Download - Anatomy of Lower Limb and Abdomen

INGUINAL REGION/GRINGUINAL REGION/GROINOIN

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 structurepassing through

✓ briefly describe femoral sheath, femoral canal, andfemoral ring

✓ discuss the mechanism of occurrence of femoral hernia

✓ describe inguinal canal in detail and discuss its affectedanatomy

✓ elucidate the constituents and coverings of the spermaticcord

✓ discuss the location and boundaries of inguinal triangle(Hesselbach’s triangle)

✓ compare and contrast the indirect and direct inguinalhernias

✓ understand the given clinical case and answer the relatedquestions

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

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Abdomen and Lower Limb50

INTRODUCTION

The inguinal region is the junction between the anteriorabdominal wall and the anterior aspect of the thigh. Itextends between the anterior superior iliac spine and thepubic tubercle. This region is important both anatomicallyand clinically, anatomically because it is the region wherestructures exit and enter the abdominal cavity and clinicallybecause pathways of exit and entry are potential sites of her-niation. Majority of abdominal hernias occur in this region,e.g., inguinal and femoral hernias; only inguinal herniasaccount for 75% of all hernias of the body. The key structurein this region is the inguinal ligament. Hence, surgically it isthe most important region.

INGUINAL LIGAMENT

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-rior iliac spine to the pubic tubercle and its edge is curvedback on itself to form a groove on its abdominal aspect (Fig. 4.1).

The strong deep fascia of the thigh, the fascia lata is attachedto the rounded lower aspect of the entire length of the ligament,which makes it convex inferiorly by its pull due to tension.

EXTENSIONS/EXPANSIONS

The extensions/expansions of the inguinal ligament are asfollows:

LACUNAR LIGAMENT (OR GIMBERNAT’S LIGAMENT)From the medial end the deep fibers of the inguinal ligamentcurve horizontally backward to the medial part of the pectenpubis forming lacunar ligament. This ligament is triangularin shape with apex attached to the pubic tubercle. Its sharplateral edge forms the medial boundary of the femoral canal,which is the site of production of a femoral hernia.

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. Someauthorities regard it as a thickening in the upper part of thepectineal fascia.

REFLECTED PART OF INGUINAL LIGAMENT

The superficial fibers from the medial end of the inguinalligament expand upward and medially to form this ligament.It lies behind the superficial inguinal ring and in front of theconjoint tendon. Its fibers interlace with those of its counter-part of the opposite side at the linea alba.

ILIOINGUINAL LIGAMENT

It is a fibrous band extending from the inferior aspect of theinguinal ligament to the iliopectineal eminence.

SUBINGUINAL SPACE (PELVIFEMORALSPACE)

The space between the inguinal ligament and the hip bone iscalled pelvifemoral/subinguinal space (Fig. 4.2). The muscles(psoas major and iliacus) and neurovascular structures ofposterior abdominal wall/pelvis pass into the femoral regionof the thigh through this space. This space is divided by theilioinguinal ligament/arch into two parts:

(a) Large lateral part called lacuna musculorum.(b) Small medial part called lacuna vasculorum.

The iliacus and psoas muscles, and femoral and lateralcutaneous nerves of thigh pass through the lacuna musculo-rum behind the fascia iliaca.

The external iliac vessels in abdomen become femoral ves-sels as they pass through the medial part of the subinguinalspace—the lacuna vasculorum.

The fascial lining of the abdomen is prolonged into thethigh to enclose the upper 3.75 cm of the femoral vesselsforming the femoral sheath.

N.B.On the surface, inguinal ligament is marked by the inguinal foldwhich demarcates the abdomen from the lower limb.

Reflected partof inguinalligament

Inguinalligament

Rectusabdominis

Ilioinguinalligament

Pectinealligament

Lacunarligament

AEO

IL

FL

Linea alba

Fig. 4.1 Inguinal ligament and its extensions. Figure in theinset shows formation of inguinal ligament and itsattachment to the fascia lata (AEO = aponeurosis of externaloblique, IL = inguinal ligament, FL = fascia lata).


