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ANUS - Surgery Exam Answers

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1. VAAFT (Video-Assisted Anal Fistula Treatment)

Equipment

• A specially designed rigid fistulascope (Karl Storz) with a working channel for instruments
• An electrode for fulguration, a brush for debridement, a forceps
• Saline irrigation for distension and visibility
• A monopolar diathermy probe

Principle

1. Diagnostic phase - the fistuloscope is inserted through the external opening under direct vision to map the entire fistula tract, identify internal opening, and detect secondary tracks or branches
2. Operative phase - granulation tissue is debrided with a brush, the tract is ablated under direct vision with a monopolar electrode without dividing sphincter muscle. The internal opening is closed with a stapler or suture ligation

Advantages

• No sphincter division - preserves continence
• Direct visualization of the entire tract
• Can identify secondary tracks missed clinically
• Can be repeated if initial attempt fails
• Applicable to complex transsphincteric fistulae

Results

Comparison with FiLaC

• FiLaC (Fistula Laser Closure) uses a radially emitting laser probe to ablate the tract rather than an electrode. Meta-analysis shows 65% healing at median 24 months.
• Both techniques follow the same principle: ablate from inside without dividing sphincter

Source: Sabiston Textbook of Surgery, Bailey & Love 28e, Current Surgical Therapy 14e

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2. Management of Fissure in Ano

Definition

Pathophysiology

Classification

• Acute fissure: <6 weeks, fresh tear, no sentinel pile
• Chronic fissure: >6 weeks, indurated edges, sentinel pile, hypertrophied papilla at proximal end, exposed sphincter fibers at base

Treatment

Conservative (Acute Fissures)

• High-fiber diet, stool softeners, increased fluid intake
• Warm sitz baths for symptom relief
• Topical anesthetics (lidocaine)

Medical (Chronic Fissures) - Chemical Sphincterotomy

Surgical - Lateral Internal Sphincterotomy (LIS)

• Gold standard for chronic anal fissure
• Healing rates 92-95% - the standard by which all treatments are measured
• Divides the IAS at the lateral position (3 or 9 o'clock) to reduce hypertonia
• Can be open (conventional) or closed (Parks) technique
• Done under local, regional, or general anesthesia
• Risk: fecal incontinence (minor soiling 0-36%, significant incontinence rare)

Other Surgical Options

• Anal dilatation (Lord's procedure) - largely abandoned due to high incontinence rates
• Fissurectomy with or without advancement flap - for complex cases
• Posterior midline sphincterotomy - avoided (risk of keyhole deformity)

Source: Sabiston 28e, Bailey & Love 28e, Sleisenger & Fordtran's GI Disease, Goldman-Cecil Medicine

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3. Management of Fistula in Ano + Recent Advances

Definition

Etiology

• Idiopathic/cryptoglandular (majority) - infection of anal glands at dentate line (cryptoglandular theory)
• Crohn's disease, TB, actinomycosis, lymphogranuloma venereum, foreign body, malignancy

Goodsall's Rule

• External opening posterior to a transverse line through the anus → fistula tracks in a curved manner to a posterior internal opening
• External opening anterior to the transverse line → fistula tracks directly to the nearest internal opening

Parks Classification

1. Intersphincteric (45%) - track confined to intersphincteric plane, does not cross external sphincter
2. Transsphincteric (30%) - track traverses external sphincter; can be low (lower 1/3) or high (upper 2/3)
3. Suprasphincteric (20%) - track passes above puborectalis, loops over it
4. Extrasphincteric (5%) - track passes outside both sphincters; often iatrogenic or from pelvic disease

AGA Classification (Clinical)

• Simple fistula: low (intersphincteric or low transsphincteric), single external opening, no abscess
• Complex fistula: high transsphincteric/extrasphincteric/suprasphincteric, multiple openings, abscess, Crohn's

Investigations

• EAUS (Endoanal Ultrasound) with H2O2 instillation - determines simple vs complex
• MRI (STIR sequence) - gold standard; identifies secondary extensions, pus, and granulation tissue without contrast

Surgical Treatment

1. Fistulotomy (Laying Open)

• For intersphincteric and low transsphincteric fistulae (<30% external sphincter)
• Best results when <1/3 of sphincter is divided
• Marsupialisation of wound edges speeds healing
• Continence maintained if minimum 2 cm of external sphincter retained

2. Seton Technique

• Cutting seton (tightening seton): Progressively tightened to gradually cut through sphincter with fibrosis preventing incontinence. Largely replaced by other techniques.
• Draining/loose seton: Used for high/complex fistulae to drain sepsis and allow fibrosis before definitive repair. Often used as first stage.

