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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.