Inguinal Region/Groin 51

FEMORAL SHEATH

It is a funnel-shaped fascial sheath enclosing upper 3.75 cmof femoral vessels. The base of the sheath is directed upwardtoward the abdominal cavity and apex merges with thetunica adventitia of the femoral vessels (Fig. 4.3).

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 fasciailiaca (Fig. 4.3).

The femoral sheath is not symmetrical. Its lateral wall isvertical whereas its medial wall is oblique being directeddownward and laterally (Fig. 4.4).

COMPARTMENTS (FIG. 4.5)The interior of the femoral sheath is divided into three compartments by two anteroposterior fibrous septa.

1. Lateral compartment lodges the femoral artery and genitalbranch of the genitofemoral nerve.

Fig. 4.2 Subinguinal space and structures passing through it.

Inguinal ligament

Lateral cutaneous nerve of thigh

Iliopectineal arch

Femoral arteryFemoral vein

Inguinal canal

Lacunar ligament

Pectineus

Psoas major

Iliacus

Femoral nerve

Fig. 4.3 Formation of the femoral sheath.

Fig. 4.4 Walls and contents of the femoral sheath.

Iliacus

Ilium

External obliqueInternal oblique

Transversus abdominis

Fascia transversalis

Femoral artery

Fascia iliaca

Inguinalligament

Femoralsheath

Lymph nodeof Cloquet/Rosenmüller

Femoral sheath

Femoral veinFemoral artery

Femoral branch ofgenitofemoral nerve

Lymph node (of Cloquet)

Femoral vein

Lymphatics

Femoral artery

Femoral branch of genitofemoral nerve

Intermediate MedialLateral

Compartments

Fig. 4.5 Compartment of the femoral sheath.



2. Middle compartment contains the femoral vein.3. Medial compartment is empty and called femoral canal.

FEMORAL CANAL

It is a short fascial tube (medial compartment of femoralsheath) 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 tissuecalled femoral septum normally closes it. Cloquet’s node is alymph node situated in the femoral canal. The canal providesa dead space for the expansion of femoral vein duringincreased venous return.

BOUNDARIES

Anterior: Inguinal ligamentMedial: Sharp edge of the lacunar ligamentPosterior: Pecten pubis

Below the inguinal ligament, the canal lies posterior to thesaphenous opening and thin cribriform fascia, and anteriorto the fascia covering the pectineus muscle.

ILIOPUBIC TRACT (FIG. 4.7)

It is the thickened inferior margin of the fascia transversaliswhich appears as a fibrous band running parallel and posterior

to the inguinal ligament. When the inguinal region is viewedfrom its posterior aspect, the iliopubic tract is seen in placeof the inguinal ligament.

INGUINAL CANAL

The inguinal canal is an oblique intermuscular passage about4 cm long lying above the medial half of the inguinal ligament.

EXTENT AND DIRECTION

The inguinal canal extends from deep inguinal ring (an ovalopening in the fascia transversalis) to the superficial inguinalring (a triangular gap in the external oblique aponeurosis).It is directed downward, forward, and medially.

On the surface the canal is marked by two parallel lines(1 cm apart and 4 cm long) just above the medial half of theinguinal ligament. The deep inguinal ring is marked 1.2 cmabove the midinguinal point as an oval opening at the lateralend of two parallel lines (vide supra). The superficialinguinal ring is marked just above the pubic tubercle as a tri-angular opening at the medial end of two parallel lines. Thecenter of superficial inguinal ring lies 1 cm above and lateralto the pubic tubercle (Fig. 4.8).

INGUINAL RINGS

Deep Inguinal Ring1. The deep inguinal ring is an oval opening in the fascia

transversalis and lies about 1.25 cm (1/2 inch) above themidinguinal point.

