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Surgery case presentation on anterior abdominal wall hernia

SUPRAUMBILICAL HERNIA WITH DIVERICATION OF RECTI

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Surgery case presentation on anterior abdominal wall hernia

  1. 1. SURGERY CASE PRESENTATION A CASE OF VENTRAL HERNIA
  2. 2. A CASE OF VENTRAL HERNIA
  3. 3. PRESENTED BY
  4. 4. HISTORY
  5. 5. PATIENT’S PARTICULARS Name – Karthik Rajbongshi Hospital no. – 211168/16 Age – 26 years Deptt. Regd. No. – 16675/16 Sex – Male Ward – Surgery Religion – Hinduism Unit – MSU II+V Address – C/O Karuna Rajbongshi, Bed no. – 31 Village: Kathalbari, P.S.- Nalbari, District- Nalbari, Ph. No.- 9018142488 Occupation – CRPF Personnel Marital Status – Bachelor Date of Admission – 1/7/2016 Date of Examination – 4/7/2016
  6. 6. CHIEF COMPLAINTS  Abdominal swelling for 18 years.  Pain abdomen for 4-5 months.
  7. 7. HISTORY OF PRESENT ILLNESS  The patient complains of a lump in the abdomen along the midline just above the umbilicus which he first noticed when he was 8-9 years of age and ignored it. It resembled a marble then.  Suddenly 4-5 months back, he felt pain in the umbilical region along the midline when he noticed that the lump had then rapidly increased to the size of a betel-nut. It becomes prominent on coughing or straining such as on strenous exercise and reduces spontaneously on lying down on the bed.  The pain is an intermittent dull-ache, moderate in intensity, aggravated on straining and relieved on leaning forward. There is no radiation of the pain.
  8. 8. HISTORY OF PRESENT ILLNESS  There is no vomiting, no yellowish discolouration of eyes or urine, no chronic cough or constipation or abdominal distension.  The bowel, bladder habits are normal, sleep is normal and the appetite is good. There is no loss of weight.  The patient was referred to GMCH from a CRPF hospital and after the necessary investigations, he has been called for surgery at a later date.
  9. 9. HISTORY OF PAST ILLNESS  The patient has no history of similar swelling in the past, elsewhere in the body.  The patient has no history of respiratory problems such as asthma, cardiac ailments, tuberculosis, diabetes, hypertension, malaria or any surgical history in the past.
  10. 10. PERSONAL HISTORY  The patient is a non-vegetarian and consumes an average Assamese diet. He does not consume any intoxicants.
  11. 11. FAMILY HISTORY  The patient’s family presents with no similar complaints. No disease runs in the family.
  12. 12. SOCIOECONOMIC HISTORY  The patient lives in a pucca house in a 3 membered nuclear family with his parents and a younger brother.  He is the sole earning member with a monthly income of Rs 18000 and a per capita income of Rs 6000. They use LPG cylinder as the fuel source for cooking.  They consume tubewell water after filtration.
  13. 13. DRUG AND ALLERGY HISTORY  There is no routine consumption of any drug.  There is no history of allergy to any known contactant, ingestant or inhalant.
  14. 14. IMMUNISATION HISTORY  The patient could not specify his immunisation history.  No BCG scar seen.
  15. 15. GENERAL EXAMINATION
  16. 16. • Consciousness- The patient is alert and conscious • Orientation- Well oriented to time, place and person • Appearance and Facies- Normal • Decubitus- Of choice • Build- Average • Nutrition- Good • Gait- Normal • Pallor- Absent • Icterus- Absent • Cyanosis-Absent • Clubbing- Absent • Dehydration -Absent • Neck Veins- Not engorged • Lymph nodes- Not palpable • Edema- Absent • Hair ,skin and nails- Normal • Oral Cavity- Oral hygiene is maintained, no features of malnutrition, no dental caries, gums , tongue is moist with normal papillae
  17. 17. VITALS • PULSE- 1. Rate- 84 beats/ min 2. Rhythm- regular 3. Character- normal 4. Volume- normovolumic 5. Radioradial or Radiofemoral delay- Absent 6. All peripheral pulses- Palpable 7.Elasticity of arterial wall- present • BLOOD PRESSURE- 120/72 mm Hg in left arm taken in supine position • RESPIRATORY RATE- 18/ min, regular, abdominothoracic. • TEMPERATURE- 98˚F
  18. 18. OTHER SYSTEMIC EXAMINATION
  19. 19. CENTRAL NERVOUS SYSTEM a) Higher function: The patient is alert, conscious, cooperative and well oriented to time, place and person. b) Cranial Nerves: Functions of all the cranial nerves are intact. c) Motor system: Tone, power and bulk of muscles of all four limbs are normal. Coordination is normal. No abnormality detected. All the superficial and deep reflexes are intact. d) Sensory and autonomic functions are normal.