3. LIFT (Ligation of Intersphincteric Fistula Tract)

• Rojanasakul technique (2007)
• Access via intersphincteric plane, ligate the tract at both sides and divide
• Preserves external sphincter; healing 50-80%
• If it fails, often results in a simpler intersphincteric fistula amenable to fistulotomy

4. Endorectal Advancement Flap

• For complex transsphincteric fistulae
• Excise fistula tract; close rectal/internal opening with vascularized mucosal flap from proximal rectum
• Healing rates 66-87%
• Risk of incontinence if internal sphincter included in flap

5. Fistula Plug (Surgisis)

• Biological absorbable plug inserted into tract
• Does not require sphincter division
• Healing rates variable (25-87%); less predictable

Recent Advances (High Yield)

Source: Sabiston 28e, Bailey & Love 28e, Current Surgical Therapy 14e

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4. Surgical Anatomy of Anal Canal

Length and Position

• Surgical anal canal: 4 cm long - extends from the anorectal ring (puborectalis) above to the anal verge below
• Anatomical anal canal: 2 cm - from dentate line to anal verge
• The surgical length is what matters clinically

Lining / Zones (Craniocaudal)

Dentate Line - Surgical Importance

• Above: No somatic pain sensation (only visceral pressure), columnar epithelium, lymphatics drain to internal iliac nodes, venous drainage to portal system (superior rectal vein)
• Below: Somatic pain sensation (inferior rectal nerve), squamous epithelium, lymphatics drain to inguinal nodes, venous drainage to systemic (inferior/middle rectal veins)

Anal Columns of Morgagni

• 8-14 longitudinal folds of mucosa above the dentate line
• At their bases are anal crypts where anal glands open
• Cryptoglandular infection here is origin of fistula/abscess

Anal Sphincter Complex

Continence Mechanism

• IAS - resting tone
• EAS - voluntary squeeze
• Puborectalis - anorectal angle (normal ~90°; relaxes to 130° during defecation)
• Anal cushions/haemorrhoids - fine-tune closure
• Anal sampling reflex (RAIR - rectoanal inhibitory reflex): relaxation of IAS allows ATZ to "sample" content

Blood Supply

• Arterial: Superior rectal artery (inferior mesenteric) + inferior rectal artery (internal pudendal) + middle rectal artery (internal iliac)
• Venous: Superior rectal vein (portal) → portal hypertension causes internal haemorrhoids; Inferior rectal vein (systemic)

Lymphatic Drainage

• Above dentate line → Internal iliac nodes
• Below dentate line → Superficial inguinal nodes

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5. Management of Haemorrhoids

Definition

Classification (Grade)

Symptoms

• Bright red rectal bleeding (painless, fresh, on paper/pan) - most common
• Prolapse
• Mucus discharge, pruritus ani
• Discomfort (pain only if strangulated/thrombosed)
• Anaemia (rare, chronic)

External vs Internal Haemorrhoids

• Internal: Above dentate line, no pain sensation, covered by columnar/transitional epithelium; graded I-IV
• External: Below dentate line, painful when thrombosed, covered by squamous epithelium

Management

Conservative (All grades initially)

• High-fiber diet, increased fluid, stool softeners, avoid straining
• Sitz baths for comfort

Office Procedures (Grade I-III)

Surgical (Grade III-IV, failed office procedures)

1. Milligan-Morgan Haemorrhoidectomy (open) - standard; three piles excised with V-shaped wounds left open; most widely practiced
2. Ferguson Haemorrhoidectomy (closed) - wounds sutured closed; popular in USA
3. Stapled Haemorrhoidopexy (PPH - Procedure for Prolapse and Haemorrhoids) - circular stapling device removes a ring of mucosa and submucosa above the haemorrhoids, returning prolapsed piles to normal position. Less pain, faster return to work. Risk: recurrence, persistent prolapse.
4. HALO (Haemorrhoidal Artery Ligation Operation) - Doppler-guided ligation of superior rectal artery branches; can be combined with mucopexy (RAR - rectoanal repair). RCT (HubBLe trial, Lancet 2016) showed RBL superior for recurrence vs HALO at 1 year, but HALO had less pain.

Acute/Emergency

• Acutely thrombosed external haemorrhoid: Excision under local anesthesia within 48-72 hours if severe pain; after 72 hours - conservative management
• Prolapsed strangulated internal haemorrhoids: Emergency haemorrhoidectomy can be done safely even in emergency setting

Source: Schwartz's Principles of Surgery 11e, Sabiston 28e, Harrison's 22e

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6. Benign Perianal Disease & its Management

Conditions:

1. Haemorrhoids - see above
2. Anal Fissure - see above
3. Fistula in Ano - see above
4. Perianal/Anorectal Abscess
5. Pilonidal Disease
6. Pruritus Ani
7. Anal Condylomata

Perianal/Anorectal Abscess

Classification (by space involved)

• Perianal abscess (most common, ~40%) - just under perianal skin
• Ischiorectal abscess - in ischiorectal fossa
• Intersphincteric abscess - in intersphincteric plane
• Supralevator abscess (rarest) - above levator ani

Principles

• Cryptoglandular theory: all start from infection of anal glands at dentate line
• Horseshoe abscess: spreads across deep postanal space to both ischiorectal fossae

Treatment

• Incision and drainage (I&D) is the cornerstone; never try to aspirate or antibiotics alone
• Antibiotics only if cellulitis, Crohn's, diabetes, immunocompromise, or valvular heart disease
• After drainage: ~50% will develop fistula - may be found at time of drainage and treated simultaneously

Pilonidal Sinus

• Sinus in the natal cleft, containing hair tufts; common in young hirsute males
• Pit-picking (Bascom procedure) for acute abscess
• Definitive management: Karydakis flap or Bascom cleft lift (off-midline closure) - superior to midline closure (higher recurrence)
• Rhomboid (Limberg) flap - for complex/recurrent disease

