Inguinal Hernia.pptx
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Inguinal Hernia.pptx
- 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. Good for self study also. Display blank slide> Think what you already know about this > Read next slide.
- 2. Learning Objectives At the end of this session the learner will be able to describe- • Aetiology • Pathophysiology • Clinical Features • Management Of Inguinal Hernia
- 3. Learning Objectives 1. Introduction & History 2. Relevant Anatomy, Physiology 3. Aetiology 4. Pathophysiology 5. Pathology 6. Classification 7. Clinical Features 8. Investigations 9. Management 10. Controversies 11. Prevention 12. Guidelines 13. Take home messages
- 5. Hernia: Definition An abnormal protrusion of a viscus or its part through a normal or abnormal opening in the walls of its containing cavity.
- 7. Pathophysiology Anatomy • Hesselbach's triangle- • Lateral border of the rectus abdominis • Inguinal ligament • Inferior epigastric vessels.
- 9. Anatomy Inguinal Canal • Anterior- . • Posterior- • Inferior- • Superior- • Lateral /Entry- • Medial/Exit- • Content-
- 10. Anatomy Inguinal Canal • Anterior- Ext. Obl. Aponeurosis. • Posterior- Fascia Transversalis Conjoint tendon medially • Inferior- Inguinal ligament. • Superior- Conjoint tendon. • Lateral /Entry- Internal/deep ring • Medial/Exit- External/Supf. ring • Content- Spermatic cord
- 11. Anatomy • The spermatic cord- • Vas deferens • Processus vaginalis. • Cremasteric muscle fibers, • Testicular artery and accompanying veins • Genital branch of the genitofemoral nerve • Cremasteric vessels, • Lymphatics,
- 12. Anatomy • Inguinal Ligament • The lacunar ligament
- 13. Anatomy • Inguinal Ligament:(Poupart’s ligament) is the inferior edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to the pubic tubercle, turning posteriorly to form a shelving edge. • The lacunar ligament is the fan-shaped medial expansion of the inguinal ligament, which inserts into the pubis and forms the medial border of the femoral space
- 14. Anatomy • The external (superficial) inguinal ring: • The Internal (Deep ) ring
- 15. Anatomy • The external (superficial) inguinal ring:is an ovoid opening of the external oblique aponeurosis that is positioned superiorly and slightly laterally to the pubic tubercle. • The Internal (Deep ) ring : Opening in Fascia transversalis at mid inguinal point. 1.25 cm above the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine
- 16. Anatomy • Important sensory nerves- 1. Iliohypogastric n. 2. Ilioinguinal n. 3. Genital branch of the genitofemoral nerve
- 17. Anatomy • The inferior epigastric artery and vein .
- 18. Anatomy • The inferior epigastric artery and vein . Defines the type of inguinal hernia. Indirect inguinal hernias occur lateral to the inferior epigastric vessels, whereas direct hernias occur medial to these vessels.
- 20. Anatomy • Cremaster muscle- arise from the internal oblique, encompass the spermatic cord, and attach to the tunica vaginalis of the testis.
- 21. Anatomy Parts of Hernia- • Sac • Coverings of the sac • Contents of the sac. • Neck of sac is at internal ring where sac communicates with peritoneal cavity.
- 22. Anatomy Types of Hernia- 1. Bubonocele. The hernia is limited to the inguinal canal. 2. Funicular. The processus vaginalis is closed just above the epididymis. 3. Complete (synonym: scrotal).
- 24. Defense of inguinal canal • Shutter mechanism • Obliquity of inguinal canal • Ball valve mechanism of cremaster Contraction of cremaster helps the spermatic cord to plug superficial inguinal ring. • The pinchcock action of the internal ring musculature • Flap valve mechanism • The superficial inguinal ring is guarded from behind by the conjoint tendon and by the reflected part of the inguinal canal. • The anterior wall opposite the deep ring is reinforced laterally by the internal oblique muscles. • Slit valve mechanism Contraction of the external oblique results in approximation of the two crura of the superficial inguinal ring
- 25. Aetiology • Idiopathic • Traumatic • Infections /Infestation • Neoplastic (Benign/Malignant) • Congenital/ Genetic • Nutritional Deficiency/excess • Autoimmune • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
- 26. Inguinal hernia: Etiology • Idiopathic • Congenital • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative
- 27. Inguinal hernia: Etiology • Risk factors • Elevated intra-abdominal pressure is associated with chronic cough, ascites, increased peritoneal fluid from biliary atresia, peritoneal dialysis or ventriculoperitoneal shunts, intraperitoneal masses or organomegaly, and obstipation. • Premature infants • Exstrophy of bladder, neonatal intraventricular hemorrhage, myelomeningocele, and undescended testes.