2. From its margins, the fascia transversalis is prolongedinto the canal like a sleeve, the internal spermatic fascia,around the structures that pass through the ring.

These structures constitute the spermatic cord in male.

Superficial Inguinal Ring1. The superficial inguinal ring is a triangular gap in the

aponeurosis of external oblique and lies above and lateralto the pubic crest.

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.

3. It is 2.5 cm long and 1.2 cm broad (at the base).

Table 4.1 enumerates the structures passing through thedeep and superficial inguinal rings.

N.B.According to Fruchaud, the inguinal ligament and iliopubic tract spanan innate area of weakness in the inguinal region.

Femoral hernia (Fig. 4.6): The protrusion of abdominalcontents (a loop of intestine) through the femoral canal iscalled femoral hernia.

The femoral ring is the site of potential weakness ofthe 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-abdominal pressure, e.g., repeated forceful coughing orstraining forces the loop of intestine into the femoral ring, itcarries with it the peritoneal covering of the abdominalopening of the canal in front of it. This forms the hernial sac, which descends in the femoral canal posterior to the weak cribriform fascia and bulges forward through it into the superficial fascia of the thigh close to the saphenous vein.

If hernial sac continues to enlarge, it expands superolaterallyin the superficial fascia. Consequently, the entire herniabecomes U-shaped. The femoral hernia presents as a globularswelling in groin inferolateral to the pubic tubercle below theinguinal ligament.

The femoral hernia is common in female because thefemoral ring is larger due to greater width of the pelvis.

Clinical correlation


BOUNDARIES

The boundaries of the inguinal canal (Fig. 4.9) are givenbelow.Anterior wall: It is formed from superficial to deep by:

(a) skin(b) superficial fascia } in the whole extent(c) external oblique

aponeurosis(d) internal oblique muscle fibers, in lateral

one-third.

Posterior wall: It is formed from deep to superficial by:(a) fascia transversalis, in the whole extent,(b) conjoint tendon, in medial two-third, and(c) reflected part of the inguinal ligament,

in medial most part.Roof: It is formed by the lower arched fibers of

internal oblique and transversus abdominismuscles.

Floor: It is formed by:(a) grooved upper surface of the inguinal

ligament in the whole extent, and


Fig. 4.6 A, Formation of the hernial sac; B, course of the femoral hernia.

Femoral fossa

Peritoneum

Femoral septum

Femoral sheathLymph node of Cloquet

Pectineal fascia

Pectineus

Fascia lata

Arrow indicatesthe course taken

by femoral hernia

B

Fatty layer of superficial fascia

Skin

Membranous layer of superficialfascia of abdomen (Scarpa’s fascia)

Hernial sac

Extraperitoneal fat

Lymph node of Cloquet

Cribriform fascia

Fascia lata

Pectineus fascia

Pectineus muscle

Superior ramus of pubis

Pectineal ligament

Fascia iliaca


muscles

External obliqueInternal oblique

Transversusabdominis

Peritoneum

A

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(b) abdominal surface of the lacunar ligamentat the medial end.

The arrangement of muscles (external oblique, internaloblique, and transversus abdominis) and fascia transversalisin relation to the inguinal canal is shown in Figure 4.10.

CONTENTS

In male: Spermatic cord and ilioinguinal nerve.In female: Round ligament of the uterus and ilioinguinal

nerve.

SPERMATIC CORD

The spermatic cord is a collection of structures that pass toand fro from testis through the inguinal canal. It extends

from the deep inguinal ring to the posterior border of thetestis and is covered by three fascial layers.

Constituents/Contents (Fig. 4.11)The spermatic cord consists of the following six groups ofstructures:

1. Ductus deferens, in the posterior part.2. Three arteries:

(a) Testicular artery, from abdominal aorta.