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7. Anatomy of Ischiorectal Fossa & Surgical Importance

Boundaries

Contents

• Fat - the bulk (important surgical tissue plane)
• Inferior rectal (pudendal) vessels and nerve - traverse the fossa in Alcock's canal (pudendal canal) on the lateral wall
• Inferior rectal artery - branch of internal pudendal artery
• Inferior rectal nerve - branch of pudendal nerve (S2,3,4) - supplies EAS and perianal skin
• Perineal branch of S4

Alcock's Canal (Pudendal Canal)

• Fascial canal in the lateral wall of the ischiorectal fossa
• Contains: internal pudendal artery and vein, pudendal nerve
• Nerve divides here into: dorsal nerve of penis/clitoris, perineal nerve, inferior rectal nerve

Surgical Importance

1. Perianal/Ischiorectal Abscess: The ischiorectal fossa is a common site of anorectal abscess. Infection can spread across the deep postanal space (Courtney's space) behind the EAS to form a horseshoe abscess.
2. Anal Fistula Surgery: Transsphincteric fistulae pass through the EAS to reach the ischiorectal fossa. Knowledge of the fossa anatomy is essential to identify and drain secondary extensions.
3. Haemorrhoidectomy: The inferior rectal nerves in the fossa must be preserved.
4. APR (Abdominoperineal Resection): The perineal dissection proceeds through the ischiorectal fossae on both sides, and inadvertent entry into Alcock's canal can damage the pudendal nerve causing sexual dysfunction.
5. ELAPE (Extralevator APR): Newer technique that excises levator ani en-bloc; proceeds lateral to the ischiorectal fossa rather than through it, reducing positive circumferential resection margin rates.
6. Drainage of Supralevator Abscess: Incorrect drainage through the ischiorectal fossa can create a iatrogenic extrasphincteric fistula.

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8. Anorectal Malformations (ARM) & Management

Incidence & Genetics

• 1 in 5000 live births; slight male predominance
• 95% have some form of fistulization
• Associated anomalies: VACTERL (Vertebral, Anal, Cardiac, Tracheo-Esophageal, Renal, Limb defects) - screen all ARM cases

Classification (Wingspread Classification)

Key Clinical Points

• Males without visible perineal fistula → assume high ARM (rectourethral fistula) until proven otherwise
• Females: most common malformation is rectovestibular fistula
• Cloaca (females only): single channel for all three structures; requires complex reconstruction
• Low lesions have better prognosis for fecal continence than high lesions

Diagnosis

• Invertogram (Wangensteen-Rice) - inverted lateral X-ray at 24 hours of life; gas bubble level vs perineum (largely replaced by MRI/US)
• Cross-table lateral X-ray with prone positioning - gas ascends to rectal pouch
• Perineal US - identify distance of rectal pouch from perineum (<1 cm = low; >1 cm = high)
• MRI - gold standard for defining sphincter muscle complex
• Micturating Cystourethrogram (MCUG) - to identify urethral fistula
• Renal/spinal US, echocardiogram - screen for VACTERL

Management

Low ARM (perineal fistula present)

• Anal transposition (PSARP - posterior sagittal anorectoplasty) without colostomy - can be done in neonatal period
• Or simple cutback procedure for perineal fistula in female (anal stenosis)

High/Intermediate ARM

• Step 1: Neonatal colostomy (sigmoid divided colostomy) - defunctioning + provides distal limb for later contrast study
• Step 2: Definitive repair at 1-3 months - PSARP (Peña procedure) - posterior sagittal approach
  • Patient placed prone, midline incision from sacrum to perineum
  • Identify sphincter complex with electrical stimulation
  • Mobilize rectum, divide fistula, place rectum within sphincter complex
• Step 3: Colostomy closure - 6-8 weeks after PSARP when healed

PSARP (Peña Procedure) - Key Points

• Devised by Alberto Peña
• Excellent visualization of sphincter complex
• Electrical stimulator identifies external sphincter boundaries
• Rectum is mobilized and placed accurately within the sphincter complex
• Fistula is divided and closed
• Continence depends on quality of sphincter complex and accuracy of placement

Complications

• Urethral injury - commonest serious complication in males
• Fecal incontinence - related to level of lesion and sphincter quality
• Constipation (paradoxically common after repair) - treated with bowel management program

Source: Mulholland & Greenfield's Surgery 7e, Sabiston 28e, Yamada's Gastroenterology

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9. Total Mesorectal Excision (TME)

Definition

Anatomical Basis

• The mesorectum is the fatty tissue posterior and lateral to the rectum, enclosed within the visceral fascia (fascia propria of the rectum/mesorectal fascia)
• It contains: superior rectal vessels, lymphatics, autonomic nerve plexuses, perirectal lymph nodes
• A clear plane exists between the mesorectal (visceral) fascia and the parietal (presacral) fascia - the "holy plane" of Heald

Surgical Principle

Extent

• Total TME: For mid and low rectal tumours - mesorectum removed to the pelvic floor; used with anterior resection (sphincter-preserving) or APR
• Partial TME: For upper rectal tumours - mesorectum divided 5 cm distal to lower edge of tumour (adequate distal clearance)

