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Transcript
Inguinal Region and Testis
Highlight of the anatomy of the inguinal canal
•Description.
•Site.
INGUINAL
CANAL
•Length.
•Extension.
•Entrance(superficial and
deep rings).
•Walls.
•Contents.
TESTIS
SPERMATIC
CORD
INGUINAL CANAL
Inguinal Canal
The inguinal canal is
an oblique passage
through the lower part
of the anterior
abdominal wall.
In the males, it allows
structures to pass to
and from the testis to
the abdomen.
In females it allows
the round ligament of
the uterus to pass from
the uterus to the
labium majus.
The canal is about 1.5
in. (4 cm) long in the
adult and extends from
the deep inguinal ring,
a hole in the fascia
transversalis,
downward and medially
to the superficial
inguinal ring, a hole in
the aponeurosis of the
external oblique muscle.
It lies parallel to and
immediately above the
inguinal ligament. In
the newborn child, the
deep ring lies almost
directly posterior to
the superficial ring so
that the canal is
considerably shorter at
this age. Later, as the
result of growth, the
deep ring moves
laterally.
The deep inguinal ring
an oval opening in the
fascia transversalis, lies
about 0.5 in. (1.3 cm) above
the inguinal ligament
midway between the
anterior superior iliac spine
and the symphysis.
Related to it medially are
the inferior epigastric
vessels, which pass upward
from the external iliac
vessels. The margins of the
ring give attachment to the
internal spermatic fascia (or
the internal covering of the
round ligament of the
uterus).
The superficial inguinal ring
is a triangular-shaped
defect in the
aponeurosis of the
external oblique
muscle and lies
immediately above and
medial to the pubic
tubercle.
The margins of the
ring, sometimes called
the crura, give
attachment to the
external spermatic
fascia.
Walls of the Inguinal Canal
Anterior wall:
External oblique
aponeurosis,
reinforced laterally by
the origin of the
internal oblique from
the inguinal ligament.
This wall is therefore
strongest where it lies
opposite the weakest
part of the posterior
wall, namely, the
deep inguinal ring.
Posterior wall:
Conjoint tendon
medially, fascia
transversalis laterally.
This wall is therefore
strongest where it lies
opposite the weakest
part of the anterior
wall, namely, the
superficial inguinal
ring.
Roof or superior
wall: Arching lowest
fibers of the internal
oblique and
transversus abdominis
muscles.
Floor or inferior
wall: Upturned lower
edge of the inguinal
ligament and, at its
medial end, the
lacunar ligament.
Function of the Inguinal Canal
The inguinal canal allows structures of the spermatic cord to
pass to and from the testis to the abdomen in the male. In the
female, the smaller canal permits the passage of the round
ligament of the uterus from the uterus to the labium majus.
Mechanics of the Inguinal Canal
The inguinal canal is a site of
potential weakness in both sexes.
Except in the newborn infant, the
canal is an oblique passage with the
weakest areas, namely, the
superficial and deep rings, lying
some distance apart.
The anterior wall of the canal is
reinforced by the fibers of the
internal oblique muscle immediately
in front of the deep ring.
The posterior wall of the canal is
reinforced by the strong conjoint
tendon immediately behind the
superficial ring.
On coughing and straining, as in
micturition, defecation, and parturition,
the arching lowest fibers of the internal
oblique and transversus abdominis
muscles contract, flattening out the
arched roof so that it is lowered toward
the floor. The roof may actually
compress the contents of the canal
against the floor so that the canal is
virtually closed.
When great straining efforts may be
necessary, as in defecation and
parturition, the person naturally tends to
assume the squatting position; the hip
joints are flexed, and the anterior
surfaces of the thighs are brought up
against the anterior abdominal wall. By
this means, the lower part of the anterior
abdominal wall is protected by the
thighs.
Spermatic Cord
The spermatic cord
is a collection of
structures that pass
through the inguinal
canal to and from
the testis. It begins
at the deep inguinal
ring lateral to the
inferior epigastric
artery and ends at
the testis.
Structures of the Spermatic Cord
The structures are as
follows:
Vas deferens
Testicular artery
Testicular veins
(pampiniform plexus)
Testicular lymph vessels
Autonomic nerves
Remains of the processus
vaginalis
Genital branch of the
genitofemoral nerve, which
supplies the cremaster
muscle
Vas Deferens (Ductus
Deferens)
The vas deferens is a cord like
structure that can be palpated
between finger and thumb in the
upper part of the scrotum. It is a
thick-walled muscular duct that
transports spermatozoa from the
epididymis to the urethra.