N.B.The ilioinguinal nerve, although a content of the inguinal canal,does not enter the canal through the deep inguinal ring. It entersthe 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.

Fig. 4.7 Iliopubic tract.

Iliopubic(Thomson’s) ligament

Inguinal ligament

Cooper’s ligament

Lacunar ligament


Inferior epigastric artery

Interfoveolar (Hesselbach’s)ligament

Deep inguinal ring

Fig. 4.8 Surface marking of the inguinal canal.

Inguinal canal

Superficial inguinal ring

Deep inguinal ring

1.2

cm

Table 4.1 Structures passing through the inguinal rings

Deep inguinal ring

In male In female

• Ductus deferens and • Round ligament of uterusand its artery • Obliterated remains of

• Testicular artery and the processus vaginalisaccompanying veins • Lymphatics from the

• Obliterated remains of uterusprocessus vaginalis

• Genital branch ofgenitofemoral nerve

• Autonomic nerves and lymphatics


In male In female

• Spermatic cord • Round ligament of uterus• Ilioinguinal nerve* • Ilioinguinal nerve*

*Ilioinguinal nerve enters the inguinal canal by piercing the wall and

not through the deep inguinal ring.



(b) Cremasteric artery, from inferior epigastric artery.(c) Artery to ductus deferens, from inferior vesical artery.

3. Veins, the pampiniform venous plexus.4. Lymphatics, especially from testis draining into pre- and

para-aortic nodes, and some from the coverings drain-ing into external iliac nodes.

5. Nerves, genital branch of genitofemoral nerve and sym-pathetic fibers which accompany the arteries.

6. Remains of processus vaginalis.

Coverings (Fig. 4.11)The spermatic cord is covered by three fascial layers fromwithin outward, these are:

1. Internal spermatic fascia, derived from fascia transversalis.2. Cremasteric fascia consisting of loops of skeletal muscle

fibers united by areolar tissue. The muscle fibers arederived from internal oblique muscle.

3. External spermatic fascia, derived from aponeurosis ofexternal oblique muscle.

MECHANISMS TO MAINTAIN THEINTEGRITY OF THE INGUINAL CANAL

The inguinal canal is a site of potential weakness in the lowerpart of the anterior abdominal wall, and may provide herni-ation of abdominal viscera. But, normally it is prevented bystrength and good tone of the muscles of the anterior abdom-inal wall by the following mechanisms:

FLAP-VALVE MECHANISM

The canal is oblique hence its deep and superficial inguinalrings do not lie opposite to each other. As a result whenintra-abdominal pressure is raised the anterior and posteriorwalls of the canal are approximated like a flap.

GUARDING OF THE INGUINAL RINGS

The deep inguinal ring is guarded anteriorly by the internaloblique muscle, and superficial inguinal ring is guarded pos-teriorly by the conjoint tendon and reflected part of theinguinal ligament (Fig. 4.12).

SHUTTER MECHANISM

The internal oblique surrounds the canal in front, above, andbehind like a flexible mobile arch and thus forming its ante-rior wall, roof, and posterior wall. Consequently, when itcontracts, the roof is pulled and approximated on the floorlike a shutter.

SLIT-VALVE MECHANISM

The contraction of external oblique muscle approximatesthe two crura (crus anterius and crus posterius) of superficialinguinal ring like a slit valve. The intercrural fibers also helpin this act.

BALL-VALVE MECHANISM

Contraction of cremaster muscle pulls the testis up and thesuperficial inguinal ring is plugged by the spermatic cord.

Fig. 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.

Inguinal ligament



Internal oblique

Roof

Floor

Spermatic cord


A

B

Internal oblique

External oblique


Deep inguinal ring

Obliterated umbilical artery


Conjoint tendonExternal obliqueaponeurosis

Skin

Testis DartosExternal spermatic fasciaCremasteric fascia

Internal spermatic fascia




Iliohypogastricnerve

Ilioinguinal nerve

Inferior epigastricartery

Spermatic cord

Deep inguinalring

Genital branch ofgenitofemoral nerve

Femoral sheath

Femoral artery

Femoral vein

Femoral canal

Iliohypogastric nerve

Ilioinguinal nerve

Intercrural fibers

Conjoint tendon

Pectineal line

Ilioinguinalnerve

B

C D

A

Fig. 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.