Key Oncological Importance

Structures at Risk During TME

1. Hypogastric nerves (sympathetic) - at level of sacral promontory; injury → retrograde ejaculation, dry orgasm
2. Pelvic plexus (S2,3,4 - parasympathetic) - lateral pelvic sidewall; injury → bladder dysfunction, erectile dysfunction
3. Neurovascular bundles of Walsh - posterolateral to prostate/vagina; injury → sexual dysfunction
4. Ureter - must be identified bilaterally
5. Middle rectal vessels - controlled laterally

Anastomosis After TME

• Low anterior resection (LAR) with TME → colorectal/coloanal anastomosis with defunctioning loop ileostomy (to protect the low anastomosis)
• Colonic J-pouch or side-to-end anastomosis to improve functional outcomes (low anterior resection syndrome)

Laparoscopic and Robotic TME

• Laparoscopic TME: equivalent oncological outcomes to open (COLOR II, COREAN trials); faster recovery
• Robotic TME: technically easier in narrow male pelvis; improved visualization; data accumulating
• Transanal TME (TaTME): newest approach - simultaneous transanal and transabdominal dissection, particularly for obese males with narrow pelvis

Source: Bailey & Love 28e, Sabiston 28e, Schwartz's Surgery 11e

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Summary of Exam Weightage (from your notes)

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What's Covered (Topic-by-Topic Summary)

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HERNIA - Detailed Exam Answers

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1. Recent Advances in Management of Incisional Hernia (30 marks)

Definition

Etiology / Risk Factors

• Wound infection (most important risk factor)
• Obesity (BMI >30)
• Malnutrition, hypoalbuminaemia
• Diabetes mellitus
• Steroid/immunosuppressive therapy
• Technical errors: tension on closure, mass closure with inadequate bites, wrong suture material
• Emergency surgery, re-exploration
• Chronic cough, constipation, prostatism (raised intra-abdominal pressure)

Classification (European Hernia Society - EHS)

• Width: W1 (<4 cm), W2 (4-10 cm), W3 (>10 cm)
• Location: Midline (M) vs lateral (L)
• Recurrent vs primary
• Loss of domain: herniated volume >20% of total abdominal cavity volume

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TRADITIONAL OPEN REPAIR TECHNIQUES

1. Mayo's "Vest over Pants" Repair

• Overlapping flap repair for small umbilical/epigastric hernias
• High recurrence (>30%) with primary suture repair alone - largely abandoned for large hernias

2. Rives-Stoppa Retromuscular Repair

• Gold standard open technique
• Mesh placed in the retromuscular/preperitoneal space (sublay position) posterior to the rectus muscle and anterior to the posterior rectus sheath
• Wide mesh overlap (minimum 5 cm in all directions)
• Reduced recurrence (<5%) due to intraabdominal pressure pushing mesh against the wall

3. Onlay Repair

• Mesh placed anterior to the anterior rectus sheath after fascial closure
• High SSO and wound complication rates
• Acceptable where other planes are unavailable

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COMPONENT SEPARATION TECHNIQUES (Recent Advance)

Anterior Component Separation (ACS) - Ramirez, 1990

• Division of external oblique aponeurosis 2 cm lateral to semilunar line from rib to inguinal ligament
• Allows 3-10 cm of medialization per side
• Disadvantage: large skin flaps - high wound complication rate (seroma, necrosis)

Posterior Component Separation - TAR (Transversus Abdominis Release)

• Developed by Novitsky (2012) - the most important recent advance in incisional hernia repair
• Technique: Division of posterior lamella of internal oblique followed by division of the transversus abdominis muscle, entering the plane between transversalis fascia and the retromuscular space
• Provides >10 cm medialization per side
• Allows placement of a large uncoated mesh in the retromuscular space
• Can be performed MIS (minimally invasive) - robotic/laparoscopic TAR
• Avoids large skin flaps - lower wound complication rate than ACS
• Currently the preferred technique for complex/large incisional hernias

Posterior Component Separation Steps (TAR):

1. Posterior rectus sheath release (enter retrorectus space)
2. Reach linea semilunaris
3. Divide posterior lamella of internal oblique
4. Divide transversus abdominis muscle
5. Dissect transversalis fascia off underside of transversus
6. Reach midaxillary line and beyond
7. Posterior flaps approximated in midline with running suture
8. Large uncoated mesh placed in retromuscular space

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MESH POSITIONS (from deep to superficial)

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MESH TYPES

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LAPAROSCOPIC INCISIONAL HERNIA REPAIR (LIHR)

IPOM (Intraperitoneal Onlay Mesh)

• Most common laparoscopic technique
• Composite mesh placed intraperitoneally, fixed with tacks ± transfascial sutures
• Advantages: minimal wound complications, early recovery
• Disadvantages: mesh in peritoneal cavity; higher recurrence with bridging repair

IPOM-Plus

• Primary fascial closure before mesh placement (reduces recurrence and bulge)

Robotic/MIS TAR

• Increasing adoption for complex large hernias
• Same principles as open TAR but with MIS advantages