Testicular Artery
A branch of the abdominal
aorta (at the level of the second
lumbar vertebra), the testicular
artery is long and slender and
descends on the posterior
abdominal wall. It traverses the
inguinal canal and supplies the
testis and the epididymis.
Testicular Veins
An extensive venous
plexus, the pampiniform
plexus, leaves the posterior
border of the testis. As the
plexus ascends, it becomes
reduced in size so that at
about the level of the deep
inguinal ring, a single
testicular vein is formed.
This runs up on the
posterior abdominal wall
and drains into the left
renal vein on the left side
and into the inferior vena
cava on the right side.
Lymph Vessels
The testicular lymph
vessels ascend through
the inguinal canal and
pass up over the
posterior abdominal
wall to reach the
lumbar (para-aortic)
lymph nodes on the
side of the aorta at the
level of the first
lumbar vertebra.
Autonomic Nerves
Sympathetic fibers run with the testicular artery from the renal or
aortic sympathetic plexuses. Afferent sensory nerves accompany
the efferent sympathetic fibers.
Processus Vaginalis
The remains of the processus vaginalis are present within the
cord.
Genital Branch of the Genitofemoral Nerve
This nerve supplies the cremaster muscle.
Coverings of the Spermatic Cord (the Spermatic Fasciae)
The coverings of the spermatic cord are
three concentric layers of fascia derived
from the layers of the anterior abdominal
wall. Each covering is acquired as the
processus vaginalis descends into the
scrotum through the layers of the
abdominal wall.
External spermatic fascia derived from
the external oblique aponeurosis and
attached to the margins of the superficial
inguinal ring.
Cremasteric fascia derived from the
internal oblique muscle.
Internal spermatic fascia derived from
the fascia transversalis and attached to the
margins of the deep inguinal ring.
Development of the Inguinal Canal
Before the descent of the testis and the ovary from their site of origin
high on the posterior abdominal wall (L1), a peritoneal diverticulum
called the processus vaginalis is formed. The processus vaginalis passes
through the layers of the lower part of the anterior abdominal wall and,
as it does so, acquires a tubular covering from each layer. It traverses
the fascia transversalis at the deep inguinal ring and acquires a tubular
covering, the internal spermatic fascia. As it passes through the lower
part of the internal oblique muscle, it takes with it some of its lowest
fibers, which form the cremaster muscle. The muscle fibers are
embedded in fascia, and thus the second tubular sheath is known as the
cremasteric fascia. On reaching the aponeurosis of the external oblique,
it evaginates this to form the superficial inguinal ring and acquires a
third tubular fascial coat, the external spermatic fascia.
Meanwhile, a band of mesenchyme, extending from the lower pole of
the developing gonad through the inguinal canal to the labioscrotal
swelling, has condensed to form the gubernaculum.
In the male, the testis descends through the pelvis and inguinal canal during
the seventh and eighth months of fetal life. The testis follows the gubernaculum
and descends behind the peritoneum on the posterior abdominal wall. The testis
then passes behind the processus vaginalis and pulls down its duct, blood
vessels, nerves, and lymph vessels. The testis takes up its final position in the
developing scrotum by the end of the eighth month.
Because the testis and its accompanying vessels, ducts, and so on follow the
course previously taken by the processus vaginalis, they acquire the same three
coverings as they pass down the inguinal canal.
In the female, the ovary descends into the pelvis following the
gubernaculum. The gubernaculum becomes attached to the side of the
developing uterus, and the gonad descends no farther. That part of the
gubernaculum extending from the uterus into the developing labium majus
persists as the round ligament of the uterus. Thus, in the female, the only
structures that pass through the inguinal canal from the abdominal cavity are
the round ligament of the uterus and a few lymph vessels. The lymph vessels
convey a small amount of lymph from the body of the uterus to the superficial
inguinal nodes.
