Chapter SECTION 1 : GASTROINTESTINAL SURGERY
1
HERNIAS
A hernia results from protrusion of a viscus through a
weakness in its containing wall.
INGUINAL HERNIA
Inguinal hernias occur when abdominal contents pass
through the inguinal canal. They usually occur above the
inguinal ligament and medial to the pubic tubercle.
SURGICAL ANATOMY OF THE INGUINAL
CANAL
Openings
1 . Deep Inguinal Ring: It is an opening in the fascia
transversalis, 1 cm above the inguinal ligament,
midway between the anterior superior iliac spine
(ASIS) and the symphysis pubis. The inferior
epigastric vessels lie medial to this opening.
2. Superficial Inguinal Ring: It is a triangular defect in
the external oblique aponeurosis, overlying the pubic
crest which forms the base of the triangle.
Boundaries
1 . Anterior: Formed by the external oblique aponeurosis,
reinforced in the lateral one-thirds by the internal
oblique muscle.
2. Posterior: Formed by the fascia transversalis,
reinforced in the medial one-thirds by the conjoint
tendon.
3. Floor: Formed by the inguinal ligament and lower
border of external oblique aponeurosis. It is continuous
medially with the lacunar ligament and gives
attachment to the fascia lata on its inferior border.
4. Roof: Formed by the arched fibres of the conjoint
tendon.
Contents of Inguinal Canal
• Males: Spermatic cord and ilioinguinal nerve.
• Females: Round ligament of uterus and ilioinguinal
nerve.
Coverings of Spermatic Cord
• From within outwards the coverings are derived as
follows:
o Internal spermatic fascia from fascia transversalis.
o Cremasteric fascia from internal oblique.
o External spermatic fascia from external oblique.
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Contents of Spermatic Cord
• Vas deferens.
• Artery to vas deferens (branch of inferior vesical artery).
• Testicular artery (branch of abdominal aorta).
• Testicular vein (drains into the IVC on the right and
the renal vein on the left).
• Testicular lymphatics.
• Testicular nerve fibres.
• Processus vaginalis.
• Cremasteric artery (branch of inferior epigastric artery).
• Nerve to cremaster muscle (genital branch of
genitofemoral nerve).
Hesselbach’s Triangle
• Boundaries
o Base: Medial half of inguinal ligament.
o Medial Border: Linea semilunaris (lateral border
of rectus abdominis).
o Lateral Border: Inferior epigastric artery.
• Significance: This area is potentially weak because it
is not reinforced by the conjoint tendon and therefore
most of the direct inguinal hernias protrude through
it.
TYPES OF INGUINAL HERNIAS
Indirect Inguinal Hernia
• Cause: Failure of embryonic closure of the deep
inguinal ring after the descent of testes.
• Peritoneum traverses the deep inguinal ring to come
into the inguinal canal.
• More common in younger age groups.
• The origin of hernial sac is lateral to the inferior
epigastric artery.
• The hernial sac has a narrow neck and higher chances
of strangulation than in a direct inguinal hernia.
• Subtypes:
o Bubonocoele: Hernia limited to the inguinal canal.
o Funicular: The processus vaginalis closes at its
lower end just above the epididymis and the
contents can be felt distinctly from the testis,
which lies below the sac.
o Complete: The processus vaginalis is patent
throughout here and the hernia sac is continuous
with the tunica vaginalis of the testis. Therefore,
the contents of the hernial sac reach the very
bottom of the scrotum and are indistinguishable
from the testis.
• Indirect hernias can also occur in females (4% as
common as in males) and when they do occur, they
can eventually reach the ipsilateral labium majus.
Direct Inguinal Hernia
• Cause: Weakness in the abdominal wall, increased
intra-abdominal pressure.
• Peritoneum does not traverse the deep inguinal ring.
It enters the inguinal canal through the posterior wall
from a defect in fascia transversalis.
• More common in older age groups and males (four
times more common than in females).
• The hernial sac originates from the Hesselbach’s
triangle, medial to the inferior epigastric vessels.
• The hernial sac has a broad neck and therefore, lesser
chances of strangulation than in an indirect inguinal
hernia.