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LOSS OF DOMAIN

• Herniated viscera have "lost domain" in abdominal cavity - >20% abdominal contents outside
• Forcible reduction may cause abdominal compartment syndrome (ACS)
• Preoperative management:
  • Progressive pneumoperitoneum (Goñi Moreno technique) - progressive CO2 insufflation of peritoneal cavity to stretch abdominal wall over weeks
  • Botulinum toxin injection to lateral abdominal wall muscles - causes temporary paralysis, elongation, and increased compliance
  • Weight loss/nutritional optimization
• Surgery: TAR with large mesh; biologic mesh if contaminated

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COMPLICATIONS OF INCISIONAL HERNIA REPAIR

• Wound infection/SSO (seroma, hematoma, wound dehiscence)
• Mesh infection (require mesh explantation in 50%)
• Bowel injury (especially adhesiolysis)
• Recurrence
• Abdominal compartment syndrome (in loss of domain cases)
• Adhesive small bowel obstruction (IPOM)
• Chronic pain

Source: Sabiston Textbook of Surgery 28e, Mulholland & Greenfield's Surgery 7e

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2. Loss of Domain of Hernia (20 marks)

Definition

Pathophysiology

• Chronic herniation → abdominal wall muscle atrophy and retraction → lateral muscles shorten
• Abdominal wall becomes fixed in shortened configuration
• Forcible reduction raises intra-abdominal pressure (IAP >20 mmHg = ACS)
• ACS causes: respiratory failure (diaphragm elevation), renal failure (renal vein compression), cardiac compromise (IVC compression), bowel ischaemia

Assessment

• CT abdomen with volumetry: measure hernia volume and peritoneal cavity volume; ratio >20% = loss of domain
• Assess muscle atrophy (CT: measuring muscle cross-sectional area)
• Functional respiratory test (spirometry) - predict post-repair respiratory compromise

Preoperative Preparation

1. Botulinum toxin A injection (Ibáñez Aguirre technique) - injected into bilateral lateral abdominal muscles (external oblique, internal oblique, transversus abdominis) 4-6 weeks before surgery. Causes temporary paralysis and lengthening, increasing abdominal wall compliance and permitting closure
2. Progressive pneumoperitoneum (Goñi Moreno, 1947) - serial CO2 insufflation of peritoneal cavity over 7-14 days pre-op; stretches abdominal wall; allows accommodation
3. Nutritional optimization - correct malnutrition, optimize albumin
4. Weight loss - aim BMI <30 pre-op where possible
5. Chest physiotherapy - prepare for post-op respiratory demands

Surgical Strategy

• TAR with large mesh (60 x 40 cm if needed)
• Component separation mandatory
• Biologic/biosynthetic mesh if contaminated
• Consider staged repair in extreme cases
• Post-op: high-dependency care, respiratory support, vigilance for ACS

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3. TAR (Transversus Abdominis Release) / Posterior Component Separation (10 marks)

Key Points Summary

• Introduced by Novitsky et al., 2012
• Divides: posterior lamella of internal oblique + transversus abdominis muscle
• Creates wide retromuscular space for large uncoated mesh
• Provides >10 cm advancement per side (more than anterior CS)
• Preserves perforators to overlying skin (lower wound morbidity than ACS)
• Can be performed open or MIS (robotic/laparoscopic)
• Indications: large midline hernias (W2/W3), recurrent hernias, those requiring wide mesh coverage

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4. Laparoscopic Ventral Hernia Repair - Complications, Limitations, Principles & Mesh

Principles

• Reduce hernia contents
• Close or bridge the defect
• Reinforce with prosthetic mesh with wide overlap
• Fix mesh with trans-fascial sutures ± tacks (spiral fixation)

Steps of Laparoscopic IPOM

1. Patient supine; 3-port technique (lateral ports)
2. Adhesiolysis (careful; bowel injury risk)
3. Reduce hernia sac contents
4. Optionally close the fascial defect (IPOM-Plus)
5. Composite mesh - anti-adhesion side inward, ingrowth side against abdominal wall
6. Min 5 cm overlap all sides
7. Transfascial sutures at cardinal points + spiral tack fixation every 1.5 cm at periphery

Advantages vs Open

Limitations of Laparoscopic Hernia Repair

• Cannot achieve fascial closure easily (bridging repair = higher recurrence)
• Inability to address loss of domain
• Strangulated/incarcerated hernia with bowel involvement: requires bowel resection, prevents mesh use
• Adhesions from previous surgery (high bowel injury risk)
• Large hernias (W3): inadequate coverage
• Cannot perform component separation laparoscopically easily (except MIS-TAR)
• Learning curve is steep
• Requires general anaesthesia (open can be done under local)

Complications of Laparoscopic Hernia Repair

• Intraoperative: bowel injury (most feared), major vascular injury, solid organ injury, bladder injury
• Mesh-related: seroma (very common, 15-20%), mesh migration, mesh folding, mesh adhesion to bowel
• Chronic pain: from tacks/transfascial sutures
• Recurrence: higher with bridging repair
• Conversion: to open in dense adhesions
• Port site hernia: at 10-12 mm ports

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5. Surgical Anatomy in Relation to Laparoscopic Inguinal Hernia Repair (Preperitoneal Anatomy)

