Petrut Gogalniceanu

A minimally invasive approach to undergraduate anatomy teaching

Anatomy is one of the cornerstones of medical education. Unfortunately, sufficient evidence has accumulated to suggest a worldwide decline in the resources and time allocated to its teaching. Integration of anatomy with clinical medicine has been frequently advocated as the solution to this academic crisis. Consequently, new ways of harnessing clinical relevance to the teaching of anatomy must be sought to make it applicable to contemporary clinical practice. Human cadavers have been used to teach laparoscopic skills to surgical trainees for some time. More recently, centers in the United States have piloted the use of minimally invasive techniques in the teaching of anatomy to undergraduates. We believe that the use of laparoscopy on human cadavers may also be used to complement the teaching of anatomy to United Kingdom and European medical students. This would not only familiarize students with the topography and morphology of human anatomy, but also with the concept of manipulating anatomical structures to achieve a clinical outcome. Other benefits include improved three‐dimensional orientation, increased dexterity, and development team‐working skills amongst students. A UK feasibility study is currently underway. Anat Sci Ed 1:46–47, 2008.

Examination of gait

Overview of the gait cycle 1. Stance phase – 60% of cycle • Heel strike – flat foot – mid-stance – heel off – toe off 2. Swing phase – 40% of cycle • Acceleration – mid-swing – deceleration What is the lower limb biomechanical assessment used for? A lower limb biomechanical assessment analyses the link between the structure, function, strengths and weaknesses of the lower limb joints and muscles. Lower limb pain can be caused or referred from a number of joints. A comprehensive examination is needed to identify the numerous contributing pathological processes, which may need to be treated concurrently with physiotherapy, orthotics, injections or surgery. What is the difference between open and closed kinetic chains? In open kinetic chain assessment the joint is able to move freely, either by active movement or by passive movement by the examiner. Closed kinetic chain is the assessment of gait and lower limb function whilst it is in contact with the ground. What is the normal gait cycle? A gait cycle is the sequence that starts with the heel strike of one foot and ends with the subsequent floor contact of the same foot. The gait is defined as a series of rhythmical and alternating movements of the trunk and lower limbs that result in forward progression of the centre of gravity. During increasing walking speeds and running the swing phase increases and the stance phase decreases until the ratio of stance to swing phase reverses. What are the commonly used terms? • A step length is the distance from one heel strike to the contralateral heel strike. • A stride length is the distance between two heel contacts of the same foot, and in a normal gait it is double the step length.

Examination of the hip

History: What is your trouble? Pain, stiffness, limp Please tell me more about your problem? ....Listen Listen for at least one minute: Let patient do the talking Do not ask leading question to start with Ask what might have brought it on? If trauma: Mechanism of injury and previous treatment Any red flags: weight loss, night pain, rest pain, fever, night sweats If insidious: how long and how bad it is now.

Examination of the penis

Checklist WIPER • Patient supine. Trousers removed. Groins and genitals exposed. Chaperone as required. Physiological parameters Inspection • Penile shape: chordae, priapism • Presence or absence of foreskin (circumcision) • Retract foreskin (if uncircumcised): phimosis, paraphimosis, tight frenulum • Position of external meatus: normal, hypospadias, epispadias • Lesions on glans: carcinoma, papillomata acuminata, balanitis, ulcers (chancre) • Lesions on inner or outer foreskin: as above Palpation • Open external meatus to assess size of urethral opening: • discharge (urinary incontinence, pus, blood) • erythema/ulceration • pinhole meatus • Palpate glans and shaft of penis: evidence of Peyronies disease. • Palpate urethra: urethral stricture, carcinoma, diverticulum or abscess. To complete the examination … • Palpate inguinal lymph nodes: particularly in the presence of a penile lesion. • Perform a scrotal, perineal and rectal examination. • Urine dipstick. Examination notes What are the essential history points prior to a penile examination? • Nature of lesion • Circumcised or not • Effect of erection on lesion • Sexual history including erectile function and risk of sexually transmitted infections What do you look for on inspection? Assess whether the patient is circumcised. If the patient is not circumcised it is important to retract the foreskin to expose the glans. This allows inspection of the glans as well as the inner surface of the prepuce for any suspicious lesions. One needs to assess the position of the external urethral meatus. What do you palpate in a penile examination? Assess the actual diameter of the urethral opening deep to the external meatus, as a pinhole meatus may be present despite an apparently large external orifice. This is best performed by gently squeezing the tip of the glans in the anteroposterior axis, which encourages the slit-like urethra to open into a circular orifice. The glans and shaft of the penis need to be palpated. There may be palpable fibrotic plaques on the penile shaft suggestive of Peyronies disease. Gross urethral lesions in the penile shaft may also be palpable.

