Home » 02. Congenital anomalies of front abdominal wall

02. Congenital anomalies of front abdominal wall

June 25, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6^TH COURSE

Medical Faculty

Content module 5. “Malformation in children”

LESSON № 2 (PRACTICAL – 6 HOURS)

Theme: Defects of development of front abdominal wall. (omphalocele, gastroschisis, umbilical and inguinal hernias, cryptorchidism).-6h.

Aim: To discover the basic clinical and supplementary (radiographic, endoscopic, laboratory and instrumental) signs of disease, choice of optimal conservative or operative treatment.

Professional orientation of students: 98% of hernias require elective surgery at different ages (excluding cases of incarceration). The other 2% are cases of omphalocele which require a combined approach. The risk of incarceration of all hernia types however, makes knowledge of the diagnosis and basic principles of management of hernias imperative on all physicians.

Individual students’ work with patients – 9.00-12.00

Methodology of Practical Class.

Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):

Work 1.

1. Friendly facial expression, smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Tactful and calm conversation with patient’s relatives, if it is necessary.

5. Explanation of planned actions of the patient’s treatment (hospitalization, performing certain examinations, etc.).

6. Conversation accomplishment.

7. Explain to a patient what examination will be performing and get his/her informed consent.

8. Prepare yourself to perform examination (clean and warm hands, warm phonedoscope, etc).

9. Explain the necessity of transportation to the examination place (medical examination room, ultrasonic investigation, computer tomography, endoscopy, etc).

10. Perform examination.

11. Explain to the patient results of his/her lab tests correctly and accessibly.

12. Conversation accomplishment.

13. Involve patient’s relatives into the conversation (compare present examination results with previous ones, clarify whether your explanations are clear for them).

14. Conversation accomplishment.

15. Get the patient’s agreement on bandaging.

16. Explain to the patient manipulation actions which are performed or will be performed in the future and strategy of further treatment.

17. Inform the patient with a stoma about possibility of further rehabilitation and improvement of life quality.

Individual Students Program.

1. Embryogenesis, developmental abnormalities of the anterior abdominal wall, diaphragm.

2. Pathomorphologic and pathophysiologic changes in congenital abnormalities of the anterior abdominal wall and processus vaginalis.

3. Clinical, radiologic, instrumental diagnosis.

4. Special features of anesthesia and surgical repair of inguinal, abdominal wall and diaphragmatic hernias.

Break – 12.⁰⁰-12.³⁰

Seminar discussion of theoretical issues. – 12.³⁰-14.⁰⁰

1. Etiology, embryology, clinical manifestations and differential diagnosis of the congenital inguinal hernia

2. Umbilical hernia in childhood: clinical manifestations, diagnosis, treatment

3. Cryptorchidism: pathophysiology, types, clinical features, complications, treatment

4. Abdominal wall defects (gastroschisis and omphalocele): causes, embryology, pathogenesis, prenatal diagnosis

5. Abdominal wall defects (gastroschisis and omphalocele): diagnosis and treatment

Test evaluation and situational tasks.

1. During inguinal herniotomy in a 12 year old the testis was found in the hernia sac. What type of hernia is this?

A. Richter’s hernia

B. Congenital indirect hernia

C. Acquired direct hernia

D. Direct hernia

E. Femoral hernia

2. A hernia containing the vermiform appendix in its sac is known as:

A. Richter’s hernia

B. Amyand’s hernia

C. Littre’s hernia

D. Omentocele

E. Indirect hernia

3. An exomphalos is:

A. A strangulated umbilical hernia

B. Synonymous with an omphalocele

C. A strangulated femoral hernia

D. A strangulated inguinal hernia

E. A sliding hernia

4. Which of the following hernias is diaphragmatic?

A. Richter’s hernia

B. Bogdalech’s hernia

C. Amyand’s hernia

D. Littre’s hernia

E. None of the above

5. A patent processus vaginalis can lead to all of the following, except:

A. Funiculocele

B. Omphalocele

C. Bubonocele

D. Scrotal hernia

E. Hydrocele

6. Congenital absence of one of the testes is known as:

A. cryptorchidism

B. anorchia

C. monorchism

D. ectopia

E. dystopia

7. Cryptorchidism is most frequently found:

A. on the left side

B. bilaterally

C. on the right side

D. retroperitoneally

E. in the abdomen

8. All are possible complications of an undescended testis except:

A. malignization

B. acute scrotum

C. torsion and trauma

D. hypoplasia

E. sterility

Clinical situation tests:

