General Surgery

General Surgery; Lecture 1
ABDOMINAL TUMOR
Abdominal Region, divided into 4 quadrants;
Right Upper Quadrant (RUQ)
Left Upper Quadrant (LUQ)
Right Lower Quadrant (RLQ)
Left Lower Quadrant(LLQ)
ABDOMINAL COMPARTMENT
- Intraperitoneal
- Retroperitoneal
ABDOMINAL WALL
- Skin
- Subcutaneous
- Muscles
TUMOR LOCATION
1. Abdominal Wall
2. Intraperitoneal
3. Retroperitoneal
DIFFERENTIATING TUMOR LOCATION
 Abdominal wall was tightened by;
- raising both lower limbs
- straining or blowing something
On tightened condition, we evaluate whether tumor is;
- More “obvious” à tumor is locate at abdominal wall
- “disappear“ or smaller à tumor is locate at intra- or retro-peritoneal
To differentiate between intra- and retro-peritoneal à bimanual examination, to find ballotement sign .
Ballotement (+) à retroperitoneal tumor
Ballotement (-) à intraperitoneal tumor
Sometimes ballotement sign is hard to evaluate in big tumor
WORK-UP (intra- or retro-peritoneal tumor)
1. USG
2. IVP
3. CT- Scan
4. Ba- meal
5. Ba- enema
WORK-UP (intra- or retro-peritoneal tumor)
USG:
to detect “solid” organs (kidney, spleen, liver)
IVP :
when tumor origin is kidney, there is delayed function of influence kidney
CT-Scan :
To differentiate whether the tumor origin is kidney, spleen, or liver with transverse view
Barium meal (upper gastrointestinal series):
“ filling defect” showing anomalies on digestive tract
Barium enema (lower gastrointestinal series):
Barium contrast is inserted retrograde from anus into rectum to see colorectal condition
ABDOMINAL TUMOR
INTRAPERITONEAL TUMOR
Liver
Spleen
Caecum
Transverse Colon
Sigmoid Colon
Ovarium
Stomach
RETROPERITONEAL TUMOR :
Kidney (hidronephrosis, Grawitz Tumor, Wilms’ Tumor)
Neuroblastoma
Teratoma
INGUINAL TUMOR/LUMP
Diff.Diagnosis
1. Inguinal Hernia, femoral hernia
2. Enlarge Inguinal lymph nodes (lymphadenopathy, inflamation)
3. Abscess (cold abscess, chronic abscess)
4. Skin Tumor (lipoma, atheroma, etc)
2.1 Inguinal Hernia
Reducible :
Hernia can be returned to intraabdomen
Irreducible :
Hernia cannot be returned to intraabdomen
Upper edge of the lump à diffuse, vague, indistinctive
2.2. Enlarged Inguinal Lymph Nodes
Irreducible
Pain , redness à inflamation
No Pain :
à chronic lymphadenopaty
à Lymph sarcoma
à Cancer metastasis
2.3 Cold Abscess
TB Spondylitis
Fungus Infection
2.4 Skin Tumor
Atheroma
Lipoma
Femoral Region : irreducible
Irreducible Scrotal Hernia
irreducible, upper edge is undistinctive
Testical Tumor
Irreducible
diaphanoscopy / transillumination test (-)
Hydrocele
Irreducible
Diaphanockopy (+)
Orchitis
Irreducible
Painful
Inflamation symptom (+)
HERNIA
Anatomy of Abdominal Wall :
Superficial
skin
Adipose tissue
Scarpa’s Fascia
External Abdominal Oblique Muscle
aponeurosis
Deep
Canalis Inguinalis
Internal Abdominal Oblique Muscle
Transversus Abdominis Muscle
Transverse Fascia
Peritoneum
Inguinal Canal
Surrounded by Cremaster Muscle
superior wall (roof): internal oblique muscle, transvesus abdominis muscle
anterior wall : aponeurosis of external oblique, aponeurosis of internal oblique
inferior wall (floor): inguinal ligament, lacunar ligament, iliopubic tract
posterior wall : transversalis fascia, conjoint tendon
Content : Funikulus spermatikus (spermatic vessel, ilioinguinal nerve, iliofemorale nerve, proc vaginalis, lig rotundum)


Pathophysiology
Definition :
a protrusion of a tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained
Structure :
 Hernia ring
 Hernia Sac (fundus, corpus and neck)
 Content (omentum, bowel, etc.)