The "Landmarks of Danger" (Laparoscopic View)

Myopectineal Orifice (MPO) of Fruchaud

• Single potential weak area through which all groin hernias protrude
• Bounded by: internal oblique/transversus above; iliopsoas lateral; Cooper's ligament below; rectus sheath medial
• Divided by inguinal ligament into: upper (direct/indirect inguinal hernia) and lower (femoral hernia) compartments
• One large mesh (15x10 cm) covers the entire MPO - basis of laparoscopic repair

Key Preperitoneal Landmarks (TEP/TAPP view)

"3 Things to Look For - 2 to Preserve, 1 to Avoid"

• Preserve: vas deferens + testicular vessels
• Avoid: external iliac vessels (Triangle of Doom)

Hesselbach's Triangle (site of direct inguinal hernia)

• Medial: lateral edge of rectus abdominis
• Lateral: inferior epigastric vessels
• Inferior: inguinal ligament (medial half) / Cooper's ligament

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6. Surgical Anatomy of Inguinal Canal + Clinical Tests + Strangulated Inguinal Hernia

Inguinal Canal - Anatomy

Contents of Inguinal Canal

• Male: Spermatic cord (vas deferens, testicular artery, pampiniform plexus, cremasteric artery, artery to vas, genital branch of genitofemoral nerve, sympathetic fibres, processus vaginalis remnant) + ilioinguinal nerve (outside spermatic cord)
• Female: Round ligament of uterus + ilioinguinal nerve

Clinical Tests for Inguinal Hernia

Anatomical Basis of Tests

• Indirect hernia: enters deep ring (lateral to inferior epigastric vessels), travels through canal in spermatic cord; comes straight down the finger when finger invaginates scrotum
• Direct hernia: pushes directly through posterior wall of inguinal canal (Hesselbach's triangle); strikes the end of the examining finger; not controlled by deep ring occlusion
• Zieman's test maps the three rings - the site of impulse corresponds to which ring the hernia passes through

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Strangulated Inguinal Hernia - Clinical Features & Management

Clinical Features

• Sudden increase in size of pre-existing hernia with pain
• Irreducible - cannot be reduced manually
• Tender on palpation - progressive tenderness
• No cough impulse (tense)
• Signs of bowel obstruction if small bowel involved: colicky pain, vomiting, distension, constipation
• Signs of strangulation (bowel ischaemia): continuous pain (not colicky), fever, tachycardia, localized peritonism
• Richter's hernia: only part of bowel wall (antimesentric) is strangulated; may strangulate without features of obstruction

Pathophysiology of Strangulation

• Tight neck of hernia compresses contents
• Venous congestion → oedema → arterial occlusion → ischaemia → gangrene
• Bowel: mucosal necrosis → bacterial translocation → sepsis → peritonitis

Femoral hernia strangulates more commonly than inguinal (tight narrow neck)

Management

• IV fluids (correct dehydration/electrolytes)
• IV antibiotics (broad spectrum - 2nd gen cephalosporin + metronidazole)
• Nasogastric tube (if obstructed)
• Urinary catheter
• Analgesia

1. Incision: oblique inguinal incision (same as for elective repair)
2. Open the sac carefully - warm saline-soaked pack over bowel while strangulation is released
3. Assess bowel viability after releasing constriction:
   • Viable: pink colour, peristalsis present, mesentery pulsations visible
   • Doubtful: warm packs for 5 minutes; if no recovery → non-viable
   • Non-viable: resect and anastomose (usually via separate incision)
4. Reduction: do NOT reduce without visual assessment (to avoid reducing gangrenous bowel - "reduction en masse")
5. Repair: if clean field → mesh repair (Lichtenstein) acceptable; if contaminated → tissue repair (Bassini/Shouldice); no mesh in contaminated field
6. Antibiotics continued post-op

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7. Diaphragmatic Hernia - Classification, Features & Management

Classification

A. Congenital Diaphragmatic Hernia (CDH)

B. Traumatic Diaphragmatic Hernia

• Blunt (motor vehicle) or penetrating injury
• Left side more common (liver protects right)
• May present late (weeks-years) as stomach/bowel herniates

C. Hiatal Hernia (most common in adults)

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Features

Bochdalek Hernia (Newborn)

• Respiratory distress at birth (scaphoid abdomen)
• Cyanosis, tachypnoea
• Bowel sounds in chest
• CXR: bowel loops in chest, mediastinal shift to contralateral side
• Pulmonary hypoplasia (main determinant of prognosis)

Hiatal Hernia (Adult)

• Heartburn, regurgitation, dysphagia
• Shortness of breath with large paraesophageal hernias
• Volvulus/strangulation in type II-IV (emergency)
• CXR: retrocardiac air-fluid level

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Management

Congenital (Bochdalek)

• Pre-op stabilization: ECMO if severe pulmonary hypertension; NO immediate surgery until stabilized
• Surgical repair: once stable (not emergency)
  • Reduce herniated viscera
  • Close diaphragm primarily or with mesh
  • Approach: open (transabdominal) or laparoscopic in selected cases
• Prognosis: depends on degree of pulmonary hypoplasia