Clinical Notes
Vasectomy
Bilateral vasectomy is a simple operation performed to
produce infertility. Under local anesthesia, a small incision
is made in the upper part of the scrotal wall, and the vas
deferens is divided between ligatures. Spermatozoa may be
present in the first few postoperative ejaculations, but that is
simply an emptying process. Now only the secretions of the
seminal vesicles and prostate constitute the seminal fluid,
which can be ejaculated as before.
Scrotum, Testis, and Epididymides
Scrotum
The scrotum is an
outpouching of the
lower part of the
anterior abdominal
wall. It contains the
testes, the
epididymides, and the
lower ends of the
spermatic cords.
A. Continuity of the different layers of the anterior
abdominal wall with coverings of the spermatic
cord.
The wall of the scrotum has the following layers:
Skin: The skin of the
scrotum is thin, wrinkled,
and pigmented and forms
a single pouch. A slightly
raised ridge in the midline
indicates the line of fusion
of the two lateral
labioscrotal swellings. (In
the female, the swellings
remain separate and form
the labia majora.)
B. The skin and superficial fascia of the
abdominal wall and scrotum have been
included, and the tunica vaginalis is shown.
Superficial fascia: This is
continuous with the fatty and
membranous layers of the anterior
abdominal wall; the fat is, however,
replaced by smooth muscle called
the dartos muscle. This is innervated
by sympathetic nerve fibers and is
responsible for the wrinkling of the
overlying skin. The membranous
layer of the superficial fascia
(Colles' fascia) is continuous in front
with the membranous layer of the
anterior abdominal wall (Scarpa's
fascia), and behind it is attached to
the perineal body and the posterior
edge of the perineal membrane. At
the sides it is attached to the
ischiopubic rami. Both layers of
superficial fascia contribute to a
median partition that crosses the
scrotum and separates the testes
from each other.
A. Arrangement of the fatty layer and the
membranous layer of the superficial fascia in the
lower part of the anterior abdominal wall. Note the
line of fusion between the membranous layer and
the deep fascia of the thigh (fascia lata). B. Note the
attachment of the membranous layer to the posterior
margin of the perineal membrane. Arrows indicate
paths taken by urine in cases of ruptured urethra.
Spermatic fasciae: These three layers lie beneath the superficial
fascia and are derived from the three layers of the anterior
abdominal wall on each side. The external spermatic fascia is
derived from the aponeurosis of the external oblique muscle; the
cremasteric fascia is derived from the internal oblique muscle;
and, finally, the internal spermatic fascia is derived from the
fascia transversalis. The cremaster muscle is supplied by the
genital branch of the genitofemoral nerve. The cremaster
muscle can be made to contract by stroking the skin on the
medial aspect of the thigh. This is called the cremasteric
reflex. The afferent fibers of this reflex arc travel in the
femoral branch of the genitofemoral nerve (L1 and 2), and
the efferent motor nerve fibers travel in the genital branch of
the genitofemoral nerve. The function of the cremaster muscle
is to raise the testis and the scrotum upward for warmth and for
protection against injury. For testicular temperature and fertility.
Tunica vaginalis
This lies within the
spermatic fasciae and
covers the anterior,
medial, and lateral
surfaces of each testis.
It is the lower
expanded part of the
processus vaginalis;
normally, just before
birth, it becomes shut
off from the upper part
of the processus and
the peritoneal cavity.
The tunica vaginalis is
thus a closed sac,
invaginated from
behind by the testis.
B. The skin and superficial fascia of the
abdominal wall and scrotum have been included,
and the tunica vaginalis is shown.
Lymph Drainage of the Scrotum
Lymph from the skin
and fascia, including
the tunica vaginalis,
drains into the
superficial inguinal
lymph nodes.
Testis
The testis is a firm, mobile
organ lying within the scrotum.
The left testis usually lies at a
lower level than the right. Each
testis is surrounded by a tough
fibrous capsule, the tunica
albuginea. Extending from the
inner surface of the capsule is a
series of fibrous septa that
divide the interior of the organ
into lobules. Lying within each
lobule are one to three coiled
seminiferous tubules. The
tubules open into a network of
channels called the rete testis.
Small efferent ductules connect
the rete testis to the upper end
of the epididymis.
Epididymis
The epididymis is a firm
structure lying posterior to
the testis, with the vas
deferens lying on its
medial side. It has an
expanded upper end, the
head, a body, and a pointed
tail inferiorly. Laterally, a
distinct groove lies
between the testis and the
epididymis, which is lined
with the inner visceral
layer of the tunica
vaginalis and is called the
sinus of the epididymis.