Predispose à lokus minoris ressistentiae
Risk Factor à Increasing intraabdominal tension (chronic cough, ascites, urinate obstruction, straining)
Hernia Prevention mechanism on healthy people:
Oblique inguinal canal
Internal oblique muscle that always close internal ring when contracting
Firm transverse fascia that close Hasselbach Triangle
Preventive mechanism disruption à hernia
Based on pathophysiology :
1. Congenital Hernia
2. Aquired Hernia
Based on location
1. Inguinal Hernia
2. Femoral Hernia
3. Umbilical Hernia
4. Diafraphmatic Hernia
5. Hernia of Morgagni
6. Hernia through the foramen of Winslow
7. Obturator Hernia
Based on clinical symptomps
Reducible Hernia
An uncomplicated hernia which returns, either spontaneously or after manipulation, to its original site
Irreducible Hernia
A hernia that will not return to its normal position in the body cavity, even with gentle manipulation
Incarcerated Hernia
A hernia is traped in its ring, there’s risk of strangulation à necrotic tissue
Inguinal Hernia : (majority)
1. Indirect Inguinal Hernia
2. Direct Inguinal Hernia
Older Man
Rounded Lump
Long standing-high-intraabdominal-tension and weak muscle floor of Hasselbach Triangle
Rarely become incarcerated
Sometimes become a sliding hernia
Mostly affect old women
Groin lump below the inguinale ligament and medial site of femoralis vein dan at lateral site of tuberkulum pubikum
Hernia protrudes à femoralis ring à femoral canal à exit at fossa ovalis at groin
Chronic increasing of intraabdominal tension, pregnancy, obesity, connective tissue degeneration in older men
Secondary à hernioraphy’s complication (Bassini and Shouldice Procedure)
Umbilical Hernia :
Congenital, prostrution of viscera organ through umbilical ring à Increased abdominal tension
< 2cm à spontaneous regression
Adult à surgery
Incision Hernia
Usually affect on post ceilotomy wound
Nerve disruption => skin anastesia and muscle paralisis (lumbotomy incision)
Diagnosis:
Anamnesis
Reducible lump on groin which can be persisted (irreducible)
The lump usually appear on increasing intra abdominal tension
The lump can manually reduced when the patient lying
Intestinal pasase disruption à incarserated hernia
Pain in incarcerated or strangulated condition
Watch out for predispose factors
I = there is lump, without skin color alteration
P = there is palpable lump, with indistinctive upper border, the protrusion can return back to the abdominal cavity
Reducible Lump:
On inguinal region can be doubtful à “ finger-tip “ test/ Valsava’s test
Irreducible Lump:
Whether in inguinal or other region;
Accompanied obstructive bowel symptoms à incarcerated hernia
Without obstructive symptoms' à irreducible hernia only
Strangulation : tissue/bowel necrosis due to vascularization disruption
1. Testicular tumor
2. Hidrocele
3. Orchitis
4. Incarserated hernia
To differentiate:
- (1) and (2): has distinctive border
- Diaphanoscopy test : (1) negative,(2) positive
- (3) : distinctive border, negative diaphanoscopy test , pain on pressure manipulation
- (4) : indistinctive border, pain on upper part of lump, there’s possibility of obstruction symptoms
TERAPHY
Surgery is the only way :
- Herniotomy
- Hernioplasty
Time to operate :
- As soon as the diagnosis has been confirm
Emergency operation:
- Incarcerated hernia
- Incarceration à can happen anytime!
