Abnormal findings

Skin. In elderly patients seborrhoeic warts, ranging from

TABLE 5.26 Surgical incisions

Non-specific incisions

Vertical incisions

Midline or paramedian

(used for general access)

Upper, lower or lull length

Specific incisions

Subcostal

Gall bladder

Suprapubic

Bladder, prostate, gynaecology

McBurney's point

Appendix

Inguinal

Hernia

pink to brown or black, and haemangiomas (Campbell de Morgan spots) are so common that they could be considered normal changes. The presence of striae requires explanation. Any abnormality of the skin should be noted, including surgical scars, and the nature of the surgery undertaken should be identified. Laparoscopic incisions are usually immediately below the umbilicus and may be difficult to see. The common sites of surgical incisions are shown in Table 5.26 and illustrated in Figure 5.7. Other transverse incisions are used for access to the aorta, kidneys, adrenals, ureters, sympathetic chain or stoma closures. The common types of stoma arc illustrated in Figure 5.8. The effluent from a colostomy is solid with a faecal odour: in an ileostomy there is a fluid, odourless effluent.

Hair. Secondary sexual hair appears at puberty; its absence after this time suggests the possibility of hypopituitarism or hypogonadism (p. 38). Virilism in the female leads to a male distribution of pubic and body hair, whereas cirrhosis in the male may produce a female distribution of body hair.

Veins. Collateral veins may be visible if the inferior vena cava is obstructed or if there is portal hypertension. These are usually tortuous dilated superficial epigastric veins; in obstruction of the inferior vena cava, the blood flows upwards in the lower abdomen instead of downwards towards the groins. In cirrhosis, dilated collateral veins may also radiate from the umbilicus (caput Medusa), blood flowing away from the umbilicus as the portal vein drains through collateral vessels along the falciform ligament.

Shape. A sunken abdomen (scaphoid abdomen) may be due to starvation or wasting diseases. Protuberance may be due to obesity, gaseous distension, ascites, pregnancy or other swellings. In obesity the umbilicus is usually sunken, whereas in the other conditions it is flat or even projecting. Visible enlargement of the bladder, uterus or ovary may be evident as a characteristic shape arising from the pelvis, the swelling being predominantly central in contrast to the bulging of the flanks In ascites. Visible bulges may also be due to gross enlargement of the liver, spleen or kidneys or to large tumours. Distension of the stomach due to pyloric obstruction causes bulging of the upper part of the abdomen.

Enlarged Liver Causes

Fig. 5.7 Surgical incision. 5) Vertical incisions may be midline or paramedian and are used for general access. QD Specific incisions may indicate the nature of operation, e.g. biliary or appendix. Note also that McBurney's point is situated one-third of the distance along a line from the anterior superior lilac spine to the umbilicus.

Mcburney Point

Fig. 5,8 Surgical stomas. H An Ileostomy is usually In the right iliac fossa and is formed as a spout. E A colostomy may be terminal. I.e. resected distal bowel-It is usually flush and in the left iliac fossa, H] A loop colostomy may be created lor temporary defunctioning of the distal bowel. It is usually in the transverse colon and has aflerent and efferent limbs.

Fig. 5.7 Surgical incision. 5) Vertical incisions may be midline or paramedian and are used for general access. QD Specific incisions may indicate the nature of operation, e.g. biliary or appendix. Note also that McBurney's point is situated one-third of the distance along a line from the anterior superior lilac spine to the umbilicus.

Fig. 5,8 Surgical stomas. H An Ileostomy is usually In the right iliac fossa and is formed as a spout. E A colostomy may be terminal. I.e. resected distal bowel-It is usually flush and in the left iliac fossa, H] A loop colostomy may be created lor temporary defunctioning of the distal bowel. It is usually in the transverse colon and has aflerent and efferent limbs.

Movements. Respiratory movements of the abdomen usually eease in the presence of acute peritonitis.

Pulsation in the epigastrium is usually transmitted from the abdominal aorta. Less frequently it is caused by the right ventricle, the liver or an abdominal aneurysm. It may sometimes he difficult to distinguish pulsation of ihe aorta transmitted through an abdominal mass from pulsation of an aneurysmal aorta. Expansile pulsation favours the latter. The distinction is best confirmed by abdominal ultrasonography.

Small intestinal peristalsis may be seen through a thin abdominal wall, or if there is divarication of the recti abdominis or an incisional hernia. It may become unduly prominent in small intestinal obstruction. Ii is recognised as writhing movements in the centre of the abdomen.

Hernias. Hernias are common causes of localised swellings and should be distinguished from divarication ol the recti abdominis. Divarication of the recti, common in the muciparous, becomes more obvious as the supine patient attempts to sil upright: the intra-abdominal pressure rises and the region of the linea alba bulges between the recti. An umbilical hernia bulges through the navel. It is very common in babies and usually disappears spontaneously. An epigastric hernia is visible as a small swelling, usually not more than 1 cm in diameter. It is due to herniation of extraperitoneal fat through a defect in the linea alba. By gentle massage with the fingertip it is often possible to reduce such a hernia and then the small defect can be felt. An incisional hernia may form at the site of any operation on the abdomen, especially if the wound has been complicated by sepsis. Femoral and inguinal hernias are considered on page 170.

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