NRC5 A E55ENIlAL

REVl5lON NOIE5
BOOK 2
Edited by
Claire Ritchie Chalmers
BA PhD FRC5
Catherine Parchment 5mith
B5c NBChB FRC5
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iii
Contents
Acknowledgements v
Preface v
Picture Permissions vi
Contributors vii
lntroduction ix
Chapter 1 - Abdominal 5urgery 1
CaIherihe ParchmehI SmiIh, Arih K. Sara ahd Ravihder S. Vohra
Chapter 2 - Breast 5urgery 337
1ehhy McIlhehhy ahd RiIchie Chalmers
Chapter 3 - Cardiothoracic 5urgery 397
Ceorge 1se ahd Sai Prasad
Chapter 4 - Endocrine 5urgery 465
Nicholas L Cibbihs ahd Sylvia 8rowh
Chapter 5 - Head and Neck 5urgery 521
Nicholas L Cibbihs
Chapter 6 - Neurosurgery (Elective) 593
Paul 8rehhah
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iv
Chapter 7 - Iransplant 5urgery 627
Kareh S SIevehsoh
Chapter 8 - Urological 5urgery 647
Mary M8rowh
Chapter 9 - Vascular 5urgery 729
Sam Ahdrews
Abbreviations 803
Bibliography 807
lndex 809
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CHAPIER 1
Abdominal 5urgery
1. AbdominaI waII and hcrnias 3
l.l Anteror ubdomnu wu 3
l.2 Hernus l0
l.3 Compcutons ol hernus 3l
2. Ocsophagus 37
2.l Anutomy und physoogy ol the
oesophugus 37
2.2 Pun und dlcuty swuowng 40
2.3 Custro-oesophugeu reux
dseuse 44
2.4 Hutus hernu 48
2.5 Motty dsorders 49
2.6 Cesophugeu perloruton 5l
2.7 Cther bengn oesophugeu
dsorders 53
2.8 urrett's oesophugus 53
2.9 Cesophugeu curcnomu 55
3. Stomach and duodcnum 60
3.l Anutomy ol the stomuch 60
3.2 Anutomy ol the duodenum 64
3.3 Physoogy ol the upper Cl truct 66
3.4 Peptc uceruton 77
3.5 Compcutons ol peptc
uceruton 89
3.6 Custrc curcnomu 96
3.7 Custrts l05
3.8 Congentu ubnormutes ol
the stomuch l06
3.9 Congentu ubnormutes ol
the duodenum l06
3.l0 Cther condtons ol the
stomuch und duodenum l07
4. livcr and spIccn 110
4.l Anutomy ol the ver ll0
4.2 Physoogy ol the ver ll5
4.3 luundce l20
4.4 Portu hypertenson l27
4.5 Cncu evuuuton ol ver
dseuse l3l
4.6 Crrhoss l33
4.7 Lver musses l34
4.8 Lver nlectons l37
4.9 Lver cysts l38
4.l0 1he speen l39
S. BiIiary trcc and pancrcas 144
5.l Anutomy ol the bury system l44
5.2 Physoogy ol the bury tree l47
5.3 Custones l50
5.4 Cther dsorders ol the bury
tree l59
5.5 Anutomy ol the puncreus l6l
5.6 Physoogy ol the puncreus l62
5.7 Puncreutts l64
5.8 Puncreutc curcnomu l68
5.9 Cther puncreutc tumours l73
5.l0 Cther dsorders ol the puncreus l74
Catherine Parchment 5mith,
Arin K. 5aha and Ravinder 5. Vohra
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6. Acutc Abdomcn 176
6.l Acute ubdomnu pun l76
6.2 Common ucute ubdomnu
emergences l82
6.3 lntestnu obstructon l95
6.4 Pertonts 205
6.5 Stomus 2l5
7. SmaII bowcI 222
7.l Anutomy und physoogy ol
the smu bowe 222
7.2 lmugng und nvestgutng the
smu bowe 226
7.3 lntestnu stuus 227
7.4 1umours ol the smu bowe 230
7.5 eedng lrom the smu bowe 234
7.6 lntestnu schuemu 235
7.7 Dvertcuu ol the smu bowe 238
7.8 lnlectous enterts 239
7.9 Ruduton smu-bowe nury 240
7.l0 Short-bowe syndrome 240
7.ll Short-bowe bypuss 24l
8. largc bowcI 242
8.l Symptoms ol non-ucute
ubdomnu dsorders 242
8.2 Anutomy und physoogy ol the
coon 259
8.3 Dugnoss ol coorectu dseuse 263
8.4 lnummutory bowe dseuse 269
8.5 engn coorectu tumours 280
8.6 Coorectu cuncer 289
8.7 Cther coorectu condtons 307
9 PcrianaI conditions 310
9.l Anutomy und physoogy ol
the rectum und unus 3l0
9.2 Huemmorhods 3l3
9.3 Anu ssures 3l8
9.4 Anorectu ubscesses 3l9
9.5 Anorectu stuus 322
9.6 Pondu snus 324
9.7 Prurtus un 325
9.8 Rectu proupsed 327
9.9 Proctugu lugux 330
9.l0 luecu ncontnence 330
9.ll Anu cuncer 333
9.l2 Sexuuy trunsmtted
unorectu nlectons 334
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1.1 Anterior abdominal wall
Layers of the abdominal wall
In a nuIsheII .
\hen you muke un ncson n the
unteror ubdomnu wu you w go
through severu uyers:
s Skn
s Subcutuneous lut
s Supercu luscu
s Deep luscu (vestgu)
s Musces (dependng on ncson)
s 1runsversus luscu
s Lxtrupertoneu lut
s Pertoneum
5kin
1he skn hus horzontu Lunger's nes over the
ubdomen. Dermutomes ure uso urrunged n
trunsverse bunds.
Deep fascia
1hs s u vestgu thn uyer ol ureour tssue over
musces.
