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What is it all about?Surgery is often split into different specialties including general, breast, vascular, transplant,orthopedic and trauma. It is linked to nearly every other specialty from pediatrics to care of theelderly. The practice of surgery is separated into emergency and elective care. Patient carecovers emergency admission, operating room sessions, day-to-day inpatient care and outpatientclinics.Conditions you will be asked about in your first weekFavorites for surgery are varicose veins and hernias. Essential knowledge includes definition,anatomy, examination and classification.HerniaA hernia is the abnormal protrusion of an organ or tissue through a weakness in the surroundingstructures. Hernias may be described as: Reducible Easily put back Irreducible Contents cannot be put back due to adhesions Strangulated Contents are stuck and there is constriction of the tissues at the neck of the hernia leading to reduced venous drainage and arterial occlusion. Richters Only part of the visceral wall is strangulatedRefer to Fig. 32.2 from Sweetland Crash Course SurgeryTypes of hernia Type Description Risk of Strangulation Incisional Herniation through an area weakened by a scar. Low Umbilical Congenital defect of the abdominal wall seen in Low infants as a swelling at the umbilicus Paraumbilical Acquired defect above or below the umbilicus High Epigastric Often small painful swelling in the midline of abdomen above the umbilicus caused by a defect in linea alba, usually contains extraperitoneal fat. Femoral Herniation through the femoral canal which appears Highest below and lateral to the pubic tubercle. More common in women than men. Inguinal Typically seen ‘above and medial to the pubic Low tubercle’; swelling is caused by weakness in the abdominal wall in the area of Hasselbach’s triangle. Indirect -The most common Hernia, of which there are two(inguinal) types. First, congenital, is caused by a patent High processus vaginalis. Second, acquired, herniates through deep ring and travels along the inguinal canal within the coverings of the spermatic cord.
For anatomy, refer to Fig. 32.3 and Fig. 32.4 from Sweetland Crash Course Surgery.ExaminationInspection: • With patient standing, look for a swelling. • Note position and involvement of scrotum. • Look for scars- carefully check other side. • Watch for cough impulse.Palpation: • Repeat cough impulse. • Lie patient down. • Decide type of hernia by position. • Is it reduced or reducible? • Is it inflamed or tender?By the end of the history and examination you should have answered these questions: • Does the patient have a hernia? (i.e. a swelling with a cough impulse) • What type of hernia is it? • Is it reducible? • Is surgery appropriate?Varicose VeinsVaricose veins are superficial veins that can be seen and are more tortuous and dilated thannormal. Varicose veins can be asymptomatic. Patients may complain of the unsightliness of theveins. Other symptoms include aching, ankle swelling, dry and itchy skin, discoloration orulceration of the skin and vein rupture with bleeding.AnatomyThe anatomy of the superficial leg veins and some understanding of the venous drainage of theleg are essential.If someone presents with varicose veins it is necessary to differentiate between problems of theshort and long (small and great) saphenous veins. This is done by knowledge of the anatomy.Remember that veins drain from bottom to top and therefore refer to the anatomy in this direction.Venous drainage of the leg is from the superficial veins to the deep veins. There are perforatingveins which join the two and have one way valves to prevent back flow. If these valves are faulty,blood goes back into the superficial veins making them varicose.
Classification of varicose veinsVaricose veins can be broadly categorized into primary and secondary.Primary:These are common. The deep venous system is normal. The varicose veins are due toincompetent valves either in the main venous junctions, i.e. the saphenofemoral, or in theperforating veins. They can be considered idiopathic or familial. Varicose veins are worsened bypregnancy, obesity, constipation or long periods of standing.Secondary:These are varicose veins caused by another pathological process. In the postphlebitic limb, thedeep veins are occluded and all or most of the venous return is in the superficial system causingsecondary varicosities. If there is re-canulization after a deep vein thrombosis, the venouspressure in the deep system is increased (because the valves have been destroyed); this cancause damage to the valves leading to secondary varicosities.ExaminationInspection: • The patient needs to be exposed - i.e. underwear, and standing in a good light. • Get down low, sit on a stool if available. • Inspect from the front and behind. • Have one leg in front of the other to see the medial aspect of the limb. • Look for distribution, scars (both legs, in groin and popliteal creases), venous flare, edema, lipodermatosclerosis, ulceration.Palpation:Feel the veins, they might not be visible.Feel for a cough impulse, just below the saphenofemoral junction.Percussion:Gently feel over the saphenous opening while tapping the varicosities, feeling the impulsetransmitted implies incompetent valves.Trendelenburg’s TestWith the patient supine, lift the leg and milk out the blood. Either place your fingers over thesaphenofemoral junction or place a tourniquet around the limb. Keeping pressure on the limb,have the patient stand. If there is no venous filling saphenofemoral incompetence isdemonstrated and the patient is very impressed! If there is filling of the veins the incompetencemust be lower down the limb. A similar test can be performed for short saphenous incompetencealthough the best confirmation is with ultrasound. (Practice this examination technique!)