The inguinal canal is a fibromuscular passage in the lower anterior abdominal wall that extends from the deep inguinal ring to the superficial inguinal ring. It contains the spermatic cord structures in males or the round ligament in females. The main contents include the ductus deferens, testicular vessels, and nerves like the ilioinguinal and genital branch of the genitofemoral nerve. Inguinal hernias occur when abdominal contents like intestine protrude through weak areas in the inguinal canal walls. They can be indirect, occurring through the deep inguinal ring, or direct, through the posterior inguinal wall. Treatment involves surgical hernia repair using techniques

1. APPLIED ANATOMY OF INGUINAL CANAL

2. EXTERNAL OBLIQUE
INTERNAL OBLIQUE
TRANSVERSUS
ABDOMINIS
FASCIA TRANSVERSALIS
INGUINAL LIGAMENT
EXTERNAL OBLIQUE
APONEUROSIS
BLADDER
RECTUS
ABDOMINIS
CREMASTERIC MUSCLE

3. WHAT IS INGUINAL CANAL??
• Oblique fibromuscular passage in the
lower part of anterior abdominal wall,
situated just above the medial half of
inguinal ligament.
• LENGTH & WIDTH: 4 cm long & 1 cm
broad
• DIRECTION: Downwards, Forwards &
Medially

5. EXTENSION:
Deep inguinal ring to Superficial Inguinal ring
DEEP INGUINAL RING :
• Beginning of Inguinal Canal.
• Oval opening in fascia transversalis.
• Lies 1.25cm above midinguinal point.
• From its margins, the fascia transversalis is
prolonged to form one of the covering called the
internal spermatic fascia of the spermatic cord.
DEEP INGUINAL RING
SUPERFICIAL
INGUINAL RING
SUPERFICIAL INGUINAL RING :
• End of Inguinal Canal.
• Triangular defect in external oblique aponeurosis.
• Apex points superolaterally and base is formed by
pubic crest
• Two remainining sides of triangle are called medial
crus and lateral crus, and are attached to pubic
symphysis and pubic tubercle respectively.
• At the apex of triangle, two crura are held together
by crossing intercrural fibres which prevent further
widening of superficial inguinal ring.
• From its margins, the external oblique aponeurosis is
prolonged to form another covering called the
external spermatic fascia of the spermatic cord.

6. BOUNDARIES OF INGUINAL CANAL
ANTERIOR WALL & FLOOR:
EXTERNAL OBLIQUE
APONEUROSIS
INTERNAL
OBLIQUE
INGUINAL
LIGAMENT

7. ROOF:
TA
Arching fibres of
internal oblique
Arching fibres of
transversus abdominis
Conjoint tendon
Arching fibres of
transversus abdominis
Arching fibres of
internal oblique

8. POSTERIOR WALL :
Conjoint tendon
CONJOINT TENDON
FASCIA TRANSVERSALIS

9. CONTENTS OF INGUINAL CANAL
Ductus deferens & its artery
Testicular vessels & pampiniform
plexus
Cremasteric vessels
Internal spermatic
fascia
Cremasteric muscle
External spermatic fascia
Genital branch of genitofemoral
nerve
Remains of processus vaginalis
Ilioinguinal nerve

10. HESSELBACH’S TRIANGLE
Medial umbilical ligament

11. CLINICAL ANATOMY

12. CREMASTERIC REFLEX
Touch on anterior
aspect of
superomedial part
of thigh
Ilioinguinal nerve
carries sensation
to the spinal cord
at level L1
Simulation of
motor fibres of
genital branch of
genitofemoral n.
Contraction of
cremateric muscle
and elevation of
testis
• Cremasteric reflex in children : Hyperactive
• May be helpful to diagnose upper and lower motor lesions and/or spinal injury at
L1-L2 level

13. DEFENCE MECHANISMS OF INGUINAL CANAL
• FLAP-VALVE MECHANISM:
Inguinal Canal – Site of potential weakness in lower anterior abdominal
wall & may provide site for herniation.
WALLS ARE APPROXIMATED

14. • SLIT-VALVE MECHANISM :
LATERAL & MEDIAL CRUS
APPROXIMATED
BALL- VALVE MECHANISM :
UPWARD PULLING OF
TESTES BY CREMASTERIC
MUSCLE

15. SHUTTER MECHANISM :
GUARDING MECHANISM:
Deep inguinal ring – guarded anteriorly by Internal oblique
Superficial inguinal ring – guarded posteriorly by Conjoint tendon & reflected part of
inguinal ligament.
Contraction of Internal
Oblique and Transversus
abdominis

16. INGUINAL HERNIA

17. WHAT IS HERNIA?
• Hernia is a condition in which part of an organ is displaced &
protrudes through the wall of the cavity containing it.
• Hernia :
1) Sac
2)Coverings of the sac
3) Contents of sac

18. INGUINAL HERNIA
• An inguinal hernia is the protrusion or passage of peritoneal
sac, with/without abdominal contents through a weakened
part of abdominal wall in the groin.
• Cause: peritoneal sac enters the inguinal canal either
through deep inguinal ring or through posterior wall of
inguinal canal.
• Inguinal hernia are therefore, mainly classified as
DIRECT & INDIRECT.

19. INDIRECT INGUINAL HERNIA
• Most common of the two types.
• Occurs because some part or all, of the
embryonic processus vaginalis remains open
or patent & hence, it is referred to as
congenital indirect inguinal hernia.
• The protruding peritoneal sac enters the
inguinal canal by passing through deep
inguinal ring.
• Protrusion occurs lateral to the inferior
epigastric vessels.
• The extent of protrusion down the inguinal
canal depends on the amount of processus
vaginalis that remains patent.

