Anatomy of Lower Limb and Abdomen

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INGUINAL REGION/GR INGUINAL REGION/GR OIN OIN LEARNING OBJECTIVES After studying this chapter, the student should be able to: describe inguinal ligament and discuss its expansions define pelvifemoral space and enumerate the structure passing through briefly describe femoral sheath, femoral canal, and femoral ring discuss the mechanism of occurrence of femoral hernia describe inguinal canal in detail and discuss its affected anatomy elucidate the constituents and coverings of the spermatic cord discuss the location and boundaries of inguinal triangle (Hesselbach’s triangle) compare and contrast the indirect and direct inguinal hernias understand the given clinical case and answer the related questions CHAPTER OUTLINE Introduction Inguinal ligament Extensions/Expansions Subinguinal space (pelvifemoral space) Femoral sheath Femoral canal Iliopubic tract Inguinal canal Extent and direction Boundaries Contents Mechanisms to maintain the integrity of the inguinal canal Inguinal triangle (Hesselbach’s triangle) Boundaries Coverings of the indirect and direct inguinal hernias Golden facts to remember Clinical case study Chapter-04.qxd 3/22/2011 11:44 AM Page 49

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Following recent trends of anatomy education, the book in addition to basic information, provides knowledge on anatomical/embryological basis of clinical conditions through its features of Clinical Correlation and Clinical Case Study. Written in simple and easy-to-understand language, this profusely.

Transcript of Anatomy of Lower Limb and Abdomen

  • 1.Chapter-04.qxd 3/22/201111:44 AMPage 49INGUINAL REGION/GROINCHAPTER OUTLINELEARNING OBJECTIVES After studying this chapter, the student should be able to: Introduction describe inguinal ligament and discuss its expansions Inguinal ligament define pelvifemoral space and enumerate the structure Extensions/Expansions passing through Subinguinal space (pelvifemoral space) Femoral sheath briefly describe femoral sheath, femoral canal, and Femoral canalfemoral ring discuss the mechanism of occurrence of femoral hernia Iliopubic tract describe inguinal canal in detail and discuss its affected Inguinal canal anatomy Extent and direction elucidate the constituents and coverings of the spermatic Boundaries cord Contents Mechanisms to maintain the integrity of the inguinal discuss the location and boundaries of inguinal trianglecanal(Hesselbachs triangle) compare and contrast the indirect and direct inguinal Inguinal triangle (Hesselbachs triangle) hernias Boundaries Coverings of the indirect and direct inguinal hernias understand the given clinical case and answer the related questions Golden facts to remember Clinical case study

2. Chapter-04.qxd3/22/2011 11:44 AMPage 5050 Abdomen and Lower LimbINTRODUCTIONEXTENSIONS/EXPANSIONSThe inguinal region is the junction between the anteriorThe extensions/expansions of the inguinal ligament are asabdominal wall and the anterior aspect of the thigh. It follows:extends between the anterior superior iliac spine and thepubic tubercle. This region is important both anatomicallyLACUNAR LIGAMENT (OR GIMBERNATS LIGAMENT)and clinically, anatomically because it is the region where From the medial end the deep fibers of the inguinal ligamentstructures exit and enter the abdominal cavity and clinically curve horizontally backward to the medial part of the pectenbecause pathways of exit and entry are potential sites of her-pubis forming lacunar ligament. This ligament is triangularniation. Majority of abdominal hernias occur in this region,in shape with apex attached to the pubic tubercle. Its sharpe.g., inguinal and femoral hernias; only inguinal hernias lateral edge forms the medial boundary of the femoral canal,account for 75% of all hernias of the body. The key structure which is the site of production of a femoral hernia.in this region is the inguinal ligament. Hence, surgically it isthe most important region.PECTINEAL LIGAMENT (LIGAMENT OF COOPER)It is