Clinical Notes
Varicocele
A varicocele is a condition in which the veins of the pampiniform
plexus are elongated and dilated. It is a common disorder in
adolescents and young adults, with most occurring on the left side.
Rarely, malignant disease of the left kidney extends along the renal vein
and blocks the exit of the testicular vein.
Malignant Tumor of the Testis
A malignant tumor of the testis spreads upward via the lymph vessels
to the lumbar (para-aortic) lymph nodes at the level of the first lumbar
vertebra. It is only later, when the tumor spreads locally to involve the
tissues and skin of the scrotum, that the superficial inguinal lymph
nodes are involved.
Congenital anomalies:
Torsion of the Testis
Torsion of the testis is a rotation of the testis around the spermatic cord within the
scrotum. It is often associated with an excessively large tunica vaginalis. Torsion commonly
occurs in active young men and children and is accompanied by severe pain. If not treated
quickly, the testicular artery may be occluded, followed by necrosis of the testis.
Processus Vaginalis
Normally, the upper part becomes obliterated just before birth and the lower part remains as
the tunica vaginalis.
The processus is subject to the following common congenital anomalies:
•It may persist partially or in its entirety as a preformed hernial sac for an indirect inguinal
hernia.
•It may become very much narrowed, but its lumen remains in communication with the
abdominal cavity. Peritoneal fluid accumulates in it, forming a congenital hydrocele.
•The upper and lower ends of the processus may become obliterated, leaving a small
intermediate cystic area referred to as an encysted hydrocele of the cord.
It is therefore not surprising to find that inflammation of the testis can cause an
accumulation of fluid within the tunica vaginalis. This is referred to simply as a hydrocele.
The long length of the duct of the epididymis provides storage space for the spermatozoa
and allows them to mature. A main function of the epididymis is the absorption of fluid.
Another function may be the addition of substances to the seminal fluid to nourish the
maturing sperm.
Blood Supply of the Testis and Epididymis
The testicular artery is a
branch of the abdominal
aorta. The testicular
veins emerge from the
testis and the epididymis
as a venous network, the
pampiniform plexus.
This becomes reduced to
a single vein as it
ascends through the
inguinal canal. The right
testicular vein drains into
the inferior vena cava,
and the left vein joins the
left renal vein.
Lymph Drainage of the Testis and Epididymis
The lymph vessels ascend
in the spermatic cord and
end in the lymph nodes on
the side of the aorta (lumbar
or para-aortic) nodes at the
level of the first lumbar
vertebra (i.e., on the
transpyloric plane). This is
to be expected because
during development the
testis has migrated from
high up on the posterior
abdominal wall, down
through the inguinal canal,
and into the scrotum,
dragging its blood supply
and lymph vessels after it.
Embryologic Notes
Development of the Testis
The sex cords of the genital ridge become separated from the coelomic epithelium by
the proliferation of the mesenchyme . The outer part of the mesenchyme condenses to
form a dense fibrous layer, the tunica albuginea. The sex cords become U-shaped and
form the seminiferous tubules. The free ends of the tubules form the straight tubules,
which join one another in the mediastinum testis to become the rete testis. The
primordial sex cells in the seminiferous tubules form the spermatogonia, and the sex
cord cells form the Sertoli cells. The mesenchyme in the developing gonad makes up
the connective tissue and fibrous septa. The interstitial cells, which are already
secreting testosterone, are also formed of mesenchyme. The rete testis becomes
canalized, and the tubules extend into the mesonephric tissue, where they join the
remnants of the mesonephric tubules; the latter tubules become the efferent ductules
of the testis. The duct of the epididymis, the vas deferens, the seminal vesicle, and the
ejaculatory duct are formed from the mesonephric duct.
Descent of the Testis
The testis develops high up on the posterior abdominal wall, and in late fetal life it
descends behind the peritoneum, dragging its blood supply, nerve supply, and
lymphatic drainage after it.
Congenital Anomalies of the Testis
The testis may be subject to the following congenital anomalies.
