Anatomy of Lower Limb and Abdomen


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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.

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Anatomy of Lower Limb and Abdomen

  1. 1. Chapter-04.qxd 3/22/2011 11:44 AM Page 49 INGUINAL REGION/GROIN CHAPTER OUTLINE LEARNING 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 canal femoral 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 triangle canal (Hesselbach’s triangle) ✓ compare and contrast the indirect and direct inguinal • Inguinal triangle (Hesselbach’s 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. 2. Chapter-04.qxd 3/22/2011 11:44 AM Page 50 50 Abdomen and Lower Limb INTRODUCTION EXTENSIONS/EXPANSIONS The inguinal region is the junction between the anterior The extensions/expansions of the inguinal ligament are as abdominal wall and the anterior aspect of the thigh. It follows: extends between the anterior superior iliac spine and the pubic tubercle. This region is important both anatomically LACUNAR LIGAMENT (OR GIMBERNAT’S LIGAMENT) and clinically, anatomically because it is the region where From the medial end the deep fibers of the inguinal ligament structures exit and enter the abdominal cavity and clinically curve horizontally backward to the medial part of the pecten because pathways of exit and entry are potential sites of her- pubis forming lacunar ligament. This ligament is triangular niation. Majority of abdominal hernias occur in this region, in shape with apex attached to the pubic tubercle. Its sharp e.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 is the most important region. PECTINEAL LIGAMENT (LIGAMENT OF COOPER) It is the extension of the posterior part of the lacunar ligament along the pecten pubis up to the iliopectineal eminence. Some INGUINAL LIGAMENT authorities regard it as a thickening in the upper part of the pectineal fascia. The inguinal ligament is a thick, fibrous band, formed by the lower free border of the aponeurosis of the external oblique muscle of the abdominal wall. It extends from the anterior supe- REFLECTED PART OF INGUINAL LIGAMENT The superficial fibers from the medial end of the inguinal rior iliac spine to the pubic tubercle and its edge is curved ligament 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 the The strong deep fascia of the thigh, the fascia lata is attached conjoint 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 (PELVIFEMORAL SPACE) The space between the inguinal ligament and the hip bone is AEO Rectus called pelvifemoral/subinguinal space (Fig. 4.2). The muscles abdominis (psoas major and iliacus) and neurovascular structures of Inguinal IL posterior abdominal wall/pelvis pass into the femoral region ligament 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. ligament Pectineal ligament The iliacus and psoas muscles, and femoral and lateral cutaneous nerves of thigh pass through the lacuna musculo- Lacunar rum behind the fascia iliaca. ligament The external iliac vessels in abdomen become femoral ves- sels as they pass through the medial part of the subinguinal Fig. 4.1 Inguinal ligament and its extensions. Figure in the space—the lacuna vasculorum. inset shows formation of inguinal ligament and its The fascial lining of the abdomen is prolonged into the attachment to the fascia lata (AEO = aponeurosis of external thigh to enclose the upper 3.75 cm of the femoral vessels oblique, IL = inguinal ligament, FL = fascia lata). forming the femoral sheath.
  3. 3. Chapter-04.qxd 3/22/2011 11:44 AM Page 51 Inguinal Region/Groin 51 Lateral cutaneous nerve of thigh Inguinal ligament Iliacus Iliopectineal arch Femoral nerve Femoral artery Psoas major Femoral vein Inguinal canal Pectineus Lacunar ligament Fig. 4.2 Subinguinal space and structures passing through it. External oblique Femoral artery Internal oblique Femoral vein Transversus abdominis Femoral branch of Lymph node Fascia transversalis genitofemoral nerve of Cloquet/ Femoral artery Rosenmüller Fascia iliaca Femoral sheath Ilium Inguinal ligament Iliacus Femoral sheath Fig. 4.4 Walls and contents of the femoral sheath. Femoral branch of genitofemoral nerve Fig. 4.3 Formation of the femoral sheath. Femoral artery Femoral vein Lymphatics Lymph node (of Cloquet) FEMORAL SHEATH It is a funnel-shaped fascial sheath enclosing upper 3.75 cm Lateral Medial Intermediate of femoral vessels. The base of the sheath is directed upward toward the abdominal cavity and apex merges with the Compartments tunica 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 the downward prolongation of the fascia transversalis and the posterior wall by the downward prolongation of the fascia COMPARTMENTS (FIG. 4.5) iliaca (Fig. 4.3). The interior of the femoral sheath is divided into three The 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 genital downward and laterally (Fig. 4.4). branch of the genitofemoral nerve.