the extension of the posterior part of the lacunar ligamentalong the pecten pubis up to the iliopectineal eminence. SomeINGUINAL LIGAMENT authorities regard it as a thickening in the upper part of thepectineal fascia.The inguinal ligament is a thick, fibrous band, formed by thelower free border of the aponeurosis of the external obliquemuscle of the abdominal wall. It extends from the anterior supe-REFLECTED PART OF INGUINAL LIGAMENTThe superficial fibers from the medial end of the inguinalrior iliac spine to the pubic tubercle and its edge is curvedligament expand upward and medially to form this ligament.back on itself to form a groove on its abdominal aspect (Fig. 4.1).It lies behind the superficial inguinal ring and in front of theThe strong deep fascia of the thigh, the fascia lata is attachedconjoint tendon. Its fibers interlace with those of its counter-to the rounded lower aspect of the entire length of the ligament,part of the opposite side at the linea alba.which makes it convex inferiorly by its pull due to tension.ILIOINGUINAL LIGAMENT N.B.It is a fibrous band extending from the inferior aspect of the On the surface, inguinal ligament is marked by the inguinal fold which demarcates the abdomen from the lower limb.inguinal ligament to the iliopectineal eminence.SUBINGUINAL SPACE (PELVIFEMORALSPACE)The space between the inguinal ligament and the hip bone is AEO Rectus called pelvifemoral/subinguinal space (Fig. 4.2). The musclesabdominis (psoas major and iliacus) and neurovascular structures of InguinalIL posterior abdominal wall/pelvis pass into the femoral regionligament FL of the thigh through this space. This space is divided by the Linea alba ilioinguinal ligament/arch into two parts:Ilioinguinal Reflected part (a) Large lateral part called lacuna musculorum.ligament of inguinal(b) Small medial part called lacuna vasculorum. ligamentPectinealligament The iliacus and psoas muscles, and femoral and lateralcutaneous nerves of thigh pass through the lacuna musculo-Lacunarrum behind the fascia iliaca. ligament The external iliac vessels in abdomen become femoral ves-sels as they pass through the medial part of the subinguinalFig. 4.1 Inguinal ligament and its extensions. Figure in thespacethe lacuna vasculorum.inset shows formation of inguinal ligament and its The fascial lining of the abdomen is prolonged into theattachment to the fascia lata (AEO = aponeurosis of externalthigh to enclose the upper 3.75 cm of the femoral vesselsoblique, IL = inguinal ligament, FL = fascia lata). forming the femoral sheath. 3. Chapter-04.qxd 3/22/2011 11:44 AMPage 51 Inguinal Region/Groin51Lateral cutaneous nerve of thighInguinal ligamentIliacusIliopectineal arch Femoral nerveFemoral arteryPsoas majorFemoral vein Inguinal canal PectineusLacunar ligamentFig. 4.2 Subinguinal space and structures passing through it. External oblique Femoral artery Internal obliqueFemoral vein Transversus abdominis Femoral branch of Lymph node Fascia transversalisgenitofemoral nerveof Cloquet/ Femoral arteryRosenmller Fascia iliaca Femoral sheathIlium Inguinalligament IliacusFemoral sheathFig. 4.4 Walls and contents of the femoral sheath. Femoral branch of genitofemoral nerveFig. 4.3 Formation of the femoral sheath. Femoral arteryFemoral veinLymphatics Lymph node (of Cloquet)FEMORAL SHEATHIt is a funnel-shaped fascial sheath enclosing upper 3.75 cmLateralMedial Intermediateof femoral vessels. The base of the sheath is directed upwardtoward the abdominal cavity and apex merges with theCompartmentstunica adventitia of the femoral vessels (Fig. 4.3). Fig. 4.5 Compartment of the femoral sheath.The anterior wall of the femoral sheath is formed by thedownward prolongation of the fascia transversalis and theposterior wall by the downward prolongation of the fasciaCOMPARTMENTS (FIG. 4.5)iliaca (Fig. 4.3). The interior of the femoral sheath is divided into threeThe femoral sheath is not symmetrical. Its lateral wall is compartments by two anteroposterior fibrous septa.vertical whereas its medial wall is oblique being directed 1. Lateral compartment lodges the femoral artery and genitaldownward and laterally (Fig. 4.4).branch of the genitofemoral nerve. 