall stones or cholelithiasis, and kidney stones; if the soundwaves comes in contact with soft tissues only, what is seen in the ultrasound are static projections) IMPRESSION AND PLAN  Impression: Chronic Calculous Cholecystitis ( Inflammation of the gallbladder)  Plan: Cholecystectomy - removal of the gallbladder (right hepatic artery must be located 1 before ligation of the cystic artery) Figure 4. Laparoscopic and Open Cholecystectomies Figure 5. Types of Incisions: (1.)classical cholecystectomy), (2) laparoscopic cholecystectomy, (3) single incision laparoscopic surgery VI. CASE # 4 PATIENT HISTORY  EA, 38M, Pasig City  CHIEF COMPLAINT: HEMATOCHEZIA (fresh blood in the stool)  HISTORY OF THE PRESENT ILLNESS: 1 DAY PTA o Bloody stools (2 episodes)  Day of admission o 1 episode o Hematochezia o Sudden weakness  ADMITTED  On Admission:  o BP: 70/50 (increased) o CR: 120’s ( increased) o RR: 20 o Afebrile o Abd: non surgical, no masses o Double line o NGT, FC o Blood works o Hgb: 86 ( decreased) o Hct: .25 (decreased) o Had an episode of hematocheia (fresh blood in stool) on admission o VS the same o Transfusion of 3 units PRBC o 5 liters of crystalloids in 24h o Kept on NPO w antacids  2 HD o No hematochezia Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo Page 4 of 5 " id="pdf-obj-3-112" src="pdf-obj-3-112.jpg">

Figure 5. Types of Incisions: (1.)classical cholecystectomy), (2) laparoscopic cholecystectomy, (3) single incision laparoscopic surgery

VI. CASE # 4
VI. CASE # 4

PATIENT HISTORY

EA, 38M, Pasig City

CHIEF COMPLAINT: HEMATOCHEZIA (fresh blood in the stool) HISTORY OF THE PRESENT ILLNESS:

1 DAY PTA o Bloody stools (2 episodes) Day of admission o 1 episode o Hematochezia o Sudden weakness ADMITTED On Admission:

o BP: 70/50 (increased) o CR: 120’s (increased)

o RR: 20

o Afebrile o Abd: non surgical, no masses o Double line o NGT, FC o Blood works o Hgb: 86 (decreased) o Hct: .25 (decreased) o Had an episode of hematocheia (fresh blood in stool) on admission o VS the same o Transfusion of 3 units PRBC o 5 liters of crystalloids in 24h o Kept on NPO w antacids

2 nd HD o No hematochezia

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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o BP: 100/60 o CR: 90’s

RR: 20’s

o Pale conjunctivae and skin o Repeat Hgb: 97 o Hct: .28 o Abd: flabby, soft, Hyperactive BS, soft, Non-tender, no masses o DRE: tight sphincter; (+) tarry material on tactating finger

3 rd HD o No hematochezia in am; stable VS o Maintained on conservative management o 8pm: hematochezia ~ 350 ml o NO abdominal pain o VS: 80/50 o CR: 112/min

o RR: 20

o Hgb: 84 o Hct: . 24 o Resuscitation w crystalloids and blood requested 4 th HD o Emergency Colonoscopy done o Fresh Blood and Clots noted from rectum to mid transverse; rectum cleared of bleeders o Proximal transverse to Cecum Normal; terminal Ileum Normal o Bleeding point not visualized due to persistent bleeding o Patient Referred to Surgery

PERTINENT PE FINDINGS

BP: 80/50

CR: 122/min Thready pulses Pale conjunctivae and membranes Clear Breath Sounds; distinct heart sounds Abd: slightly globular, hyperactive BS; soft, non-tender. No masses DRE: fresh blood on tactating finger Resuscitation continued w whole blood and crystalloids

PLAN

Immediate Ex-Lap Probable Left Hemicolectomy

Colitis

-Chronic inflammation of the colon (Moore) -Severe inflammation and ulceration of the colon and rectum (Moore)

Colectomy

-terminal ileum and colon, as well as rectum and anal canal are removed (Moore)

FINDINGS

Colonic polyp that is highly vascular and found at the distal transverse colon Collapsed small bowel Large bowel with blood clots from proximal transverse to rectum Proceeded w Left Hemicolectomy; Hartmann’s Procedure Transfused 4 units of PRBC and 4 units of FFP intra-op Large Bowel Lesions: at right hepatic flexure: complete dissection

Note: Marginal artery of Drummond: interconnects the iliocolic, right, left and median colic, sigmoid rectal

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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