- 28. Inguinal hernia: Etiology • Molecular Risk factors • The rectus sheath adjacent to groin hernias is thinner than normal. The rate of fibroblast proliferation is less than normal, and the rate of collagenolysis appears increased. • Sailors who developed scurvy had an increased incidence of hernia • Aberrant collagen states (eg, Ehlers-Danlos, fetal hydantoin, Freeman-Sheldon, Hunter-Hurler, Kniest, Marfan, and Morquio syndromes), have increased rates of hernia formation, as do osteogenesis imperfecta, pseudo- Hurler polydystrophy, and Scheie syndrome.
- 29. Inguinal hernia: Etiology • Molecular Risk factors • Acquired elastase deficiency • Heavy smokers The contribution of biochemical or metabolic factors to the creation of inguinal hernias is unclear.
- 30. Pathophysiology
- 31. Pathophysiology • An indirect inguinal hernia follows the tract through the inguinal canal. It results from a persistent processus vaginalis. • The processus fails to close adequately at birth in 40-50% of boys. • A familial tendency exists, with 11.5% of patients having a family history. • Direct hernia is caused by weakness of posterior wall – abdominal wall and thinning of fascia.
- 32. Pathophysiology Increased intra-abdominal pressure: • Marked obesity • Heavy lifting • Coughing • Straining with defecation or urination • Ascites • Peritoneal dialysis • Ventriculoperitoneal shunt • Chronic obstructive pulmonary disease (COPD) • Family history of hernias
- 33. Classification
- 34. Classification • Indirect Inguinal hernia. • Direct Inguinal hernia. • Congenital Inguinal hernia. • A sliding hernia :a portion of the sac is composed of visceral peritoneum covering part of a retroperitoneal organ, usually the colon or bladder
- 36. Clinical Features • Demography • Symptoms • Signs • Prognosis • Complications
- 37. Demography
- 38. Demography • Incidence & Prevalence • Geographical distribution. • Race • Age • Sex • Socioeconomic status • Temporal behaviour
- 39. • Incidence 5-10 % • Geographical distribution : none • Age- increases with age. • Sex -25 times more common in males. • Even in females most common groin hernia is inguinal hernia. • Side-More common on right side.
- 40. Symptoms
- 41. Symptoms • Swelling in inguinoscrotal region. • Painless unless complicated.
- 42. Signs
- 43. Signs • Male • Complaint painless inguinoscrotal swelling on and off. • Skin over swelling – normal. • Visible peristalsis. • O/E local temperature normal • Non tender • Testis palpable separately • Getting above swelling not possible • Reducible. • Impulse on coughing present • Resonant on percussion • Opaque • Three finger test • Invagination test • Ring Occlussion test.
- 44. Prognosis
- 45. Prognosis • Morbidity • Mortality rate • 5 year survival in Malignancy
- 46. • Congenital and indirect hernias have high risk of strangulation .
- 47. Complications
- 48. • Irreducible / Incarcerated • Obstruction • Strangulation • Inflammed hernia.
- 49. Investigations • Laboratory Studies – Routine – Special • Imaging Studies • Tissue diagnosis – Cytology • FNAC – Histology – Germ line Testing and Molecular Analysis • Diagnostic Laparotomy.
- 50. Diagnostic Studies Imaging Studies • X-Ray • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
- 51. Diagnostic Studies Imaging Studies • X-Ray • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
- 53. Differential Diagnosis • Hydrocele • Encysted hydrocele of the cord • Varicocele • Ectopic testis • Epididymitis • Testicular torsion • Lipoma • Hematoma • Sebaceous cyst • Hidradenitis • Inguinal lymphadenop athy • Lymphoma • Metastatic neoplasm • Femoral hernia • Femoral lymphadenopathy • Femoral artery aneurysm or pseudoaneurysm
- 54. Management
- 56. Non Operative Therapy • Elderly with direct hernia .
- 58. Operative Therapy • Herniotomy • Herniorrhaphy. • Hernioplasty using mesh.