  20. 20. CARDIOVASCULAR SYSTEM a) Inspection: Precordium is normal. No visible pulsations or engorged veins seen. No scar is seen. b) Palpation: Apex beat is palpable just medial to mid-clavicular line in the left 5th intercostal space. It is normal in character. c) Auscultation: Heart sounds are normal. No added sounds heard.
  21. 21. RESPIRATORY SYSTEM a) Inspection: Shape and symmetry of chest is normal and symmetrical. Respiratory movements are bilaterally symmetrical. Respiratory rate is 18/minute and regular in rhythm. No deformity detected. b) Palpation: Trachea is in midline. Chest expansion is normal and bilaterally symmetrical on both sides. Vocal fremitus is bilaterally symmetrical and normal. c) Percussion: Lung field is uniformly resonant in all the areas. No abnormality detected. d) Auscultation: Normal breath sounds are heard in all the areas. Vocal resonance is normal and bilaterally symmetrical in all the areas. No added sounds heard.
  22. 22. ABDOMINAL EXAMINATION
  23. 23. INSPECTION a) Shape and contour of abdomen – Normal. b) Umbilicus – Inverted, midline in position and midway between the xiphisternum and pubic symphysis. c) Skin over the abdomen – No scar, abnormal pigmentation or engorged veins seen. d) Movement of abdomen with respiration – All regions are moving normally with respiration. e) Any visible peristalsis – None. f) Any visible pulsations – None.
  24. 24. INSPECTION g) Prominent divaricated edges of both recti along with visi ble mass is seen.  Site – present in the supraumbilical region along the midline.  Shape – oval in shape.  Surface – Smooth.  Margins – Well defined.  ‘Leg rising test’ and ‘Head rising test’ – the visible swelling becomes more prominent, hence it is a PARIETAL SWELLING.  Cough Impulse Test – Expansile impulse on cough is present.  Any ulceration or skin changes over the defect – None.
  25. 25. INSPECTION h) Inspection of other hernia sites – No swelling and no expansile impulse on coughing is seen. i) Inspection of external genitalia – Normal.
  26. 26. SUPERFICIAL PALPATION a) Temperature – No local rise of temperature. b) Superficial tenderness – Tenderness is present in the umbilical region over the area of the defect as well as in the midline. No tenderness present in any of the other areas. c) Feel of abdomen – Soft and elastic. d) Any muscle guarding and rigidity – None. e) Palpation of swelling :-  Site and extent – midline in position just over the umbilicus.  Size – 3x4 cm.  Shape – Oval.  Surface – Smooth.  Margin – Well-defined.  Reducibility of swelling – Swelling is reducible.  Cough impulse test – Positive.  Consistency – Soft, doughy feel on knee elbow position.  Pulsation – none.  Compressibility of swelling – Not compressible on knee elbow position.  Fluctuation – Absent on knee elbow position.
  27. 27. DEEP PALPATION a) Tenderness – tenderness present only over the defect and in midline, no tenderness over any of the other areas. b) Palpation of liver – Not palpable. c) Palpation of spleen – Not palpable. d) Palpation of kidneys – Not palpable.
  28. 28. PERCUSSION a) General percussion note over the abdomen – Tympanitic. b) Percussion note over the swelling – Dull. c) Shifting dullness – Absent. d) Fluid thrill – Absent. e) Liver span – 12.5 cm, upper border in the right 5th intercostal space.
  29. 29. AUSCULATATION a) Auscultationovertheswelling –nobowelsoundsheard. b) Peristalticsoundintheotherareas–Presentand normal. c) Bruit–Absentinanyareas.
