Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1281 - файл
.pdf
CHAPTER 8 Liver, pancreatic, and biliary surgery
332332
Acute pancreatitis
Causes and features
Infl ammatory process with cascade of release of infl ammatory cytokines
(TNFA, IL2, IL6, platelet-activating factor (PAF)) and pancreatic enzymes
(trypsin, lipases, co-lipases) initiated by pancreatic injury, but which may
develop into full blown MODS or SIRS (see b p. 138).
Causes
• Gallstones (60%).
• Alcohol (30%).
• Hyperlipidaemia.
• Hypercalcaemia (hyperparathyroidism, multiple myeloma).
• Direct damage (trauma, ERCP, post-surgery, cardiopulmonary bypass).
• Toxins:
Drugs, e.g. azathioprine, oestrogens, thiazides, isoniazid, steroids, •
NSAIDs.
Infection, e.g. viral (mumps, CMV, hepatitis B), mycoplasma.•
Venom (scorpion, snake bites).•
• Idiopathic.
Classifi cation/complications
• Oedematous (70%). May be simple or associated with phlegmon
formation; transient fl uid collections common.
• Severe/necrotizing (25%). Necrosis may be sterile or infected.
Persistent large peripancreatic fl uid collections may form
(‘pseudocyst’), which may become infected.
• Haemorrhagic (5%).
See b p. 138 for complications of SIRS.
Clinical features
• Severe epigastric pain radiating to the back.
• Severe nausea and vomiting.
• Fever, dehydration, hypotension, tachycardia (may be frankly shocked).
• Epigastric tenderness associated with guarding and in severe cases,
rigidity which may be generalized.
• Left fl ank ecchymosis (Grey–Turner’s sign) and periumbilical
ecchymosis (Cullen’s sign), 1–3% of cases haemorrhagic pancreatitis.
Emergency management
Resuscitation
• Establish large calibre IV access. Give crystalloid fl uid up to 1000mL
if tachycardic or hypotensive; may require ongoing fl uids IV.
• Catheterize and place on a fl uid balance chart.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (bilirubin,
albumin), amylase, group and save, clotting.
• Monitor pulse rate, BP, and urine output (urinary catheter).
• Consider insertion of a central line and manage patient in HDU if
haemodynamically unstable or fails to respond to early resuscitation.
• Assess the severity of the attack by the Glasgow Imrie criteria
(see Box 8.1).
ACUTE PANCREATITIS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Box 8.1 Glasgow Imrie criteria
Three or more positive criteria within 48h of admission = severe attack
(mnemonic: PANCREAS):
<8kPa.
- PaO
2
- Age >55y.
- Neutrophils/WCC >15 000
× 10
9
/L.
- Corrected calcium <2mmol/L.
- Raised blood urea >16mmol/L.
- Elevated Enzymes, AST>200U/L, LDH >600U/L.
- Albumin <32g/L.
- Sugar, blood glucose >10mmol/L.
Establish a diagnosis
• Serum amylase >1000U. Diagnostic, but may be normal even in
severe cases; elevated amylase may occur in a wide range of other
acute abdominal events (intestinal ischaemia, leaking aneurysm,
perforated ulcer, cholecystitis).
• Serum lipase. Remains elevated longer than serum amylase; more
specifi c, but less sensitive.
• AXR (non-specifi c fi ndings). Absent psoas shadows, ‘sentinel loop sign’
(dilated proximal jejunal loop adjacent to pancreas because of local
ileus’), ‘colon cut-off sign’ (distended colon to mid-transverse colon
with no air distally); may show gallstone, pancreatic calcifi cation.
• CT may be required. Shows pancreatic oedema, swelling, loss of fat
planes; may show haemorrhagic or necrotic complications.
• Ultrasound scan. Must be done within 48h of admission to identify
gallstones in the bile duct.
1
Early treatment Urgent ERCP and stone extraction are indicated for
proven bile duct stones causing obstruction and pancreatitis.
Defi nitive management
Identify/prevent complications
• IV antibiotics (e.g. IV imipenem tds), sometimes started in
moderate to severe cases even without evidence of infected necrosis.
• CT scan identifi es development of pancreatic phlegmon, early fl uid
collections, necrosis, or haemorrhage.
• CT-guided pancreatic aspiration to identify infected necrosis.
• Early low volume enteral feeding is increasingly used to reduce the risk
of stress ulceration and bacterial translocation causing sepsis.
Treatment of early complications
• Consider treating all severe cases on HDU/ITU for optimized fl uid
balance, respiratory, cardiovascular, and renal support.
• Proven infected necrosis. Surgical debridement may be required, but is
associated with a poor prognosis.
• Acute pseudocysts rarely need drainage unless very large.
333333
CHAPTER 8 Liver, pancreatic, and biliary surgery
334
Overall outcome Mortality is associated with pancreatic necrosis and
the presence of sepsis, including MODS.
Reference
1 UK Working Party on Acute Pancreatitis (2005). UK guidelines for the management of acute
pancreatitis. Gut 54, iii1–iii9.
