Download Inguinal Hernia

By
Prof. Saeed Abuel Makarem
GROIN OR INGUINAL REGION
• The groin or the inguinal region, extending between
the ASIS and pubic tubercle.
• It is a very important area surgically and anatomically
where structures enter and exit the abdominal cavity
• It is a potential site for herniation.
• In fact, the majority of all abdominal hernias, occur in
this region in particular the Inguinal hernia, which
account for 80-90 % of all abdominal hernias.
• It is an oblique intramuscular slit in the
lower medial part of the Anterior
Abdominal Wall.
• It runs just above and parallel to the
medial part of the inguinal ligament.
• Its length is about one & half inches
(4 cm) in adult.
• Its gives a passage for the spermatic
cord in male, or round ligament of the
uterus in female.
• Also it gives a passage for the
Ilioinguinal nerve in both sexes.
• Extends from the deep
inguinal ring to the superficial
inguinal ring
• In the newborn child, the deep
ring lies almost directly
posterior to the superficial ring
• The deep inguinal ring is an
oval opening lies in the fascia
transversalis
• It lies ½ inch just above the
midpoint of the inguinal
ligament
• Its margin gives attachment to
the internal spermatic fascia.
Inguinal Canal
Deep inguinal ring
Superficial inguinal ring
External
oblique
Lateral
Medial
Boundaries of the Inguinal canal
Ant. Wall: External oblique along whole length
Internal oblique along lateral half.
Post. Wall: Fascia Transversalis along whole length.
Conjoint tendon (inguinal falx) along
the medial part.
Reflected ligament along medial ¼.
Floor: Inguinal ligament supported medially by
Lacunar ligament.
Roof: Arching lower fibers of internal oblique.
• The anterior wall is reinforced
laterally by the origin of the internal
oblique from the inguinal ligament
• This wall is strongest where it lies
opposite the weakest part of
posterior wall, that is deep inguinal
ring
• The posterior wall is reinforced
medially by the conjoint tendon.
• This wall is strongest where it lies
opposite the weakest part of the
anterior wall, that is superficial
inguinal ring
• Collection of structures
that traverse the
inguinal canal and pass
to and from the testis
• Covered by three
layers of fascia derived
from the layers of the
abdominal wall
• Begins at the deep
inguinal ring, lateral to
the inferior epigastric
vessels, and ends at
the testis
Spermatic Cord
Contents of the Spermatic Cord
• 1- Vas deferens:
– Thick muscular tube transmitting sperms
from the epididymis to the urethra
• 2- Arteries:
 A -Testicular artery (branch of abdominal
aorta)
 B-- Cremasteric artery (branch of inferior
epigastric artery)
 C-- Artery of the vas deferens (branch of
inferior vesical artery)
• 3- Veins:
– Pampinioform plexus draining testis,
continues as a single testicular vein, in
the deep inguinal ring which drains into
the inferior vena cava on right and into
left renal vein on the left side
Contents of the Spermatic Cord
• 4- Lymphatics:
– Draining testis, pass through
inguinal canal and drain into
para-aortic lymph nodes.
• 5- Nerves:
 A. Autonomic nerves from renal
and aortic plexuses, run with
testicular artery
 B - Genital branch of the
genitofemoral nerve, which
supplies the Cremasteric
muscle
• 6- Remains of the
processus vaginalis
Coverings of the Spermatic Cord
• Internal spermatic fascia,
derived from the fascia
transversalis
• Cremasteric muscle and
fascia: derived from the
internal oblique muscle.
