Abdominal Examination

Set-Up The Abdomen

Pt. exposed from nipples to pubis
Lying flat Inspection
Distension: fat, fluid, flatus, faeces, foetus
Peripheral Stigmata Scars: describe location and healing
Stomas: site, contents, lumens, spout
General Drains: contents, type
General condition of the pt. Asymmetry: masses
Jaundice (BR >50mM), pallor (Hb <7g/dL)
Cachexia
Abdominal distension Palpation
Abdominal asymmetry Kneel on floor and look @ pts. face for pain
Drains, stomas, scars Superficial, then deep
Ask pt. to cough and lift head from bed Describe any masses
Liver
Hands Note consistency, edge, tenderness, pulse
Percuss
CLD Abdominal Clubbing Spleen
1. Clubbing Role pt. towards you
Cirrhosis: esp. c̄ PBC
2. Leukonychia Percuss if palpable
IBD
3. Terry’s nails Kidneys
Coeliac Left then right
White ground glass nail
GI lymphoma Ballot c̄ respiration
Loss of lunula
Pink tips AAA
4. Palmer erythema Just to left on midline, above the umbilicus
5. Dupuytron’s contracture
6. Asterixis
Percussion
Anaemia Percuss any masses or organomegaly
Koilonychia If distended, percuss for shifting dullness
Pale palmer creases

Pulse and BP
Auscultate
Face Bowel sounds
Aortic bruits
Eyes
Keiser Fleischer rings
Pale conjunctivae Palpate Ankles for Oedema
Jaundice
Xanthelasma
Completion
Mouth Digital rectal examination
Telangiectasia: HHT External genitalia
Pigmented macules: Peutz-Jehgers Stand pt. to examine hernial orifices
Stomatitis and glossitis Dipstick the urine
Ulceration Look at the observation chart
Jaundice

Neck
Inspect for scars: venous lines
Sit forward and palpate for lymphadenopathy: esp.
Virchow’s node in left supraclavicular fossa

Back Spider Naevi

Inspect back c̄ pt. sitting forward Central arteriole c̄ radiating vessels
Spider naevi Fill from the centre
Scars: e.g. loin incisions Telangiectasia fill from edge
Distribution of SVC
Chest >4 abnormal
Spider naevi : CLD, OCP, pregnancy
Gynaecomastia
Loss of axillary hair

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 Inguinal Hernia
Examination Viva

Set-Up Groin Lump Differential

Expose pt. from umbilicus to knees
Begin c̄ pt. standing Tissue Lump
Skin Sebaceous cyst, psoas abscess
Fat Lipoma
Inspection Connective tissue Fibroma
Look for any masses in groins. Ask pt. to cough. Nerves Neuroma of femoral N.
Comment on appearance of mass Lymphatics LN
Veins Saphena varix
Site, size
Features of inflammation (suggesting strangulation) Arteries Femoral artery aneurysm
Inguinal canal Inguinal hernia
Look for any scars
Hydrocele or lipoma of the cord
Previous hernia operations
Femoral canal Femoral hernia
Appendicectomy: ? risk factor for direct hernia
Testes Undescended testis

4 distinguishing features of an inguinal hernia

Palpation Above and medial to pubic tubercle
Check if pt. in any pain. Cough impulse
Palpate from the side of the pt. Reducible
Palpate mass for cough impulse Bowel sounds
Define anatomy: relation to pubic tubercle?
Above (and medial): inguinal hernia
Below (and lateral): femoral hernia
Hx
Predisposing factors: cough, straining, lifting
Does mass extend into scrotum?
Inguinoscrotal hernia are more likely to be indirect Pain
Auscultate for bowel sounds Reducible
Hernia may lack bowel sounds if it just contains fat. Episodes of obstruction or strangulation
Previous repairs

Repeat Inspection and Palpation c̄ pt. Supine

Mx
Does the mass disappear when lying down?
Conservative
Manage RFs: e.g. constipation, cough
Test for Direct vs. Indirect Hernia Weight loss
Ask pt. to reduce hernia Elasticated corset or truss
Place 2 fingers over deep ring and ask pt. to cough.
Mid pt. of ing. lig. or 1.5cm above femoral pulse Surgical
Hernia controlled = indirect Open: Lichtenstein Tension Free Mesh
Not controlled = direct Lap: TEP or TAPP mesh
Not an accurate test: definitive determination in theatre.