Fig. 4.11 Transverse section of the spermatic cord showing its covering content.

Testicular artery

Pampiniform plexusaround testicular artery

Sympathetic nerves

Remains of processus vaginalis

Ilioinguinal nerve

Cremasteric nerveand vessels

Pampiniform plexus andlymphatics surrounding

the ductus deferens Ductus deferensArtery to ductus deferens

Genital branch ofgenitofemoral nerve

1. External spermatic fascia

2. Cremasteric fascia

3. Internal spermatic fascia

Coverings of spermatic cord


The features of the inguinal canal are summarized in Table 4.2.

INGUINAL TRIANGLE (HESSELBACH’S TRIANGLE)

The inguinal triangle is situated deep to the posterior wall ofthe inguinal canal, hence it is seen on the inner aspect of thelower part of the anterior abdominal wall.

BOUNDARIES

The boundaries of the inguinal triangle are as follows (Fig. 4.14):Medial: Lower 5 cm of the lateral border of the rectus

abdominis muscle.Lateral: Inferior epigastric artery.Inferior: Medial half of the inguinal ligament.

The floor of the triangle is covered by the peritoneum,extraperitoneal tissue, and fascia transversalis.

N.B.The lateral umbilical ligament (obliterated umbilical artery) crosses thetriangle and divides it into medial and lateral parts. The medial partof the floor of the triangle is strengthened by the conjoint tendon.

The lateral part of the floor of the triangle is weak, hence directinguinal hernia usually occurs through this part.

N.B.In addition to the above mechanisms, the interfoveolar ligament alsohelps to maintain the integrity of the inguinal canal by strengtheningfascia transversalis laterally. The muscle fibers arch down from thelower border of transversus abdominis to the superior ramus of tubisand constitute the interfoveolar ligament—the functional medialedge of the deep inguinal ring (Fig. 4.13).


Fig. 4.12 Structures protecting the anterior and posteriorwalls of the inguinal canal.

Inguinal canal

Conjoint tendon


Reflected partof inguinalligament

Superficial inguinalring

Internal oblique Externaloblique

Deep inguinalring

Fig. 4.13 Interfoveolar ligament.

Rectus abdominis

Conjoint tendon

Linea alba

Reflected part ofinguinal ligament

Interfoveolar ligament



Table 4.2 Features of the inguinal canal

Features Formed by

Boundaries • Anterior wall External 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)• Floor Inguinal ligament (supplemented by lacunar ligament medially)

Openings • Superficial inguinal ring Triangular 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



COVERINGS OF THE INDIRECT AND DIRECT INGUINAL HERNIAS

The coverings of the hernia are the structures separating thehernial sac/peritoneal sac from the surface of the body. Thesecoverings are summarized in Table 4.3.

N.B.The term complete inguinal hernia is used if hernial contentsreach the tunica vaginalis. If the hernial contents remain confinedto inguinal canal and do not pass through superficial inguinal ring itis called incomplete inguinal hernia/bubonocele.

Fig. 4.14 Boundaries of the inguinal (Hesselbach's) triangle.


Rectusabdominis

Obliteratedumbilical artery

Spernatic cord

Inguinal ligament

External iliac artery

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 • Skin

Inguinal hernias: A protrusion of abdominal viscera (e.g.,loops of intestine) into the inguinal canal is termed inguinalhernia. There are two types of inguinal hernias, direct andindirect.1. Direct inguinal hernia. The direct inguinal hernia occurs if

the hernial sac enters the inguinal canal directly by pushingthe posterior wall of the inguinal canal forward, medial toinferior epigastric artery through the Hesselbach’s triangle.The neck of hernial sac is wide. The direct inguinal herniasare common in elderly due to weak abdominal muscles. Thedirect hernia leaves the triangle through its lateral part ormedial part, and therefore it is of two types: (a) lateral directinguinal hernia, and (b) medial direct inguinal hernia.