• External spermatic fascia,
derived from the external
oblique aponeurosis
Male External Genitalia
• It is an out- pouch of the
anterior abdominal wall
• Formed of two pouches,
fused in the midline
• Contains testis, epididymis
and lower part of the
spermatic cord
• Wall has following layers:
–
–
–
–
–
–
Skin
Dartos muscle
External spermatic fascia
Cremesteric fascia
Internal spermatic fascia
Tunica vaginalis
Scrotum
• Skin is thin & wrinkled
• Superficial fascia
continuous with the fatty
& membranous layers of
the abdominal wall
 In the fatty layer, fat
is replaced by dartos
muscle, a smooth
muscle supplied by
sympathetic nerves
and responsible for
wrinkling of skin of
the scrotum
Scrotum
Membranous layer is
called Colle’s fascia
It is continuous with the
Scarpa’s fascia of the
anterior abdominal wall
• External spermatic fascia
• Cremasteric muscle and
fascia
• Internal spermatic fascia
• Tunica vaginalis:
• Closed sac, derived from
peritoneal cavity, covers
the anterior, medial and
lateral surfaces of testis
Scrotum
• Mobile primary sex organ, lies
in the scrotum
• Left usually lies at a lower level
than right
• Each testis is surrounded by
tough fibrous capsule, the
tunica albuginea
• Septae extending from capsule
dividing the testis into lobules,
which contain seminiferous
tubules
• Tubules open into rete testis,
which are connected to
epididymis through efferent
ductules
Testis
• 20 feet long, coiled tube,
embeded in connective tissue
forming a firm structure
• Lies posterior to testis and
lateral to vas deferens
• Has head, body and tail.
• Tail continues with the vas
deferens
• Is separated from the testis
laterally by a groove lined by
visceral layer of tunica
vaginalis, called sinus of
epididymis
• It is called sinus of epididymis
• Epididymis is the storage
and maturation space for the
spermatozoa
Epididymis
Lymphatic Drainage of Scrotum &
Its contents
• Skin, fasciae ,and
tunica vaginalis:
• drain into superficial
inguinal lymph nodes
• Testis and epididymis:
drain into lumbar (paraaortic) lymph nodes.
Clinical Notes
• Undescended testis
• Anomalies of the
processus vaginalis:
– Hydrocele
– Encysted Hydrocele
– Hernias
• Tapping of Hydrocele
• Hernia is the protrusion
of part of abdominal
viscera beyond the
normal confines of the
abdominal walls
• It has three parts:
– The sac
– Contents of the sac
– Coverings of the sac
Hernia
• Epigastric
• Umbilical:
congenital
(Omphalocele) or
acquired
• Inguinal:
• direct or indirect
• Femoral
• Incisional
• Semilunar
Hernia: Types
• Diaphragmatic or
Hiatal
• Lumbar Or (Petit’s
triangle)
• Obturator
Hernia: Types
• Herniation of the
abdominal viscera
(usually small
intestinal coils)
through the inguinal
region
• It is of two type:
– Direct
– Indirect
Inguinal Hernia
Indirect Or oblique Inguinal hernia
• Most common form of
hernia
• Most common in
children & young
adults
• About 20 times more
common in male than
in female
• 1/3rd are bilateral
• More common on the
right side
• Hernial sac:
Indirect Inguinal
– Formed of remains of
hernia
processus vaginalis
– Enters inguinal canal
through deep ring
– Lies lateral to the inferior
epigastric artery
• Can be complete,
extending to the scrotal
sac, or incomplete,
arrested in the inguinal
canal
• About 15% of inguinal hernia,
• Rare in females
• Common in old men with weak
abdominal muscles
• Hernial sac:
– Bulges directly through the
posterior wall of the inguinal
canal i.e.through the inguinal
(Hasselbach’s) triangle. This
triangle is bounded medially by
lateral edge of rectus abdominis
muscle, laterally by inferior
epigastric artery, infeiorly by
inguinal ligament.
– Lies medial to the inferior
epigastric vessels
• Usually nothing more than a
generalized bulge
Direct Inguinal
hernia
DIRECT INGUINAL
HERNIA
OBLIQUE INGUINAL
HERNIA
Femoral Hernia
• Protrusion of
abdominal viscera
through the femoral
ring into the upper
part of the thigh
• More common in
women (wider femoral
ring)
• Neck of the sac lies
below and lateral to
the pubic tubercle
Relation of inguinal & femoral
hernial sacs to pubic tubercle
• Inguinal:
• sac lies above and
medial to the pubic
tubercle
• Femoral:
• sac lies below and
lateral to the pubic
tubercle
Management
• Reduction of hernia (pushing the contents
and the sac back to the abdominal cavity)
• Repair of the weakness in the abdominal
wall