Physical Examination for Surgeons: Renal access and transplant examination

Checklist WIPER • Patient supine. Expose both arms completely, as well as chest and abdomen. Physiological parameters General • Fluid status: shortness of breath, audible crackles, dry mucous membranes, facial oedema, peripheral oedema, cyanosis • Clinical features of immunosuppression or chronic steroid use Inspection Arm fistulas: • Radiocephalic fistula (wrist) • Brachiocephalic or brachiobasilic fistulas (antecubital fossa) • Prosthetic straight or loop grafts (PTFE) Fistula complications: • Non-functioning/thrombosed fistulas • Haematomas or ecchymosis from needling • Aneurysmal changes: tight or shiny skin • Hand ischaemia from fistula: steal syndrome or embolization Neck and chest (subclavian and internal jugular veins): • Raised JVP (fluid overload) • Dilated neck veins: central vein stenosis from long-term central dialysis lines • Temporary non-tunnelled haemodialysis intravenous catheters (VasCath) • Long-term tunnelled haemodialysis intravenous catheters (PermCath) Abdomen: • Peritoneal dialysis (PD) catheter • Scars: nephrectomy scars in flanks, midline scars for PD catheters, suprapubic catheter scars, iliac fossae scars for renal transplant (Rutherford Morison incision, ‘ hockey-stick ’ incision), laparoscopic scars for nephrectomy (donor) Leg: • Prosthetic PTFE loop graft. Palpation • Skin turgor: fluid status • Fistula (if present): thrill or pulse, palpable stenosis • Pulses (if fistula present): radial, ulnar, brachial, axillary, subclavian • Abdomen: • ascites • peritonitis (if PD catheter present) • ballotable masses (polycystic kidneys) •iliac fossa masses (transplanted kidney) Percussion • Percuss any iliac fossa mass to confirm it is dull (kidney) rather than cystic. Auscultate • Fistula: bruit (continuous ‘ machinery ’ bruit) • Chest: crackles, effusions (fluid overload) To complete the examination … • Examine groins (femoral lines) and lower limbs (fistulas and grafts). Examination notes What are the three most likely clinical scenarios? 1. End-stage renal failure patient on dialysis: a. peritoneal dialysis b. dialysis via fistula c. dialysis via intravenous line d. haemofiltration via intravenous line 2. Low-clearance patient approaching need for renal replacement with a fistula created in advance; still passes urine 3. Renal transplant patient: a. transplant working: not on dialysis but on immunosuppressive therapy b. transplant failed: recommenced dialysis; transplanted kidney may be in situ or removed What are the basic history points that need to be established in assessing for fistula formation? • Is the patient left- or right-handed?

Physical Examination for Surgeons: Examination of the scrotum

Checklist WIPER • Patient standing, trousers removed, groin and genitals exposed. Chaperone as required. Physiological parameters Inspection • Evidence of raised intra-abdominal pressure: nicotine stains, barrel chest in COPD, abdominal distension • Masses: groin lumps • Scars: laparoscopic port access, groin scars • Scrotal asymmetry: absent testicle, inguinoscrotal hernias Ask: ‘ Have you noticed a lump in your groin? Please show me where it is. ’ Ask: ‘ Can you cough please? ’ Palpation Patient standing: Ask: ‘ Do you have pain in the groin? ’ • Define anatomy: ASIS, pubic tubercle, inguinal ligament. • Feel the mass: Tender? Cough reflex? Borborygmi? Pulsatile? • Locate mass: Finger on pubic tubercle and ask patient to cough. • Is it superior/medial or inferior/lateral? • Palpate scrotum: Both testes present? Scrotal masses? Cough impulse? • Palpate contralateral groin: Bilateral hernias? Patient supine: Ask patient to reduce hernia . • Reduce hernia: reducible or irreducible? • Control hernia: pressure at midpoint of inguinal ligament. Ask patient to cough . •Controlled (indirect hernia) or uncontrolled (direct hernia) by pressure? Percussion • Bowel gas present? Auscultation • Bowel sounds present in mass? • Transillumination is optional. To complete the examination … • Examine the scrotum, contralateral groin and abdomen (if not done). • Perform a digital rectal examination. Examination notes What are the risk factors for hernia formation that may be elicited in the examination? Any factor that increases intra-abdominal pressure: smoking, chronic cough, constipation or change in bowel habit, chronic urinary retention, pelvic masses, pregnancy or ascites. How do you prepare for the examination of the groin? If examining a patient of the opposite sex ask for a chaperone. The patient needs to be standing so as to allow any hernias to become evident under the effect of gravity. Expose the patients abdomen, groins and upper thighs.

Examination of a stoma

Checklist WIPER Physiological parameters Inspection Scars: • Midline laparotomy • Laparoscopic scars • No scars and stoma: trephine colostomy • Linear or purse-string scar in RIF or LIF: reversed stoma Stoma character: • Site: RIF vs. LIF • Spouted vs. flush • Size of lumen • Number of lumens • Stoma bridge • Bag contents: •urine (urostomy) •small bowel contents: liquid (ileostomy) •formed faeces (colostomy) Stoma complications: • Parastomal mass (hernia) • Dusky or ischaemic mucosa • Surrounding skin excoriated • Stoma edge dehiscence • Stoma retraction Palpation • Palpate around stoma and ask patient to cough to exclude parastomal hernia. • Digitate stoma with a well-lubricated finger (only if required). Percussion • Hyper-resonance: bowel obstruction Auscultation • Hyperactive bowel sounds in bowel obstruction • Quiet bowel sounds in ileus To complete the examination … • Ask to examine the perineum to determine if the anal orifice is present. • Perform a full examination of the abdomen. Examination notes What is the definition of a stoma? A stoma is a surgically created communication between a hollow viscus and the skin. What are the different types of stomas? • Ileostomy – ileum • Colostomy – colon • Urostomy – ileum anastomosed to ureters How are stomas constructed? • End-stoma: single lumen. Suggests that the distal end of the viscus has either been resected or closed and left in the abdomen; e.g. Hartmanns procedure. • Loop-ileostomy: two lumens may be seen. The distal end of the viscus is present but defunctioned, e.g. to allow an anastomosis to heal. • A urostomy is formed when the urinary bladder has been excised. A loop of ileum (ileal conduit) is separated proximally and distally. The ureters are anastomosed to one end, and the other end is used to form the stoma (urostomy).