4. Chapter-04.qxd 3/22/201111:44 AMPage 5252Abdomen and Lower Limb2. Middle compartment contains the femoral vein. to the inguinal ligament. When the inguinal region is viewed3. Medial compartment is empty and called femoral canal. from its posterior aspect, the iliopubic tract is seen in place of the inguinal ligament. FEMORAL CANAL N.B. According to Fruchaud, the inguinal ligament and iliopubic tract spanIt is a short fascial tube (medial compartment of femoralan innate area of weakness in the inguinal region.sheath) which diminishes rapidly in width from abovedownward and is closed inferiorly by the fusion of its walls. The upper end of the femoral canal, which opens into theabdominal cavity is called femoral ring. A fatty areolar tissue INGUINAL CANALcalled femoral septum normally closes it. Cloquets node is alymph node situated in the femoral canal. The canal provides The inguinal canal is an oblique intermuscular passage abouta dead space for the expansion of femoral vein during4 cm long lying above the medial half of the inguinal ligament.increased venous return.BOUNDARIES EXTENT AND DIRECTIONAnterior: Inguinal ligament The inguinal canal extends from deep inguinal ring (an ovalMedial:Sharp edge of the lacunar ligament opening in the fascia transversalis) to the superficial inguinalPosterior: Pecten pubis ring (a triangular gap in the external oblique aponeurosis). Below the inguinal ligament, the canal lies posterior to the It is directed downward, forward, and medially.saphenous opening and thin cribriform fascia, and anterior On the surface the canal is marked by two parallel linesto the fascia covering the pectineus muscle. (1 cm apart and 4 cm long) just above the medial half of the inguinal ligament. The deep inguinal ring is marked 1.2 cmClinical correlation above the midinguinal point as an oval opening at the lateral end of two parallel lines (vide supra). The superficialFemoral hernia (Fig. 4.6): The protrusion of abdominal inguinal ring is marked just above the pubic tubercle as a tri-contents (a loop of intestine) through the femoral canal isangular opening at the medial end of two parallel lines. Thecalled femoral hernia. center of superficial inguinal ring lies 1 cm above and lateral The femoral ring is the site of potential weakness of to the pubic tubercle (Fig. 4.8).the groin when the femoral ring is enlarged due to theabdominal distention with weakness of abdominal muscles,e.g., pregnancy. Any condition, which raises the intra-INGUINAL RINGSabdominal pressure, e.g., repeated forceful coughing orDeep Inguinal Ringstraining forces the loop of intestine into the femoral ring, it 1. The deep inguinal ring is an oval opening in the fasciacarries with it the peritoneal covering of the abdominaltransversalis and lies about 1.25 cm (1/2 inch) above theopening of the canal in front of it. This forms the hernial midinguinal point.sac, which descends in the femoral canal posterior to the2. From its margins, the fascia transversalis is prolongedweak cribriform fascia and bulges forward through it into into the canal like a sleeve, the internal spermatic fascia,the superficial fascia of the thigh close to the saphenousaround the structures that pass through the ring.vein. If hernial sac continues to enlarge, it expands superolaterallyThese structures constitute the spermatic cord in male.in the superficial fascia. Consequently, the entire herniabecomes U-shaped. The femoral hernia presents as a globularSuperficial Inguinal Ringswelling in groin inferolateral to the pubic tubercle below the1. The superficial inguinal ring is a triangular gap in theinguinal ligament.aponeurosis of external oblique and lies above and lateral The femoral hernia is common in female because theto the pubic crest.femoral ring is larger due to greater width of the pelvis. 