•Anterior inversion, in which the epididymis lies anteriorly and the testis and the tunica
vaginalis lie posteriorly
•Polar inversion, in which the testis and epididymis are completely inverted
•Imperfect descent (cryptorchidism): Incomplete descent, in which the testis, although
traveling down its normal path, fails to reach the floor of the scrotum. It may be found
within the abdomen, within the inguinal canal, at the superficial inguinal ring, or high
up in the scrotum. Maldescent, in which the testis travels down an abnormal path and
fails to reach the scrotum. It may be found in the superficial fascia of the anterior
abdominal wall above the inguinal ligament, in front of the pubis, in the perineum, or in
the thigh.
If an incompletely descended testis is brought down into the scrotum by surgery before
puberty, it will develop and function normally. A maldescended testis, although often
developing normally, is susceptible to traumatic injury and, for this reason, should be
placed in the scrotum. Many authorities believe that the incidence of tumor formation is
greater in testes that have not descended into the scrotum.
The appendix of the testis and the appendix of the epididymis are embryologic
remnants found at the upper poles of these organs that may become cystic. The
appendix of the testis is derived from the paramesonephric ducts, and the appendix of
the epididymis is a remnant of the mesonephric tubules.
Surgical anatomy of the inguinal hernia
Abdominal Herniae
A hernia is the protrusion of
part of the abdominal contents
beyond the normal confines of the
abdominal wall. It consists of
three parts: the sac, the contents
of the sac, and the coverings of
the sac. The hernial sac is a
pouch (diverticulum) of
peritoneum and has a neck and a
body. The hernial contents may
consist of any structure found
within the abdominal cavity and
may vary from a small piece of
omentum to a large viscus such as
the kidney. The hernial coverings
are formed from the layers of the
abdominal wall through which
the hernial sac passes.
Abdominal herniae are of the following common types:
•Inguinal (indirect or direct)
•Femoral
•Umbilical (congenital or acquired)
•Epigastric
•Separation of the recti abdominis
•Incisional
•Hernia of the linea semilunaris (Spigelian hernia)
•Lumbar (Petit's triangle hernia)
•Internal
Indirect Inguinal Hernia
The indirect inguinal hernia is the most common form of hernia and is
believed to be congenital in origin. The hernial sac is the remains of the
processus vaginalis (It follows that the sac enters the inguinal canal
through the deep inguinal ring lateral to the inferior epigastric vessels.
It may extend part of the way along the canal or the full length, as far as
the superficial inguinal ring. If the processus vaginalis has undergone no
obliteration, then the hernia is complete and extends through the
superficial inguinal ring down into the scrotum or labium majus. Under
these circumstances the neck of the hernial sac lies at the deep inguinal
ring lateral to the inferior epigastric vessels, and the body of the sac
resides in the inguinal canal and scrotum (or base of labium majus).
An indirect inguinal hernia is about 20 times more common in males
than in females, and nearly one third are bilateral. It is more common
on the right (normally, the right processus vaginalis becomes obliterated
after the left; the right testis descends later than the left). It is most
common in children and young adults.
Direct Inguinal Hernia
The direct inguinal hernia makes
up about 15% of all inguinal
hernias. The sac of a direct hernia
bulges directly anteriorly through
the posterior wall of the inguinal
canal medial to the inferior
epigastric vessels. Because of the
presence of the strong conjoint
tendon (combined tendons of
insertion of the internal oblique
and transversus muscles), this
hernia is usually nothing more
than a generalized bulge;
therefore, the neck of the hernial
sac is wide.
Direct inguinal hernias are rare
in women and most are bilateral.
It is a disease of old men with
weak abdominal muscles.
An inguinal hernia can
be distinguished from
a femoral hernia by
the fact that the sac, as
it emerges through the
superficial inguinal
ring, lies above and
medial to the pubic
tubercle, whereas that
of a femoral hernia
lies below and lateral
to the tubercle.
Femoral Hernia
The hernial sac descends through the
femoral canal within the femoral
sheath, creating a femoral hernia. The
femoral artery, as it enters the thigh
below the inguinal ligament, occupies
the lateral compartment of the sheath.
The femoral vein, which lies on its
medial side and is separated from it by
a fibrous septum, occupies the
intermediate compartment. The lymph
vessels, which are separated from the
vein by a fibrous septum, occupy the
most medial compartment. The femoral
canal, the compartment for the
lymphatics, occupies the medial part of
the sheath. It is about 0.5 in. (1.3 cm)
long, and its upper opening is referred
to as the femoral ring. The femoral
septum, which is a condensation of
extraperitoneal tissue, plugs the
opening of the femoral ring.