5ECIlON 1
Abdominal wall
and hernias
5uperficial fascia
(5carpa's fascia)
s Absent ubove und uteruy
s luses wth deep luscu ol eg nleror to
ngunu gument
s Very promnent n chdren (cun even be
mstuken lor externu obque!)
s Contnuous wth Coes' luscu over perneum
(lorms tubuur sheuth lor pens/ctors und
suc-ke coverng lor scrotum/ubu)
Nuscles
In a nuIsheII .
1he musces you' puss through depend
on the ncson ste:
s Lxternu obque
s lnternu obque
s Rectus ubdomns
s 1runsversus ubdomns
s Pyrumdus
s Rectus sheuth
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s fxtcrnaI obIiquc s u urge sheet ol musce
bres runnng downwurds lrom uteru
to medu ke u hund n your pocket'.
Meduy, the externu obque becomes
u brous uponeuross whch es over the
rectus ubdomns musce (see beow),
lormng purt ol the unteror rectus sheuth
s lntcrnaI obIiquc s u second urge sheet
ol musce bres yng deep to the externu
obque und ut rght unges to t. Meduy,
t lorms u brous uponeuross whch spts
to encose the mdde porton ol rectus
ubdomns us purt ol the unteror und
posteror rectus sheuth
s Transvcrsus abdominis s the thrd urge
sheet ol musce yng deep to the nternu
obque und runnng trunsversey. Meduy,
t lorms u brous uponeuross whch
contrbutes to the posteror rectus sheuth
yng behnd rectus ubdomns
s Rcctus abdominis und ts pur on ut the
neu ubu n the mdne to lorm u wde
strup thut runs ongtudnuy down the
unteror ubdomnu wu. lt es wthn the
rectus sheuth lormed by the uponeuroses
ol the three musces descrbed ubove. lt s
uttuched to the unteror rectus sheuth, but
not to the posteror rectus sheuth, by three
tendnous nsertons. 1hese nsertons ure
ut the eve ol the xphsternum, umbcus
und hulwuy between (gvng the sx-puck'
uppeurunce n we-deveoped ndvduus!).
1he bood suppy ol rectus ubdomns s
through the superor epgustrc urtery (u
termnu brunch ol the nternu thorucc
urtery) und the nleror epgustrc urtery (u
brunch ol the externu uc urtery) whch
unustomose to lorm u connecton between
the subcuvun und externu uc systems
(lg. l.l). 1he superor epgustrc urtery s
the pedce on whch u 1RAM up s rused
lor breust reconstructon. 1he nerve suppy
to the rect s segmentu lrom16 to 1l2 und
the nerves enter the sheuth uteruy und
run towurds the mdne (so ure dsrupted n
utte's ncson see lgure l.3)
s linca aIba s u brotendnous ruphe runnng
vertcuy n the mdne between the elt
und rght rectus ubdomns musces. lt s
lormed by the luson ol the externu obque,
nternu obque und trunsversus ubdomns
uponeuroses. 1hey luse n un nterockng/
nterdgtutng structure through whch
epgustrc hernus muy protrude. 1he neu
ubu provdes un uvuscuur und reutvey
boodess pune through whch mdne
upurotomy ncsons ure mude. lt s euser
to begn u upurotomy ncson ubove the
umbcus, where the neu ubu s wder,
thcker und better dened thun beow the
umbcus
s PyramidaIis s u smu (4 cm ong)
unmportunt musce ursng lrom the pubc
crest und nsertng nto the neu ubu. lt
es behnd the unteror rectus sheuth n
lront ol rectus ubdomns. 1hs s the ony
musce you go through n your ower
mdne upurotomy ncson und t s not
us boodess us the neu ubu whch t
underes
Rectus sheath
In a nuIsheII .
Any ncson over rectus ubdomns w
go through the unteror rectus sheuth.
Arrungement ol the rectus sheuth s best
consdered n three sectons:
s Above the eve ol the costu murgn
s lrom the costu murgn to ust beow
the umbcus
s eow the ne ol Dougus
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s Abovc thc IcvcI of thc costaI margin: the
unteror rectus sheuth s lormed by the
externu obque uponeuross ony. 1here s
no nternu obque or trunsversus ubdomns
uponeuross ut ths eve. 1herelore there
s no posteror rectus sheuth und rectus
ubdomns es drecty on the lth to
seventh costu curtuges
s from thc costaI margin to just bcIow thc
umbiIicus: the unteror rectus sheuth s lormed
by the externu obque uponeuross und
the unteror eul ol the spt nternu obque
uponeuross. lt s uttuched to rectus ubdomns
by tendnous ntersectons. 1he posteror
rectus sheuth s lormed by the posteror eul
ol the nternu obque uponeuross und the
trunsversus ubdomns uponeuross
s BcIow thc Iinc of DougIas: ubout 2.5 cm
beow the umbcus es u ne cued the
urcuute ne ol Dougus' (lg. l.l). At
ths eve, the posteror rectus sheuth (e
the posteror eul ol the nternu obque
uponeuross uong wth the trunsversus
ubdomns uponeuroses) pusses unteror
to rectus ubdomns. 1herelore, beow the
urcuute ne ol Dougus there s no posteror
rectus sheuth. Rectus ubdomns es drecty
on trunsversus luscu, whch s thckened
here, und cued the opubc truct'. 1he
unteror rectus sheuth s now lormed by u
the combned uponeuroses ol the externu
obque, nternu obque und trunsversus
ubdomns musces
figurc 1.1 SagittaI scction of thc abdominaI waII
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(A) TranspyIoric Iinc: hulwuy between uguur
notch und pubc symphyss ut Ll, ths pune
pusses through pyorus, puncreutc neck,
duodenoeunu exure, lundus ol gubudder,
tp ol nnth costu curtuge, hu ol kdneys, uso
t s the eve ol termnuton ol the spnu cord.
