This document discusses inguinal hernias, including their definition, etiology, risk factors, classification, complications, and the surgical anatomy of the inguinal region. An inguinal hernia is the abnormal protrusion of abdominal contents through the inguinal canal. They are usually congenital or acquired defects in the inguinal canal structures. Risk factors include male sex, older age, smoking, family history, and connective tissue disorders. Classification systems include the Nyhus and EHS classifications. Complications can include incarceration or strangulation. The surgical anatomy of the inguinal region contains important structures like nerves, blood vessels, and fascial layers.

1. Inguinal Hernia
&
Surgical Anatomy
DR. MAMOON SALEH
SUPERVISED BY: DR. ZAKI QULA GHASI

2. Outlines:
Definition of hernia.
Etiology and embryology of the inguinal hernia.
Risk factors of the inguinal hernia.
Classification of the inguinal hernia.
Complication & investigation.
Surgical anatomy of the inguinal area.

3. Definition :
Its an abnormal protrusion of intra-abdominal contents through the fascial defect.
Groin hernias represent the most common type of abdominal wall hernia (75%).
Of all groin hernias, 95% are hernias of the inguinal canal.

4. Etiology:
Inguinal hernia occurs because of a defect in the structure of the inguinal canal that
may be either congenital or acquired:
1. Congenital forms of indirect hernia occur because the processus vaginalis fails to
undergo regression.
2. Acquired defects occur because of degeneration and fatty changes in the wall of the
inguinal floor.
There is a familial or hereditary predisposition to development of inguinal hernia.
Connective tissue disorders such as Marfan syndrome and Ehlers-Danlos
syndrome may predispose to hernia formation.

5. Embryology :
During embryogenesis, testicles descend from the posterior abdominal wall and
gradually migrate into the scrotal area.
This descent or migration movement of the testicles is guided by a cord-like
structure called the gubernaculum.
With the descent of the testicles, a peritoneal outpouching called the processus
vaginalis follows the testicles to the scrotum.
Following the descent of the testicles into the scrotum, the processus vaginalis
degenerates.
This process of degeneration or obliteration may be delayed, or it may fail
completely. which leads to develop a number of abnormalities.

6. Risk factors :
Strong weak
Male sex Heavy lifting
Old age Pregnancy
Smoking Ascites
Family history Benign prostatic hypertrophy
Prematurity Urethral stricture
Abdominal aortic aneurysm (AAA)
Previous RLQ incision
Chronic bronchitis or emphysema

7. History & examination :
Presence of risk factors (common).
Groin discomfort or pain with bulge (common).
Groin mass (common).
Abdominal discomfort or pain (uncommon).
Acute abdomen (uncommon)

8. Classification :
Nyhus classification.
European Hernia Society (EHS) classification.
Gilbert Classification.

10. Investigation :
Diagnosis is usually clinical. There is no requirement for imaging for a clinically
obvious inguinal hernia.
Radiographic imaging may be helpful if there is diagnostic uncertainty (e.g., in a
patient with morbid obesity or with unexplained groin pain).
If imaging is required, an ultrasound scan of the groin should be the initial
investigation.
A computed tomography (CT) scan of the groin is indicated if the ultrasound scan is
negative and clinical suspicion is high.

11. Complications :
Incarceration.
Strangulation.
Obstruction.

12. Surgical Anatomy

13. ASIS

20. Contents of spermatic cord in males:
•3 Arteries: artery to vas deferens (or ductus deferens), testicular artery, cremasteric
artery.
•3 Fascial layers: external spermatic, cremasteric, and internal spermatic fascia.
•3 Nerves: genital branch of the genitofemoral nerve (L1/2), sympathetic and visceral
afferent fibers, ilioinguinal nerve (it's OUTSIDE spermatic cord but travels next to it).
•3 Other Structures: pampiniform plexus, vas deferens (ductus deferens), testicular
lymphatics

21. Nerves :
There are three known nerves that pass within the structures of the
inguinal canal:
1. The ilioinguinal nerve.
2. The genitofemoral nerves.
3. Iliohypogastric nerve.

23. The ilioinguinal nerve is a branch of L1.
It passes through the deep inguinal orifice.
It provides sensation to the anterior perineum and medial and upper thigh.
In males, it also provides sensation to the anterior scrotal area.
In women, the nerve provides sensation to the labia majora and mons pubis.

24. The genitofemoral nerve is derived from the L1-L2 spinal nerve roots.
It divided above the inguinal canal to the genital branch that passes through the
deep inguinal ring with the cord structures, and the femoral branch that passes
below the inguinal canal.
It provides a motor function to the cremasteric muscle and sensory innervation to
the scrotum (genital branch) and the upper thigh (femoral branch) in males, and labia
in females.

25.  Iliohypogastric nerve:
Supply sensation to the skin above the genitalia
Does not pass through the inguinal canal.
It pierces the transversus abdominis then the external oblique in the inguinal area.

26. References :
Zollinger’s Atlas of Surgical Operations.
Final Binder Surgery Sixer 4th edition.
The BMJ: British Medical Journal.
Tuma F, Lopez RA, Varacallo M. Anatomy, Abdomen and Pelvis, Inguinal Region
(Inguinal Canal) [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470204/