HERNIAS , GASTROINTESTINAL PROCEDURES AND DEVICE.pptx

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1. HERNIAS , GASTROINTESTINAL PROCEDURES AND DEVICE PRESENTE D BY - DR. RAHUL KUMAR YADAV GUIDE - PROF. AND HEAD DR. HAIDER ABBAS ASSIST. PROF. DR. MUKESH KUMAR

2. INTRODUCTION OF HERNIA Definition : A hernia is a condition where an organ or tissue protrudes through a weak spot in the muscular wall of the abdomen. Common types : * Inguinal hernia * Femoral hernia * Umbilical hernia * Incisional hernia

3. Prevalence : Nearly 10% of the population will develop a hernia in their lifetime, making it a common surgical issue. Classification : Hernias are classified based on: Anatomic location (e.g., inguinal, umbilical, femoral) Contents of the hernia sac Status of the contents : reducible, incarcerated, or strangulated. Reducible Hernia: The hernia sac is soft and can be manually returned through the defect. Incarcerated Hernia: The hernia sac is firm, painful, and cannot be reduced by manual pressure.

4. Strangulated Hernia: Occurs after incarceration, where blood flow is impaired, leading to severe pain, signs of intestinal obstruction, toxic appearance, and possibly skin changes over the hernia. Surgical Emergency : A strangulated hernia is an acute condition requiring immediate surgical intervention.

5. 1. Inguinal Hernia: Prevalence : 75% of all hernias occur in the inguinal region, two-thirds being indirect. Presentation : Appears as a groin mass, which may enlarge or present symptoms of incarceration or strangulation over time. Diagnosis : Physical exam is often sufficient; bedside ultrasound (US) has 100% sensitivity and specificity for diagnosis.

6. Types : Direct inguinal hernia : Passes through a weakness in the transversalis fascia in the Hesselbach triangle. Indirect inguinal hernia : Passes from the internal to the external inguinal ring through the patent process vaginalis.

7. 2. Ventral and Incisional Hernias: Ventral Hernia: Develops from a defect in the anterior abdominal wall and can be spontaneous or acquired. Classified by location: epigastric, umbilical, incisional, or hypogastric. Incisional Hernia : Accounts for 20% of all abdominal wall hernias. Caused by excess wall tension, inadequate wound healing, or infection. Risk factors include obesity, age, and conditions increasing intra-abdominal pressure (e.g., COPD). Can lead to discomfort, extrusion of abdominal contents, incarceration, and strangulation.

8. 3. Umbilical Hernia: Cause : Often acquired due to conditions like ascites, pregnancy, or obesity. Risk : Chronic ascites patients (e.g., cirrhotics) are at risk for strangulation, rupture, and death from peritonitis.

9. 4. Femoral Hernia: Location: Hernia sac protrudes through the femoral canal, below the inguinal ring. Prevalence: More common in women (10:1 female predilection). Complications: Prone to incarceration and strangulation. 40% of femoral hernias require emergency surgery. Delays in repair increase strangulation rates (45% at 21 months).

10. 5. Spigelian Hernia: Location : Arises at the lateral edge of the rectus muscle and the arcuate (semilunar) line. Cause : Nearly always acquired due to comorbidities that increase intra-abdominal pressure. Presentation : Difficult to diagnose; typically presents with abdominal pain and a lateral abdominal wall bulge.

11. 6 Obturator Hernia: Involves herniation of the bowel through the obturator canal. Elderly, frail females with symptoms of bowel obstruction. Symptoms: Often presents with partial or complete intestinal obstruction. Howship-Romberg Sign: Pain in the medial thigh due to obturator nerve compression; however, this sign is not consistently useful in clinical practice. Complications : High complication rate, including perforation (>50% of cases) and mortality rates approaching 20%.

12. 7. Richter Hernia: Location : Involves only the antimesenteric border of the intestine, affecting only a portion of the intestinal wall circumference. Presentation : Often presents without the typical signs of vomiting or intestinal obstruction, as it does not fully obstruct the intestine. Complications : More prone to strangulation and gangrene due to the incomplete involvement

13. DIAGNOSIS CBC, serum chemistries, and urinalysis are typically of minimal value unless needed to rule out alternative diagnoses or for preoperative clearance. Ultrasound (US): Useful for diagnosing hernias, particularly in children and pregnant women, as it avoids ionizing radiation. Can assess hernia size, contents, reducibility, facial defect location, and tenderness. Free fluid in the hernia sac and absence of peristalsis are signs of incarceration or strangulation. CT : Best imaging modality for diagnosing hernias, especially uncommon types (e.g., Spigelian, obturator), and for identifying incarceration and strangulation.