Indication of surgery:
Reducible hernia
Irreducible hernia
Incarcerated hernia
Strangulated hernia
Contraindications of surgery :
General
Spesific (increasing intra-abdominal tension : prostat hyperthrophy, lung disease)
Complication of Surgery
- bleeding
- Wound infection
- Iatrogenic trauma of bowel, bladder, vas deferen, testis
- Orchitis, atrophy of the testis
- Intrainguinal nerve trauma, ilio hipogastrik or genota femoral
Mortality
Depend on hernia condition : reducible or strangulate, patient general conditin and accompanied disease
Post Operative Care
Post operative, observe the possibility of complication that might happen (bleeding or hematom)
Follow-Up
Pasien is advised not to have heavy physical work in 6-8 weeks, to prevent recurrency
Patient on supine posistion under either general, spinal or local anesthesia
Executing aseptic and antiseptic prosedur on operating field
Narrowing operating field using sterile fabric
Executing oblique or skin crease incission paralel to inguinal ligament. Incise deeper until we found external oblique aponeurosis
External oblique aponeurosis is opened in sharp fashion.
Identify hernia sac, transect the sac transversally and return the content of hernia
Ligate the hernia sac as high as preperitoneum fat, continue with herniotomy
Stop the bleeding if there is, follow with hernioplasty close it with mesh graft
Close the operation wound layer by layer
JAUNDICE
Definition : increase level of bilirubin in the blood
Normal : < 9 mu mol/L (0,5 Mg % )
Obvious jaundice : >35 mu mol/L (2 mg %).
Based on patophysiology :
Pre-Hepatic events
Hepatic events
Post-Hepatic events
Prehepatic Jaundice
The pathology is occurring prior the liver
Increased rate of Haemolisis :
No evidence of liver disease
Sign of high hemolisis
Very high level of UCB

Hepatic Jaundice
Liver Disease ( + )
Defect of liver physiology
Increased level of UCB

Post-hepatic Jaundice
Intrahepatic obstruction;
- liver cirrhosis, liver abscess, hepatocholangitis, primary or secondary malignancy
Biliary system obstruction;
- Gall stones, ascariasis
Disruption of biliary system’s wall
- congenital atresia, traumatic strictur, biliary system tumor
Extrabiliary system pressure :
- Pancreas head tumor, ampula vater tumor, pancreatitis, secondary malignancy at hepatoduodenale ligament
Physical Examination
Family history of anemia, gall stone
Acholic stool
Urobilinuria
History of blood transfusion, drug/alkohol consumption
Jaundice without colicky pain or pain on liver palpation
à Hepatitis
Colicky pain with chill , intermittent obstructive jaundice à gallstone or cholagitis
Progressive jaundice with pain in flank area
à pancreatic malignancy
Orange skin discoloration + moderate jaundice + anemia à prehepatic jaundice
Deep color jaundice à hepatic and posthepatic events
Enlarged gallbladder, hepatomegaly, without pain on palpation à Tumor (Courvoisier’s sign)
Splenomegaly à liver cirrhosis, hematologic disorder, malaria, reticulosis.
Work Up
Laboratorium :
Liver function , bilirubin, stercobilinogen, urobilinogen, urinary bilirubin
Obstructive jaundice : high level of conj. bilirubin , low level of fecal stercobilinogen dan urinary urobilin,
Increased level of SGOT/PT ,
High level of Gamma GT
USG : gall stone, enlarge duct, mass, liver parenchimal disorder.
Work Up
Abdominal plain photo
USG
Abdominal CT
ERCP
PTC
Liver Biopsy à for non obstruktive jaundice only
JAUNDICE OBSTRUCTIVE ALGORITHM
MANAGEMENT
Paralel to the etiology
Surgery case à post hepatic jaundice
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