- 60. Minimally invasive Therapy • TAPP • TEP
- 61. Controversies
- 62. Controversies
- 63. Futuristic
- 64. Futuristic
- 65. Guidelines
- 66. MCQ Hernia with highest rate of strangulation is? • (A) Direct inguinal hernia • (B) Indirect inguinal hernia • (C) Femoral hernia • (D) Incisional hernia
- 67. MCQ Hernia with highest rate of strangulation is? • (A) Direct inguinal hernia • (B) Indirect inguinal hernia • (C) Femoral hernia • (D) Incisional hernia
- 68. MCQ The following are the risk factors for inguinal hernia except: a) Family history of inguinal hernia b) Weight lifter c) COPD d) Female e) Obesity
- 69. MCQ The following are the risk factors for inguinal hernia except: a) Family history of inguinal hernia b) Weight lifter c) COPD d) Female e) Obesity
- 70. MCQ Hernia that is least likely to strangulate is a) Femoral hernia b) Direct inguinal hernia c) Indirect inguinal hernia d) Umbilical hernia
- 71. MCQ Hernia that is least likely to strangulate is a) Femoral hernia b) Direct inguinal hernia c) Indirect inguinal hernia d) Umbilical hernia
- 72. MCQ Which of these would you like to do for a case of strangulated hernia - a) X-ray abdomen b) USG abdomen c) Aspiration of contents of sac d) Correction of hypovolemia e) Prepare OT for urgent surgery
- 73. MCQ Which of these would you like to do for a case of strangulated hernia - a) X-ray abdomen b) USG abdomen c) Aspiration of contents of sac d) Correction of hypovolemia e) Prepare OT for urgent surgery
- 74. MCQ • Viscera forms wall of which hernia- A. Lumbar hernia B. Sliding hernia C. Epigastric hernia D. Femoral hernia
- 75. MCQ • Viscera forms wall of which hernia- A. Lumbar hernia B. Sliding hernia C. Epigastric hernia D. Femoral hernia
- 76. MCQ • All of the following statements are true about repair of groin hernias except - A. Lichtenstein tension free repair has a low recurrence rate B. TEP repair is an extraperitoneal approach to laparoscopic repair of groin hernia C. In Shouldice repair, non-abosorbable mesh is used D. The surgery can be done under local
- 77. MCQ • All of the following statements are true about repair of groin hernias except - A. Lichtenstein tension free repair has a low recurrence rate B. TEP repair is an extraperitoneal approach to laparoscopic repair of groin hernia C. In Shouldice repair, non-abosorbable mesh is used D. The surgery can be done under local
- 78. MCQ • Sliding constituent of a large direct hernia is - • Bladder • Sigmoid colon • Caecum • Appendix
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- surgical anatomy Inguinal canal anatomy dr.vishnu 1. Dr Vishnu Mohan 29/11/2014 2. Inguinal Canal This is an oblique intermuscular passage in the lower part of the anterior abdominal wall , Situated just above the medial half of the inguinal ligament 3. Inguinal Canal Location Inferior part of the anterolateral abdominal wall 4. Length & direction It is about 4cm(1.5 inches) long, and is directed downwards, forwards and medially 5. The inguinal canal extends from the deep inguinal ring to the superficial inguinal ring 6. A Box? Floor Lateral Medial Imagine the right side inguinal canal viewed from the front as a box with anterior & posterior walls, a roof & floor. The arrow indicates that structures can run through it from lateral to medial – e.g. in males it transmits the spermatic cord, and in females, the round ligament of the uterus. 7. Deep inguinal ring An oval opening in the fascia transversalis situated 1.2 cm above the midinguinal point, and immediately lateral to the stem of the inferior epigastric artery 8. Inguinal canal Deep inguinal ring Floor Lateral Medial Here are the posterior wall, which has the DEEP inguinal ring situated laterally, and the floor. (Roof and anterior wall removed). 9. Superficial inguinal ring Is a triangular gap in the external oblique aponeurosis . It is shaped like an obtuse angled triangle . The base of the triangle is formed by the pubic crest, the two sides of the triangle from the lateral or lower and the medial or upper margins of the opening. It is 2.5 cm long and 1.2 cm broad at the base these margins are referred as crura. At and beyond the apex of the triangle 2 crura are united by intercrural fibers 10. Inguinal canal Superficial inguinal ring Floor Lateral Medial Here are the anterior wall (which has the SUPERFICIAL inguinal ring situated medially), and the roof. 11. BOUNDARIES OF INGUINAL CANAL THE ANTERIOR WALL 1.In its whole extent a. Skin b. Superficial fascia c. External oblique aponeurosis 2.In its lateral one-third The fleshy fibres of the internal oblique muscle. 