Test 38:

One hour after birth, an anterior abdominal wall herniation10X12cm in size was noticed in the newborn. Parts of the abdominal viscera were discovered in the umbilical sac. What is your diagnosis and course of action?

Test 39:

A neonate was discovered to have an omphalocele without associated developmental abnormalities or pathological conditions in other organs. What would be your course of action in this case?

Test 40:

An umbilical bulge 1.5X1.5cm was discovered in a newborn. At rest and in the supine position the hernia was reducible and the umbilical ring was palpable. What is your diagnosis and course of action?

Test 41:

On physical examination a child of 2 was found to have a bulge 2X2cm in size in the right inguinal region which increases in size on restlessness and crying and disappears at rest or in the supine position. The bulge was non-tender, spherical and elastic. During attempts at reduction a gurgling sound is heard and the external inguinal ring is well pronounced beneath the examiner’s finger. What is your diagnosis and course of action?

Test 42:

A 4 year old child was presented with a 2X3cm bulge in the left inguinal region, noticed by the parents 2 hours ago. The child was crying, restless and complains of pain over the bulge. On palpation the bulge was found to be tense, markedly tender and irreducible. Vomiting has been reported and the external inguinal ring caot be palpated under the examiner’s finger. What would be your diagnosis and course of action?

Test 43:

Physical examination of a neonate revealed the baby to be under respiratory distress, periodically cyanotic and out of breath, especially after feeding. The physical signs were: a flat “scaphoid” abdomen, asymmetric thorax (with a larger left side); percussion: tympany over the left side of the thorax, dextrocardia; auscultation: reduction of breath sounds on the left side with periodic elicitation of peristaltic sounds. Plain chest radiograph reveals an oval-shaped multiple-loop pattern on the left side. What would be your diagnosis and course of action?

Test 62:

A 4 year old boy presented with absence of the testicle on the right side of the scrotum. There were no other complaints. On examination in the horizontal position a mobile testis was palpated in the inguinal canal but all attempts to pull it down to the scrotum proved futile. What would be your diagnosis and course of action?

Test 66:

A 10 year old boy was admitted with a diagnosis of right-sided cryptorchidism. On examination a tumor, which increases in size on exertion was elicited in the right inguinal region. The tumor was spherical in shape, non-tender, elastic. Borborygmi were elicited while attempting to place it into the scrotum. The external inguinal ring was found to be widened. What would be your diagnosis?

Break – 14.⁰⁰-14.¹⁵

Individual work 14¹⁵-15⁰⁰

– Analysis of test tasks licensing examinations “Step”;

– Assessment of students who have not passed the day before the test control system «Moodle»;

– Putting the students practical skills in the entry matrykul book.

Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.

(the instructor has tests & situational tasks)

Student should know:

1. Special features of embryonogenetic, pathophysiologic changes in developmental abnormalities of processus vaginalis, the anterior abdominal wall, diaphragm:

a). Embryogenesis of processus vaginalis, types of inguinal hernias (bubonocele, funicular, complete)

– reducible, irreducible, incarcerated.

b). Embryogenesis of anterior abdominal wall development, types of umbilical hernias (reducible,

irreducible, incarcerated)

c). Types of omphalocele:

small (up to 5cm.)

medium (up to 10cm.)

large (greater than 10cm.)

-uncomplicated, complicated.

d). Embryogenesis of testicular anomalies.

Types of testicular retention : abdominal, inguinal.

Testicular ectopia: pubic, inguinal, femoral and perineal.