Discussion
Wash hands Difference between direct and indirect inguinal hernia
Difference between inguinal and femoral hernias
Inguinal canal anatomy
Complete Examination Contents of the spermatic cord
Examine external genitalia: incidental lumps, testes Recovery from inguinal hernia repair
Examine contralateral groin Operative techniques
Examine abdomen Complications of repair
Evidence of ↑ IAP: masses, ascites
Other hernias: paraumbilical, umbilical

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 Inguinal Hernia: Key Facts
Definition Surgery
Protrusion of a viscus or part of a viscus into an abnormal Open and lap approaches: lap if bilateral / recurrent
position through a defect in its containing cavity. Mention risk of testicular damage when consenting pt.

Open
Anatomy Open can be done under LA or GA: day case
RCS recommends the Lichtenstein Tension Free
Inguinal Canal Mesh Repair
Ant: ext. oblique + int. oblique for lateral 3rd Less recurrence cf. older Shouldice Repair
Post: transversalis fascia + conjoint tendon for medial 3rd
Floor: inguinal ligament NB. In children, simple ligation and division of the patent
Roof: arching fibres of transversus and int. oblique processus suffices: no mesh needed.

Femoral Canal Lap

Med: lacunar ligament 2 main techniques
Lat: femoral vein Totally ExtraPeritoneal (TEP)
Ant: inguinal ligament Trans-Abdominal Pre-Peritoneal (TAPP)
Post: pectineal ligament (of Cooper) Better for bilateral hernia
Contents: fat and Cloquet’s Node
Complications
Contents of Inguinal Canal
M: spermatic cord + ilioinguinal N. Early
F: round lig., ilioinguinal N., gen branch of genfem N. Urinary retention
Haematoma / seroma formation: 10%
Contents of Spermatic Cord Infection: 1%
3 layers of fascia Intra-abdominal injury (lap)
3 arteries + 3 veins
Late
2 nerves
Recurrence: <2%
3 other things
Ischaemic orchitis: 0.5%
O
2 thrombosis of pampiniform plexus
Operative Distinction Chronic groin pain / paraesthesia: 5%
Indirect: arise lateral to inf. epigastric vessels
Direct: arise medial to inguinal ligament, through
Post-Op Recovery
Hesselbach’s Triangle
Med: rectus abdominis muscle Pee before leaving
Lat: inf. epigastric artery Early mobilisation is important
Inf: inguinal ligament Can be painful: given good analgesia
Avoid constipation: lactulose
Keep the area clean and dry: wash carefully
Classification of Inguinal Hernias Can bathe immediately
Work in 1-2wks (6wks if heavy lifting)
Indirect: 80%
Commoner in young
Congenital patent processus vaginalis Femoral Hernia
Emerge through deep ring Commoner in females (wider femoral canal)
Same 3 coverings as cord and descend into the scrotum Middle aged and elderly
Can strangulate Neck is inferior and lateral to pubic tubercle
High risk of obstruction and strangulation
Direct: 20%
Commoner in elderly Mx
Acquired: weak posterior wall of canal 50% risk of strangulation w/i 1mo
Emerge through Hesselbach’s triangle Urgent surgery
Can acquire internal and external spermatic fascia
Rarely descend into scrotum Elective: Lockwood Low Approach
Rarely strangulate Low incision over hernia c̄ herniotomy and
herniorrhaphy (suture ing. ligt. to pectineal ligt.)
Clinical Distinction
Cameron, BJS 1994 Emergency: McEvedy High Approach
56% of direct hernias were wrongly classified as indirect on High approach in inguinal region to allow inspection
examination by consultant surgeons. and resection of non-viable bowel.
Then herniotomy and herniorrhaphy

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 Incisional Hernia
Examination Viva
Inspection Hx
Pt. may be overweight Previous surgery
Describe scars + drain sites Post-operative wound infection or other complications
Any evidence of inflammation (e.g. from strangulation) Co-morbidities → ↑ risk: e.g. chronic cough
Ask pt. to lift head off bed Discomfort or episodes of obstruction
Ask pt. to cough