12. Inguinal canal 13 Medial Superficial inguinal ring The anterior wall is made up of the external oblique muscle throughout, and is reinforced by the internal oblique m. laterally. The transversus abdominus m. lies even more laterally as part of the anterior abdominal wall. Lateral 13. 1.In its whole extent a. The fascia transversalis b. The extra peritoneal tissue c. The parietal peritoneum. 2.In its medial two-thirds a. The conjoint tendon b. At its medial end by the reflected part of the inguinal ligament. THE POSTERIOR WALL 14. Posterior wall of the inguinal canal 15 Deep inguinal ring Medial The posterior wall is formed by transversalis fascia (orange) throughout and the conjoint tendon (red) medially. The wall is particularly weak over the deep inguinal ring Lateral Conjoint tendon medially Posterior wall 15. Inguinal canal 16 Floor Spermatic cord Medial Lateral The transversus abdominis and internal oblique mm. combine to form the CONJOINT tendon that arches over the contents of the inguinal canal The conjoint tendon attaches to the pubic crest, reinforces the posterior canal wall medially and also forms the ROOF of the canal Conjoint tendon 16. ROOF OF THE INGUINAL CANAL It is formed by the arched fibres of the internal oblique and transverse abdominis muscles. 17. Roof and anterior wall of the inguinal canal 18 Medial The anterior wall of the canal is formed by external oblique muscle (orange) throughout and by internal oblique muscles (red/black/white) laterally. This wall is weak medially because of the “hole” in the external oblique muscle (= superficial inguinal ring). Lateral Superficial inguinal ring 18. FLOOR It is formed by the grooved upper surface of the inguinal ligament; and at the medial end by the lacunae ligament 19. Floor of the inguinal canal 20 Floor Medial The floor is formed by an incurving of the inguinal ligament, which is part of the external oblique muscle, forming a gutter. (Medially it forms the lacunar ligament which is not illustrated). Lateral 20. SEX DIFFERENCE The inguinal canal is larger in males than in females. 21. STRUCTURES PASSING THROUGH THE CANAL 1.The spermatic cord in males, or the round ligament of the uterus in females, enters the inguinal canal through the deep inguinal ring and passes out through the superficial inguinal ring. 2.The ilioinguinal nerve enters the canal through the interval between the external and internal oblique muscles and passes out through the superficial inguinal ring. 22. Inguinal canal Spermatic cord enters the inguinal canal through the deep inguinal ring FloorSpermatic cord exits through the superficial inguinal ring Deep inguinal ring Superficial inguinal ring Lateral Medial 23. Inguinal canals – why have them? Allow contents of the scrotum to communicate with intra-abdominal contents Prevent mobile intra-abdominal contents (e.g. intestine) from entering the scrotum and possibly becoming damaged, while at the same time permitting blood vessels, nerves, lymphatics, vas deferens etc. to supply the scrotal contents 24. MECHANISM OF INGUINAL CANAL The presence of the inguinal canal is the cause of weakness in the lower part of the anterior abdominal wall. This weakness is compensated by the following factors 25. Obliquity of the inguinal canal The two inguinal rings do not lie opposite to each other. Therefore, when the intra- abdominal pressure rises the anterior and posterior walls of the canal are approximated, thus obliterating the passage. This is known as the flap valve mechanism. 26. The superficial inguinal ring is guarded from behind by the conjoint tendon and by the reflected part of the inguinal canal. 27. The deep inguinal ring is guarded from the front by the fleshy fibres of the internal oblique. 28. Shutter mechanism of the internal oblique This muscle has a triple relation to the inguinal canal. It forms the anterior wall, the roof, and the posterior wall of the canal. When it contracts the roof is approximated to the floor, like a shutter. 29. Ball valve mechanism Contraction of the cremaster helps the spermatic cord to plug the superficial inguinal ring 30. Slit valve mechanism Contraction of the external oblique results in approximation of the two crura of the superficial inguinal ring . The integrity of the superficial inguinal ring is greatly increased by the intercrural fibres. 31. Hormones may play a role in maintaining the tone of the inguinal musculature 32. Whenever, there is a rise in intra abdominal pressure as in coughing , sneezing, lifting heavy weights all these mechanisms come to play, so that the inguinal canal is obliterated, its openings are closed, and herniation of abdominal viscera is prevented. 