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Prof. Saeed Abuel Makarem

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Title: Prof. Saeed Abuel Makarem


1
Inguinal Region
  • By
  • Prof. Saeed Abuel Makarem

2
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.

3
Inguinal Canal
  • 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.

4
Inguinal Canal
  • 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.

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7
Deep inguinal ring
Superficial inguinal ring
External oblique
Medial
Lateral
8
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.

9
  • 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

10
Spermatic Cord
  • 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

11
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

12
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

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14
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

15
Male External Genitalia
16
Scrotum
  • 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

17
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

18
Scrotum
  • Membranous layer is called Colles fascia
  • It is continuous with the Scarpas 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

19
Testis
  • 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

20
Epididymis
  • 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

21
Lymphatic Drainage of Scrotum Its contents
  • Skin, fasciae ,and tunica vaginalis
  • drain into superficial inguinal lymph nodes
  • Testis and epididymis drain into lumbar
    (para-aortic) lymph nodes.

22
Clinical Notes
  • Undescended testis
  • Anomalies of the processus vaginalis
  • Hydrocele
  • Encysted Hydrocele
  • Hernias
  • Tapping of Hydrocele

23
Hernia
  • 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

24
Hernia Types
  • Epigastric
  • Umbilical congenital (Omphalocele) or acquired
  • Inguinal
  • direct or indirect
  • Femoral
  • Incisional
  • Semilunar

25
Hernia Types
  • Diaphragmatic or Hiatal
  • Lumbar Or (Petits triangle)
  • Obturator

26
Inguinal Hernia
  • Herniation of the abdominal viscera (usually
    small intestinal coils) through the inguinal
    region
  • It is of two type
  • Direct
  • Indirect

27
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

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29
Indirect Inguinal hernia
  • Hernial sac
  • Formed of remains of 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

30
Direct Inguinal hernia
  • 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
    (Hasselbachs) 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

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  • DIRECT INGUINAL HERNIA
  • OBLIQUE INGUINAL HERNIA

33
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

34
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

35
Management
  • Reduction of hernia (pushing the contents and the
    sac back to the abdominal cavity)
  • Repair of the weakness in the abdominal wall
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