A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is
discharged home. He is readmitted 10 days later with symptoms of vomiting and
colicky abdominal pain. On examination he has a swelling of the loop colostomy site
and it is tender. What is the most likely underlying diagnosis?
A. Haematoma
B. Intra abdominal adhesions
C. Anastomotic leak
D. Anastomotic stricture
E. Obstructed incisional hernia
Theme from September 2011 Exam
In this scenario the most likely diagnosis would be obstructed incisional hernia. The
tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt
surgical exploration is warranted. Loop colostomy reversals are at high risk of this
complication as the operative site is at increased risk of the development of post
operative wound infections.
Acute incisional hernia
Any surgical procedure involving entry into a cavity containing viscera may
be complicated by post operative hernia
The abdomen is the commonest site
The deep layer of the wound has usually broken down, allowing internal
viscera to protrude through
Management is dictated by the patients clinical status and the timing of the
hernia in relation to recent surgery
Bowel obstruction or tenderness at the hernia site both mandate early surgical
intervention to reduce the risk of bowel necrosis
Mature incisional hernias with a wide neck and no symptoms may be either
left or listed for elective repair
Risk factors for the development of post operative incisional hernias include
post operative wound infections, long term steroid use, obesity and chronic
cough
Theme: Abdominal stomas
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy
E. End jejunostomy
,F. Loop jejunostomy
G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma
to be constructed. Each option may be selected once, more than once or not at all.
2. A 56 year old man is undergoing a low anterior resection for carcinoma of the
rectum. It is planned to restore intestinal continuity.
You answered End colostomy
The correct answer is Loop ileostomy
Colonic resections with an anastomosis below the peritoneal reflection may
have an anastomotic leak rate (both clinical and radiological) of up to 15%.
Therefore most surgeons will defunction such an anastomosis to reduce the
clinical severity of an anastomotic leak. A loop ileostomy will achieve this end
point and is relatively easy to reverse.
3. A 23 year old man with uncontrolled ulcerative colitis is undergoing an
emergency sub total colectomy.
You answered Loop ileostomy
The correct answer is End ileostomy
Following a sub total colectomy the immediate surgical options include an end
ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal
anastomosis would be unsafe.
4. A 63 year old women presents with large bowel obstruction. On examination
she has a carcinoma 10cm from the anal verge.
You answered End colostomy
The correct answer is Loop colostomy
Large bowel obstruction resulting from carcinoma should be resected, stented or
defunctioned. The first two options typically apply to tumours above the
peritoneal reflection. Lower tumours should be defunctioned with a loop
colostomy and then formal staging undertaken prior to definitive surgery. An
emergency attempted rectal resection carries a high risk of involvement of the
circumferential resection margin and is not recommended.
,Abdominal stomas
Stomas may be sited during a range of abdominal procedures and involve bringing the
lumen or visceral contents onto the skin. In most cases this applies to the bowel.
However, other organs or their contents may be diverted in case of need.
With bowel stomas the type method of construction and to a lesser extent the site will
be determined by the contents of the bowel. In practice, small bowel stomas should be
spouted so that their irritant contents are not in contact with the skin. Colonic stomas
do not need to be spouted as their contents are less irritant.
In the ideal situation the site of the stoma should be marked with the patient prior to
surgery. Stoma siting is important as it will ultimately influence the ability of the
patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma
contents and subsequent maceration of the surrounding skin can rapidly progress into
a spiraling loss of control of stoma contents.