  4. 4. Chapter-04.qxd 3/22/2011 11:44 AM Page 52 52 Abdomen and Lower Limb 2. Middle compartment contains the femoral vein. to the inguinal ligament. When the inguinal region is viewed 3. 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 span It is a short fascial tube (medial compartment of femoral an innate area of weakness in the inguinal region. sheath) which diminishes rapidly in width from above downward and is closed inferiorly by the fusion of its walls. The upper end of the femoral canal, which opens into the abdominal cavity is called femoral ring. A fatty areolar tissue INGUINAL CANAL called femoral septum normally closes it. Cloquet’s node is a lymph node situated in the femoral canal. The canal provides The inguinal canal is an oblique intermuscular passage about a dead space for the expansion of femoral vein during 4 cm long lying above the medial half of the inguinal ligament. increased venous return. BOUNDARIES EXTENT AND DIRECTION Anterior: Inguinal ligament The inguinal canal extends from deep inguinal ring (an oval Medial: Sharp edge of the lacunar ligament opening in the fascia transversalis) to the superficial inguinal Posterior: 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 lines to 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 cm Clinical correlation above the midinguinal point as an oval opening at the lateral end of two parallel lines (vide supra). The superficial Femoral 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 is angular opening at the medial end of two parallel lines. The called 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 the abdominal distention with weakness of abdominal muscles, e.g., pregnancy. Any condition, which raises the intra- INGUINAL RINGS abdominal pressure, e.g., repeated forceful coughing or Deep Inguinal Ring straining forces the loop of intestine into the femoral ring, it 1. The deep inguinal ring is an oval opening in the fascia carries with it the peritoneal covering of the abdominal transversalis and lies about 1.25 cm (1/2 inch) above the opening of the canal in front of it. This forms the hernial midinguinal point. sac, which descends in the femoral canal posterior to the 2. From its margins, the fascia transversalis is prolonged weak 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 saphenous around the structures that pass through the ring. vein. If hernial sac continues to enlarge, it expands superolaterally These structures constitute the spermatic cord in male. in the superficial fascia. Consequently, the entire hernia becomes U-shaped. The femoral hernia presents as a globular Superficial Inguinal Ring swelling in groin inferolateral to the pubic tubercle below the 1. The superficial inguinal ring is a triangular gap in the inguinal ligament. aponeurosis of external oblique and lies above and lateral The femoral hernia is common in female because the to 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 the apex, 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 transversalis Table 4.1 enumerates the structures passing through the which appears as a fibrous band running parallel and posterior deep and superficial inguinal rings.
  5. 5. Chapter-04.qxd 3/22/2011 11:44 AM Page 53 Inguinal Region/Groin 53 External oblique Internal oblique muscles Transversus Fatty layer of superficial fascia abdominis Peritoneum Skin Fascia transversalis Membranous layer of superficial fascia of abdomen (Scarpa’s fascia) Fascia iliaca Hernial sac Pectineal ligament Superior ramus of pubis Extraperitoneal fat Lymph node of Cloquet Pectineus muscle Cribriform fascia Pectineus fascia Fascia lata A Femoral fossa Peritoneum Femoral septum Arrow indicates Femoral sheath the course taken Lymph node of Cloquet by femoral hernia Pectineal fascia Pectineus Fascia lata B Fig. 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, and below. (c) reflected part of the inguinal ligament, Anterior wall: It is formed from superficial to deep by: in medial most part. } (a) skin Roof: It is formed by the lower arched fibers of (b) superficial fascia in the whole extent internal oblique and transversus abdominis (c) external oblique muscles. 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. 