() SubcostaI Iinc: under owest rb (rb l0 ut L3).
(C) lntcrtubcrcuIar/transtubcrcuIar Iinc: between
two tuberces ol uc crest (L5), note thut pune
ol uc crests (suprucrstu pune) s hgher (ut
L4).
(D) MidcIavicuIar Iinc: through mdngunu pont,
hulwuy between ASlS und symphyss pubs.
(l) Xiphoid proccss: xphsternu uncton s ut 19.
(2) CostaI margins: rbs 7l0 n lront, rbs ll und
l2 behnd, tenth costu curtuge s owest ut L3.
(3) lIiac crcst: unteror superor uc spne (ASlS)
to posteror superor uc spne (PSlS), hghest
pont L4.
(4) ASlS.
(5) TubcrcIc of iIiac crcst: 5 cm behnd ASlS ut L5.
(6) lnguinaI Iigamcnt: runnng lrom ASlS to pubc
tuberce.
(7) Pubic tubcrcIc: tuberce on superor surluce ol
pubs, ngunu gument uttuches to t, us uteru
end ol the supercu ngunu rng.
(8) SupcrciaI inguinaI ring: ngunu hernu comes
out ubove und medu to pubc tuberce ut pont
murked (l), lemoru hernu beow und uteru to
pubc tuberce ut pont murked (l).
(9) Symphysis pubis: mdne curtugnous ont
between pubc bones.
(l0) Pubic crcst: rdge on superor surluce ol pubc
bone medu to pubc tuberce.
(ll) linca aIba: symphyss pubs to xphod process
mdne.
(l2) linca scmiIunaris: uteru edge ol rectus crosses
costu murgn ut nnth costu curtuge (tp ol
gu budder pupube here).
figurc 1.2 Surfacc
Iandmarks of thc
antcrior abdominaI
waII
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ConIenIs o! Ihe recIus sheaIh
s Rectus ubdomns
s Pyrumdus
s Segmentu nerves
s Segmentu vesses lrom17 to 1l2
s Superor und nleror epgustrc vesses (see
lgure l.l)
laycrs of thc abdominaI waII dividcd in thrcc common incisions
MidIinc Iaparotomy kochcr's incision Gridiron appcndiccctomy
incision
Skn Skn Skn
Subcutuneous lut Subcutuneous lut Subcutuneous lut
Scurpu's luscu Scurpu's luscu Scurpu's luscu
Lneu ubu Meduy:
Anteror rectus sheuth
Rectus ubdomns
Posteror rectus sheuth
Luteruy:
Lxternu obque
lnternu obque
1runsversus ubdomns
Lxternu obque
lnternu obque
1runsversus ubdomns
luscu trunsversus luscu trunsversus luscu trunsversus
Prepertoneu lut Prepertoneu lut Prepertoneu lut
Puretu pertoneum Puretu pertoneum Puretu pertoneum
Diseases o! Ihe umbiIicus
CongcnitaI
s Cord hernus
s Custroschss
s Lxomphuos
Tumours
s Prmury
s engn (pupomu, pomu)
s Mugnunt (squumous ce curcnomu
SCC, meunomu)
s Secondury
s reust
s Cvurun
s Coon (vu ymphutc, trunscooemc und
drect spreud uong luclorm gument)
Lndomctriosis
Hcrnias
s Chdhood (umbcu)
s Adut (puruumbcu)
fistuIa
s Lrnury truct (vu uruchu remnunt)
s Custrontestnu truct (vu vteon-
testnu duct)
Suppurations
s Prmury
s Cbesty
s Pondu
s lungu nlectons
s Secondury
s lrom ntru-ubdomnu ubscess
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5ur!ace markings o! abdominaI
organs and vesseIs
s GaIIbIaddcr: tp ol rght nnth costu
curtuge where neu semunurs ntersects
the costu murgn (lgure l.2)
s SpIccn: under rbs 9, l0 und ll on the
elt, ong uxs es uong rb l0, pupube n
nlunts
s Pancrcas: es uong the trunspyorc pune
(Ll)
s kidncy: lrom the eve ol 1l2 to L3, the
hum es on the trunspyorc pune (Ll),
rght kdney s ower, kdneys move 25 cm
n respruton
s Appcndix: Mcurney's pont s the surluce
murkng ol the buse ol the uppendx one
thrd ol the wuy up the ne onng the
unteror superor uc spne to the umbcus
s Aortic bifurcation: ut the eve ol L4
vertebru to elt ol mdne
s fxtcrnaI iIiac artcry: pupube ut
mdngunu pont hulwuy between ASlS
und symphyss pubs
AbdominaI incisions
The ideaI abdominaI incision
s Aows eusy und rupd uccess to
reevunt structures
s Aows eusy extenson (l necessury)
s luvours secure heung n the short
term (no dehscence) und n the ong
term (no hernuton)
s Leuves putents reutvey pun-lree
postoperutvey
s Cves u sutsluctory cosmetc
uppeurunce
figurc 1.3
AbdominaI
incisions
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(l) MidIinc incision through Iinca aIba: provdes
good uccess. Cun be extended eusy. Quck
to muke und cose. Reutvey uvuscuur. More
punlu thun trunsverse ncsons. lncson
crosses Lunger's nes so t hus poor cosmetc
uppeurunce. Nurrow neu ubu beow
umbcus. Some vesses cross the mdne. Muy
cuuse budder dumuge.
(2) SubumbiIicaI incision: used lor repur ol
puruumbcu hernus und upuroscopc port.
(3) Paramcdian incision: l.5 cm lrom mdne
through rectus ubdomns sheuth. 1hs wus the
ony ellectve vertcu ncson n the duys when
cutgut wus the ony uvuube suture muteru.
1ukes onger to muke thun mdne ncson.
Does not end tsel to cosure by lenkns
rue' (ength ol suture s 4 ength ol wound).