14. TREATMENT Reducible Hernia: Refer for elective outpatient surgical repair if the hernia is easily reducible. Strangulated Hernia: If the patient has signs of strangulation (e.g., severe tenderness, intestinal obstruction, toxic appearance), immediately consult general surgery. Administer broad-spectrum IV antibiotics, fluid resuscitation, and analgesia. Incarcerated Hernia: If no signs of strangulation, attempt one or two reductions in the emergency department (ED). Observe the patient in the ED for serial abdominal exams post-reduction to check for complications like "reduction en masse," where a loop of bowel remains incarcerated despite apparent clinical reduction.

15. Gastrointestinal Procedures and Device Gastrointestinal (GI) procedures commonly encountered in emergency medicine, such as nasogastric (NG) tube insertion, orogastric lavage, abdominal paracentesis, and management of transabdominal feeding tubes. These procedures, though common in emergency settings, require careful technique and appropriate use to minimize complications.

16. 1 NASOGASTRIC ASPIRATIONS: 1. Primary Use : NG aspiration is mainly for gastric decompression in cases like small bowel obstruction and GI bleeding. 2. GI Bleeding : In GI bleeding, especially upper GI, NG aspiration can assess bleeding rates. It is less reliable for detecting bleeding sources beyond the stomach. 3. Procedure Techniques : Important procedural tips include the correct positioning, pain management (e.g., using anesthetics and premedication), and ensuring the tube is correctly placed.

17. NASOGASTRIC ASPIRATIONS

18. 2 OROGASTRIC LAVAGE : Orogastric lavage is used to remove pills and fragments from the stomach, primarily within 1 hour after a potentially lethal ingestion. Tube Selection : A large-bore tube (e.g., Ewald tube, Tum-E-Vac®) is required as NG tubes are too small to retrieve pill fragments. This procedure is done orally, not through the nose. Complications : Risks include aspiration, tube misplacement into the bronchi, pharyngeal injury, and viscus perforation. Gagging and vomiting are common. Aspiration risk is particularly high if airway protection is compromised.

19. Endotracheal Intubation : Intubation before the procedure is recommended for patients who are, or may become, obtunded to reduce the risk of aspiration. Procedure : Position the patient similarly to NG tube insertion. Ensure the proximal end of the tube is aimed away from others. Insert the bite block in uncooperative patients. Insert the gastric tube to the level of the glottis and encourage the patient to swallow. Quickly pass the tube into the stomach. Coughing or airflow from the tube may indicate tracheal misplacement. Ask the patient to vocalize to exclude this. Irrigation : * After confirming correct tube placement, suction and irrigate gastric contents. * Charcoal and sorbitol can be instilled before withdrawing the tube.

20. 3 Esophageal Balloon (Sengstaken-Blakemore) Tamponade: The Sengstaken-Blakemore tube is designed to tamponade bleeding from esophageal varices, typically in patients with severe hematemesis and signs of cirrhosis. Its use has declined due to advancements in endoscopy and medical therapy with octreotide, somatostatin, and vasopressin. Still useful when endoscopy is unavailable or when hemorrhage is refractory to endoscopic techniques.

21. In many cases, survivors undergo a transjugular intrahepatic portosystemic shunt (TIPS) in addition to balloon tamponade. Appropriate for patients with known or suspected esophageal varices. Insert the tube orally following the same procedure as orogastric lavage. Confirm tube placement before proceeding. Balloon Inflation: Inflate the distal balloon with water or normal saline, then apply gentle traction to the tube. The distal balloon targets bleeding at the gastroesophageal junction. If bleeding persists, inflate the proximal balloon. Complications: High risk of emesis and aspiration, which can be minimized by endotracheal intubation. Potential risk of gastric or esophageal rupture.

22. Securing the Tube: -To maintain traction, tape the proximal end of the tube to the face guard of a baseball catcher’s mask or lacrosse helmet. -Maintain the minimum amount of traction necessary to stop bleeding to reduce the risk of tissue ischemia. -Maintain balloon tamponade until more definitive treatment can be administered.

23. 4 Abdominal Paracentesis: Paracentesis is used to remove ascitic fluid for diagnostic or therapeutic reasons. Diagnostic Paracentesis: Performed when patients with ascites present with abdominal pain or GI symptoms, indicating possible peritonitis, even if pain is mild and without systemic infection signs. Therapeutic Paracentesis: Performed in cases of respiratory compromise or severe pain due to tense ascites. Large-volume paracentesis (removal of >5 L) is time-consuming and carries risks like hyponatremia, renal impairment, and encephalopathy, often requiring albumin infusion.