6. Chapter-04.qxd 3/22/2011 11:44 AM Page 54 54 Abdomen and Lower Limb Fascia transversalis Deep inguinal ring Inferior epigastric artery Iliopubic Interfoveolar (Hesselbach’s) (Thomson’s) ligament ligament Inguinal ligament Cooper’s ligament Lacunar ligament Fig. 4.7 Iliopubic tract. Table 4.1 Structures passing through the inguinal rings Deep inguinal ring Deep inguinal ring In male In female mc 1.2 Inguinal canal • Ductus deferens and • Round ligament of uterus Superficial inguinal ring and its artery • Obliterated remains of • Testicular artery and the processus vaginalis accompanying veins • Lymphatics from the • Obliterated remains of uterus Fig. 4.8 Surface marking of the inguinal canal. processus vaginalis • Genital branch of genitofemoral nerve (b) abdominal surface of the lacunar ligament • Autonomic nerves and at the medial end. lymphatics The arrangement of muscles (external oblique, internal oblique, and transversus abdominis) and fascia transversalis Superficial inguinal ring in relation to the inguinal canal is shown in Figure 4.10. In male In female CONTENTS • Spermatic cord • Round ligament of uterus In 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 and not 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 the does not enter the canal through the deep inguinal ring. It enters testis and is covered by three fascial layers. the canal from side through a slit between the external and internal oblique muscles. It lies in front of the cord and passes out of canal through the superficial inguinal ring to supply the inguinal region. Constituents/Contents (Fig. 4.11) The spermatic cord consists of the following six groups of structures: SPERMATIC CORD 1. 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. 7. Chapter-04.qxd 3/22/2011 11:44 AM Page 55 Inguinal Region/Groin 55 Roof Deep inguinal ring Inferior epigastric artery Internal oblique Transversus abdominis Obliterated umbilical artery Transversus abdominis Internal oblique External oblique Fascia transversalis Fascia transversalis Conjoint tendon External oblique aponeurosis Spermatic cord Superficial inguinal ring Inguinal ligament B Floor Skin External spermatic fascia Testis Dartos Cremasteric fascia Internal spermatic fascia A Fig. 4.9 Boundaries of the inguinal canal: A, anterior and posterior walls as seen in coronal section; B, roof and floor as seen in 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 inguinal 3. Veins, the pampiniform venous plexus. rings do not lie opposite to each other. As a result when 4. 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 internal 6. Remains of processus vaginalis. oblique muscle, and superficial inguinal ring is guarded pos- teriorly by the conjoint tendon and reflected part of the Coverings (Fig. 4.11) inguinal ligament (Fig. 4.12). The spermatic cord is covered by three fascial layers from within outward, these are: SHUTTER MECHANISM 1. Internal spermatic fascia, derived from fascia transversalis. The internal oblique surrounds the canal in front, above, and 2. 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 are rior wall, roof, and posterior wall. Consequently, when it derived from internal oblique muscle. contracts, the roof is pulled and approximated on the floor 3. External spermatic fascia, derived from aponeurosis of like a shutter. external oblique muscle. SLIT-VALVE MECHANISM MECHANISMS TO MAINTAIN THE The 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 help The inguinal canal is a site of potential weakness in the lower in this act. part of the anterior abdominal wall, and may provide herni- ation of abdominal viscera. But, normally it is prevented by BALL-VALVE MECHANISM strength and good tone of the muscles of the anterior abdom- Contraction of cremaster muscle pulls the testis up and the inal wall by the following mechanisms: superficial inguinal ring is plugged by the spermatic cord.
  8. 8. Chapter-04.qxd 3/22/2011 11:44 AM Page 56 56 Abdomen and Lower Limb Iliohypogastric nerve Iliohypogastric nerve Ilioinguinal nerve Intercrural fibers Ilioinguinal nerve Pectineal line A B Inferior epigastric artery Deep inguinal Ilioinguinal nerve ring Conjoint tendon Femoral sheath Femoral artery Spermatic cord Femoral vein Femoral canal Genital branch of C D genitofemoral nerve Fig. 4.10 Schematic diagrams to show the representation of the walls of inguinal canal from outside inwards: A, external oblique; B, internal oblique; C, transversus abdominis; D, fascia transversalis. The formation of anterior and posterior walls and location of inguinal rings can easily be deduced from these figures. Testicular artery Pampiniform plexus around testicular artery Coverings of spermatic cord Sympathetic nerves 1. External spermatic fascia Remains of processus 2. Cremasteric fascia vaginalis 3. Internal spermatic fascia Ilioinguinal nerve Genital branch of Cremasteric nerve genitofemoral nerve and vessels Pampiniform plexus and Artery to ductus deferens lymphatics surrounding the ductus deferens Ductus deferens Fig. 4.11 Transverse section of the spermatic cord showing its covering content.