Poor cosmetc resut. Cun eud to nlecton
n rectus sheuth. Cther huzurds: tendnous
ntersectons must be dssected oll, need to
dvde luclorm gument ubove umbcus on
the rght, l rectus s spt more thun l cm lrom
medu border, ntercostu nerves ure dsrupted
eudng to denervuton ol medu rectus (uvod
by retructng rectus wthout spttng).
(4) PararcctaI BattIc's' incision: now not used
becuuse ol dumuge to nerves enterng rectus
sheuth und poor heung eudng to postop-
erutve ncsonu hernus.
(5) kochcr's incision: 3 cm beow und purue to
costu murgn lrom mdne to rectus border.
Cood ncson lor choecystectomy on the
rght und spenectomy on the elt but bewure
superor epgustrc vesses. ll wound s extended
uteruy too muny ntercostu nerves ure
severed. Cunnot be extended cuuduy.
(6) DoubIc kochcr's (rooftop) incision: good
uccess to ver und speen. Lselu lor
ntruheputc surgery. Lsed lor rudcu puncreutc
und gustrc surgery und buteru udrenuectomy.
(7) Transvcrsc muscIc-cutting incision: cun be
ucross u musces. ewure ol ntercostu nerves.
(8) McBurncy's/gridiron incision: cussc upprouch
to uppendx through uncton ol the outer und
mdde thrd ol u ne lrom the unteror superor
uc spne (ASlS) to the umbcus ut rght unges
to thut ne. Muy be moded nto u skn-creuse
horzontu cut. Lxternu obque uponeuross
s cut n the ne ol the bres. lnternu obque
und trunsversus ubdomns ure spt trunsversey
n the ne ol the bres. ewure: scurrng l not
horzontu, ohypogustrc und ongunu
nerves, deep crcumex urtery.
(8u) Ruthcrford-Morrison incision: grdron cun
be extended cephuud und uteruy, obquey
spttng the externu obque to ullord good
uccess to cuecum, uppendx und rght coon.
(9) lanz incision: ower ncson thun Mcurney's
und coser to the ASlS. etter cosmetc resut
(conceued by bkn). 1ends to dvde ohy-
pogustrc und ongunu nerves, eudng to
denervuton ol ngunu cunu mechunsm (cun
ncreuse rsk ol ngunu hernu).
(l0) PfanncnsticI's incision: most lrequenty used
trunsverse ncson n uduts. Lxceent uccess
to lemue gentuu lor cuesureun secton und
lor budder und prostute operutons. Aso used
lor buteru hernu repur. Skn ncsed n u
downwurd convex urc nto suprupubc skn
creuse 2 cm ubove the pubs. Lpper up s
rused und rectus sheuth ncsed l cm cephuc
to the skn ncson (not extendng uteru to the
rectus). Rectus s then dvded ongtudnuy n
the mdne.
(ll) Transvcrsc incision: purtcuury uselu n
neonutes und chdren (who do not huve
the subduphrugmutc und pevc recesses
ol uduts). Heus securey und cosmetcuy.
Less pun und lewer resprutory probems
thun wth ongtudnu mdne ncson but
dvson ol red musce nvoves more bood
oss thun ongtudnu ncson. Not extended
eusy. 1ukes onger to muke und cose. Lmted
uccess n uduts to pevc or subduphrugmutc
structures.
(l2) ThoracoabdominaI incision: uccess to ower
thorux und upper ubdomen. Lsed (rurey) lor
ver und bury surgery on the rght. Lsed
(rurey) lor oesophugeu, gustrc und uortc
surgery on the elt.
figurc 1.3 AbdominaI incisions
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1.2 Hernias
In a nuIsheII .
A hernu s u protruson ol u or purt ol
u vscus through the wu ol the cuvty n
whch t s normuy contuned.
1ypes ol ubdomnu hernus:
Cron:
s lngunu
s lemoru
Lmbcu
Puruumbcu
lncsonu
Lpgustrc
Spgeun
Lumbur
Cuteu
Scutc
Groin hernias
lngunu und lemoru hernus ure two ol the most
common types ol hernu. 1her repurs muke up
u urge proporton ol eectve surgery.
All groin hernias
A hernus ure more common on the rght thun
on the elt (muy be due to uter descent ol rght
tests or prevous uppendcectomy)
Incidence o! groin hernias
Male chldren
s 4% ol mue nlunts huve ndrect
ngunu hernu
s Rsk ol ncurceruton s hgh n bubes
s Presents us ump n the gron when
chd cres
s lndrect ngunu > drect ngunu >
lemoru (very rure)
Female chldren
s A gron hernus rure n lemue
chdren
s Presence ol buteru hernus shoud
uert cncuns to possbe testcuur
lemnsuton syndrome
s Hernus n lemue chdren muy
contun un ovury n the hernu suc
whch must be reduced ut surgery
s lndrect ngunu > drect ngunu >
lemoru (very rure)
Male adulls
s Drect ngunu > ndrect ngunu >
lemoru
Female adulls
s lndrect ngunu > lemoru > drect
(rure)
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!!
lnguinal hernias
AnaIomy o! Ihe inguinaI region
Ihguihal cahal
1hs s un obque ntermuscuur st, 6 cm ong,
ubove the medu hul ol the ngunu gument
between the deep und supercu rngs. lt
trunsmts the spermutc cord n the mue und the
round gument ol the uterus n the lemue.
Deep ihguihal rihg
1hs s un ovu openng n the trunsversus luscu,
l.3 cm ubove the ngunu gument, mdwuy
between the ASlS und the pubc tuberce. 1hs
s the mdpont ol the ngunu gument ust
uteru to the mdngunu pont. 1he deep rng
s bounded uteruy by the unge between the
trunsversus ubdomns und the ngunu gument.
lt s bounded meduy by the trunsversus luscu
und the nleror epgustrc vesses behnd ths.
figurc 1.4 Anatomy of thc
inguinaI rcgion:
l. \th skn und cutuneous
lut removed
2. \th externu obque
removed
3. \th nternu obque
removed
4. \th trunsversus musce
removed
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Super!icial ihguihal rihg
1hs s u trunguur openng n the externu
obque uponeuross. 1he uteru crus uttuches to
the pubc tuberce. 1he medu crus uttuches to
the pubc crest neur the symphyss. 1he buse ol
the supercu rng s the pubc crest.
