Summary 

Overall, I had a really good experience on my surgery rotation.  Going in I thought I would have little interest in surgery, however I was surprised by how much I enjoyed it.  I liked having the opportunity to see the whole process, getting to scrub in for a procedure and follow the patient’s progress on the surgical floor.  I was pleasantly surprised to learn that much of working in surgery is not just time spent in the operating room.  I was able to see consults in the emergency room, evaluate patients in clinic, observe patients in the PACU, help manage patients on the floor, and see patients back in the clinic for post op evaluations.  These experiences gave me a good understanding or the many aspects that have to be evaluated prior to scheduling surgery, the complications that may arise following an operation in addition to hands on experience in the OR.

One challenge I encountered was the fact that I was rotating with many students and had to vouch for myself to be able to have certain opportunities.  I view these other students as future colleagues, and it was important to me to work with them so we can all benefit from the rotation with the given limitations.  This required some extra care in communicating with the other students while still maintaining a level of assertiveness.  I think over the course of the rotation, I was able to strike that balance.

Here is a log of all the patients I saw Case logs7

Site Evaluation 

I really enjoyed my meeting with my site elevator this rotation.  I am able to appreciate that as I get further in my rotations and my fund of knowledge becomes more broad, my case presentations have become more of a discussion of the case than just me presenting an H&P.  At my first site evaluation, I presented a case of a patient with an inguinal hernia I evaluated preoperatively in the clinic.  At my second site evaluation I presented a patient with cholecystitis.  I think I definitely improved on providing differentials and the appropriate tests to rule in and rule out different diagnoses. Through these evaluations,  I have been able to see myself slowly become more confident in my ability to present and discuss the cases.

Here is the history and physical I presented HP Rotation 7

Journal Article

The New England Journal of Medicine

Groin Hernias in Adults

Groin hernias are defined as both inguinal and femoral hernias.  Inguinal hernias are divided into direct and indirect, direct hernias are located laterally to inferior epigastric vessels while indirect are medial.  Femoral hernias protrude below the inguinal ligament and medial to femoral vessels.

Incidence/Risk factors

• Of groin hernias, inguinal hernias are more common than femoral hernias and indirect are more common than direct.
• Incidence of hernia repair increases consistently with age according to Danish study.
• Femoral hernias are <5% of groin hernias, diagnosed when present with obstruction or strangulation. MC with recurrent hernias.
• Women more likely than men to have femoral hernias.
• Family history increases risk x 8
• Conditions associated with hernias- COPD, smoking, low BMI, high intrabdominal pressure, TAA and AAA, patent processus vaginalis, and hx of open appendectomy.
• Relationship between heavy lifting and hernias is inconclusive.

Strategies and Evidence

• S/S: heaviness, dragging, burning, pain with cough, defecation, exercise and sex. Worse at the end of the day, better with lying down and reduction. Sudden onset of severe pain- ED
• Exam: palpate mass on straining on external ring, unnecessary to differentiate, might be the same. Imagining only necessary if there are symptoms with out physical findings to rule out occult hernia.  CT/MRI > U/S.

Management

• Strangulated-very tender, may have signs of sepsisà emergency surgery
• Incarcerated- non reducible, may be asymptomatic
• Signs of bowel obstruction- will lead to strangulation

Asymptomatic or minimally symptomatic

• Two studies found no reduction in pain when treating patients w surgery vs. watchful waiting.
  • RCT in UK with 160 pts- no significant difference in pain score at one year
  • Multicenter trial in North America- no significant difference in pain or QL at two years
  • Both studies- ¼ of pts assigned to watchful waiting switched to surgery do to increased pain, no increase in complications.
  • Later follow up, more participants from both groups switched to surgery bc of increased pain, no increase in complications in these surgeries. Applies only to inguinal, bc femoral associated with more complications which is why females are recommended to have surgery.

Surgical treatment

• Tension-free vs sutures- Cochrane metanalysis reports tension-free reduces recurrence by 50-75%
• Only would recommend sutures in the case where mesh is contaminated

Laparoscopic Inguinal Hernia repair

• Laparoscopic- less pain, can return earlier to everyday activities, easier to do lap for recurrence after open one preformed, bilateral repair thru same incision points, complications similar to open.
  • Negatives- associated with life-threatening damage to vascular and visceral damage. Requires general anesthesia and more expensive.
• Cochrane meta-analysis 41 RCTs- no sig difference in recurrence
• Large cohort and meta-analysis 27 RCTs (more recent)- higher risk of recurrence after lap

Areas of uncertainty

• Still incidence of postherniorrhaphy pain in 10% may be due to trapped/damaged nerves, scar tissue, or reaction to prosthetic material. Has been effectively treated with mesh and suture excision, neurectomy, and neuroma excision.
• Treatment in women- Swedish study showed femoral hernias to be significantly more common in women especially with direct hernia. Suggests to treat laparoscopically since it can be missed with Lichtenstein operation.

groin hernia