24. Complications: Potential complications include bowel perforation, ascitic fluid leakage, hemorrhage, introduction of infection, hyponatremia, and other complications after large-volume paracentesis. Equipment : Sterile drapes, sterilizing solution (povidone-iodine or chlorhexidine), syringes (3, 10, 30 mL), needles (27- and 21-gauge), local anesthetic (lidocaine), and containers for laboratory analysis (cell count and culture). For therapeutic paracentesis: a three-way stopcock, sterile tubing, suction source (vacuum bottles or wall suction), and a large-bore needle or catheter (18- or 16-gauge).

25. Ultrasound Guidance: Ultrasound (US) can confirm ascites and identify the best fluid collection target, helping avoid bowel perforation and reducing the risk of bleeding by identifying subcutaneous vessels.

26. Coagulopathy and Thrombocytopenia: Correct deficiencies if the patient has severe coagulopathy (INR >2.5) or thrombocytopenia (platelets <50,000/μL) before performing paracentesis. Site Selection and Patient Positioning: Left lower quadrant is preferred to minimize liver injury, but the right lower quadrant may be used if the left has distorted anatomy (e.g., prior surgery). Place the patient in a comfortable supine position. Anesthesia and Needle Insertion: Anesthetize the skin using a Z-track technique to minimize infection and leakage. Insert a larger-bore needle to infiltrate lidocaine until peritoneal fluid is aspirated. Fluid Collection: Once fluid is aspirated, switch syringes and aspirate at least 50 mL of fluid for laboratory analysis.

27. Therapeutic Paracentesis Setup: For large fluid removal, connect tubing to the needle or catheter and use suction. Even if performed for diagnostic reasons, removing 1-2 L may provide symptomatic relief without complications. Post-procedure Care: After the needle or catheter is withdrawn, cover the insertion site with a dressing (or use a purse-string suture to minimize leakage). Reassess the patient after 30 minutes for complications or leakage. For large-volume paracentesis, monitor the patient for hypotension for several hours.

28. 5 Transabdominal Feeding Tubes: Types of Tubes: Gastrostomy (G-tube), Jejunostomy (J-tube), and Gastrojejunostomy. Inserted by surgeons, gastroenterologists, or radiologists.

29. Common Complications: Minor issues: purulent drainage, leakage around stomal site, clogging, dislodgement, diarrhea, and vomiting. Local drainage is common and is a foreign body reaction; treat with local skin care unless there is cellulitis or necrotizing fasciitis. Granuloma formation may cause local bleeding, treatable with silver nitrate. Leakage: Caused by excessive pressure between bolsters, excessive tube mobility, or malposition. Management: Adjust bolsters, tube replacement, or temporary tube removal for healing.

30. Clogging: Prevent by flushing tubes regularly with water and carefully crushing pills. To unclog, use warm water or carbonated beverages like cola or alkalinized pancreatic enzymes. Tube Replacement: If the tube cannot be unclogged or has dislodged, it must be replaced. Consider bolster removal by a professional if required (endoscopist or surgeon). Replace dislodged tubes quickly to prevent tract closure, especially within a few hours of dislodgment. Confirm placement using water-soluble contrast material and radiographs, or by ultrasound or pH testing of aspirated gastric fluid.

31. Special Caution for Jejunostomy Tubes: Smaller tracts (8- to 14-F tubes) and usually not sutured. Replacement may use catheters or Foley catheters (but do not inflate the balloon).

32. Ostomy Complications: Types of Ostomies: Common types: Colostomies, Ileostomies, Catheterizable Ileal Pouches, and Ileal Conduits. Surgical Complications: Wound infections, dehiscence, parasomal herniation, bowel obstruction, volvulus, and bleeding may occur post-surgery. Usually require surgical consultation. Dermatitis Caused by exposure to urine or feces, abrasion, or allergies to adhesives or ostomy materials. Treatment includes resizing the ostomy contact, using ostomy powder and paste, and potentially patch testing.

33. Urinary Diversion: Ileal Conduit: Detached ileum forms a small reservoir with continuous output, requiring no catheterization. Catheterizable Ileal Pouch: A larger reservoir requiring periodic catheterization to maintain continence. Both types are prone to urinary infections, requiring regular irrigation to prevent colonization.

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