Groin Hernias

Groin hernias (inguinal hernias) are extremely common and have a lifetime incidence of 10% in men. They are five times more common in men than in women.

Inguinal hernias are classified as direct or indirect, depending on where the intraabdominal contents pass through the abdominal wall. Indirect hernias protrude lateral to the epigastric vessels (i.e., in close association with the spermatic cord cords) and direct inguinal hernias protrude through the floor of the inguinal canal.

Femoral hernias do occur in both men and women but are more frequent in women (but still relatively rare.)

Even experienced examiners have difficulty differentiating direct from indirect inguinal hernias on exam. The best test method to detect a hernia is having the examiner place their forefinger into the inguinal canal and evaluating for a bulge when the patient coughs.

Pre-operative Risk For Myocardial Infarction

The best risk factor for estimating pre-operatively the risk for a myocardial infarction (MI or heart attack) is the occurence of a myocardial infarction in the previous 6 months.

Truly elective surgery should be delayed at least six months after a previous MI.

Although the phrase “cardiology cleared the patient for surgery” is often used, there is no such thing as “cardiac clearance.” More accurately, clinicians and patients should refer to a risk stratification for the patient.

Mediatstinal Masses In Children

Although rare, mediatstinal masses in children do occur. The most common cause is a T-cell lymphoma. Other causes include teratomas, germ cell tumors, and tumors of neuro tissue origin such as neurofibroma, neuroblastoma, and neuroganglionoma.

Causes Of Hypertension That Are Surgically Correctable

There are five causes of hypertension that are caused by surgically correctable conditions. These are:

1. Renal artery stenosis or disease (most common)

2. Coarctation of the aorta

3. Cushing’s Disease

4. Primary hyperaldosteronism (Conn’s disease)

5. Pheochromocytoma

Validity Of The Screening Test For H1N1 (Swine) Flu

In a conversation at the place of work of one InsideSurgery editor this last week, a visiting official from the Centers for Disease Control (CDC) discussed the poor sensitivity and specificity of the screening test used in adults for detecting presence of the H1N1 virus.

The correct technique for sampling is a nasopharyngeal swab which requires an experienced technician to perform it correctly. Too often, the swab is not placed “far enough” up the nose.

If done correctly, the sampling is very uncomfortable for the few seconds it takes. As flu professionals say, if the patient does not want to slug the tester after the swab is obtained, it probably was not performed correctly.

Even in the setting of an adequate sample, the shedding of virus in adults is low, leading to a sensitivity (accuracy rate) of about 40%.

So, a negative screening for H1N1 in adults in no way rules out an infection with this worrisome influenza virus.

Closing Fistulas in Crohn’s Disease

One strategy recently developed for closing bowel fistulas that form in Crohn’s disease is use of the anti-tumor necrosis factor drug infliximab (Remicade.)

This is an uncommon condition that occurs when a gallstone passes into the bowel through a fistulous connection (i.e., not through the common bile duct), often in the setting of chronic cholecystitis.

The stone travels distally in the bowel with large stones becoming trapped at the ileocecal valve.

It occurs most typically in elderly women and is marked by nausea, vomiting, obstipation, and crampy abdominal pain.

Pneumobilia (air in the bile duct on radiographic examination) occurs in 50% of cases.

The treament is surgery with an enterotomy (incision in the bowel) to retrieve the stone. Stones trapped in the duodenum should be milked back into the stomach to avoid performing a duodenotomy (surgical opening of the duodenum.)

Multiple stones can pass through a fistula and a diligent search of the entire bowel must be made to insure all stones have been removed.

Definitive treatment is a cholecystectomy and fistula repair at the time of stone retrieval if the patient can tolerate the procedure.

Medical Treatment of Benign Prostatic Hypertrophy (BPH)

The two most commonly used drugs to treat BPH are Proscar (finasteride) and Flomax (tamsulosin).

Proscar actually reduces the size of the prostate gland. It is a 5-alpha reductase inhibitor and works by decreasing the amount of dihydrotestosterone in the prostate gland.

Flomax does not reduce the size of the prostate gland. It is a selective alpha-1 antagonist and it generally takes 2-3 weeks to have a clinical effect.

Anal warts (aka condyloma acuminata) are caused by an infection of the human papillovirus (HPV). Although troubling for the patient, up to 75% of cases respond well to medical management with topical medications such as acetic acid and podophyllin, topcial flourouracil, and topical interferon and imiquimod.

More recalcitrant cases may require excision or fulguration.

Anal warts are considered a sexually transmitted disease and risk factors include unprotective receptive anal intercourse, multiple sexual partners, and immunosuppression.

Calcineurin Inhibitors

These immunosuppression agents are widely used in solid organ transplantation and contributed significantly to improved outcomes. Drugs in this category include tacrolimus (Prograf) and cyclosporine (Neoral and Gengraf.)

The mechanism of action is through the inhibition of IL-2 production by activated T cells, which reduces cellular proliferation. Although extremely effective, side effects include toxicity to the kidney and nerves and hair loss (tacrolimus) and hirsuitism (cyclosporine,)

Causes of Hemophilia

Although they are clinically indistinguishable, there are actually two causes of the syndrome of hemophilia. Hemophilia A is caused by a deficiency in factor 8. Hemophilia B is caused by a deficiency in factor 9.

The treatment for each type is repletion of the deficient factor. It is important to know the specific type of hemophilia before attempting surgery as repletion of factor 8 will not prevent or stop a life-threatening bleed caused by hemophilia B (deficient factor 9.)

Also, DDAVP can be used to treat some mild cases of hemophila A, but is not effective in hemophilia B.

Blood Tranfusion Errors

Despite safeguards used by all hospitals, transfusion of mismatched blood does occur and usually results because of clerical error.

For patients who receive mismatched blood while undergoing surgery, the first sign is commonly diffuse bleeding shortly after the transfusion.

Basilar Skull Fractures

Basilar skull fracture are commonly seen in blunt trauma. These fractures are usually managed conservatively and do not require surgery. They present with the following:

1. Racoon’s eyes (periorbital edema)
2. Battle’s sign (postauricular ecchymoses)
3. Hemotympanum (blood behind the ear canal)
4. Cerebrospinal fluid otorrhea (drainage through the ear canal)
5. CSF rhinorrhea (drainage through the nostrils)
6. Cranial nerve deficits

Nasogastric tubes should not be placed in cases of suspected or confirmed basilar skull fractures as the tube can be inadvertently placed intracranially.

Metastatic Tumors To The Lung

The cancers that are most commonly metastatic to the lung are:

1. Colon
2. Breast
3. Renal (kidney)

In many cases, these tumors can be resected (surgically removed) if the following criteria are met:

1. There is no other metastatic disease in the body.
2. The amount of lung resection leaves adequate pulmonary reserve.
3. The primary tumor is adequately controlled.

Electrocardiogram Findings in Pericarditis

Pericarditis (inflammation of the sac around the heart) is associated with several ECG findings:

1. Low voltage (i.e., “small”) QRS complexes.
2. Electrical alternans.
3. ST segment elevations with a “concave up” morphology more common.
4. Depression of the PR wave.
5. T wave inversion, but usually only after the ST segment has normalized