Classification of Hernia
Nyhus Classification
Table 1.1: Nyhus classification of hernias
Type 1 Indirect inguinal hernia with a normal ring; sac in
the canal
Type 2 Indirect inguinal hernia with an enlarged internal
ring but the posterior wall is intact; inferior deep
epigastric vessels not displaced; sac not in scrotum
Type 3a Direct hernia with a posterior floor defect only
Type 3b Indirect hernia with enlargement of internal ring
and posterior floor defect
Type 3c Femoral hernia
Type 4 Recurrent hernia: A-direct, B-indirect,
C-femoral, D-combinations of A-B-C

Complications of Inguinal Hernia
1. Irreducible hernia: Formation of adhesions between
the sac and its contents.
2. Obstructed hernia: Occurs when the inguinal rings/
constrict, thereby occluding the lumen of the bowel
contained within the sac. But the blood supply to
bowel wall is intact.
3. Strangulated hernia: The constriction is so severe
that it occludes the bowel wall blood supply, therefore
causing ischemia of the bowel loop. It is a surgical
emergency.
Other Types of Inguinal Hernias
1. Hernia en W a.k.a Maydl’s Hernia: Two bowel loops
in a single hernial sac, causing gangrene at the apex of
the double loop which lies inside the abdomen.
2. Sliding hernia a.k.a Hernia en Glissade: Occurs
when extra-peritoneal structures like the sigmoid
colon (most common) descend with the hernial sac,
forming its wall.
3. Richter’s hernia: Occurs when the lumen of the
bowel loop contained in the sac is not obstructed but
only a part of the bowel wall is being constricted by
the neck of the sac.
4. Litter’s hernia: A hernia containing Meckel’s
diverticulum.
5. Pantaloons’ hernia: Contains both the direct and
indirect hernias, one on either side of the inferior
epigastric artery.
6. Phantom hernia: Occurs when a weak abdominal
muscle bulges and produces a visible protrusion,
without any abdominal contents being involved. It
can occur with poliomyelitis and hypokalemia in
children.
7. Amyand’s hernia: A hernia containing the appendix
which becomes incarcerated.
8. Spigelian hernia: A hernia developing at the arcuate
line through the Spigelian’s fascia, which is the
aponeurosis between the rectus abdominis muscle
medially and semilunar line laterally.
9. Berger’s hernia: A hernia in the Pouch of Douglas.
Hernias 3
10. Laugier’s hernia: A hernia arising from the lacunar
ligament defect.
TREATMENT OF INGUINAL HERNIA
1. Herniotomy – used only for congenital hernias.
2. Herniorrhaphy – uses the tissue present in the body.
a. Bassini’s repair – used silk for approximation of
tissues.
b. Shouldice repair – used stainless steel wire for
approximation of tissues.
3. Hernioplasty – uses foreign objects like prosthetic
meshes
Lichtenstein’s mesh repair
• Tension-free repair.
• Variety of meshes can be used.
• Fibrosis occurs on the mesh and provides support
to the floor of the canal.
• The mesh per-say does not provide support.
4. Laparoscopic hernia repair
a. Intraperitoneal onlay mesh (IPOM).
b. Transabdominal pre-peritoneal repair (TAPP).
c. Totally extra-peritoneal repair (TEP).
*Post-Herniorrhaphy pain syndrome or inguino-
dynia: Upto 20% of patients can experience a chronic
groin pain lasting for more than three months after surgical
or laparoscopic repair of inguinal hernias. It is a type of
neuropathic pain due to insult to the nerve supplying the
operative site like the genitofemoral nerve. It is mostly
described as burning or stabbing pain. Triple neurectomy
including the genitofemoral nerve has shown some benefit
in studies.
FEMORAL HERNIA
Femoral hernias occur when abdominal contents pass
through a naturally-occurring defect known as the femoral
canal. They usually occur below the inguinal ligament
and lateral to the pubic tubercle. They point towards the
pubic tubercle and bear a shape known as the Retort shape.
• Account for only 3% of all hernias.
• Can occur in both males and females, but occur more
commonly in females (M:F = 1:4) due to the wider
bony pelvis.
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• More common in adults than children. over the diaphragmatic defect. The baby must be
• The complications are similar to inguinal hernias. mechanically ventilated during the procedure and may
also require respiratory assistance postoperatively to
• Treatment options:
expand the lungs. ECMO (Extra-Corporeal
1. Lockwood’s infra-inguinal approach (preferred for Membrane Oxygenation) is also a useful option in
elective surgeries). these babies.