Chapter 9
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Abdominal wall
Abdominal wall hernias 336
Inguinal hernia 338
Femoral hernia 340
Umbilical and epigastric hernias 342
Incisional hernias 344
Other types of hernia 346
Rectus sheath haematoma 347
Groin disruption 348
Acute groin swelling 350
335
CHAPTER 9 Abdominal wall
336
Abdominal wall hernias
No disease of the human body, belonging to the province of the surgeon,
requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than hernia in all its varieties.
Defi nition of a hernia The abnormal protrusion of a viscus or part
of a viscus through a weakness in its containing wall.
Aetiology
• Congenital. Associated with a developmental disorder, such as
persistent processus vaginalis (infantile inguinal hernia) or failure of
complete obliteration of umbilical opening (infantile umbilical hernia).
• Acquired. Weakness of the abdominal wall due to ageing or previous
surgery; risk increases in conditions where there is i intra-abdominal
pressure, such as heavy lifting, chronic cough, straining on urination or
defecation, abdominal distension, ascites, pregnancy, etc.
Composition of a hernia
• Sac. Peritoneal lining of a hernia; may be complete or incomplete as in
sliding hernia (b p. 346).
• Neck of the sack. At the level of the defect in the abdominal wall
where the hernia emerges.
• Contents. Bowel or omentum.
Behaviour
• Reducible. Contents can be fully restored to the abdominal cavity,
spontaneously or with manipulation.
• Incarcerated. Part or all of the contents cannot be reduced due to a
narrow neck and/or adhesions; there is a risk of strangulation.
• Obstructed. Contains an obstructed bowel loop due to kinking; usually
goes on to strangulation.
Groin hernias rank third, after adhesive obstruction and cancer, as
the most common cause of bowel obstruction in the west. In tropical
Africa, strangulated external hernia is the commonest cause of intestinal
obstruction.
• Strangulated. Blood supply to the contents of the sac is cut off; the
tight neck of the peritoneal sac is the usual site of strangulation.
Pathological sequence Venous and lymphatic occlusion l oedema and
i venous pressure l impeding arterial fl ow l bowel necrosis and
perforation.
2 If not diagnosed and managed early, bowel infarction can result and lead
to serious complications like peritonitis and septic shock.
Sir Astley Paston Cooper (1804)
ABDOMINAL WALL HERNIAS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Key revision points—general considerations in assessing
a patient with a hernia
History
- Is it a hernia? (history of reducibility)
- Site?
- Simple or complicated? Complicated if:
-
Incarcerated: patient can’t reduce it anymore.
Obstructed: symptoms of bowel obstruction.Strangulated: acute and severe pain, bowel obstruction, and patient is generally unwell.
- Any risk factors? (heavy lifting, COPD, constipation, BPH, previous
surgery).
Physical examination
- Confi rm the diagnosis and type (reducibility, cough impulse,
anatomical location).
- Always examine both sides in suspected groin hernias.
- Any scars? (recurrent or incisional hernia)
- General examination is essential to look for predisposing factors like
bowel pathology and BPH.
Decision making
Is surgery warranted? (symptomatic, i risk of strangulation as with narrow neck, patient mobility and fi tness for surgery).
337
CHAPTER 9 Abdominal wall
338
Inguinal hernia
Key facts
• It has been estimated that worldwide, >20 million repairs of inguinal
hernia are carried each year and in the UK 100 000.
• Commonest type of abdominal hernia; ♂:♀, 8:1.
• Abdominal contents protrude through the inguinal canal.
• Classifi ed to indirect and direct according to its (surgically determined)
relationship to the inferior epigastric artery (see Table 9.1).
• Coexistence of direct and indirect hernias descending either side of
the epigastric artery produces a ‘pantaloon hernia’.
Clinical features
• Most have no symptoms until a lump is noticed in the groin.
• Ache or dragging sensation, especially towards the end of the day.
• Some can relate the onset of the pain and bulge to a specifi c activity
(e.g. lifting).
Diagnosis and investigations
If the diagnosis is uncertain, investigations are of some help.
• Ultrasound. Least invasive and cheap, but may lead to false results.
• CT and MRI. Highly accurate, but CT involves substantial radiation.
• Herniography (intraperitoneal contrast injection and subsequent X-ray).
Aids in the diagnosis in cases of groin pain when no hernia can be felt;
rarely performed.
Treatment
• Patients with symptoms or have had episodes of irreducibility or bowel
obstruction documented should be offered repair.
• Elderly, immobile patients or those with high morbidity for operation
may be safely observed if asymptomatic or mildly symptomatic (annual
risk of incarceration is 2–3 per 1000 patients per year).
• A groin truss is of limited symptomatic benefi t for non-surgical
patients.
Technical aspects
• Repair may be performed by open surgery or via the laparoscopic
approach (either transperitoneal or in the pre-peritoneal space).
• General or local anaesthesia if done via the open approach.
• Tension-free reinforcement of the transversalis fascia (TVF) layer
(usually with non-absorbable mesh); in open repairs, this lies in front of
the TVF and in laparoscopic, behind it).