Floor o! Ihe ihguihal cahal
1he ngunu gument lorms most ol the oor ol
the ngunu cunu. 1he ucunur gument lorms
the medu purt ol the oor, ng n the unge
between the ngunu gument und the pectneu
ne.
Ceilihg o! Ihe ihguihal cahal
Luteru to medu, ths s lormed by trunsversus
ubdomns, nternu obque und the conont
tendon.
Transvcrsus abdominis urses uteru to the
deep rng lrom the uteru hul ol the ngunu
gument. lt urches over the rool ol the ngunu
cunu to become the conont tendon.
1he intcrnaI obIiquc urses n lront ol the deep
rng lrom the uteru two-thrds ol the ngunu
gument und, yng supercu to trunsversus
ubdomns, behuves n the sume wuy.
1he conjoint tcndon s lormed by the luson
ol the uponeuross ol the nternu obque und
trunsversus ubdomns. lt urches over the cunu,
lormng the medu rool, strengthenng the
posteror wu. lt nserts nto the pubc crest und
the pectneu ne ut rght unges to the ucunur
gument, whch lorms the oor here.
1runsversus ubdomns, the nternu obque und
conont tendon cun contruct und ower the rool
ol the ngunu cunu, thereby strengthenng t.
1hey ure supped by Ll lrom the ohypogustrc
und ongunu nerves. 1hese nerves ure ut rsk
n the musce-spttng ncson lor uppend-
cectomy, whch euds to ncreused rsk ol drect
hernu.
AhIerior wall o! Ihe ihguihal cahal
1he unteror wu s lormed mosty by the
externu obque strengthened uteruy by the
nternu obque. 1he supercu rng s u delect
n the unteror wu. 1he unteror wu s strongest
opposte the weukest pont ol the posteror
wu the uteruy puced deep rng. Here, the
unteror wu s strengthened by the nternu
obque bres thut orgnute unteror lrom the
uteru two-thrds ol the ngunu gument.
PosIerior wall o! Ihe ihguihal cahal
1he posteror wu s lormed by the trunsversus
luscu, strengthened meduy by the conont
tendon. 1he deep rng s u delect n the posteror
wu. 1he posteror wu s strongest opposte the
weukest pont ol the unteror wu the meduy
puced supercu rng. Here, the posteror wu
s strengthened by the conont tendon bres,
lormed lromthe nternu obque und trunsversus
ubdomns us they curve over to nsert posterory
nto the pubc crest und the pectneu ne.
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ConIenIs o! Ihe inguinaI canaI in Ihe maIe
Vas
Artcrics:
s 1estcuur
s Artery to vus
s Cremusterc
Vcins: pumpnlorm pexus
lymphatic vcsscIs: the tests druns to the puru-uortc ymph nodes, the coverngs ol the tests
drun to the externu uc nodes
Ncrvcs:
s Centu brunch ol gentolemoru (suppes cremuster musce)
s Symputhetc nerves uccompunyng urteres
s longunu nerve (enters vu unteror wu ol cunu, not vu nternu rng, und runs n lront
ol spermutc cord) suppes skn ol ngunu regon, upper purt ol thgh und unteror thrd
ol scrotum or ubu
Proccssus vaginaIis: obteruted remuns ol pertoneu connecton to tuncu vugnus
A ol these ure n the spermutc cord except the ongunu nerve
s \hen ubdomnu pressure ncreuses, we
uutomutcuy squut so the unteror thgh
presses ugunst the ngunu cunu und
renlorces t
IndirecI inguinaI hernias
In a nuIsheII .
s 60% ol udut mue ngunu hernus ure
ndrect
s 4% ol mue nlunts huve ndrect
ngunu hernus
lndrect ngunu hernus ure the most
common type ol gron hernu n chdren.
1hey ure thought to be cuused by the
congentu luure ol the processus
vugnus to cose (succuur theory ol
Russe).
Coverings o! Ihe spermaIic cord
s lnternu spermutc luscu (lrom
trunsversus luscu)
s Cremusterc luscu (lrom nternu
obque und trunsversus ubdomns)
s Lxternu spermutc luscu (lrom
externu obque)
1he ngunu cunu s u nuturu pont ol weukness
n the ubdomnu wu. 1here ure severu leutures
thut normuy reduce ths weukness:
s 1he rngs e some dstunce upurt (except n
nlunts)
s 1he unteror wu s renlorced by the
nternu obque n lront ol the deep rng
s 1he posteror wu s renlorced by the
conont tendon opposte the supercu rng
s \hen ubdomnu pressure ncreuses, the
nternu obque und trunsversus ubdomns
contruct, owerng the rool
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Predisposing !acIors !or indirecI
hernia
s MaIcs: bgger processus vugnus thun
n women
s Prcmaturc twins or Iow birthwcight:
processus vugnus not cosed
s Africans: the ower urch n the more
obque Alrcun pevs meuns the
nternu obque orgn does not
protect the deep rng
s On thc right sidc: rght tests descends
uter thun the elt
s TcsticuIar fcminisation syndromc:
genotypc mue but undrogen-
nsenstve so phenotypcuy lemue
s Young mcn: drect hernus become
more common wth uge
s lncrcascd intrapcritoncaI uid: lrom
whutever cuuse, eg curduc, crrhotc,
curcnomutoss, duyss, tends to open
up the processus vugnus
1he ndrect ngunu hernu suc s the remuns
ol the processus vugnus. 1he suc extends
through the deep rng, ngunu cunu und
supercu rng. 1he nleror epgustrc urtery
es medu to the neck. ln u compete suc the
tests s lound n the lundus. ln un ncompete
suc, the suc s mted to the cunu or s
ngunoscrotu or ngunoubu. 1he ndrect
hernu commony descends nto the scrotum.
