Content

A hernia is the protrusion of an organ or tissue through a defect in the wall that normally contains it: sac (peritoneum), neck and contents (omentum, bowel). Inguinal canal: about 4 cm long, from the deep ring (in the transversalis fascia) to the superficial ring (in the external oblique aponeurosis); contains the spermatic cord in men and the round ligament in women, and the ilioinguinal nerve. Hesselbach's triangle is bounded by the inferior epigastric vessels, the rectus sheath and the inguinal ligament. - Indirect hernia: passes through the deep ring lateral to the inferior epigastric vessels along the canal; congenital (patent processus vaginalis), any age, may enter the scrotum. - Direct hernia: bulges through Hesselbach's triangle medial to the vessels; acquired weakness of the posterior wall, older men. - Femoral hernia (below the inguinal ligament, more common in women) has the highest risk of strangulation.

Presentation: a groin swelling that appears on standing or straining (cough impulse) and reduces when lying. Examination: standing and lying, cough impulse, and whether it can be reduced. Complications: incarceration (irreducible), obstruction, and strangulation (loss of blood supply; painful tender irreducible lump, vomiting, needs emergency surgery). Risk factors: chronic cough, constipation, straining, obesity, prostate disease, previous surgery. Treatment: surgical repair, most often with a prosthetic mesh (open Lichtenstein tension-free repair, or laparoscopic TEP or TAPP repair). Asymptomatic hernias in men may be observed. Recurrence and chronic groin pain are the main long-term problems.

Umbilical hernia: through the umbilical ring; in infants often closes spontaneously by age 4-5, in adults associated with obesity, pregnancy and ascites, repaired with mesh if symptomatic. Paraumbilical hernias are just beside the umbilicus. Epigastric hernia: through the linea alba above the umbilicus. Incisional hernia: through a scar of a previous laparotomy (up to about 10-15 percent of laparotomies), repaired with mesh. Also Spigelian, obturator and lumbar hernias, and hiatal hernia (stomach through the oesophageal hiatus).

1. How do indirect and direct inguinal hernias differ anatomically? 2. Which hernia has the highest risk of strangulation? 3. Describe the signs of strangulation. 4. Name two repair techniques for an inguinal hernia.

1. Indirect: through the deep ring lateral to the inferior epigastric vessels. Direct: through Hesselbach triangle medial to the vessels. 2. Femoral hernia. 3. A tender, irreducible lump with severe pain, vomiting and signs of obstruction, needing emergency surgery. 4. Open mesh repair (Lichtenstein) and laparoscopic repair (TEP or TAPP).

Causes: Helicobacter pylori infection and NSAIDs; also stress, smoking and Zollinger-Ellison syndrome. Duodenal ulcers are more common than gastric ulcers; gastric ulcers must be biopsied to exclude cancer. Medical treatment: eradication of H. pylori (proton pump inhibitor plus antibiotics), stopping NSAIDs. Surgical complications - Perforation: sudden severe epigastric pain, rigid abdomen, free air under the diaphragm on an upright chest X-ray; treated by closure (omental patch) and eradication. - Bleeding: haematemesis or melaena, managed by endoscopic haemostasis; surgery or embolisation if it fails. - Gastric outlet obstruction from scarring: vomiting of undigested food; endoscopic dilation or surgery. - Penetration into adjacent organs.

Risk factors: H. pylori infection, atrophic gastritis, diet (salt, smoked food), smoking, family history (CDH1 mutation for hereditary diffuse gastric cancer). Types (Lauren): intestinal and diffuse. Symptoms: vague epigastric pain, early satiety, weight loss, anaemia, dysphagia, vomiting; alarm features need urgent endoscopy with biopsies. Staging: CT, endoscopic ultrasound, laparoscopy to detect peritoneal disease; TNM. Treatment: endoscopic resection for early cancers, and gastrectomy (total or subtotal) with D2 lymphadenectomy plus perioperative chemotherapy for advanced disease. Prognosis depends on stage.

Indications: body mass index 40 or more, or 35 or more with obesity-related disease (type 2 diabetes, hypertension, sleep apnoea), after failure of non-surgical measures, with multidisciplinary assessment. Procedures: sleeve gastrectomy (restrictive; removal of most of the stomach along the greater curvature), Roux-en-Y gastric bypass (restrictive and malabsorptive; also hormonal changes), biliopancreatic diversion (mostly malabsorptive) and adjustable gastric band (rarely used now). Most are laparoscopic. Complications: leak, bleeding, stricture, dumping syndrome, nutritional deficiencies (vitamin B12, iron, calcium; lifelong supplements), gallstones and marginal ulcer. Benefits: sustained weight loss and remission of diabetes in many patients.

1. Name the main causes of peptic ulcer. 2. What signs indicate a perforated ulcer? 3. What is the curative treatment of resectable gastric cancer? 4. State the indications for bariatric surgery. 5. Give two complications of gastric bypass.

1. Helicobacter pylori infection and NSAIDs. 2. Sudden severe epigastric pain, rigid abdomen and free air under the diaphragm. 3. Gastrectomy with D2 lymphadenectomy, with perioperative chemotherapy in advanced disease. 4. BMI at least 40, or at least 35 with obesity-related disease, after failed conservative therapy. 5. Leak, stricture, dumping, nutritional deficiencies, marginal ulcer.

Types: cholesterol stones (most common; risk factors 'fat, female, forty, fertile') and pigment stones (haemolysis). Presentations: asymptomatic; biliary colic (right upper quadrant pain after fatty meals); acute cholecystitis (persistent pain, fever, Murphy sign, ultrasound with thick wall and stones); choledocholithiasis with cholangitis (Charcot triad: fever, jaundice, right upper quadrant pain); gallstone pancreatitis; Mirizzi syndrome. Treatment: laparoscopic cholecystectomy for symptomatic stones; ERCP with sphincterotomy to clear duct stones; antibiotics and urgent drainage in cholangitis.

Features: jaundice, dark urine, pale stools, pruritus; raised conjugated bilirubin and alkaline phosphatase. Causes: stones in the common bile duct, pancreatic head cancer (painless jaundice, palpable gallbladder: Courvoisier law), cholangiocarcinoma, strictures and external compression. Investigation: ultrasound (dilated ducts), then CT, MRCP or endoscopic ultrasound; ERCP for both diagnosis and treatment (stones, stent).

Primary survey ABCDE, with simultaneous resuscitation - A: airway with cervical spine protection. - B: breathing (tension pneumothorax, open pneumothorax, massive haemothorax, flail chest). - C: circulation and control of haemorrhage (shock: two large-bore intravenous lines, warmed fluids and blood products, tourniquet or pressure for external bleeding; FAST ultrasound for free fluid). - D: disability (Glasgow Coma Scale, pupils, glucose). - E: exposure and environment (undress fully, prevent hypothermia). A secondary survey follows: head to toe examination and history (AMPLE), with tests and imaging, then definitive care. Life-threatening injuries are treated as they are found. Damage-control surgery limits operation time in the unstable patient.

1. What is the Charcot triad? 2. Explain the Courvoisier law. 3. List the steps of the ATLS primary survey. 4. What is the initial treatment of severe cholangitis?

1. Fever, jaundice and right upper quadrant pain (cholangitis). 2. A palpable non-tender gallbladder with jaundice suggests malignant obstruction (pancreatic head cancer) rather than stones. 3. Airway with spine protection, Breathing, Circulation with haemorrhage control, Disability, Exposure. 4. Antibiotics, fluid resuscitation and urgent biliary drainage (ERCP).