2. Lotheissen’s trans-inguinal approach.
Umbilical Hernia
3. McEvedy’s high approach.
• These hernias usually occur in the newborn and
Congenital Diaphragmatic Hernia involve a protrusion of abdominal contents at the
site of the navel due to a congenital defect in the
• In the foetus, pleuroperitoneal membranes exist
umbilicus.
between the thorax and abdomen.
• Usually resolve without any treatment by the age of
• These membranes have openings known as the
2-3 years.
pleuroperitoneal canals, which normally get
obliterated and disappear by the ninth or tenth week • Categories.
of intrauterine life. Table 1.2: Different types of umbilical hernia
• Diaphragmatic hernia results when these canals persist Minor Major
beyond that time and abdominal contents protrude • Bulge becomes • OMPHALOCOELE
through them into the thorax. prominent when • It is a big defect with a
the child cries peritoneal sac containing
• Since the position of these canals is fixed, the position
• Common in low birth a major part of the bowel
of diaphragmatic hernias is also fixed. weight babies outside the abdominal
• May be associated with cavity
1. Canal of Bochdalek – Left posterior (posterolateral
Beckwith-Wiedemann • Surgical emergency
diaphragmatic hernia). syndrome
• Resolves spontaneously
2. Canal of Morgagni–Right anterior (retrosternal
in most of the children
or parasternal diaphragmatic hernia). by the age of 2-3 years,
• Diaphragmatic hernias are more common in boys. otherwise surgery may
be required
• More commonly, hernias protrude through the canal • Surgery is also indicated
of Bochdalek. if the neck of the
sac is narrow, although
• Upto fifty percent of patients with Bochdalek’s hernia this is very rare
have an associated cardiac anomaly.
• Treatment: Mayo’s operation, which involves
• Morgagni’s hernia is more common in females.
overlapping the rectus muscles on either side of the
• Presentation: Respiratory failure owing to pulmonary midline.
hypertension and pulmonary hypoplasia due to
compression by the abdominal contents. GASTROSCHISIS
• Diagnosis: • Protrusion of intestinal contents freely outside the
1. X-Ray: Shows bowel gas in the thorax. abdomen, through a defect on the right side of the
umbilical cord is known as Gastroschisis.
2. Barium swallow: Confirms plain X-ray findings.
• The contents are not covered by any hernial sac, rather
3. Endoscopy. a gelatinous substance covers them.
• Treatment: Surgery is required to reduce the abdominal • The size of the congenital abdominal defect is usually
contents back into the abdomen and place a mesh less than 4 cm in size.

• Many hypotheses have been formed to explain this
defect. These theories involve a failure of mesoderm
to form in the abdominal wall, rupture of amnion
around the umbilical ring, abnormal involution of
the right umbilical vein, disruption of the right
vitelline artery and abnormal folding of the body wall.
Hernias 5
• This condition is a surgical emergency.
• Surgery involves reduction of contents back into the
abdomen and application of a pressure band until the
wall defect heals itself.
• Multiple surgeries may be required to correct the defect.
 Chapter SECTION 1 : GASTROINTESTINAL SURGERY

2
OESOPHAGUS
ZENKER’S DIVERTICULUM lying below the inferior constrictor muscle and above
the cricopharyngeus muscle.
A.k.a. Pharyngoesophageal diverticulum, hypopharyngeal
diverticulum, pharyngeal pouch.
• A diverticulum arises by two mechanisms:
o Pulsion diverticulum: Push from inside the
lumen increases intraluminal pressure and results
in an outpouching, e.g., Upper and lower
oesophageal diverticuli.
o Traction diverticulum: Pull from outside results
in an outpouching, e.g., Middle oesophageal
diverticulum.
• Diverticuli can be of 2 types:
o Congenital diverticuli: Full thickness, mucosa to
serosa, e.g., Meckel’s diverticulum.
o Acquired diverticuli: Partial thickness, muscles
are not involved, e.g., Zenker’s diverticulum. Fig. 2.1: Zenker’s diverticulum
• Zenker’s diverticulum results from an uncoordinated • Clinical Presentation:
swallowing associated with cricopharyngeal muscle o Dysphagia.
spasm and delayed muscle relaxation which cause
o Lumpiness.
increased intrapharyngeal pressure and outpouching
of the mucosa at the weakest point of the pharyngeal o Regurgitation of swallowed food.
wall – Killian’s dehiscence. o Halitosis.
• Killian’s dehiscence is a weak area of the pharynx o Cough.