DirecI inguinaI hernias
In a nuIsheII .
s 35% ol udut mue ngunu hernus ure
drect
s 5% ol udut mue ngunu hernus ure
u combnuton ol drect und ndrect
1he drect ngunu hernu s un ucqured
weukness n the ubdomnu wu whch
tends to deveop n uduthood (unke
ndrect hernus whch ure common n
chdren) und ure therelore the most
common gron hernus n od men.
1he drect ngunu hernu suc es behnd the
cord. 1he nleror epgustrc urtery es uteru to
the neck. 1he hernu pusses drecty lorwurds
through the delect n the posteror wu (luscu
trunsversus) ol the ngunu cunu. 1hs hernu
does not typcuy run down uongsde the cord
to the scrotum, but muy do so.
Femoral hernias
AnaIomy o! Ihe !emoraI region
Femoral sheaIh
1he lemoru sheuth s u downwurd protruson
nto the thgh ol the luscu enveope nng
the ubdomnu wus. lt surrounds the lemoru
vesses und ymphutcs lor ubout 2.5 cm beow
the ngunu gument. 1he sheuth ends by lusng
wth the tuncu udventtu ol the lemoru vesses.
1hs occurs cose to the suphenous openng n
the deep luscu ol thgh.
1he unteror wu s contnuous ubove wth luscu
trunsversus und the posteror wu s contnuous
ubove wth luscu ucus/psous luscu. lt does
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not protrude beow the ngunu gument n the
letu poston.
1he lemoru sheuth exsts to provde lreedom lor
vesse movement beneuth the ngunu gument
durng movement ol the hp.
ConIenIs o! Ihe !emoraI sheaIh
s fcmoraI artcry: n uteru compurtment
s fcmoraI vcins: n ntermedute
compurtment
s lymphatics: n medu compurtment or
lemoru cunu
s fcmoraI branch (l1) of gcnitofcmoraI
ncrvc: perces the unteror wu ol the
lemoru sheuth runnng on the unteror
surluce ol the externu uc urtery
Note thut the lemoru nerve es n the
uc lossu between the psous und the
ucus behnd the luscu, so t enters the
thgh outsde the lemoru sheuth.
Femoral cahal
1he lemoru cunu s the medu compurtment ol
the lemoru sheuth contunng ymphutcs. lt s
ubout l.3 cm ong wth un upper openng cued
the lemoru rng'.
1he lemoru cunu uows ymph vesses to be
trunsmtted lromthe ower mbs to the ubdomen
und s uso u deud spuce nto whch the lemoru
ven cun expund when venous return ncreuses.
1he lemoru cunu s the puth tuken by lemoru
hernus.
ConIenIs o! Ihe !emoraI canaI
s lutty connectve tssue
s Lllerent ymph vesses lrom deep
ngunu nodes
s Deep ngunu node ol Coquet (druns
pens/ctors)
Femoral rihg
1he top ol the lemoru cunu s cued the lemoru
rng. lt s covered by the lemoru septum u
condensuton ol extrupertoneu tssue. 1hs s
pushed downwurds nto the cunu n u hernu.
figurc 1.S Thc
fcmoraI rcgion
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oundaries o! Ihe !emoraI ring
s AntcriorIy: ngunu gument
s PostcriorIy: superor rumus ol pubs
und pectneu gument
s McdiaIIy: ucunur gument or
opubc truct
s latcraIIy: lemoru ven
1hese ure uso the murgns ol the neck ol
u lemoru hernu. Note thut three ol the
lour boundures ure rgd, so u lemoru
hernu s prone to strunguuton.
1he ucunur gument muy huve to be ncsed to
reeuse u strunguuted hernu, rskng beedng
lrom the uccessory (ubnormu) obturutor urtery.
EpidemioIogy o! !emoraI hernia
ln lemues, ndrect ngunu hernus ure st
more common thun lemoru hernus. However,
they ure lound 2.5 tmes more commony n
lemues becuuse:
s 1he ngunu gument mukes u wder unge
wth the pubs n the lemue
s Lnurgement ol the lut n the lemoru cunu
ol lut mdde-uged women stretches the
lemoru cunu, ths lut dsuppeurs n od
uge, euvng u bgger cunu
s Pregnuncy ncreuses ntru-ubdomnu
pressure und stretches the luscu
trunsversus
Mechanics o! !emoraI hernia
1he lemoru hernu enters the lemoru cunu
through the lemoru rng. 1he hernu urrves n
the thgh next to the suphenous openng ol the
lemoru sheuth. 1he crbrlorm luscu over the
suphenous openng becomes stretched over
the hernu. 1he hernu enurges upwurds und
meduy nto the supercu luscu ol the ngunu
gument. 1ypcuy t es between the supercu
externu pudendu und supercu epgustrc
vens, compressng the suphenous ven us t
emerges through the suphenous openng.
CharacIerisIics o! a IypicaI !emoraI
hernia
s Smu (hurd to nd n un obese putent)
s Not reducbe
s No cough mpuse
s Clten contuns ony omentum
s Muy contun u knucke ol bowe (most
common ste lor Rchter's hernu)
s More common on the rght
s 3550% ol u strunguuted gron
hernus n uduts ure lemoru hernus
Di!!erenIiaI diagnosis o! !emoraI
hernia
lngunu hernu:
s lemoru hernu emerges beow und
uteru to pubc tuberce
s lngunu hernu emerges ubove und
medu to pubc tuberce
Suphenu vurx
Lnurged ymph node
Lpomu
lemoru urtery uneurysm
Surcomu
Lctopc tests
Cbturutor hernu
Psous bursu
Psous ubscess
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Nanagement of groin hernias
Dugnoss ol u gron hernu s usuuy cncu.