2. The pubic crest forms the base of the triangle. The sides(upper and lower margins) of the triangle are called crura,which meet laterally to form an obtuse apex. Near theapex, the two crura are united by the intercrural fibers.ILIOPUBIC TRACT (FIG. 4.7) 3. It is 2.5 cm long and 1.2 cm broad (at the base).It is the thickened inferior margin of the fascia transversalisTable 4.1 enumerates the structures passing through thewhich appears as a fibrous band running parallel and posterior deep and superficial inguinal rings. 5. Chapter-04.qxd 3/22/2011 11:44 AM Page 53Inguinal Region/Groin 53 External oblique Internal oblique muscles Transversus Fatty layer of superficial fascia abdominis Peritoneum Skin Fascia transversalisMembranous layer of superficialfascia of abdomen (Scarpas fascia) Fascia iliaca Hernial sac Pectineal ligamentSuperior ramus of pubisExtraperitoneal fatLymph node of Cloquet Pectineus muscle Cribriform fascia Pectineus fascia Fascia lataAFemoral fossaPeritoneumFemoral septumArrow indicatesFemoral sheath the course takenLymph node of Cloquetby femoral hernia Pectineal fasciaPectineusFascia lataBFig. 4.6 A, Formation of the hernial sac; B, course of the femoral hernia.BOUNDARIES Posterior wall: It is formed from deep to superficial by: (a) fascia transversalis, in the whole extent,The boundaries of the inguinal canal (Fig. 4.9) are given(b) conjoint tendon, in medial two-third, andbelow. (c) reflected part of the inguinal ligament,Anterior wall: It is formed from superficial to deep by: in medial most part. } (a) skinRoof: It is formed by the lower arched fibers of (b) superficial fasciain the whole extent internal oblique and transversus abdominis (c) external obliquemuscles. aponeurosis Floor:It is formed by: (d) internal oblique muscle fibers, in lateral(a) grooved upper surface of the inguinal one-third.ligament in the whole extent, and 6. Chapter-04.qxd 3/22/2011 11:44 AM Page 5454Abdomen and Lower LimbFascia transversalis Deep inguinal ring Inferior epigastric arteryIliopubic Interfoveolar (Hesselbachs)(Thomsons) ligamentligamentInguinal ligamentCoopers ligament Lacunar ligamentFig. 4.7 Iliopubic tract.Table 4.1 Structures passing through the inguinal ringsDeep inguinal ring Deep inguinal ringIn male In female mc1.2Inguinal canal Ductus deferens and Round ligament of uterus Superficial inguinal ringand its artery Obliterated remains of Testicular artery and the processus vaginalisaccompanying veins Lymphatics from the Obliterated remains ofuterusFig. 4.8 Surface marking of the inguinal canal.processus vaginalis Genital branch ofgenitofemoral nerve (b) abdominal surface of the lacunar ligament Autonomic nerves andat the medial end.lymphatics The arrangement of muscles (external oblique, internaloblique, and transversus abdominis) and fascia transversalis Superficial inguinal ringin relation to the inguinal canal is shown in Figure 4.10.In male In female CONTENTS Spermatic cord Round ligament of uterusIn male: Spermatic cord and ilioinguinal nerve. Ilioinguinal nerve* Ilioinguinal nerve*In female: Round ligament of the uterus and ilioinguinal nerve. *Ilioinguinal nerve enters the inguinal canal by piercing the wall andnot through the deep inguinal ring.N.B.The ilioinguinal nerve, although a content of the inguinal canal, from the deep inguinal ring to the posterior border of thedoes not enter the canal through the deep inguinal ring. It enterstestis and is covered by three fascial layers.the canal from side through a slit between the external and internaloblique muscles. It lies in front of the cord and passes out of canalthrough the superficial inguinal ring to supply the inguinal region.Constituents/Contents (Fig. 4.11)The spermatic cord consists of the following six groups ofstructures:SPERMATIC CORD1. Ductus deferens, in the posterior part.The spermatic cord is a collection of structures that pass to 2. Three arteries:and fro from testis through the inguinal canal. It extends (a) Testicular artery, from abdominal aorta. 