Types of stomas
Name of stoma Use Common sites
Gastrostomy Gastric decompression or fixation Epigastrium
Feeding
Loop Seldom used as very high output Any location according to
jejunostomy May be used following emergency need
laparotomy with planned early
closure
Percutaneous Usually performed for feeding Usually left upper quadrant
jejunostomy purposes and site in the proximal
bowel
Loop ileostomy Defunctioning of colon e.g. Usually right iliac fossa
following rectal cancer surgery
Does not decompress colon (if
ileocaecal valve competent)
End ilestomy Usually following complete Usually right iliac fossa
excision of colon or where ileo-
colic anastomosis is not planned
May be used to defunction colon,
but reversal is more difficult
End colostomy Where a colon is diverted or resected and Either left or right iliac
anastomosis is not primarily achievable fossa
or desirable
Loop colostomy To defunction a distal segment of May be located in any
colon region of the abdomen,
depending upon colonic
, Since both lumens are present the segment used
distal lumen acts as a vent
Caecostomy Stoma of last resort where loop Right iliac fossa
colostomy is not possible
Mucous fistula To decompress a distal segment of May be located in any
bowel following colonic division region of the abdomen
or resection according to clinical need
Where closure of a distal resection
margin is not safe or achievable
Theme: Acute abdominal pain
A. Ruptured abdominal aortic aneurysm
B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Small bowel obstruction
F. Large bowel obstruction
G. Pelvic inflammatory disease
H. Mesenteric adenitis
I. Pancreatitis
J. None of the above
Please select the most likely cause of abdominal pain for the scenario given. Each
option may be used once, more than once or not at all.
5. A 75 year old man is admitted with sudden onset severe generalised abdominal
pain, vomiting and a single episode of bloody diarrhoea. On examination he
looks unwell and is in uncontrolled atrial fibrillation. Although diffusely tender
his abdomen is soft.
Mesenteric infarction
In mesenteric infarction there is sudden onset of pain together with vomiting
and occasionally passage of bloody diarrhoea. The pain present is usually out of
proportion to the physical signs.
6. A 19 year old lady is admitted with lower abdominal pain. On examination she
is diffusely tender. A laparoscopy is performed and at operation multiple fine
adhesions are noted between the liver and abdominal wall. Her appendix is
normal.
You answered Small bowel obstruction
discharged home. He is readmitted 10 days later with symptoms of vomiting and
colicky abdominal pain. On examination he has a swelling of the loop colostomy site
and it is tender. What is the most likely underlying diagnosis?
A. Haematoma
B. Intra abdominal adhesions
C. Anastomotic leak
D. Anastomotic stricture
E. Obstructed incisional hernia
Theme from September 2011 Exam
In this scenario the most likely diagnosis would be obstructed incisional hernia. The
tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt
surgical exploration is warranted. Loop colostomy reversals are at high risk of this
complication as the operative site is at increased risk of the development of post
operative wound infections.
Acute incisional hernia
Any surgical procedure involving entry into a cavity containing viscera may
be complicated by post operative hernia
The abdomen is the commonest site
The deep layer of the wound has usually broken down, allowing internal
viscera to protrude through
Management is dictated by the patients clinical status and the timing of the
hernia in relation to recent surgery
Bowel obstruction or tenderness at the hernia site both mandate early surgical
intervention to reduce the risk of bowel necrosis
Mature incisional hernias with a wide neck and no symptoms may be either
left or listed for elective repair
Risk factors for the development of post operative incisional hernias include
post operative wound infections, long term steroid use, obesity and chronic
cough
Theme: Abdominal stomas
A. End ileostomy
B. End colostomy
C. Loop ileostomy
D. Loop colostomy
E. End jejunostomy
,F. Loop jejunostomy
G. Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma
to be constructed. Each option may be selected once, more than once or not at all.
2. A 56 year old man is undergoing a low anterior resection for carcinoma of the
rectum. It is planned to restore intestinal continuity.
You answered End colostomy
The correct answer is Loop ileostomy
Colonic resections with an anastomosis below the peritoneal reflection may
have an anastomotic leak rate (both clinical and radiological) of up to 15%.
Therefore most surgeons will defunction such an anastomosis to reduce the
clinical severity of an anastomotic leak. A loop ileostomy will achieve this end
point and is relatively easy to reverse.