However, vurous mugng methods ure uvuube
to conrm the dugnoss und ussess unutomy
n cuses thut ure not strughtlorwurd (utruso-
nogruphy, contrust hernogrum, computed
tomogruphy C1 / mugnetc resonunce mugng
MRl). ln u contrust hernogrum, wuter-soube
contrust medu s nected nto the pertoneu
cuvty through the unteror ubdomnu wu.
1he putent s postoned prone und poong ol
contrust nto the hernu suc s ooked lor on u
rudogruph. 1hs s now rurey perlormed.
European Hernia 5ocieIy GuideIines
!or Ihe TreaImenI o! InguinaI Hernia
in AduII PaIienIs (2009)
Primary uniIatcraI: mesh repur
(Lchtensten's or endoscopc repur l
expertse s uvuube)
Primary biIatcraI: mesh repur
(Lchtensten's or endoscopc)
Rccurrcnt inguinaI hcrnia: modly
technque n reuton:
s ll prevousy unteror open
prepertoneu mesh or endoscopc
upprouch
s ll prevousy posteror Lchtensten's
totuy extrupertoneu (1LP) s
prelerred to trunsubdomnu preper-
toneu (1APP) repur n the cuse ol
endoscopc surgery
ProphyIactic antibiotics ure not
recommended n ow-rsk putents or n
endoscopc surgery
Anacsthcsia:
ASA l/2: uwuys consder duy surgery
ASA 3/4: consder ocu unuesthesu or
duy surgery
lndications for groin hcrnia rcpair
fIcctivc
(to be
prortsed
by ob)
lndrect
Symptomutc
drect
Rute ol strungu-
uton ol ngunu
hernu s 0.32.9%
per yeur, ncreused
rsk l rreducbe
or ndrect
Prompt lrreducbe
ngunu hernu
Hstory ol ess
thun 4 weeks
Creuter rsk ol
strunguuton n
rst 3 months ulter
uppeurunce
Urgcnt A lemoru
hernus
50% strunguute
wthn l month
fmcrgcncy Punlu
rreducbe
hernus
epair o! inguinaI hernia
In a nuIsheII .
Mun ums ol ngunu hernu repur:
s Reduce hernu contents
s Remove hernu suc
s Repur delect
Main approachcs
lor prmury uncompcuted ngunu
hernus:
s Lchtensten's mesh repur
s Lupuroscopc repur
Cther recognsed technques:
s Shoudce technque
s McVuyCooper gument operuton
Hernotomy lor chdren s u dllerent
operuton lrom hernorruphy lor uduts us
there s no need to repur the posteror
wu ol the ngunu cunu n chdren
becuuse there s no delect there.
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Op ox. Open repair o! inguinaI hernia (mesh or 5houIdice)
Mesh repair
1hs s the method ol choce lor neury u eectve open ngunu hernu repurs n the LK und
s uso used n ncurceruted or even strunguuted emergency hernu repurs where there s no
gross contumnuton by pus or bowe contents.
s Renlorce posteror wu ol ngunu cunu wth Proene mesh
s Appy mesh on trunsversus luscu und nternu obque musce
s St uteru end to uccommodute spermutc cord
s Suture nleror murgn ol mesh to nner surluce ol ngunu gument usng contnuous
Proene or nyon suture
s lx medu und superor murgns to nternu obque musce usng nterrupted sutures
s Medu end shoud reuch pubc tuberce
s Suture uteru tu ends to one unother uround the cord, ensurng thut the gup elt n the
mesh lor the cord s enough to udmt the tte ngertp (therelore no cord dumuge) but
w not udmt u whoe nger (therelore no hernu recurrence)
5houIdice repair
1hs s u recognsed method lor open ngunu hernu repur und s uselu when u mesh s
contrundcuted (eg n u strunguuted hernu wth pus or bowe contents contumnutng the
ngunu cunu).
s Cremuster musce shoud uwuys be dvded to gve good uccess to the deep rng
s Murgns ol the deep rng ure dssected lrom the cord
s luscu trunsversus s opened lrom the deep rng meduy down to the pubc tuberce
s luscu trunsversus s ceuned ol extrupertoneu lut to expose: the deep surluce ol the
conont tendon ubove und meduy, und the luscu trunsversus us t punges nto the
thgh beow und uteruy to become the unteror uyer ol lemoru sheuth
s Lower uteru luscu trunsversus up s sutured to the undersurluce ol the conont tendon
s Lpper up s overupped und sutured to unteror surluce ol ower uteru up ol the luscu
trunsversus (ths reconstructs the posteror wu ol the ngunu cunu)
s Suturng s tuken uteruy to muke u new deep rng ush wth the emergent cord
s Repur s renlorced meduy by suturng the conont tendon to the uponeuross ol
externu obque
CIosure o! 5houIdice and mesh repairs
s Sume lor both methods
s lnspect lor potentu lemoru hernu belore cosure
s Cose externu obque uponeuross wth contnuous ubsorbube suture (eg PDS) over the cord
s Cose Scurpu's luscu wth nterrupted Vcry
s Cose skn wth undyed subcutcuur Monocry
s Druw down psuteru testce to the bottom ol the scrotum
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PosIoperaIive advice a!Ier opeh repair o!
ihguihal herhia
s Clten home the sume duy
s Lut, drnk und mobse on wukng
s uck to sedentury ob wthn 2 weeks
s uck to heuvy ltng, strenuous sports und
munuu ubour n 6 weeks
s Sule to drve when perlormng un
emergency stop does not cuuse uny
dscomlort (udvse them to check wth ther
nsurunce compuny l they ure n doubt)
s Cru unugesu muy be needed lor u lew
duys
s loow-up s usuuy by CP ony uness there
s un ongong uudt
InIraoperaIive hazards o! open repair o! inguinaI hernia
Damage Io Ihe iIioinguinaI nerve
1hs muy be cut when the cunu s entered
(cuusng sensory oss n the ower gron or
scrotum) or sutured nto the mesh, cuusng
chronc pun l cure s not tuken.
ln urge or emergency hernus where
dumuge or entrupment ol the nerve s
unuvodube, the nerve shoud be cut us
proxmuy us possbe becuuse numbness s
prelerube to pun.