• Mesh may be fi xed in place by sutures (open) or ‘tacking’ devices
(laparoscopic approach).
• Avoid heavy lifting and straining for fi rst to second week post-op.
• Lifetime recurrence of combined mesh repairs is approximately
1–2%.
• Laparoscopic approach is recommended for recurrent and bilateral
hernias and should be carried out by experienced surgeons in wellequipped units (NICE guidelines).
INGUINAL HERNIA
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Table 9.1 Comparison between indirect and direct inguinal hernias
Indirect Direct
Age Any age, but usually
Aetiology Congenital (patent
Relationship to inferior
epigastric artery
Descending to
scrotum
Occluding the internal
ring
Neck Narrow Wide
Strangulation More likely Rare
Treatment Infant—herniotomy
young
processus vaginalis)
Lateral Medial
Often Rarely
Controls it Does not control it
(ligation and excision of
the sac)
Adult—open mesh repair,
laparoscopic repair
Uncommon in children
and young adult
Acquired weakness in
abdominal wall
Open mesh repair,
laparoscopic repair
Key revision points—anatomy of the inguinal canal
- The inguinal canal is the oblique passage through the lower
abdominal wall. It runs from deep to superfi cial, from the internal to
the external inguinal rings.
- The inguinal canal transmits the spermatic cord (round ligament in
the female) and the ilioinguinal nerve.
- Contents of the spermatic cord are:
-
Three vessels (testicular artery, cremasteric artery, artery to the
vas).
Three nerves (genital branch of genitofemoral, autonomic supply
-
to the testicle, ilioinguinal nerve).
Three structures (vas, pampiniform venous plexus, testicular
-
lymphatics).
-
Three coverings (external spermatic fascia, cremasteric fascia,
internal spermatic fascia).
- The deep ring is formed through the transversalis fascia and lies
1–2cm above the inguinal ligament, midway between the symphysis
pubis and the anterior superior iliac spine.
- The superfi cial ring is a V-shaped defect in the aponeurosis of
external oblique, above and medial to the pubic tubercle.
- Direct inguinal hernias pass through a weakness in the transversalis
fascia in the Hesselbach’s triangle area (bounded by inguinal
ligament inferiorly, inferior epigastric artery laterally, and lateral
border of the rectus muscle medially).
339
CHAPTER 9 Abdominal wall
340
Femoral hernia
Key facts
• Commoner in women than men.
• Occurs through tissues of femoral canal.
• Has a high risk of strangulation due to the neck of the sac having bony
and ligamentous structures limiting it on three sides.
• Approximately 30% of femoral hernias present as emergencies; 50% of
these require bowel resection for strangulation and ischaemia.
Clinical features
• Appears below and lateral to pubic tubercle, medial to femoral pulse.
• May be asymptomatic until incarceration or strangulation occurs.
• May be mistaken for an upper medial thigh swelling.
Diagnosis and investigations
• Differential diagnosis includes:
Low presentation of inguinal hernia.•
Femoral canal lipoma.•
Femoral lymph node.•
Saphena varix (compressible, disappears when lying fl at, palpable •
thrill on coughing or percussion of the saphenous vein).
Femoral artery aneurysm (pulsatile).•
Psoas abscess (fl uctuant and lateral to femoral artery).•
• Ultrasound scanning may help with the differential diagnosis. If there is
signifi cant doubt, exploration is usually indicated due to the high risk of
complications in untreated femoral hernia.
Treatment
• All should be repaired because of great risk of strangulation; truss has
no place in the management.
• Once the hernia is reduced, the femoral canal should be narrowed by
interrupted sutures to prevent recurrence; care must be taken not to
narrow the adjacent femoral vein. There are two main approaches.
Low approach (infrainguinal)
• Incision below inguinal ligament approaching femoral canal from below.
• Has the advantage of not interfering with the inguinal structures, but
provides little or no scope for resecting any compromised small bowel
and so is best reserved for elective surgery.
High approach (inguinal)
• Incision above the inguinal ligament approaching femoral canal from
above by dissecting through the posterior wall of the inguinal canal.
• Requires repair of the inguinal canal on closure, but offers excellent
access to the peritoneal cavity should small bowel surgery be required
and is the usual approach in emergency presentations.
FEMORAL HERNIA
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Key revision points—anatomy of the femoral canal
- Lies medial to femoral vein within femoral sheath.
- Contains loose areolar tissue and a lymph node known as the lymph
node of Cloquet.
- The femoral ring is the abdominal opening of the femoral canal.
The increased diameter of the true pelvis in females proportionally
widens the femoral canal.
- Boundaries to the femoral ring are:
-
Anteriorly, inguinal ligament.
Medially, lacunar ligament.Posteriorly, pectineal ligament.Laterally, femoral vein.-
- An aberrant obturator artery branch of inferior epigastric may cross
the lacunar ligament and can cause haemorrhage during surgical
repair.
- Femoral hernia repair (open) involves suture-plication of the inguinal
and pectineal ligaments or placement of a mesh plug that is fi xed in
position in the defect with non-absorbable sutures.
341
Соседние файлы в папке @xirurgi_2025