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Surgical anatomy of the inguinal canal

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Surgical and applied anatomy of the inguinal canal

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Surgical anatomy of the inguinal canal

  1. 1. Surgical Anatomy of the inguinal canal Presenter: DR PASHI V.M MODERATOR: DR. TEMBO 16/01/2015 THE UNIVERSITY TEACHING HOSPITAL LUSAKA , ZAMBIA
  2. 2. Surface anatomy of anterior abdomen
  3. 3. Anterior abdominal wall • Has 8 layers before you enter the peritoneal cavity • Skin • Subcutaneous tissue- Camper’s fascia • - Scarper’s Fascia • External oblique • Internal Oblique • Transversus Abdominis • Transversalis fascia • Extraperitoneal Fat • Parietal Peritonium
  4. 4. Anterior abdominal muscles
  5. 5. Inguinal canal  It is an oblique passage through the lower part of the anterior abdominal wall  Present in both sexes  It allows structures to pass to and from the testis to the abdomen in males  In females it permits the passage of the round ligament of the uterus from the uterus to the labium majus  Transmits ilioinguinal nerve in both sexes
  6. 6. Inguinal canal • It is about 1 ½ inches or 4cm long in the adults • Extends from the deep inguinal ring downward and medially to the superficial inguinal ring • Lies parallel to and immediately above the inguinal ligament • In the newborn child, the deep ring lies almost directly posterior to the superficial ring
  7. 7. Inguinal canal in females
  8. 8. Inguinal canal in males
  9. 9. Development of the inguinal canal • The canals form the pathways for the testes to descend through the abdominal wall into the scrotum. • AS THE MESONEPHROS degenerates, the gubernaculum (a ligament) descends on each side from the lower poles of the gonads, • THE PROCESSUS VAGINALIS (peritoneal sac) develops later, on each side, ventral to the gubernaculum, and herniates through the lower abdominal wall along the pouch formed by the gubernaculum
  10. 10. Development • Each processus carries extensions of layers of the abdominal wall before it, and together they form the walls of the inguinal canal. In the male, they also form the coverings for the testes and the spermatic cord • The opening produced in the transversalis fascia by the processus is the deep inguinal ring and that in the external oblique aponeurosis becomes the external or superficial inguinal ring. Between the rings is the inguinal canal.
  11. 11. descent of gonads
  12. 12. Anomalies of inguinal c development • ANOMALIES OF TESTICULAR MIGRATION: They range from simple ectopy, where the testis may be inguinoscrotal or inguinal, to cryptorchism, where the testis is pelvic, iliac, or even lumbar • ANOMALIES OF VAGINAL PROCESS CLOSURE : They may be (not always) associated with problems of testicular migration • Cysts of the spermatic cord are signs of incomplete closure • A complete failure of closure may result in congenital oblique external hernia or communicating hydrocele
  13. 13. Structures of the inguinal canal • Deep inguinal ring half way between a line drawn from pubic symphisis to anterior superior iliac spine. Relations • Anterior: Skin, fascia, Aponeurosis external Oblique + Internal Oblique • Above: Arching Fibres of Internal Oblique & Transversus Abdominis • Posteriorly: Transversalis Fascia & Conjoint Tendon • Below: Inguinal Ligament recurved lower edge of the external oblique aponeurosis
  14. 14. j
  15. 15. Anterior Wall of Inguinal Canal • Is formed along its entire length by aponeurosis of the external oblique muscle • It is reinforced in its lateral third by the origin of the internal oblique from the inguinal ligament • This wall is strongest where it lies opposite the weakest part of posterior wall, that is deep inguinal ring
  16. 16. Posterior Wall of Inguinal Canal • Is formed along its entire length by the fascia transversalis • It is reinforced in its medial third by conjoint tendon, the common tendon of insertion of internal oblique and transversus, attached to the pubic crest and pectineal line • This wall is strongest where it lies opposite the weakest part of the anterior wall, that is superficial inguinal ring
  17. 17. Inferior Wall of Inguinal Canal • Is formed by the rolled-under inferior edge of the aponeurosis of the external oblique muscle called inguinal ligament and at its medial end, the lacunar ligament
  18. 18. Superior Wall of Inguinal Canal • Is formed by the arching lowest fibers of the internal oblique and transversus abdominis muscles
  19. 19. Functions of Inguinal Canal • It allows structures of spermatic cord to pass to and from the testis to the abdomen in male • Permits the passage of round ligament of uterus from the uterus to the labium majus in female
  20. 20. Mechanics of Inguinal Canal • The presence of inguinal canal in the lower part of the anterior abdominal wall in both sexes constitutes a potential weakness • Except in the newborn infant, the canal is an oblique passage with the weakest areas, that are superficial and deep inguinal rings
  21. 21. Mechanics of Inguinal Canal • When great straining efforts may be necessary, as in defecation and parturition, the person naturally tends to assume the squatting position • The hip joints are flexed and the anterior surfaces of the thighs are brought up against the anterior abdominal wall • By this means the lower part of the anterior abdominal wall is protected by the thighs