Damage Io Ihe cord sIrucIures in Ihe
maIe
s Vus
s 1estcuur urtery
s Pumpnlorm pexus ol vens
1hs muy eud to reduced lertty, schuemc
orchts or vurcocee respectvey.
OrchidecIomy
Very occusonuy n un emergency
stuuton wth u urge ncurceruted or
strunguuted ngunoscrotu hernu, or n
the eectve putent wth enormous chronc
ngunoscrotu hernus or recurrent open
hernus, t muy mpossbe to preserve the
cord und t mght be necessury to remove
the cord und testce to ucheve sule cosure
ol the posteror wu. 1hese putents shoud
huve the rsk expuned n the consent.
ComplicaIiohs o! opeh repair o! ihguihal
herhia
s Huemutomu
s \ound nlecton und mesh nlecton
s Recurrence
s 1estcuur utrophy or schuemc orchts due
to cord dumuge n mues
s 1emporury postoperutve urnury retenton
due to pun n edery peope or men wth
pre-exstng prostutc symptoms
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AdvanIages and disadvanIages o! mesh repair
Advuntuges Dsudvuntuges
Luser to eurn und perlorm lor trunees Rsk ol nlecton (uvod huemutomus und use
prophyuctc untbotcs)
Lower recurrence rute (l n l000)
1enson-lree repur
Reduced unugesc requrement
AdvanIages and disadvanIages o! 5houIdice repair
Advuntuges Dsudvuntuges
Low rsk ol nlecton
lndcuted n presence ol
strunguuted bowe where mesh s not
recommended
1echncuy more dlcut thun mesh repur
Hgh stundurd ol trunng needed
Low recurrence rute n the rght hunds Surgcu tme onger thun wth mesh repur
1enson-lree repur dlcut to perlorm
Postop unugesc requrement hgher thun wth
mesh repur
1hs technque wus perlected by the Shoudce Cnc. Recurrence rute s <l% there, but upprouches
3.5% esewhere. 1runee surgeons ut the Shoudce Cnc must ussst n 50 hernu repurs then perlorm
l00 hernu repurs under supervson belore beng uowed to repur ngunu hernus ndependenty.
OIher Iypes o! ihguihal herhia repair
laparoscopic rcpair s u popuur und recognsed
lorm ol hernu repur. 1here ure two types:
trunsubdomnu prepertoneu (1APP) or totuy
extrupertoneu (1LP) repur. Lupuroscopc
ngunu hernu surgery shoud be perlormed
ony by upproprutey truned surgeons.
Lupuroscopc repur s ussocuted wth un
ncreuse n operuton tme, however, there s u
shorter recovery tme when compured wth open
hernu repur. oth1APP und1LP procedures ure
ussocuted wth u reducton n wound-reuted
nlectons, huemutomu, persstent numbness
und pun compured wth open repur. 1he rutes
ol recurrence s smur lor upuroscopc und
open repur.
ln the McVay-Coopcr Iigamcnt opcration the
luscu trunsversus s opened und the upper
medu up s sutured to the opectneu
gument (Cooper's gument).
1he ussn (durn) repur s no onger
recommended due to hgh recurrence rutes.
Ihguihal herhia repair ih childreh
ln the repur ol ngunu hernus n chdren:
s Hernotomy uone s sulcent
s 1he hernu s reduced, the suc dvded und
guted but there s no need to repur the
posteror wu ol the cunu us there s no
weukness there
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s Mesh or durn hernorrhuphy s not ndcuted
Cvures shoud be ooked lor n lemues und
reduced ut the tme ol surgery. 1he possbty
ol testcuur lemnsuton syndrome shoud be
consdered n lemue chdren wth buteru
hernus.
epair o! !emoraI hernias
In a nuIsheII .
Main aims
s Reduce hernu contents
s Remove pertoneu suc
s Repur delect
Thrcc main approachcs
s Low cruru (Lockwood)
s Hgh ngunu (Lothessen)
s Hgh extrupertoneu (McLvedy)
Lupuroscopc repur cun uso be
perlormed.
C5 guideIines on repair o! !emoraI
hernias
s Recommends hgh ngunu upprouch
except n thn lemues, where u ow cruru
upprouch s ucceptube
s Advses hgh extrupertoneu upprouch n
compex, recurrent or obstructed hernus
Groin hernia repair under IocaI
anaesIheIic
1he udvuntuges ol uny surgery under ocu
unuesthetc (LA) ure dscussed luy n ook l.
1hey ncude removng the rsk ol generu
unuesthesu, us we us decreused cost und
shorter putent stuy. Cron hernu repur s un
deu operuton to be perlormed under ocu
or regonu unuesthesu, especuy when
combned wth duy-cuse surgery. 1hs s key
to become more popuur wth the ncreusng use
ol preoperutve utrusound-guded trunsversus
ubdomns pune (1AP) bock. 1he unuesthetc
ugents, precuutons und compcutons ure
dscussed n ook l. LA s not sutube lor
obese, unxous or uncooperutve putents, or n
compex or recurrent hernus.
MeIhod o! adminisIering LA in groin
hernia repair
s Subcutuneous weu n ne ol ncson
s Deep necton ut ongunu und
ohypogustrc nerves (one nger-
breudth medu to ASlS)
s lurther necton deep to proposed
ncson
s Deep ntruton us needed
s upvucune bock belore cosure n
both CA und LA
ERN 2012.indb 21 21/09/2012 15:11:40