Condensation of the internal oblique and trans-versus abdominis aponeuroses forms the conjoint tendon, and a reflection of the inguinal ligament forms the lacunar ligament.
originates from the external iliac artery proximal to the inguinal ligament, initially passing along the medial boundary of the deep inguinal ring, and ascends obliquely and medially to the rectus abdominis muscle
Image 1 -The inferior epigastric artery and its paired veins lie along the midlateral posterior surface of the rectus abdominis muscle. Image 2 - IEVs lie more laterally. Image 3 - is obtained at a level where the IEVs (arrow)lie at the edge of the rectus muscle. This is the level at which most spigelian hernias occur.
40-year-old man with right inguinal anatomy. Sonogram of inguinal region parallel and cranial to inguinal ligament corresponding to transducer position 2 shows spermatic cord (C), external iliac artery (A), inferior epigastric artery (E), femoral vein (V), and superior pubic ramus (curved arrow).
Indirect inguinal hernia is the most common type of groin hernia .testis descends from the abd to scrotum through ing canal,which can resul in delayed or incomplete closure of processus vaginalis.= In the first decade of life, it is more common on the right side in the male b/c: - F ailure of closure of processus vaginalis later descend of R testis =In indirect inguinal hernia - herniated structures enter the inguinal canal lateral to the inferior epigastric artery and superior to the inguinal ligament, and extend for a variable distance through the inguinal canal. It travels down the canal on the outer (lateral and anterior) side of the spermatic cord. NECK LIES WITHIN DEEP RING,FUNDUS LIES WITHIN INH CANAL. Its neck is lateral to the inferior epigastric vessels most common form of hernia(young) In adult males, 65% of inguinal hernias are indirect and 55% are Rt sided.
Direct inguinal hernia …..weakened area is just lateral to the conjoint tendon and medial to the inferior epigastric artery
30-year-old man with sonogram of right indirect inguinal hernia with transducer positioned parallel to and cranial to inguinal ligament corresponding to transducer position 2. Pre-Valsalva maneuver sonogram (hernia not visible) shows external iliac artery (A), inferior epigastric artery (E), and superior pubic ramus (curved arrow).
Indirect inguinal hernia. Long-axis view shows that neck of the hernia lies in the internal inguinal ring (IIR), which lies superior and lateral to the proximal inferior epigastric artery (IEA).Hernia sac then courses horizontally in an inferomedial direction within the inguinal canal (IC).Indirect inguinal hernias always pass superficial to the IEA.
Left, Drawing shows that indirect inguinal hernia sac tends to lie anterior to spermatic cord, whereas direct inguinal hernia sac lies posterior to the cord.
Center, Short-axis view shows fat-containing direct inguinal hernia (H)posterior and medial to the spermatic cord (SC).
Right, Short-axis view shows fat-containing indirect inguinal hernia (H)lying anterior and lateral to the spermatic cord (SC). indirect inguinal hernia displacing and compressing the hyperechoic spermatic cord posteriorly. direct inguinal hernia displacing and compressing the hyperechoic spermatic cord anteriorly and laterally
Almost all spigelian hernias arise from the inferior end of the spigelian fascia just lateral to where it is penetrated by the inferior epigastric vessels, lateral to the lateral edge of the rectus abdominis muscle.
25-year-old man with right spigelian hernia. Pre-Valsalva maneuve over linea semilunaris in axial plane corresponding to transducer position 1 in Figure 4 (hernia not visible) showing right rectus abdominis muscle (R), inferior epigastric artery (curved arrow), peritoneal fat stripe (straight arrows), and lateral abdominal muscles (M).
Post-Valsalva maneuver sonogram in same location showing peritoneal fat stripe distorted by fat-containing spigelian hernia (arrows) at linea semilunaris. Note rectus abdominis muscle (R) and lateral abdominal muscles (M).
The spigelian fascia is composed of several different layers of loosely apposed aponeurotic tendons.
From external to internal lie the aponeurosis of the external oblique, internal oblique, and transverse abdominis muscle.
Internal to the aponeurosis lie the transversalis fascia and peritoneum.
In spigelian hernias the transverse abdominis tendon is always torn. In most cases the internal oblique aponeurosis is also torn The external oblique tendon is always intact and usually forces the hernia sac to extend either medially over the anterior aspect of the rectus abdominis muscle or laterally over the external oblique muscle, forcing it into the shape of an anvil or mushroom.
Small, spigelian hernia in which the aponeuroses of both the transverse abdominis and internal oblique muscles are torn, but in which the external oblique aponeurosis, is intact.