3. A 23 year old man with uncontrolled ulcerative colitis is undergoing an
emergency sub total colectomy.
You answered Loop ileostomy
The correct answer is End ileostomy
Following a sub total colectomy the immediate surgical options include an end
ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal
anastomosis would be unsafe.
4. A 63 year old women presents with large bowel obstruction. On examination
she has a carcinoma 10cm from the anal verge.
You answered End colostomy
The correct answer is Loop colostomy
Large bowel obstruction resulting from carcinoma should be resected, stented or
defunctioned. The first two options typically apply to tumours above the
peritoneal reflection. Lower tumours should be defunctioned with a loop
colostomy and then formal staging undertaken prior to definitive surgery. An
emergency attempted rectal resection carries a high risk of involvement of the
circumferential resection margin and is not recommended.
,Abdominal stomas
Stomas may be sited during a range of abdominal procedures and involve bringing the
lumen or visceral contents onto the skin. In most cases this applies to the bowel.
However, other organs or their contents may be diverted in case of need.
With bowel stomas the type method of construction and to a lesser extent the site will
be determined by the contents of the bowel. In practice, small bowel stomas should be
spouted so that their irritant contents are not in contact with the skin. Colonic stomas
do not need to be spouted as their contents are less irritant.
In the ideal situation the site of the stoma should be marked with the patient prior to
surgery. Stoma siting is important as it will ultimately influence the ability of the
patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma
contents and subsequent maceration of the surrounding skin can rapidly progress into
a spiraling loss of control of stoma contents.
Types of stomas
Name of stoma Use Common sites
Gastrostomy Gastric decompression or fixation Epigastrium
Feeding
Loop Seldom used as very high output Any location according to
jejunostomy May be used following emergency need
laparotomy with planned early
closure
Percutaneous Usually performed for feeding Usually left upper quadrant
jejunostomy purposes and site in the proximal
bowel
Loop ileostomy Defunctioning of colon e.g. Usually right iliac fossa
following rectal cancer surgery
Does not decompress colon (if
ileocaecal valve competent)
End ilestomy Usually following complete Usually right iliac fossa
excision of colon or where ileo-
colic anastomosis is not planned
May be used to defunction colon,
but reversal is more difficult
End colostomy Where a colon is diverted or resected and Either left or right iliac
anastomosis is not primarily achievable fossa
or desirable
Loop colostomy To defunction a distal segment of May be located in any
colon region of the abdomen,
depending upon colonic
, Since both lumens are present the segment used
distal lumen acts as a vent
Caecostomy Stoma of last resort where loop Right iliac fossa
colostomy is not possible
Mucous fistula To decompress a distal segment of May be located in any
bowel following colonic division region of the abdomen
or resection according to clinical need
Where closure of a distal resection
margin is not safe or achievable
Theme: Acute abdominal pain
A. Ruptured abdominal aortic aneurysm
B. Perforated peptic ulcer
C. Perforated appendicitis
D. Mesenteric infarction
E. Small bowel obstruction
F. Large bowel obstruction
G. Pelvic inflammatory disease
H. Mesenteric adenitis
I. Pancreatitis
J. None of the above
Please select the most likely cause of abdominal pain for the scenario given. Each
option may be used once, more than once or not at all.
5. A 75 year old man is admitted with sudden onset severe generalised abdominal
pain, vomiting and a single episode of bloody diarrhoea. On examination he
looks unwell and is in uncontrolled atrial fibrillation. Although diffusely tender
his abdomen is soft.
Mesenteric infarction
In mesenteric infarction there is sudden onset of pain together with vomiting
and occasionally passage of bloody diarrhoea. The pain present is usually out of
proportion to the physical signs.
6. A 19 year old lady is admitted with lower abdominal pain. On examination she
is diffusely tender. A laparoscopy is performed and at operation multiple fine
adhesions are noted between the liver and abdominal wall. Her appendix is
normal.
You answered Small bowel obstruction