33. From within outwards, these are as follows: 1.The internal spermatic fascia , derived from the fascia transversalis; it covers the cord in its whole extent . 2.The cremasteric fascia is made up of the muscle loops costituting the cremaster muscle, and the intervening areolar tissue. It is derived from the internal oblique and transversus abdominis muscles. 34. Round ligament of uterus The round ligaments are two fibro muscular flat bands ,10 to 12 cm long, which lie between the two layers of broad ligament , begins at the lateral angle of the uterus, passes through the deep inguinal ring ,traverses the inguinal canal and merges with the areolar tissue of the labium majus 35. Hesselbach’s (Inguinal) Triangle is an important structure as it is the site for direct hernias. The triangle has the following borders: 1) Medial border of rectus abdominus(medially) 2) Inguinal ligament (inferiorly) 3) Inferior epigastric vessels(laterally) HESSELBACH’S TRIANGLE 36. A Brief Mention of Hernias Hernias are abnormal outpouchings of the abdominal contents (such as the small intestine) from the cavity in which they belong. There are two main types of hernias that occur at the inguinal region. Direct hernia and indirect hernia. . 37. The posterior wall of the canal is particularly weak laterally because of the deep inguinal ring The anterior wall opposite the deep ring is reinforced laterally by the internal oblique muscles. A hernia (e.g. of small bowel) that comes through the deep inguinal ring will have to travel along the inguinal canal as it cannot push into the reinforced layers of muscle in the anterior wall of the canal directly opposite the deep inguinal ring 38. The anterior wall of the canal is weak medially where the superficial inguinal ring is situated The posterior wall, opposite the superficial ring, is reinforced medially by the conjoint tendon that is formed by fibres of the internal oblique and transversus abdominis muscles Abdominal contents cannot normally force themselves through the superficial ring directly because of the reinforced posterior wall medially 39. Indirect or oblique hernia These are the most common inguinal hernias, in this the contents of the abdomen enter the deep inguinal ring and traverse the whole length of the inguinal canal to come out through the superficial inguinal ring 40. Coverings of indirect hernias Peritoneum Internal spermatic fascia (from transversalis fascia) Cremaster muscle & fascia (from transversus abdominis and internal oblique mm.) External spermatic fascia (from external oblique m.) Superficial fascia Skin 44 41. Direct Hernias Direct hernias occurs lateral to the epigastric vessels. They do not protrude through any ring, but through an area of weakness in the posterior wall of the inguinal canal; this area is likely to be Hesselbach’s Triangle. The hernia is often parallel to the spermatic cord, but almost never enters the scrotum 42. Coverings of direct hernias Peritoneum Transversalis fascia Conjoint tendon External oblique aponeurosis Superficial fascia Skin 46 43. Inguinal hernia results because pressure finds weak spot at inguinal canal About Support Dev & API Terms Privacy Copyright English © 2021 SlideShare from Scribd canal anatomy dr.vishnu31,107 views vishnu mohan 3 uploads Published on Jan 4, 2017 This is an oblique intermuscular passage in the lower part of the anterior abdominal ... Published in: Health & Medicine Recommended Surgical anatomy of the inguinal canal 6 years ago 73,749 views Surgical anatomy of inguinal hernia 6 years ago 20,861 views Inguinal cannal 6 years ago 14,227 views Case study on inguinal hernia 7 years ago 95,270 views Inguinal Hernia 9 years ago 52,813 views Inguinal Hernia- Groin Swellings 5 years ago 43,140 views Inguinal hernia 7 years ago 66,483 views surgical anatomy Inguinal canal anatomy dr.vishnu 1. Dr Vishnu Mohan 29/11/2014 2. Inguinal Canal This is an oblique intermuscular passage in the lower part of the anterior abdominal wall , Situated just above the medial half of the inguinal ligament 3. Inguinal Canal Location Inferior part of the anterolateral abdominal wall 4. Length & direction It is about 4cm(1.5 inches) long, and is directed downwards, forwards and medially 5. The inguinal canal extends from the deep inguinal ring to the superficial inguinal ring 6. A Box? Floor Lateral Medial Imagine the right side inguinal canal viewed from the front as a box with anterior & posterior walls, a roof & floor. The arrow indicates that structures can run through it from lateral to medial – e.g. in males it transmits the spermatic cord, and in females, the round ligament of the uterus. 