2. Indirect inguinal hernia: The indirect inguinal hernias occurif 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 completeor partial competency of the processus vaginalis.

The indirect inguinal hernias are more common thanthe direct inguinal hernias and occur more often in malesthan females. The indirect inguinal hernia may becongenital or acquired.

Clinical correlation – Congenital indirect inguinal hernia: It occurs due to patentprocessus vaginalis (an outpouching of the peritoneum),connecting peritoneal cavity with the tunica vaginalis.

– Acquired indirect inguinal hernia: It occurs due to increasedintra-abdominal pressure as during weight lifting. Whenintra-abdominal pressure is increased immensely, theabdominal contents are pushed through the deep inguinalring into the inguinal canal.


Table 4.3 clearly shows that coverings of both indirect anddirect inguinal hernias are more or less same. The only dif-ference is that in direct inguinal hernia (medial direct) inter-nal spermatic fascia is replaced by fascia transversalis, and

cremasteric muscle and fascia is replaced by conjoint tendonhernia.

The differences between the indirect and direct inguinal hernias are given in Table 4.3.


Fig. 4.15 Coverings of the indirect inguinal hernia.

Fig. 4.16 Coverings of the direct inguinal hernia: A, lateral direct inguinal hernia; B, medial direct inguinal hernia.


Deep inguinal ring

Entry of herniated loop ofintestine via deep inguinal ring

Parietal peritoneum

Internal spermatic fascia

Cremasteric fascia

External spermatic fascia

Internal oblique

L M

I

S

External oblique

Herniated loop of intestine

Parietal peritoneum

Fasciatransversalis

Cremasteric fascia

External spermatic fasciaConjoint tendon

Deep inguinalring

A B

Fasciatransversalis

Inferiorepigastric artery



CLINICAL CASE STUDY

A 70-year-old patient with history of chronic bronchitisand constipation complained that he noticed a graduallyincreasing swelling in his right groin and often feels drag-ging and aching sensation at that site. On physical exami-nation the doctor noticed a globular lump above the rightpubic tubercle which expands on coughing.

After manually reducing the swelling/lump, occludedthe deep inguinal ring with his thumb and asked thepatient to cough. The swelling reappeared medial to thethumb. A diagnosis of direct inguinal hernia was made.

Questions1. What is inguinal hernia?2. What are the types of inguinal hernias and how they

differ from each other?

3. Give the surface marking of deep inguinal canal.

Answers1. Protrusion of abdominal viscus into the inguinal

canal.2. (a) Indirect inguinal hernia

(b) Direct inguinal herniaIn indirect inguinal hernia abdominal viscus (e.g.,

loop of intestine) protrudes into inguinal canalthrough deep inguinal ring, whereas in direct inguinalhernia abdominal viscus protrudes into inguinalcanal by pushing its posterior wall (also see p. 58).

3. It is marked 1.25 cm above the midinguinal point ason oval opening.

■ Groin Curved linear groove forming the junction between the anterior abdominal wall and front of thigh lateral to the perineum

■ Most common hernia in the inguinal region Indirect inguinal hernia

■ All the contents of inguinal canal lie within Ilioinguinal nervethe spermatic cord except

■ Commonest symptoms of an inguinal hernia Presence of lump, and dragging and aching sensation in the groin

■ Inguinal hernia Protrusion 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 Nuck Peritoneal pouch in the female inguinal canal is due to persistence of processus vaginalis. It may extend into labium majus

■ Groin hernias Direct and indirect inguinal and femoral hernias