20. According to extent of indirect inguinal
hernia , they are of two main types:
INCOMPLETE :
• Bubonocele: Here, sac is confined to
inguinal canal
• Funicular: Here, sac crosses the
superficial ring but doesn’t reach the
bottom of the scrotum.
COMPLETE :
• Here, sac descends to the bottom of
the scrotum.
COVERINGS: Same as Spermatic cord
Bubonocele Funicular Complete

21. DIRECT INGUINAL HERNIA
• Peritoneal sac enters the
medial end of inguinal canal
directly through weakened
posterior inguinal wall.
• It is usually acquired.
• Protrusion occurs medial to
inferior epigastric vessels i.e.
in Hesselbach’s triangle.

22. COVERINGS:
MEDIAL DIRECT INGUINAL HERNIA LATERAL DIRECT INGUINAL HERNIA
Extra peritoneal tissue Extra peritoneal tissue
Fascia transversalis Fascia transversalis
Conjoint tendon Cremasteric fascia
External Spermatic fascia External Spermatic fascia
Skin Skin

23. DIFFERENCE BETWEEN DIRECT & INDIRECT INGUINAL HERNIA
CHARACTERISTIC DIRECT INGUINAL
HERNIA
INDIRECT INGUINAL
HERNIA
Acquired/Congenital Acquired Acquired or Congenital
Site of protrusion Posterior wall of canal Deep inguinal ring
Extent Rarely scrotum Generally scrotum
Neck Lies medial to inferior
epigastric vessels
Lateral to inferior epigastric
vessels
Age group Middle and old age Can be in Young age
Internal ring occlusion test Negative Positive

24. PENTALOON HERNIA
(DOUBLE, ROMBERG, SADDLE)
• Both direct and indirect inguinal sac re
present and clinically present as direct
hernia.
• During surgery, indirect sac may remain
unrecognized and so, leads to recurrent
hernia.
• Medial and Lateral sacs protrudes on
either side of inferior epigastric vessels.

25. SLIDING INGUINAL HERNIA
• Posterior wall of sac is not only
formed by parietal peritoneum but
also by sigmoid colon with its
mesentery on left side; cecum on
right side and often with a portion
of bladder.

26. STRANGULATED HERNIA
• A Strangulated hernia is a hernia that cuts off the blood
supply to intestines and tissues in the abdomen.
• Leads to formation of gangrene.
CAUSES:
1)Narrow neck
2)Adhesions
3)Irreducibility

27. DIAGNOSIS
INTERNAL RING OCCLUSION TEST
• Procedure: After reducing the herniated
contents and occluding the deep inguinal ring,
patient is asked to cough.
• Observation:
1) Swelling occur medial to thumb Direct
inguinal hernia
2) Swelling absent and appear after releasing
the thumb Indirect inguinal hernia

28. THREE FINGER TEST (ZIEMEN TEST)
Indirect
Inguinal
hernia

29. TREATMENT
It includes:-
• Open Repair
a)Lichtenstein(Tension free) repair (HERNIOPLASTY)
b)McVay (Cooper’s Ligament) repair: Suturing of conjoint
tendon with cooper’s ligament
c)Shouldice(Canadian) repair: all muscle layers are sutured
in double breasted manner.
d)Bassini repair: Conjoint tendon sutured with inguinal
ligament
• Laparoscopic repair
HERNIORRAPHY

30. LICHTENSTEIN (TENSION FREE) MESH REPAIR
• In conventional methods, sutures often
recreates the tension that created the
hernia causing pain and a higher risk of
recurrence.
• In Lichtenstein repair, polypropylene
mesh is used.
• Overtime, due to ingrowth of tissue ,
the mesh safely becomes incorporated
into muscle layer, creating a very
strong permanent repair.

31. LAPROSCOPIC HERNIA REPAIR
• Laproscope is inserted
intraperitoneally or
extraperitoneally, by making small
incisions, and the abdominal
contents are pulled inwards.
• Mesh is placed behind the fascia
tranversalis/peritoneum.

32. OTHER INGUINAL CANAL DEFECTS

33. PATENT PROCESSUS VAGINALIS
PPV may lead to:
1.Indirect Inguinal Hernia
2.Hydrocele of spermatic
cord and/or testis
3.Cyst

34. CRYPTORCHIDISM (UNDESCENDED TESTIS)
• A condition in which one or both of
the testes fail to descend into the
scrotum from abdomen.
• It may lead to compression of illio-
inguinal nerve.

35. ENTRAPMENT OF NERVES
1)Illioinguinal nerve
• Due to presence of hernia, nerve gets compressed leading to numbness
and tingling sensation of
a)Skin of root of penis/mons pubis
b)Anterior 1/3rd of scrotum/labium majus
c)Superomedial part of thigh
• It may also occur if it gets cut during hernial repair
2)Genital branch of genitofemoral nerve
• Its compression may lead to loss of cremasteric reflex

36. TESTIS
Abnormal presence of splenic lobule in inguinal canal
• Sometimes, spleen lobules gets
fused with testicular tissue,
known as SPLENOGONADAL FUSION.
• Hence, the lobule will also descend
into inguinal canal along with
testes.
SPLEENIC LOBULE

37. Roll no. 86 – 90
Guided By: Dr. Rajesh Astik Sir