7. Deep inguinal ring An oval opening in the fascia transversalis situated 1.2 cm above the midinguinal point, and immediately lateral to the stem of the inferior epigastric artery 8. Inguinal canal Deep inguinal ring Floor Lateral Medial Here are the posterior wall, which has the DEEP inguinal ring situated laterally, and the floor. (Roof and anterior wall removed). 9. Superficial inguinal ring Is a triangular gap in the external oblique aponeurosis . It is shaped like an obtuse angled triangle . The base of the triangle is formed by the pubic crest, the two sides of the triangle from the lateral or lower and the medial or upper margins of the opening. It is 2.5 cm long and 1.2 cm broad at the base these margins are referred as crura. At and beyond the apex of the triangle 2 crura are united by intercrural fibers 10. Inguinal canal Superficial inguinal ring Floor Lateral Medial Here are the anterior wall (which has the SUPERFICIAL inguinal ring situated medially), and the roof. 11. BOUNDARIES OF INGUINAL CANAL THE ANTERIOR WALL 1.In its whole extent a. Skin b. Superficial fascia c. External oblique aponeurosis 2.In its lateral one-third The fleshy fibres of the internal oblique muscle. 12. Inguinal canal 13 Medial Superficial inguinal ring The anterior wall is made up of the external oblique muscle throughout, and is reinforced by the internal oblique m. laterally. The transversus abdominus m. lies even more laterally as part of the anterior abdominal wall. Lateral 13. 1.In its whole extent a. The fascia transversalis b. The extra peritoneal tissue c. The parietal peritoneum. 2.In its medial two-thirds a. The conjoint tendon b. At its medial end by the reflected part of the inguinal ligament. THE POSTERIOR WALL 14. Posterior wall of the inguinal canal 15 Deep inguinal ring Medial The posterior wall is formed by transversalis fascia (orange) throughout and the conjoint tendon (red) medially. The wall is particularly weak over the deep inguinal ring Lateral Conjoint tendon medially Posterior wall 15. Inguinal canal 16 Floor Spermatic cord Medial Lateral The transversus abdominis and internal oblique mm. combine to form the CONJOINT tendon that arches over the contents of the inguinal canal The conjoint tendon attaches to the pubic crest, reinforces the posterior canal wall medially and also forms the ROOF of the canal Conjoint tendon 16. ROOF OF THE INGUINAL CANAL It is formed by the arched fibres of the internal oblique and transverse abdominis muscles. 17. Roof and anterior wall of the inguinal canal 18 Medial The anterior wall of the canal is formed by external oblique muscle (orange) throughout and by internal oblique muscles (red/black/white) laterally. This wall is weak medially because of the “hole” in the external oblique muscle (= superficial inguinal ring). Lateral Superficial inguinal ring 18. FLOOR It is formed by the grooved upper surface of the inguinal ligament; and at the medial end by the lacunae ligament 19. Floor of the inguinal canal 20 Floor Medial The floor is formed by an incurving of the inguinal ligament, which is part of the external oblique muscle, forming a gutter. (Medially it forms the lacunar ligament which is not illustrated). Lateral 20. SEX DIFFERENCE The inguinal canal is larger in males than in females. 21. STRUCTURES PASSING THROUGH THE CANAL 1.The spermatic cord in males, or the round ligament of the uterus in females, enters the inguinal canal through the deep inguinal ring and passes out through the superficial inguinal ring. 2.The ilioinguinal nerve enters the canal through the interval between the external and internal oblique muscles and passes out through the superficial inguinal ring. 22. Inguinal canal Spermatic cord enters the inguinal canal through the deep inguinal ring FloorSpermatic cord exits through the superficial inguinal ring Deep inguinal ring Superficial inguinal ring Lateral Medial 23. Inguinal canals – why have them? Allow contents of the scrotum to communicate with intra-abdominal contents Prevent mobile intra-abdominal contents (e.g. intestine) from entering the scrotum and possibly becoming damaged, while at the same time permitting blood vessels, nerves, lymphatics, vas deferens etc. to supply the scrotal contents 24. MECHANISM OF INGUINAL CANAL The presence of the inguinal canal is the cause of weakness in the lower part of the anterior abdominal wall. This weakness is compensated by the following factors 25. Obliquity of the inguinal canal The two inguinal rings do not lie opposite to each other. Therefore, when the intra- abdominal pressure rises the anterior and posterior walls of the canal are approximated, thus obliterating the passage. This is known as the flap valve mechanism. 