The saphenofemoral junction, similar to the origin of the inferior epigastric artery for inguinal hernias, is the key landmark for identifying the femoral hernia. Unlike inguinal hernias, femoral hernias are more common in women than men. It is thought that the increased intrapelvic pressure that occurs during the third trimester of pregnancy together with the hormone induced Softening of tissues, predisposes to the development of femoral hernias. Femoral hernias arise within the femoral canal inferior to the inguinal canal and ilioinguinal crease. The femoral canal lies just medial to the common femoral vein (CFV) and just superior to the saphenofemoral junction
The testes are a paired organ in the scrotum, The testicles have a strong organ capsule (tunica albuginea testis). The testicular parenchyma is composed of 250–350 lobules, which drain through the mediastinum testis to the epididymis. The lobules are separated by connective tissue septa (Septula testis) originating from the mediastinum testis. A lobule of the testis consists of one or several seminiferous tubules, which end and start at the rete testis [fig. cross section of the testis and epididymis].
Normal tunica albuginea. Longitudinal gray-scale US image of a normal testis depicts a thin echogenic line (arrow) around the testis.
The scrotum consists of a thin layer of skin (2-8 mm) and underlying fascia. Each hemiscrotum contains a testis with its coverings, epididymis, and spermatic cord. A normal testis measures 5 × 3 × 2 cm in size. In healthy young men the ovoid testis measures 15 to 25 mL in volume. The testicular parenchyma consists of multiple lobules, each of which is composed of many seminiferous tubules that lead via the tubuli recti to dilated spaces, called the rete testis within the mediastinum
2- 3c.m. in anterio posterior Volume 12.5 – 19 gm in adults.
The size of the testicle varies with age, increasing in size from birth to puberty and then decreasing later in life
The epididymis is located in the posterolateral aspect of the testicle as a hypoechoic structure discretely heterogeneous. With high resolution, the head, body, and tail is visualized in the mayority of cases.
Sagittal view of the body of epididymis (left). Sagittal view of the head of epididymis (right).
The mediastinum of the testis is an echogenic band of variable thickness that extends across in a craniocaudal direction. If imaged at an angle, it may resemble a testicular tumor (1).
Transverse views of the testicle demonstrating anechoic structurescorresponding to the pampiniform plexus.
A small amount of intrascrotal fluid may be normally seen.
Testicular appendages.At the upper pole of the testis is the appendix testis, a small pedunculated or sessile body similar in appearance to the appendix of the epididymis. Visible when hydrocele is present.
Normal rete testis .seen in 20% of patients. Hypoechoic striated appaerence of rete testis fingerlike projection into parenchyma adjacent to mediastinam testis.
TORSION REQUIRE IMMIDIATE SURGERY TO PRESERVE THE TESTIS. 80-90% SALVAGE IN <5 YRS 70% 6-12 20% >12HRS
A.Tuniva vaginalis does not completely surronds the testis n epididymis,normaly attaces to the post scrotal wall. B.Complete surronding .causing free movement of testis.mostly occur in puberty. C.Torsion occur and may compromise vascularity d.Usually occou in newborn. Tunina vaginALIS IS NORMALY ATTACHED BUT POOR OR ABSENT ATTACHMENT OF TESTIS WITH SCOTAL WALL.CAUSING ABNORMAL ROTATION.
Initially it becomes enlarged n nnormal echogenesity later it become hetreogenous and hypoechoic. A hypoechoic or heterogenous denotes nonviability. extratesticular sonographic findings typically occur in torsion and important to recocgnice torsion. Spermatic chord immidietly cranial to testis is twisted causing torsion knot or whirpool pattern. Epididimysis is enlarged. Reactive hydrocele and scotal skin thickening seen.
Varicocele A varicocele is a collection of tortuous and dilated veins within the pampiniform plexus of the spermatic cord. They are found in approximately 15 % of adult males and can result in infertility secondary to decreased sperm motility and count. They are due to incompetent valves in the testicular vein. The vast majority of varicoceles are located on the left side and only 1 % are bilateral. The left sided predominance of varicoceles is thought to be due to the long course and angle of entry of the left testicular vein as it empties into the left renal vein. The right testicular vein is shorter and empties directly into the inferior vena cava. Varicoceles are much more apparent when the patient performs a Valsalva maneuver or is standing. Hence, ultrasound should be performed in both supine and standing positions. Sonographically, they appear as multiple anechoic serpiginous tubular or curvilinear structures of varying sizes (larger than 2 mm in diameter) in the region of the epididymis (Figure 4). Power Doppler should be used to confirm flow in the varicocele. (5,6,7)
Reversed flow lasting more than 1-2 sec.