Hiatal Hernia

• Type I (Sliding): Treat underlying GORD medically (PPI); surgery (Nissen/Toupet fundoplication) if failed medical treatment or Barrett's oesophagus
• Type II/III/IV (Paraesophageal/Mixed): Elective surgery recommended (risk of volvulus); laparoscopic repair preferred
  • Reduce contents, excise sac, close crura (posterior cruroplasty ± mesh reinforcement)
  • Add fundoplication to prevent GORD

Traumatic

• Always repair surgically (elective or emergency)
• Thoracoscopic or laparoscopic repair if stable

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8. Umbilical Hernia (10 marks)

Types

1. Congenital/Infantile umbilical hernia: defect in linea alba at umbilicus; very common; usually closes spontaneously by age 3-5 years; repair if persists beyond 5 years, enlarging, or symptomatic
2. Acquired/Adult umbilical hernia: through umbilicus or just above (para-umbilical); contains omentum, small bowel, transverse colon

Predisposing Factors (Adult)

• Obesity (most common)
• Multiple pregnancies
• Ascites (cirrhosis)
• Chronic increase in intra-abdominal pressure
• Previous umbilical surgery

Clinical Features

• Swelling at umbilicus - reducible initially, irreducible later
• Discomfort/dragging pain
• Narrow neck (para-umbilical) → high risk of strangulation (especially small bowel, omentum)
• Skin changes: thinning, ulceration in large hernias with ascites

Management

Conservative

• Infants <5 years: watchful waiting (most close spontaneously)
• Truss: not recommended (narrow neck strangulation risk)

Surgical

• Indication: All adult umbilical hernias should be repaired (strangulation risk is high due to narrow neck)
• Mayo's repair (vest-over-pants): overlapping fascial repair for small defects; acceptable for <2 cm
• Mesh repair: for defects >2 cm; lower recurrence than Mayo's
  • Sublay (retromuscular) or onlay mesh
  • Laparoscopic IPOM: good results for defects 2-6 cm
• Ascites management: correct ascites pre-op (TIPS/diuretics) otherwise hernia will recur
• Emergency: strangulated umbilical hernia - resuscitate, emergency repair with bowel assessment

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9. Rare Abdominal Wall Hernias

Spigelian Hernia

• Through Spigelian fascia (aponeurosis between semilunar line and lateral border of rectus)
• At the level of arcuate line (below umbilicus) - junction of Spigelian fascia and posterior rectus sheath
• Interparietal: lies between internal oblique and external oblique - external oblique intact → bulge NOT visible (clinical exam unreliable)
• Diagnosis: CT abdomen/ultrasound (most accurate)
• Symptoms: lateral abdominal wall pain ± tender mass
• Management: repair as soon as diagnosed (high risk of strangulation); open or laparoscopic mesh repair

Obturator Hernia

• Through obturator canal (obturator foramen, covered by obturator membrane)
• More common in elderly, thin, multiparous women ("little old lady hernia")
• Contains small bowel (usually)
• Howship-Romberg sign: pain on medial aspect of thigh aggravated by medial rotation of hip (obturator nerve compression) - pathognomonic
• Hannington-Kiff sign: absent adductor reflex with preserved knee jerk
• Often presents with intestinal obstruction
• Diagnosis: CT (definitive)
• Management: emergency - median laparotomy/laparoscopy; reduce contents, assess bowel viability, close defect (suture or mesh); high mortality (30%) due to late diagnosis

Lumbar Hernia

• Through lumbar triangles:
  • Superior lumbar triangle (Grynfeltt): bounded by 12th rib, internal oblique, serratus posterior - larger, more common
  • Inferior lumbar triangle (Petit): bounded by iliac crest, external oblique, latissimus dorsi - smaller
• Presents as reducible lateral flank lump
• Management: open mesh repair (usually with sublay mesh)

Gluteal Hernia

• Through greater sciatic foramen
• Contains small bowel, sigmoid
• Management: repair via transperitoneal route

Perineal Hernia

• After AP resection or pelvic surgery
• Protrudes through pelvic floor into perineum

Epigastric Hernia

• Through linea alba above umbilicus
• Often contain pre-peritoneal fat only (not bowel)
• May be multiple
• Management: small (<2 cm) - direct suture repair; larger - mesh repair

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10. Umbilical Adenoma (Umbilical Granuloma)

Definition

Sister Mary Joseph's Nodule

• Named after: Sister Mary Joseph Dempsey (a nursing superintendent at Mayo Clinic who first described this finding to Dr William Mayo)
• Represents umbilical metastasis from intra-abdominal or pelvic malignancy
• Found in ~10% of GI and gynaecological cancers at some point

Primary Sources

• GI: Stomach (most common overall) > colon/rectum > pancreas > appendix
• Gynaecological: Ovary (most common in females) > uterus > cervix
• Others: bladder, prostate, renal cell carcinoma

Routes of Spread

1. Lymphatic channels (ligamentum teres/round ligament)
2. Direct transperitoneal spread
3. Haematogenous
4. Via patent urachus or vitelline duct remnants

Clinical Features

• Hard, indurated, fixed umbilical nodule
• May be painful or bleed
• Skin changes: ulceration, discharge
• Signs of primary malignancy elsewhere

