Inguinal Canal and Inguinal Hernia PDF

Inguinal Canal and Inguinal Hernia Dr. Chhiring Palmu Lama  Inguinal - latin word meaning near the groin Groin - the area between the anterior abdominal wall and the thigh Important anatomically and clinically  Inguinal Ligament / Poupart’s ligament Thickened lower bo...

Inguinal Canal and Inguinal Hernia Dr. Chhiring Palmu Lama  Inguinal - latin word meaning near the groin Groin - the area between the anterior abdominal wall and the thigh Important anatomically and clinically  Inguinal Ligament / Poupart’s ligament Thickened lower border of aponeurosis of the external oblique muscle which is folded backwards 12- 14 cm in adults  Attachments Laterally - anterior superior iliac spine Medially – pubic tubercle Above – continuous with aponeurosis of external oblique Below – blends with fascia lata  Expansions of inguinal ligament 1. Lacunar ligament – from inguinal ligament to medial part of pecten pubis 2. Reflected part of inguinal ligament 3. Pectineal ligament of cooper – lacunar ligament to rest of pecten pubis  Deep inguinal ring Oval gap in the fascia transversalis ( fascia lining the inner surface of transversus abdominis) 1.25 cm above the mid- inguinal point Bigger in male than female Structures passing through it 1. Spermatic cord in male 2. Round ligament of uterus in female 3. Genital branch of genitofemoral nerve  Superficial inguinal ring Gap in the external oblique aponeurosis Triangular in shape The centre of the ring lies 1cm above and lateral to the pubic tubercle Pubic crest – base  Structures passing through it 1. Spermatic cord in male 2. Round ligament of uterus in female 3. Ilio-inguinal nerve 4. Genital branch of genito femoral nerve  Inguinal Canal Oblique canal in the lower part of anterior abdominal wall Lies above the medial part of inguinal ligament 4 cm long  Extends from deep inguinal ring to superficial inguinal ring Narrow in female Chance of inguinal hernia is less  Boundaries of inguinal canal Anterior wall – Skin, superficial fascia, aponeurosis of external oblique, lateral 1/3rd by internal oblique Posterior wall - Fascia transversalis In medial 1/2- conjoint tendon (fusion of aponeurosis of internal oblique and tranversus) Roof – arched fibres of internal oblique and transversus abdominis muscle Floor – Grooved upper surface of inguinal ligament Inguinal canal  Hesselbach’s triangle Present in the posterior wall of the inguinal canal Boundaries: Laterally- inferior epigastric artery Medially- lateral border of rectus abdominis Below- inguinal ligament  Contents of inguinal canal Contents of Spermatic cord in male 1. Testicular artery 1. Testicular lymph vessels 2. Vas deferens 3. Testicular sympathetic plexus 4. Artery to vas deferens 5. Pampiniform plexus of veins 6. Cremasteric artery 7. Genital branch of genitofemoral nerve 8. Extraperitoneal fat Round ligament of uterus in female Ilio – inguinal nerve  Hernia Protrusion of whole or a part of a viscus through the wall that contains it Can be a protrusion of muscle or a brain Commonest variety is the abdominal hernia, where the protrusion of viscus occurs through the abdominal wall Parts of abdominal hernia 1. Hernial sac 2. Contents of the sac 3. Coverings of the sac  Hernial sac is the diverticulum of peritoneum, has a neck and a body Hernial contents vary from a piece of omentum to a large viscus Hernial coverings are formed from layers of abdominal wall  Types of abdominal hernia Inguinal hernia Femoral hernia Umbilical hernia Epigastric Divarication of recti abdominis Mainly 2 factors play a role in causing hernia Weakness of the abdominal muscle Increase abdominal pressure weakness can be either Congenital Acquired  Inguinal hernia Protrusion of part of the abdominal contents through the inguinal region of the abdominal wall Inguinal region is the weak part of the abdominal wall Due to the presence of inguinal canal, deep and superficial inguinal ring  Acquired causes Repeated pregnancy Surgical incisions Increase abdominal pressure due to Bronchitis Heavy weight lifting Vomiting Constipation Types 1. Indirect inguinal / oblique – Herniation of abdominal contents occur through the deep inguinal ring lateral to the inferior epigastric artery Traversus all along the inguinal canal Becomes superficial through the superficial inguinal ring Direct hernia comes out through the Hesselbach’s triangle - medial to the inferior epigastric artery) All direct hernias are acquired  Anatomical types According to the extent: Incomplete: hernia comes out through the superficial inguinal ring but fails to reach the bottom of the scrotum Complete: when it reaches the bottom of the scrotum Indirect Hernia Direct Hernia Hernia enters the inguinal canal through Hernia enters the inguinal canal through deep inguinal ring Hesselbach’s triangle Neck of the hernial sac lies lateral to the Neck of the hernia sac lies medial to the inferior epigastric artery inferior epigastric artery Unilateral, occurs in young age Bilateral, occurs in old age with weak abdominal muscles Directed downwards,forwards and medially Directed straight forwards Cause is congenital, due to persistence of Cause is acquired, due to weakness of the processsus vaginalis of peritoneum conjoint tendon Has to be reduced by patient Reduces when patient lies down  Femoral Hernia Protrusion of abdominal contents through the femoral ring Comes out through the saphenous opening Femoral ring is an oval opening ½ inch in diameter  Femoral hernia lies lateral to the pubic tubercle and below the inguinal ligament In late stage it may extend up above the inguinal ligament Inguinal hernia lies medial to the pubic tubercle and above the inguinal ligament  Complications of Hernia Irreducibility – contents can not be returned to the abdomen Obstructed/ incarcerated – Irreducibility + intestinal obstruction – due to occlusion of lumen of bowel Strangulation – Irreducibility + intestinal obstruction + arrest of blood supply