  30. 30. PER RECTAL EXAMINATION  Not done.
  31. 31. PROVISIONAL DIAGNOSIS
  32. 32. Our patient Karthik Rajbongshi, 26 years old Male is provisionally diagnosed to be a case of PARAUMBILICAL HERNIA IN THE SUPRAUMBILICAL REGION OF THE ABDOMEN, PROBABLY AN OMENTOCELE WITH DIVERICATION OF RECTI.
  33. 33. DIFFERENTIAL DIAGNOSIS
  34. 34. 1. Congenital weakness of rectus sheath. 2. Congenital absence of rectus.
  35. 35. INVESTIGATIONS
  36. 36. HAEMATOLOGY WBC 8.01 (10^3/uL) (WNL) Haemoglobin 16.2 (g/dl) (WNL) Platelet 205 (10^3/uL) (WNL) Neutrophil 58.9% (WNL) Lymphocyte 31.7% (WNL) Monocyte 8.4% (WNL) Eosinophil 1% (WNL) ESR 14 (mm After 1 Hour) Prothrombin(control 13 seconds ) 14.8sec PT-INR 1.24
  37. 37. SERUM SAMPLE - Glucose-Random 79 (mg/dl) (LOW) - Urea 30 (mg/dl) - Creatinine 1.0(mg/dl) - Sodium 144(mmol/l) - Potassium 4.6(mmol/l) - Total Bilirubin 1.10(mg/dl) - Conjugated Bilirubin 0.0(mg/dl) - Unconjugated Bilirubin 0.7(mg/dl) - Delta Bilirubin 0.4(mg/dl) (HIGH) - AST 35 (U/L) - ALT 47 (U/L) -ALKP 65 (U/L) -Total Protein 8.5(g/dl) (HIGH) -Albumin 5.1(g/dl) (HIGH) -Globulin 3.4(g/dl) -A/G Ratio 1.5
  38. 38. SERUM SAMPLE - Hepatitis B Virus (HBsAg TEST) NON REACTIVE - Hepatitis c Virus (Anti-HCV antibody test) NON REACTIVE - HIV NON REACTIVE - Serum TSH 2.02mIU/L
  39. 39. RADIOLOGY X-Ray Chest PA View -Both the lung fields do not reveal any active parenchymal lesions. -Trachea is normal in position. -Hilar shadows are normal. -Cardiothoracic ratio is normal.Great vessels are within normal limits. -CP angles are clear and acute. -Both domes of diaphragm are normal in position and contour. -Bony thorax is intact.
  40. 40. RADIOLOGY Ultrasonography: Report is currently not available but according to the consulting doctors who have gone through thepreviousreports,thereissomedefectintheanteriorabdominalwallwithherniation.
  41. 41. FINAL DIAGNOSIS
  42. 42. “Our patient Karthik Rajbongshi, 26 years old Male is finally diagnosed to be a case of PARAUMBILICAL HERNIA IN THE SUPRAUMBILICAL REGION OF THE ABDOMEN WITH AN OMENTOCELE WITH DIVERICATION OF RECTI.”
  43. 43. MANAGEMENT
  44. 44. THE MANAGEMENT IS PRIMARILY SURGICAL 1. Primary Closure Of The Defect- An infraumbilical incision is made encircling its lower half. Sac is dissected circumferentially and is released of from the umbilicus ande subcutaneous tissue. Sac is opened ; contents are reduced ;excess part is excised up to the umbilical ring. Defect is closed with interupted nonabsorbable suture. 2. Mayo's Operation- Through a transverse elliptical incision sac is identified and dissected . Herniotomy is done. Double breasting of the defect in the rectus sheath is done by interrupted non-absorbable suture.
  45. 45. THE MANAGEMENT IS PRIMARILY SURGICAL 3. Open Dual PTFE and Polypropylene Mesh Placement- Umbilical hernia is dissected similarly through subumbilical incision. Redundant sac is excised. Peritoneum is closed. A special composite mesh containing wider PTFE on the inner side with little smaller polypropylene mesh on the outer aspect is used. 4. Laparascopic Umbilical Hernia Repair- It is similar to any ventral hernia , done under GA. It is usually done for large umbilical hernia.
  46. 46. SUMMARY

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