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Toronto Notes 2019
Abdominal Hernia
General Surgery and Thoracic Surgery GS25
Table 8. Malignant Tumours of the Small Intestine (continued)
Adenocarcinoma
Surgical resection ± chemotherapy
5 yr survival 25% (if node positive)
TNM
Carcinoid
Surgical resection ± chemotherapy Carcinoid syndrome treated with steroids, histamine, and octreotide
Metastatic risk 2% if size <1 cm, 90% if >2 cm
5 yr survival 70%; 20% with liver metastases
TNM
Lymphoma
Low grade: chemotherapy with cyclophosphamide High grade: surgical resection, and radiation Palliative: somatostatin, doxorubicin
5 yr survival 40% Ann Arbor
Metastatic
Treatment
Prognosis
Staging System
Palliation
Poor
Short Gut Syndrome
Definition
• reducedsurfacearea(length)ofsmallbowelcausinginsufficientintestinalabsorptionleadingto diarrhea, malnutrition, and dehydration
Etiology
• acutemesentericischemia:resectionoflargeamountofbowelatonce • Crohn’sdisease:cumulativeresections
• malignancies
Prognostic Factors
• residualsmallbowellength,residualcolonlength(reabsorptionofwaterandelectrolytesandsome reabsorption of nutrients), condition of the remnant small bowel (healthier bowel facilitate better reabsorption), presence of ileocecal valve (delay transition into colon leading to more reabsorption)
• resectionofileumislesstoleratedthanresectionofjejunum(ileumreabsorbsbilesaltandvitaminB12)
Therapy
• medical
■ TPN: replenish lost fluid and electrolytes in diarrhea
■ HT2R antagonist or PPI to prevent gastric acid secretion
■ antimotility agent to prolong transit time in the small intestine
■ consider octreotide to decrease GI secretion and cholestyramine for bile acid absorption
• surgical: non-transplant
■ to slow transit time: small bowel segmental reversal, intestinal valve construction, or electrical
pacing of small bowel
■ to increase intestinal length:
◆ LILT (longitudinal intestinal lengthening and tailoring) procedure
◆ STEP (serial transverse enteroplasty procedure) in dilated small bowels • surgical: transplant
■ indication: life-threatening complication from intestinal failure or long-term TPN
◆ liver failure, thrombosis of major central veins, recurrent catheter-related sepsis, recurrent severe
dehydration
Abdominal Hernia
• seeHiatusHernia,GS13 Definition
• defectinabdominalwallcausingabnormalprotrusionofintra-abdominalcontents
Epidemiology
• M:F=9:1
• lifetimeriskofdevelopingahernia:males20-25%,females2%
• frequencyofoccurrence:50%indirectinguinal,25%directinguinal,8-10%incisional(ventral),5%
femoral, and 3-8% umbilical
• most common surgical disease of males
Risk Factors
• activitieswhichincreaseintra-abdominalpressure
■ obesity, chronic cough, asthma, COPD, pregnancy, constipation, bladder outlet obstruction, ascites,
and heavy lifting
• congenitalabnormality(e.g.patentprocessusvaginalis,andindirectinguinalhernia) • previousherniarepair,especiallyifcomplicatedbywoundinfection
• lossoftissuestrengthandelasticity(e.g.hiatushernia,aging,andrepetitivestress)
Indirect Inguinal Hernias: Rule of 5s
5% lifetime incidence in males
5x more common than direct inguinal hernias 5-10x more common in males than females Generally occur by 5th decade of life
Inguinal Hernias – MD’s don’t LIe
MD: Medial to the inferior epigastric a. = Direct inguinal hernia
LI: Lateral to the inferior epigastric a. = Indirect inguinal hernia
Inguinal Canal Walls = MALT x 2
2M Roof 2A Ant. wall
2L Floor 2TsPost.wall
2 muscles (internal
oblique, transversus abdominis) 2 aponeuroses (external
and internal oblique)
2 ligaments (inguinal and lacunar) 2T(transversalisfascia,conjoint tendon)
Borders of Hesselbach’s Triangle
• Lateral: inferior epigastric artery
• Inferior: inguinal ligament
• Medial: lateral margin of rectus sheath