7. Chapter-04.qxd 3/22/2011 11:44 AM Page 55Inguinal Region/Groin55Roof Deep inguinal ringInferior epigastric artery Internal oblique Transversus abdominisObliterated umbilical artery Transversus abdominisInternal obliqueExternal oblique Fascia transversalis Fascia transversalis Conjoint tendon External oblique aponeurosis Spermatic cordSuperficial inguinal ringInguinal ligamentB FloorSkin External spermatic fasciaTestisDartos Cremasteric fascia Internal spermatic fascia AFig. 4.9 Boundaries of the inguinal canal: A, anterior and posterior walls as seen in coronal section; B, roof and floor as seenin sagittal section. (b) Cremasteric artery, from inferior epigastric artery.FLAP-VALVE MECHANISM (c) Artery to ductus deferens, from inferior vesical artery.The canal is oblique hence its deep and superficial inguinal3. Veins, the pampiniform venous plexus. rings do not lie opposite to each other. As a result when4. Lymphatics, especially from testis draining into pre- and intra-abdominal pressure is raised the anterior and posterior para-aortic nodes, and some from the coverings drain- walls of the canal are approximated like a flap. ing into external iliac nodes.5. Nerves, genital branch of genitofemoral nerve and sym-GUARDING OF THE INGUINAL RINGS pathetic fibers which accompany the arteries. The deep inguinal ring is guarded anteriorly by the internal6. Remains of processus vaginalis. oblique muscle, and superficial inguinal ring is guarded pos- teriorly by the conjoint tendon and reflected part of theCoverings (Fig. 4.11) inguinal ligament (Fig. 4.12).The spermatic cord is covered by three fascial layers fromwithin outward, these are: SHUTTER MECHANISM1. Internal spermatic fascia, derived from fascia transversalis. The internal oblique surrounds the canal in front, above, and2. Cremasteric fascia consisting of loops of skeletal muscle behind like a flexible mobile arch and thus forming its ante- fibers united by areolar tissue. The muscle fibers arerior wall, roof, and posterior wall. Consequently, when it derived from internal oblique muscle. contracts, the roof is pulled and approximated on the floor3. External spermatic fascia, derived from aponeurosis oflike a shutter. external oblique muscle. SLIT-VALVE MECHANISM MECHANISMS TO MAINTAIN THEThe contraction of external oblique muscle approximates the two crura (crus anterius and crus posterius) of superficial INTEGRITY OF THE INGUINAL CANAL inguinal ring like a slit valve. The intercrural fibers also helpThe inguinal canal is a site of potential weakness in the lowerin this act.part of the anterior abdominal wall, and may provide herni-ation of abdominal viscera. But, normally it is prevented by BALL-VALVE MECHANISMstrength and good tone of the muscles of the anterior abdom- Contraction of cremaster muscle pulls the testis up and theinal wall by the following mechanisms: superficial inguinal ring is plugged by the spermatic cord. 8. Chapter-04.qxd 3/22/201111:44 AMPage 5656 Abdomen and Lower Limb Iliohypogastric nerve Iliohypogastric nerve IlioinguinalnerveIntercrural fibersIlioinguinal nerve Pectineal lineA B Inferior epigastric artery Deep inguinal Ilioinguinal nerveringConjoint tendonFemoral sheathFemoral artery Spermatic cordFemoral veinFemoral canal Genital branch ofC Dgenitofemoral nerveFig. 4.10 Schematic diagrams to show the representation of the walls of inguinal canal from outside inwards: A, externaloblique; B, internal oblique; C, transversus abdominis; D, fascia transversalis. The formation of anterior and posterior wallsand location of inguinal rings can easily be deduced from these figures.Testicular arteryPampiniform plexus around testicular artery Coverings of spermatic cordSympathetic nerves1. External spermatic fascia Remains of processus 2. Cremasteric fascia vaginalis3. Internal spermatic fascia Ilioinguinal nerveGenital branch of Cremasteric nervegenitofemoral nerveand vesselsPampiniform plexus and Artery to ductus deferens lymphatics surroundingthe ductus deferens Ductus deferensFig. 4.11 Transverse section of the spermatic cord showing its covering content. 