  22. 22. Spermatic Cord • It is a collection of structures that pass through the inguinal canal to and from the testis • It is covered with three concentric layers of fascia derived from the layers of anterior abdominal wall • It begins at the deep inguinal ring lateral to the inferior epigastric artery and ends at the testis
  23. 23. Structures of Spermatic Cord • Vas deferens • Testicular artery and vein • Testicular lymph vessels • Autonomic nerves • Processus vaginalis • Cremastric artery • Artery of the vas deference • Genital branch of genitofemoral nerve
  24. 24. Vas Deferens • It is a cord like structure • Can be palpated between finger and thumb in the upper part of the scrotum • It is a thick walled muscular duct that transport spermatozoa from the epididymis to the urethra
  25. 25. Testicular Artery • It is a branch of abdominal aorta • It is long and slender • Descends on the posterior abdominal wall • It traverses the inguinal canal and supplies the testis and the epididymis
  26. 26. Testicular Veins • These are the extensive venous plexus, the pampiniform plexus • Leaves the posterior border of the testis • As the plexus ascends, it becomes reduced in size so that at about the level of deep inguinal ring, a single testicular vein is formed • Drains into left renal vein on left side and inferior vena cava on right side
  27. 27. Covering of the Spermatic Cord • The covering of the spermatic cord are three concentric layers of fascia derived from the layers of the anterior abdominal wall • Each covering is acquired as the processus vaginalis descends into the scrotum through the layers of the abdominal wall
  28. 28. Covering of the Spermatic Cord • External Spermatic fascia: Is derived from the external oblique aponeurosis and attached to the margins of the superficial inguinal ring • Cremasteric Fascia: Is derived from the internal oblique muscle • Internal Spermatic Fascia: Is derived from the fascia transversalis and attached to the margins of deep inguinal ring
  29. 29. Inguinal Hernia • A hernia is the protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall • Consists of three parts: the sac, contents of the sac, covering of the sac • Hernial coverings are formed from the layers of the abdominal wall through which the hernial sac passes
  30. 30. Indirect Inguinal Hernia • If the processus vaginalis has undergone no obliteration, the hernia is complete and extends through the superficial inguinal ring down into the scrotum or labium majus • Under these circumstances the neck of the hernial sac lies at the deep inguinal ring • It is 20 times more common in young males than females • Is more common on the right side
  31. 31. Direct Inguinal Hernia • It composes about 15% of all inguinal hernias • Common in old men with weak abdominal muscles and rare in women • Hernial sac bulges forward through the posterior wall of the inguinal canal medial to the inferior epigastric artery • The neck of the hernial sac is wide • Hasselbachs triangle.. Medially the rectus sheath, laterally the inferior epigastric vessels, inferiorly , the inguinal ligament…sight of direct inguinal hernias
  32. 32. Hasselbachs triangle
  33. 33. Related hernias • Femoral hernias : Protrusion of the parietal peritoneum down the femoral canal • More common in women than men • Neck of the sac is narrow lies below and lateral to pubic tubercle • Femoral canal where the neck lies is related anteriorly to the inguinal ligament, posteriorly to pubs and pectineal line. Laterally to femoral vein and medially to the lacuna ligament.
  34. 34. Herniorraphy SUTURE REPAIR BASSINI REPAIR SHOULDICE REPAIR PLICATION - DARN REPAIR FEMORAL HERNIA REPAIR FEMORAL APPROACH INGUINAL APPROACH EXTRAPERITONEAL APPROACH MESH REPAIR OPEN REPAIR LICHTENSTEIN REPAIR (OPEN ANTERIOR) RIVES and KUGEL PATCH REPAIRS (OPEN POSTERIOR) PERFIX PLUG REPAIR PROLENE HERNIA SYSTEM REPAIR STOPPA REPAIR LAPAROSCOPIC REPAIR
  35. 35. Name of Repair Type of Repair Recurrence Rates Modified Bassini Conjoined tendon to inguinal ligament 5 - 15% Modified McVay Conjoined tendon to Cooper’s ligament 5 - 15% Shouldice / Modified Shouldice Three or four layer tissue repair <1 - 7% Plication - Darn Repair ‘Tension-free’ suture repair 2 – 9 % Lichtenstein Onlay mesh <1 - 5% Kugel Preperitoneal mesh 4% PerFix plug Plug and patch 4% Prolene Hernia System Preperitoneal and onlay mesh <1 – 3% Stoppa Large preperitoneal mesh <1%
  36. 36. Herniorraphy • Modified Bassinis Repair- Developed in 1880 involves reinforcing or repair of posterior wall by suturing the conjoint tendon to inguinal ligament. • Commonly used at UTH. • Has failure rate of about 0.2 -8.5% failure (recurrence) rate. • Technique is most important determinant!!! • Use Non absorbable sutures. • Shouldice Repair: also called Canadian repair. Involves dividing the transversalis fascia and repairing the posterior wall in four layers. Associated with 0.1- 6.1% failure rate. Dependent on surgeons technique
  37. 37. References • Ellis H. Clinical Anatomy • www.vesalius.com • Raftery, A.T(2008), Applied Basic Science for Basic Surgical Training, Elsevier, USA. • Netter, F, Interactive Atlas of Human Anatomy

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