True and pseudo-cryptorchidism.

Developmental testicular anomalies: hypoplasia, monorchism, anorchia, polyorchia.

2.Clinical, laboratory and radiologic diagnosis of hernias in childhood

a). Clinical, radiologic (plain, contrast studies, mediastinograph, pneumoperitoneograph), laboratory,

instrumental (diaphanoscopy) diagnosis of hernias in childhood.

3. Differential diagnosis of congenital hernias in childhood.

a). Inguinal hernias:

congenital hydrocele, cryptorchidism, inguinal lymphadenitis, testicular tumors, inguinal tumors, acute testis.

b). Incarcerated inguinal hernias:

inguinal lymphadenitis, testicular tumors, inguinal tumors, acute testis.

4. Basic principles of conservative and surgical management of hernias in childhood

a). Reducible inguinal hernia (Donetskiy, Roux-Krasnobaev, Duhamel, Martinov operations, Czerny,

Fallis herniorrhaphy). Special features of management of sliding hernias, inguinal hernias in females.

b). Omphalocele (Suturing of the abdominal wall, Olshausen’s operation, Tikhomiroviy, Shilovtsev,

Conservative management of large hernias, antibacterial and infusion therapy).

c). Umbilical hernias (Lexer herniorrhaphy, Mayo, Sapezhko).

d). Special features of conservative (hormonal) and surgical management of cryptorchidism (Operations:

Schudler, Keathly, Torek-Gertsen, Sokolov, Petrovskiy)

Student should be able to:

1. Define the general and local symptoms of childhood hernias.

2. Use supplementary methods of investigation in determining the types of congenital anomalies of the

anterior abdominal wall and diaphragm (plain and contrast radiography, pneumomediastinography, pneumoperitoneography, diaphanoscopy).

3. Define blood groups, Rhesus factor.

4. Evaluate laboratory and radiologic investigations.

5. Compose a detailed plan of conservative and surgical management.

6. Set up an IV infusion set.

7. Perform drainage of the pleural cavity.

8. Carry out gastric decompression.

9. Perform wound dressing.

10. Remove sutures.

Correct answers of test evaluations and situational tasks:

Multiple-choice tests:

1. B

2. B

3. B

4. B

5. B

6. C

7. C

8. B

Clinical situation tests:

Test 38 – Omphalocele, conservative treatment / alloplastic surgery.

Test 39 – Depending on the size of herniation – conservative or surgical management.

Test 40 – Umbilical hernia, conservative management.

Test 41 – Strangulated inguinal hernia, conservative reduction + subsequent surgery.

Test 32 – Diaphragmatic hernia, surgical management.

Test 62 – Inguinal cryptorchidism; orchiopexy

Test 66 – Cryptorchidism associated with an inguinal hernia; orchiopexy and herniotomy.

References:

А – Basic:

1. K.W. Ashcraft, T.M. Holder “Pediatric Surgery”. W.B. Saunders Co., Philadelphia 2010. 1101pages.

2. Practical classes materials

3. Klein M. Congenital abdominal wall defects. In: Ashcraft KW, Holcomb GW, Murphy JP. Pediatric Surgery. 4th Ed. Philadelphia: Elsevier, 2005:659-669.

4. Stovroff MA, Teague WG. Omphalocele and gastroschisis. In: Ziegler MM, Azizkhan RG, Weber TR, eds. Operative Pediatric Surgery. New York: McGraw-Hill, 2003:525-535.

5. Collins, S. Hydrocele and hernia in children. Available at http:// emedicine.medscape.com/article/1015147 (accessed 16 November 2008).

В – Additional:

1. Owen A, Marven S, Jackson L et al. Experience of bedside performed silo staged reduction and closure for gastroschisis. J Pediatr Surg 2006; 41:1830-1835.

2. Lee SL, Beyer TD, Kim SS et al. Initial nonoperative management and delayed closure for treatment of giant omphaloceles. J Pediatr Surg 2006; 41:1846-1850.