Its very difficult to distinguish the various subtypes of nsgst on sonography.
Seminoma tend to occur in slightly older patient.peak incidence 4tth to 5th. Mc tumor type in cryptorchis testes. Macroscopically homogenously solid firm round or oval mass varying sizes from small nodule to large mass.
Embryonal cell carcinomas tend to distort the testicle and frequently invade the tunica albuginea
Welldefined markedly inhomogenous mass comtaining cystic and solid areas of varying sizes.dence echogenic foci are common resulting from calcification,cartilage,fibrosis,scarring.
Associated with cryporchism,klinefeltar down aids pul alv microlithiasis,radiotharapy patint,many GCT,.
NHL mc Then laekamia Nonlyphoma….lung prost mc.kidney stomach colon melanoma
Where cyst contain serous fluid,spermatocele contain spermatozoa,fat globules,lymphocyute,cellular debris giving thick and milky appearencs.
Sperm granuloma is seen in post vasectomy patint a extratesticular hypoechic area due to extravasasion of spermatozoa into the soft tissue and surrounding necrotisisng granulomatous disease.
Scrotal mesothelioma. (a) Transverse US image shows a hydrocele with several soft-tissue nodules studding the tunica vaginalis (arrows). (b) Photograph of the resected scrotum demonstrates multiple soft-tissue nodules (arrows).
Imaging of Inguino scrotal region
DR SOUMITRA HALDER
DEPT. OF RADIO-
The inguinal ligament
The deep inguinal ring …
anatomic defect in the transversalis
The superficial inguinal ring….
defect in the external oblique
aponeurosis immediately superior
and lateral to the pubic tubercle.
--from the deep to the superficial inguinal
--3.75 cm long
--directed downwards and medially from
the deep to the superficial inguinal ring
spermatic cord (M )
Round ligament of ut ( F)
in areas of natural weakness
vessels penetrate the abdominal wall (femoral and spigelian)
fetal migration of testis, spermatic cord, or round ligament have
occurred (indirect inguinal)
broad flat weak tendons called aponeuroses (direct inguinal).
Why does hernia occurs ?
1. Bubonocele.... The hernia is limited to the
2. Funicular.... The processus vaginalis is closed
just above the epididymis. The contents of the sac
can be felt separately from the testis, which lies
below the hernia.
3. Complete ( scrotal).... The testis appears to lie
within the lower part of the hernia.
Types of indirect inguinal hernia
Left, Image shows the right direct inguinal hernia sac lying posterior to the
spermatic cord (SC).
Right, Image shows the left indirect inguinal hernia sac lying anterior to the
spermatic cord (SC).
Spigelian fascia, the complex
aponeurotic tendon that lies
between the oblique muscles
laterally and the rectus
Femoral hernias arise within the femoral canal, which lies medial to the
common femoral vein just superior to the saphenofemoral junction and
inferior to the inguinal ligament.
31-year-old woman with femoral hernia. Sonogram of right inguinal
region parallel to and caudad to inguinal ligament corresponding to
transducer position 4.
Pre-Valsalva maneuver sonogram shows (hernia not visible) femoral
artery (A), femoral vein (V), and superior pubic ramus (curved
Post-Valsalva maneuver sonogram shows dilated femoral vein (V)
lateral to femoral hernia (arrows). Superior pubic ramus (curved
arrow) is also seen.
Enlarged to inf pole, only during standing
No dilatation on supine
Reflux only during Valsalva
Supine position also that increased in standing
Supine and even prone position
Reflux evident on rest
solid ± lobulation.
They don't have calcification nor tunica invasion.
Most seminomas demonstrate increased flow on color Doppler
irregular or ill-defined margins.
Echogenic foci within the substance of the tumors represent areas of
hemorrhage, calcification, or fibrosis.
They frequently have cystic components, consistent with regions of
Nonseminomatous germ-cell neoplasms
Abnormal collection of serous ﬂuid in
a part of the processus vaginalis, usually
High-resolution real-time sonography has a high degree of accuracy and
sensitivity in the detection, characterization, and localization of scrotal lesions,
making it the undisputed modality of choice for imaging the scrotum.
In the pediatric population, sonography is helpful in the diagnosis of
developmental abnormalities, epididymitis, testicular torsion, and testicular