26. The superficial inguinal ring is guarded from behind by the conjoint tendon and by the reflected part of the inguinal canal. 27. The deep inguinal ring is guarded from the front by the fleshy fibres of the internal oblique. 28. Shutter mechanism of the internal oblique This muscle has a triple relation to the inguinal canal. It forms the anterior wall, the roof, and the posterior wall of the canal. When it contracts the roof is approximated to the floor, like a shutter. 29. Ball valve mechanism Contraction of the cremaster helps the spermatic cord to plug the superficial inguinal ring 30. Slit valve mechanism Contraction of the external oblique results in approximation of the two crura of the superficial inguinal ring . The integrity of the superficial inguinal ring is greatly increased by the intercrural fibres. 31. Hormones may play a role in maintaining the tone of the inguinal musculature 32. Whenever, there is a rise in intra abdominal pressure as in coughing , sneezing, lifting heavy weights all these mechanisms come to play, so that the inguinal canal is obliterated, its openings are closed, and herniation of abdominal viscera is prevented. 33. From within outwards, these are as follows: 1.The internal spermatic fascia , derived from the fascia transversalis; it covers the cord in its whole extent . 2.The cremasteric fascia is made up of the muscle loops costituting the cremaster muscle, and the intervening areolar tissue. It is derived from the internal oblique and transversus abdominis muscles. 34. Round ligament of uterus The round ligaments are two fibro muscular flat bands ,10 to 12 cm long, which lie between the two layers of broad ligament , begins at the lateral angle of the uterus, passes through the deep inguinal ring ,traverses the inguinal canal and merges with the areolar tissue of the labium majus 35. Hesselbach’s (Inguinal) Triangle is an important structure as it is the site for direct hernias. The triangle has the following borders: 1) Medial border of rectus abdominus(medially) 2) Inguinal ligament (inferiorly) 3) Inferior epigastric vessels(laterally) HESSELBACH’S TRIANGLE 36. A Brief Mention of Hernias Hernias are abnormal outpouchings of the abdominal contents (such as the small intestine) from the cavity in which they belong. There are two main types of hernias that occur at the inguinal region. Direct hernia and indirect hernia. . 37. The posterior wall of the canal is particularly weak laterally because of the deep inguinal ring The anterior wall opposite the deep ring is reinforced laterally by the internal oblique muscles. A hernia (e.g. of small bowel) that comes through the deep inguinal ring will have to travel along the inguinal canal as it cannot push into the reinforced layers of muscle in the anterior wall of the canal directly opposite the deep inguinal ring 38. The anterior wall of the canal is weak medially where the superficial inguinal ring is situated The posterior wall, opposite the superficial ring, is reinforced medially by the conjoint tendon that is formed by fibres of the internal oblique and transversus abdominis muscles Abdominal contents cannot normally force themselves through the superficial ring directly because of the reinforced posterior wall medially 39. Indirect or oblique hernia These are the most common inguinal hernias, in this the contents of the abdomen enter the deep inguinal ring and traverse the whole length of the inguinal canal to come out through the superficial inguinal ring 40. Coverings of indirect hernias Peritoneum Internal spermatic fascia (from transversalis fascia) Cremaster muscle & fascia (from transversus abdominis and internal oblique mm.) External spermatic fascia (from external oblique m.) Superficial fascia Skin 44 41. Direct Hernias Direct hernias occurs lateral to the epigastric vessels. They do not protrude through any ring, but through an area of weakness in the posterior wall of the inguinal canal; this area is likely to be Hesselbach’s Triangle. The hernia is often parallel to the spermatic cord, but almost never enters the scrotum 42. Coverings of direct hernias Peritoneum Transversalis fascia Conjoint tendon External oblique aponeurosis Superficial fascia Skin 46 43. Inguinal hernia results because pressure finds weak spot at inguinal canal