  9. 9. Chapter-04.qxd 3/22/2011 11:44 AM Page 57 Inguinal Region/Groin 57 N.B. INGUINAL TRIANGLE In addition to the above mechanisms, the interfoveolar ligament also (HESSELBACH’S TRIANGLE) helps to maintain the integrity of the inguinal canal by strengthening fascia transversalis laterally. The muscle fibers arch down from the The inguinal triangle is situated deep to the posterior wall of lower border of transversus abdominis to the superior ramus of tubis the inguinal canal, hence it is seen on the inner aspect of the and constitute the interfoveolar ligament—the functional medial edge of the deep inguinal ring (Fig. 4.13). lower part of the anterior abdominal wall. The features of the inguinal canal are summarized in BOUNDARIES Table 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 ring Inguinal canal abdominis muscle. Fascia transversalis Lateral: Inferior epigastric artery. Inferior: Medial half of the inguinal ligament. Conjoint tendon The floor of the triangle is covered by the peritoneum, Reflected part extraperitoneal tissue, and fascia transversalis. of inguinal ligament N.B. The lateral umbilical ligament (obliterated umbilical artery) crosses the Internal oblique External Superficial inguinal triangle and divides it into medial and lateral parts. The medial part oblique 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 direct Fig. 4.12 Structures protecting the anterior and posterior inguinal hernia usually occurs through this part. walls of the inguinal canal. Rectus abdominis Transversus abdominis Linea alba Conjoint tendon Inferior epigastric artery Reflected part of inguinal ligament Interfoveolar ligament Fig. 4.13 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
  10. 10. Chapter-04.qxd 3/22/2011 11:44 AM Page 58 58 Abdomen and Lower Limb Inferior epigastric artery Rectus abdominis Obliterated umbilical artery Inguinal ligament Spernatic cord External iliac artery Fig. 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 • Skin Clinical correlation – Congenital indirect inguinal hernia: It occurs due to patent processus 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 and intra-abdominal pressure is increased immensely, the indirect. abdominal contents are pushed through the deep inguinal 1. Direct inguinal hernia. The direct inguinal hernia occurs if ring into the inguinal canal. the hernial sac enters the inguinal canal directly by pushing the posterior wall of the inguinal canal forward, medial to inferior epigastric artery through the Hesselbach’s triangle. The neck of hernial sac is wide. The direct inguinal hernias are common in elderly due to weak abdominal muscles. The N.B. direct hernia leaves the triangle through its lateral part or The term complete inguinal hernia is used if hernial contents medial part, and therefore it is of two types: (a) lateral direct reach the tunica vaginalis. If the hernial contents remain confined inguinal 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 deep inguinal ring, lateral to the inferior epigastric artery. It is common in children and young adults. The predisposing factor for this type of hernia is the complete COVERINGS OF THE INDIRECT AND or partial competency of the processus vaginalis. The indirect inguinal hernias are more common than DIRECT INGUINAL HERNIAS the direct inguinal hernias and occur more often in males than females. The indirect inguinal hernia may be The coverings of the hernia are the structures separating the congenital or acquired. hernial sac/peritoneal sac from the surface of the body. These coverings are summarized in Table 4.3.
  11. 11. Chapter-04.qxd 3/22/2011 11:45 AM Page 59 Inguinal Region/Groin 59 Entry of herniated loop of intestine via deep inguinal ring Deep inguinal ring Inferior epigastric artery Internal oblique External oblique Parietal peritoneum Internal spermatic fascia S Cremasteric fascia L M External spermatic fascia I Fig. 4.15 Coverings of the indirect inguinal hernia. Fascia Herniated loop of intestine transversalis Deep inguinal Inferior ring Parietal peritoneum epigastric artery Fascia transversalis Cremasteric fascia Conjoint tendon External spermatic fascia A B Fig. 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 and cremasteric muscle and fascia is replaced by conjoint tendon direct 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 inguinal nal spermatic fascia is replaced by fascia transversalis, and hernias are given in Table 4.3.
  12. 12. Chapter-04.qxd 3/22/2011 11:45 AM Page 60 60 Abdomen and Lower Limb ■ 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 nerve the 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 CLINICAL CASE STUDY A 70-year-old patient with history of chronic bronchitis 3. Give the surface marking of deep inguinal canal. and constipation complained that he noticed a gradually Answers increasing swelling in his right groin and often feels drag- 1. Protrusion of abdominal viscus into the inguinal ging and aching sensation at that site. On physical exami- canal. nation the doctor noticed a globular lump above the right 2. (a) Indirect inguinal hernia pubic 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 canal patient to cough. The swelling reappeared medial to the through deep inguinal ring, whereas in direct inguinal thumb. A diagnosis of direct inguinal hernia was made. hernia abdominal viscus protrudes into inguinal Questions canal 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 as 2. What are the types of inguinal hernias and how they on oval opening. differ from each other?