9. Chapter-04.qxd3/22/2011 11:44 AMPage 57 Inguinal Region/Groin 57N.B. INGUINAL TRIANGLEIn addition to the above mechanisms, the interfoveolar ligament also(HESSELBACHS TRIANGLE)helps to maintain the integrity of the inguinal canal by strengtheningfascia transversalis laterally. The muscle fibers arch down from the The inguinal triangle is situated deep to the posterior wall oflower border of transversus abdominis to the superior ramus of tubis the inguinal canal, hence it is seen on the inner aspect of theand constitute the interfoveolar ligamentthe functional medialedge of the deep inguinal ring (Fig. 4.13). lower part of the anterior abdominal wall.The features of the inguinal canal are summarized in BOUNDARIESTable 4.2. The boundaries of the inguinal triangle are as follows (Fig. 4.14): Deep inguinal Medial: Lower 5 cm of the lateral border of the rectus ringInguinal canalabdominis muscle. Fascia transversalisLateral: Inferior epigastric artery. Inferior: Medial half of the inguinal ligament.Conjoint tendonThe floor of the triangle is covered by the peritoneum,Reflected part extraperitoneal tissue, and fascia transversalis.of inguinalligament N.B. The lateral umbilical ligament (obliterated umbilical artery) crosses theInternal obliqueExternalSuperficial inguinal triangle and divides it into medial and lateral parts. The medial partoblique ring of the floor of the triangle is strengthened by the conjoint tendon. The lateral part of the floor of the triangle is weak, hence directFig. 4.12 Structures protecting the anterior and posterior inguinal hernia usually occurs through this part.walls of the inguinal canal.Rectus abdominis Transversus abdominisLinea albaConjoint tendonInferior epigastric arteryReflected part ofinguinal ligament Interfoveolar ligamentFig. 4.13 Interfoveolar ligament.Table 4.2 Features of the inguinal canalFeaturesFormed byBoundaries Anterior wallExternal oblique aponeurosis (supplemented by internal oblique in the lateral 1/3rd) Posterior wall Fascia transversalis (supplemented by conjoint tendon in the medial 2/3rd) Roof Internal oblique and transversus abdominis muscles (arched fibers) FloorInguinal ligament (supplemented by lacunar ligament medially)Openings Superficial inguinal ringTriangular aperture in external oblique aponeurosis above and lateral to the pubic crest Deep inguinal ring Oval aperture in fascia transversalis 1.25 cm above the midinguinal point 10. Chapter-04.qxd 3/22/201111:44 AMPage 5858 Abdomen and Lower LimbInferior epigastric arteryRectus abdominis Obliteratedumbilical arteryInguinal ligamentSpernatic cordExternal iliac arteryFig. 4.14 Boundaries of the inguinal (Hesselbachs) triangle.Table 4.3 Coverings of the indirect and direct inguinal hernias (Figs 4.15 and 4.16)Indirect inguinal hernia Direct inguinal hernia Extraperitoneal tissue Extraperitoneal tissue Internal spermatic fascia Fascia transversalis Cremasteric muscle and fascia Conjoint tendon (in medial direct hernia) Cremaster muscle and fascia (in lateral direct hernia) External spermatic fascia External spermatic fascia Skin SkinClinical correlation Congenital indirect inguinal hernia: It occurs due to patentprocessus vaginalis (an outpouching of the peritoneum),connecting peritoneal cavity with the tunica vaginalis. Inguinal hernias: A protrusion of abdominal viscera (e.g., Acquired indirect inguinal hernia: It occurs due to increased loops of intestine) into the inguinal canal is termed inguinal intra-abdominal pressure as during weight lifting. When hernia. There are two types of inguinal hernias, direct andintra-abdominal pressure is increased immensely, the indirect.abdominal contents are pushed through the deep inguinal 1. Direct inguinal hernia. The direct inguinal hernia occurs ifring into the inguinal canal.the hernial sac enters the inguinal canal directly by pushingthe posterior wall of the inguinal canal forward, medial toinferior epigastric artery through the Hesselbachs triangle.The neck of hernial sac is wide. The direct inguinal herniasare common in elderly due to weak abdominal muscles. TheN.B.direct hernia leaves the triangle through its lateral part or The term complete inguinal hernia is used if hernial contentsmedial part, and therefore it is of two types: (a) lateral direct reach the tunica vaginalis. If the hernial