A femoral hernia is more common in women than in men (possibly
because of a wider pelvis and femoral canal). The hernial sac passes down
the femoral canal, pushing the femoral septum before it. On escaping
through the lower end, it expands to form a swelling in the upper part of the
thigh deep to the deep fascia. With further expansion, the hernial sac may
turn upward to cross the anterior surface of the inguinal ligament.
The neck of the sac always lies below and lateral to the pubic tubercle,
which serves to distinguish it from an inguinal hernia. The neck of the sac
is narrow and lies at the femoral ring. The ring is related anteriorly to the
inguinal ligament, posteriorly to the pectineal ligament and the pubis,
medially to the sharp free edge of the lacunar ligament, and laterally to
the femoral vein. Because of the presence of these anatomic structures, the
neck of the sac is unable to expand. Once an abdominal viscus has passed
through the neck into the body of the sac, it may be difficult to push it up
and return it to the abdominal cavity (irreducible hernia). Furthermore,
after straining or coughing, a piece of bowel may be forced through the
neck and its blood vessels may be compressed by the femoral ring, seriously
impairing its blood supply (strangulated hernia). A femoral hernia is a
dangerous disease and should always be treated surgically.
Umbilical Herniae
Congenital umbilical hernia, or exomphalos
(omphalocele), is caused by a failure of part of
the midgut to return to the abdominal cavity from
the extraembryonic coelom during fetal life.
Acquired infantile umbilical hernia is a small
hernia that sometimes occurs in children and is
caused by a weakness in the scar of the umbilicus
in the linea alba. Most become smaller and
disappear without treatment as the abdominal
cavity enlarges.
Acquired umbilical hernia of adults is more
correctly referred to as a paraumbilical hernia.
The hernial sac does not protrude through the
umbilical scar, but through the linea alba in the
region of the umbilicus. Paraumbilical herniae
gradually increase in size and hang downward.
The neck of the sac may be narrow, but the body
of the sac often contains coils of small and large
intestine and omentum. Paraumbilical herniae are
much more common in women than in men.
Epigastric Hernia
Epigastric hernia occurs through the widest part of the linea alba,
anywhere between the xiphoid process and the umbilicus. The hernia is
usually small and starts off as a small protrusion of extraperitoneal fat
between the fibers of the linea alba. During the following months or
years the fat is forced farther through the linea alba and eventually drags
behind it a small peritoneal sac. The body of the sac often contains a
small piece of greater omentum. It is common in middle-aged manual
workers.
Separation of the Recti Abdominis
Separation of the recti abdominis occurs in elderly multiparous
women with weak abdominal muscles. In this condition, the aponeuroses
forming the rectus sheath become excessively stretched. When the patient
coughs or strains, the recti separate widely, and a large hernial sac,
containing abdominal viscera, bulges forward between the medial
margins of the recti. This can be corrected by wearing a suitable
abdominal belt.
Incisional Hernia
A postoperative incisional hernia is most likely to occur in patients in whom it was
necessary to cut one of the segmental nerves supplying the muscles of the anterior
abdominal wall; postoperative wound infection with death (necrosis) of the abdominal
musculature is also a common cause. In very obese individuals the extent of the
abdominal wall weakness is often difficult to assess.
Hernia of the Linea Semilunaris (Spigelian Hernia)
The uncommon hernia of the linea semilunaris occurs through the aponeurosis of the
transversus abdominis just lateral to the lateral edge of the rectus sheath. It usually
occurs just below the level of the umbilicus.
Lumbar Hernia
The lumbar hernia occurs through the lumbar triangle and is rare. The lumbar
triangle (Petit's triangle) is a weak area in the posterior part of the abdominal wall. It
is bounded anteriorly by the posterior margin of the external oblique muscle,
posteriorly by the anterior border of the latissimus dorsi muscle, and inferiorly by the
iliac crest. The floor of the triangle is formed by the internal oblique and the
transversus abdominis muscles. The neck of the hernia is usually large, and the
incidence of strangulation low.
Internal Hernia
Occasionally, a loop of intestine enters a peritoneal recess (e.g., the lesser sac or the
duodenal recesses) and becomes strangulated at the edges of the recess.