Palpation Definition
Any tenderness? Extrusion of peritoneum and abdominal contents through
Feel for presence of defect a previously acquired defect.
Ask pt. to cough while feeling for an impulse
Is the defect present along the whole length of the scar?
Size of defect relates to risk of strangulation Complications
If a lump is present, can it be reduced? Intestinal obstruction: often intermittent
Become irreducible
Auscultate Strangulation
For bowel sounds Pain or discomfort

Risk Factors
Pre-operative
↑ age
Comorbidities: DM, renal failure
Drugs: steroids, chemo, radio
Obesity or malnutrition
Malignancy

Intra-operative
Surgical technique/skill (major factor)
Too small suture bites
Inappropriate suture material
Incision type (e.g. midline)
Placing drains through wounds

Post-operative
↑ IAP: chronic cough, straining, post-op ileus
Infection
Haematoma

Mx
Surgery is not appropriate for all patients.
Must balance risk of operation and recurrence c̄ risk of
obstruction / strangulation and pt. choice.
Usually broad-necked low risk of strangulation

Conservative
Manage RFs: e.g. constipation, cough
Weight loss
Elasticated corset or truss

Surgical
Pre-Op
Optimise cardiorespiratory function
Encourage wt. loss
Nylon mesh repair: open or lap

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 Umbilical and Paraumbilical Hernia
Examination Viva
Inspection Hx
Pt. may be overweight Predisposing factors: pregnancy, ascites, obesity
Ask pt. to lift head off bed and to cough Pain
Note any associated skin damage: e.g. ulceration Reducible
Note any overlying scars: may indicate recurrence Episodes of obstruction or strangulation
Previous repairs
Palpation
Any tenderness?
Feel for presence of defect Paraumbilical
Try to asses size
Ask pt. to cough while feeling for an impulse Pathogenesis
If a lump is present, ask pt. to reduce it. Acquired defect in the linea alba just above or below the
umbilicus
Commoner in obese, middle-aged pts.
Neck is commonly narrow
Prone to becoming irreducible or strangulated
Typically contain omentum ± large or small bowel
May be large → necrosis of the skin

Risk Factors
Obesity
Pregnancy
Ascites
Fibroids
Bowel distension

Mx
Surgery advised due to high risk of strangulation
Rx concurrent medical problems
Mayo Repair
Mobilise sac and reduce contents
Double-breast the linea alba ± sublay mesh

Umbilical
Pathogenesis
Congenital defect in the umbilical scar (cicatrix)
Typically congenital: 3% of live births

Risk Factors
Afro-Caribbean
Trisomy 21
Congenital hypothyroidism

Can recur in adults: pregnancy, ascites

Mx
Usually asymptomatic and resolve by 2-3yrs
Surgical repair advocated if no resolution by 3yrs

Other Congenital Defects

Gastroschisis
Protrusion of abdo contents through defect in abdo wall
to the right of the umbilicus.
Not usually assoc. c̄ other abnormalities
Promt surgical repair after fluid resuscitation

Exomphalos
Protrusion of abdominal contents w/i in a 3-layered sac
Commonly assoc. c̄ other defects: cardiac, anencephaly
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 Epigastric Hernia
Examination Viva
Inspection Hx
Midline lump above the umbilicus when the pt. coughs or Predisposing factors: pregnancy, obesity
lifts head from bed. Symptoms
Typically small: “pea shaped” Reducible
Associated scars? Episodes of obstruction or strangulation
Incisional hernia or previous repairs Previous repairs

Palpation
Any pain? Features
Feel for cough impulse Abnormal protrusion of abdominal contents through a
Establish size of the defect defect in the linea alba between the xiphisternum and
umbilicus.
Differential Usually contain extraperitoneal fat or omentum
Incisional hernia: ?scar Commoner in young (20-50yrs)
Divarication of the recti
Widening of gap between recti muscles
Not a hernia Symptoms
May be asymptomatic
May be confused for upper GI pathology
Pain: may ↑ after meals or exercise
Nausea and early satiety
Abdominal bloating

Mx
Conservative
Manage RFs: e.g. constipation, cough
Weight loss

Surgical
Reduce hernial contents and excise sac
Suture or mesh repair

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