contents remain confinedinguinal hernia, and (b) medial direct inguinal hernia. to inguinal canal and do not pass through superficial inguinal ring it 2. Indirect inguinal hernia: The indirect inguinal hernias occur is called incomplete inguinal hernia/bubonocele.if the hernial sac enters the inguinal canal through the deepinguinal ring, lateral to the inferior epigastric artery.It is common in children and young adults. Thepredisposing factor for this type of hernia is the complete COVERINGS OF THE INDIRECT ANDor partial competency of the processus vaginalis.The indirect inguinal hernias are more common thanDIRECT INGUINAL HERNIASthe direct inguinal hernias and occur more often in malesthan females. The indirect inguinal hernia may be The coverings of the hernia are the structures separating thecongenital or acquired. hernial sac/peritoneal sac from the surface of the body. Thesecoverings are summarized in Table 4.3. 11. Chapter-04.qxd3/22/201111:45 AM Page 59Inguinal Region/Groin59Entry of herniated loop ofintestine via deep inguinal ring Deep inguinal ring Inferior epigastric artery Internal oblique External oblique Parietal peritoneum Internal spermatic fasciaS Cremasteric fascia LM External spermatic fasciaIFig. 4.15 Coverings of the indirect inguinal hernia. Fascia Herniated loop of intestine transversalis Deep inguinalInferiorring Parietal peritoneumepigastric arteryFasciatransversalisCremasteric fasciaConjoint tendonExternal spermatic fascia A BFig. 4.16 Coverings of the direct inguinal hernia: A, lateral direct inguinal hernia; B, medial direct inguinal hernia. Table 4.3 clearly shows that coverings of both indirect andcremasteric muscle and fascia is replaced by conjoint tendondirect inguinal hernias are more or less same. The only dif-hernia.ference is that in direct inguinal hernia (medial direct) inter- The differences between the indirect and direct inguinalnal spermatic fascia is replaced by fascia transversalis, and hernias are given in Table 4.3. 12. Chapter-04.qxd 3/22/201111:45 AM Page 6060Abdomen and Lower Limb GroinCurved linear groove forming the junction between the anterior abdominal wall and front of thigh lateral to the perineum Most common hernia in the inguinal regionIndirect inguinal hernia All the contents of inguinal canal lie withinIlioinguinal nervethe spermatic cord except Commonest symptoms of an inguinal hernia Presence of lump, and dragging and aching sensation in the groin Inguinal herniaProtrusion of abdominal content into the inguinal canal Femoral hernia Protrusion of abdominal content into femoral canal Most lumps in the groin move with coughing Hernia and vascular tumor, which expand with coughing(a transmitted impulse) except Canal of NuckPeritoneal pouch in the female inguinal canal is due to persistence of processus vaginalis. It may extend into labium majus Groin herniasDirect and indirect inguinal and femoral hernias CLINICAL CASE STUDYA 70-year-old patient with history of chronic bronchitis3. Give the surface marking of deep inguinal canal.and constipation complained that he noticed a graduallyAnswersincreasing swelling in his right groin and often feels drag-1. Protrusion of abdominal viscus into the inguinalging and aching sensation at that site. On physical exami- canal.nation the doctor noticed a globular lump above the right2. (a) Indirect inguinal herniapubic tubercle which expands on coughing. (b) Direct inguinal hernia After manually reducing the swelling/lump, occluded In indirect inguinal hernia abdominal viscus (e.g.,the deep inguinal ring with his thumb and asked the loop of intestine) protrudes into inguinal canalpatient to cough. The swelling reappeared medial to the through deep inguinal ring, whereas in direct inguinalthumb. A diagnosis of direct inguinal hernia was made. hernia abdominal viscus protrudes into inguinalQuestionscanal by pushing its posterior wall (also see p. 58).1. What is inguinal hernia? 3. It is marked 1.25 cm above the midinguinal point as2. What are the types of inguinal hernias and how they on oval opening. differ from each other?