Investigations

• CT abdomen/pelvis/chest - identify primary tumour and staging
• FNA/core biopsy of nodule - tissue diagnosis
• Tumour markers: CA-125 (ovary), CEA (GI), CA 19-9 (pancreas)
• Diagnostic laparoscopy - assess peritoneal disease

Management

• Primarily treat the underlying malignancy (palliative chemotherapy, radiotherapy)
• Surgical resection of primary with umbilicectomy only if curative resection is feasible
• Prognosis is generally poor - median survival 10-11 months; represents advanced/disseminated disease

Differential Diagnosis of Umbilical Nodule

• Umbilical hernia (reducible)
• Umbilical granuloma (pink, bleeds - in newborns after cord separation)
• Endometriosis (cyclical pain + blue-black discoloration)
• Urachal cyst/fistula
• Sister Mary Joseph's nodule (hard, fixed)
• Primary umbilical malignancy (rare)

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11. Anatomical Basis of Clinical Tests for Inguinal Hernia

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12. Anatomical Basis of Inguinal Hernia Repair

Open Repairs - Anatomical Basis

Laparoscopic Repairs - Anatomical Basis

• TEP/TAPP: Use preperitoneal space to place a large mesh (15x10 cm) covering the entire myopectineal orifice (MPO)
• MPO is the common weak area for ALL groin hernias
• One mesh covers direct, indirect, and femoral spaces simultaneously

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13. TEP (Total Extra-Peritoneal) Repair of Inguinal Hernia

Principle

Patient Position

• Supine, general anaesthesia; lateral tilt away from hernia side

Steps (TEP)

1. Access: 1 cm infraumbilical incision; dissect down to anterior rectus sheath; incise sheath; retract rectus muscle laterally; enter preperitoneal space
2. Balloon dissector: Hassan balloon or blunt trocar used to develop preperitoneal space with CO2 (10-12 mmHg)
3. Port placement: 3 ports in the midline (10 mm at umbilicus, two 5 mm ports below)
4. Dissection:
   • Identify Cooper's ligament, iliopubic tract, vas deferens, testicular vessels
   • Reduce indirect hernia sac from internal ring
   • Reduce direct hernia defect (no sac to open)
   • Clear cord structures and fat (lipoma of cord)
5. Mesh placement: 15x10 cm polypropylene mesh; covers entire MPO with 3 cm overlap beyond defect edges
6. Fixation: tacks to Cooper's ligament and above iliopubic tract ONLY (avoid Triangle of Pain and Triangle of Doom); some perform no-fixation TEP
7. Desufflation: CO2 released; mesh held in place by intraabdominal pressure (Pascal's principle)
8. Port closure

Advantages of TEP over TAPP

Contraindications to TEP

• Previous extraperitoneal surgery (e.g., previous open prostatectomy, pelvic surgery)
• Large scrotal/irreducible hernias
• Uncontrolled coagulopathy
• Cannot tolerate general anaesthesia (relative)

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14. Open vs Laparoscopic Inguinal Hernia Repair - Merits & Demerits

Open (Lichtenstein) vs Laparoscopic (TEP/TAPP)

Indications for Laparoscopic Repair

• Bilateral inguinal hernias (best indication)
• Recurrent hernia after open repair (virgin preperitoneal plane)
• Patient preference (occupation requiring early return to work)
• Femoral hernia (excellent visualization)

Indications for Open Repair

• Strangulated hernia (emergency)
• Previous extraperitoneal surgery (relative CI to TEP)
• Cannot tolerate GA
• Large scrotal hernia
• Recurrent hernia after laparoscopic repair
• Rural/limited resource settings

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15. Recent Trends in Management of Inguinal Hernia

1. Robotic Inguinal Hernia Repair

• TAPP approach preferred for robotics (more space)
• No significant benefit over laparoscopic in current evidence (RIVAL trial: longer operative time, higher cost, no difference in outcomes)

2. Extended-View TEP (eTEP) / Trans-inguinal Preperitoneal (TIPP)

• Extended dissection of preperitoneal space allowing bilateral repair + ventral hernia repair in same operation
• Useful for combined inguinal + incisional hernia

3. No-Fixation Mesh Technique

• Pascal's principle: intraabdominal pressure holds mesh in place
• Avoids tack-related chronic pain
• Safe for hernias <4 cm in largest dimension

4. Self-Gripping Mesh (Progrip, TiMesh)

• Mesh with microgrips that adhere to tissue
• No sutures or tacks required
• Reduces chronic pain rates

5. 3D Mesh (ProFlor, Bard 3D)

• Conical or curved mesh matching inguinal canal anatomy
• Minimal fixation required

6. HerniaSurge Guidelines (2018)

• Most comprehensive international guidelines for inguinal hernia
• Recommend: Lichtenstein or TEP/TAPP equally; all repairs should use mesh; no-fixation TEP for non-large hernias
• Annual surveillance for asymptomatic hernias in males as watchful waiting is acceptable option

7. Glue Fixation

• Fibrin glue (Tisseel) or synthetic glue for mesh fixation
• Equivalent to tacks; lower chronic pain rates

8. Day Care/Ambulatory Hernia Surgery

• 95%+ of inguinal hernia repairs now performed as day surgery globally

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Exam Weightage Summary (from your notes)