SURGEON AND THE INGUINAL CANAL

1. SURGICAL ANATOMY OF
INGUINAL HERNIA
DR MUHAMMED MUNEER M
MS GENERAL SURGERY
SGMC & RF
TRIVANDRUM KERALA

2. Abdominal wall divided In to-
 Anterolateral abdominal wall
1.Anterior wall
2.Rt lateral wall
3.Lt lateral wall
 Posterior abdominal wall

3. .
Anterior wall extent frm thorasic cage to pelvis
& bounded by superiorly d cartillage of 7th
thru
10th
rib &xiphoid process
Inferiorly,inguinal ligament & pelvic bone.
 Wall-
skin,s/c tissue(fat),muscle,fascia,parietal
peritonium

4. .

5. .
Skin
Superficial fatty layer-CAMPER’S
Membranous deep layer-SCARPA’S
Muscles-5 muscle} - 3 flat muscle-EO
-IO
-TA
-2 vertical muscle-
(rectus abdominis n pyramidalis)

6. .

7. .
All 3 flat muscle end anteriorly in strong
sheet like aponeurosis

8. INGUINAL CANAL
 Intermuscular slit situated b/w superficial &
deep ring.
 Oblique passage (adult), 3.75cm long ,
medial ½ of inguinal ligament.
 Superficial ring; triangular opening in
external oblique aponeurosis 1.25 cm abv &
lateral to pubic tubercle, bounded by
superomedial n inferolateralcrus (stronger).

9. .

10. .

11. Deep ring-
 Verticaly oval shaped ,formed by condensation of
transversalis fascia , 1.25 cm abv mid inguinal
point.
 Inguinal ligament-(poupart’s ligament)
Formed by lower border Of EO aponeurosis which
is thickned & folded back on itsself ,extend ASIS to
pubic tubercle

13. Content
 Spermatic cord in male
 Round ligament in female
 Illioinguinal nerve (pierces IO n come)
 Remnant process vaginalis +/-

14. .

15. Boundaries
 ANTERIOR- Skin, superficial fascia, external
oblique aponeurosis & internal oblique muscle
lateraly.
 POSTERIOR- inferior epigastric Artery,
fasciatransversalis & conjoint tendon medialy
(combination of IO n Transversus muscle) &
relected part of inguinal ligament.
 ABOVE - arched fibers of conjoint muscle ( IO
muscle + transversus muscle )
 BELOW- inguinal ligament

16. Defence mechanism of inguinal canal
 Obliquity of i.c ( abdmn pres; rise,oclude)
 Arching of conjoint tendon-posterior wall
strengthen
 Shutter mech; of internal oblique
 Ball valve mech:of cremastric muscle which
plug d superior ring
 Slit valve mechanism; EO contract intercrural
fiber of superficial ring appose.

17. . .
.

18. Spermatic cord content
 3 fascia 3 artery 3 vein 2 nerve
 Fascia- external spermatic fascia
cremastric fascia
internal spermatic fascia
 Artery- testicular artery
cremastric artery,deferential A
 Vein- pampiniform plexus & testicular vein
Cremastric vein,deferential vein.
 Nerve- genital br of genito femoral (L 2)
symptic plexus

19. RELATED NERVE ,ARTERY, VEIN
 NERVE SUPPLY- muscle & skin segmental sply from
T 7---L 1
 Thoraco abdominal nerves (inferior inter costel nerve) T7—T11
 Subcostal nerve T12
 umbilicus—T 10
 Groin & scrotum– L1
 illi hypo gastric nerve.T12-L1
 Illio inguinal –L1
 Genitofemoral—L1L2L3

20. .

21. .

22. .

23. Artery
 Superior epigastric A -(internal thorasic A)
 Inferior epigastric A -( external iliac A)
 Deep circumflex iliac A - (external iliac A)
 Superficial circumflex iliac A -(external iliac A)
 Superficial epigastric A – (femoral A

24. .

25. .

26. Artery of death..
 Abnormal obturator artery—
 Obturator & inferior epigastric A usually gives a pubic
branch which is small & anastomos @ back of pubis
 30% case, pubic branch of IEA is very large,taking d
place of obturator A & being known as abnormal
obturator A
 It go down in relation to femoral ring to reach
obt.foramen
 In 10% case person with such A pass down along
edge of lacunar ligament
 Femoral hernia repair..some time need dividing of
this ligament cause bleeding…

27. .

28. Hesselbach’ triangle-inguinal triangle

31. Mayopectenial foramen of FRUCHAUD

32. .
 Above- myoaponeurotic arch of lower edge of
IO & TA
 Below –pectenial line of supra pubic ramus
 Lateral-iliopsoas muscle
 Medial-lateral border of rectus
 Upper ½ & lower ½
 Closed posteriorly by transeversalis fascia

33. Space of bogros
 Located in front of peritonium beneath d
posterior lamina of transversalis fascia, it is d
lateral extension of d retropubic sps of
Retzius.

34. Triangle of DOOM

36. .
 Misnomer.. Inverted V shaped area ,apex
deep ring,medial border vas deference,
lateraly by gonadal vessel,inferiorly by
external illiac vessels.
 only 2 borders
 Avoid staplers n suturs here.

37. TRIANGLE O PAIN

38. Anterior- iliopubic tract/inguinal ligament
Posteromedial-gonadal vessel.

39. .

40. HERNIA
 Protrution of a viscus in part or in whole
through a normal or abnl opening in
relation to the abdmen.

41. Components of a hernia

42. HERNIA-CLASSIFICATION
 ANATOMICAL- indirect & direct
 CLINICAL- reducible,irreducible,obstructed&
incarcinated,strangulated,inflamed
 ACCORDING TO EXTEND-incomplete
-bubonocele(sac contined t0 IC),funicular(Sac cross
super. Ring,not reach bottom o scrotum)
- complete- sac each bottom o scrotum
 CONGENITAL & ACQUIRED
 CONDENT:
Omentocele-omentun

43. .
 Enterocele-bowel
 Cystocele-bladder
 Littre’s hernia-meckel’s diverticulam
 Maydl’s hernia- 2 loop of bowel remain
in sac connecting loop in abdmn n
became strangulate.
 Richter’s herinia-part of bowel

44. maydls hernia

45. Richters hernia

46. Sliding hernia
 A piece of extraperitoneal bowel may
slide down into i.c pulling a sac of
peritoneum with it.
 Posterior wall is not form by peritoneum
alone,but by viscus which lies behind d
peritoneum

47. .

48. Based on site
 Inguinal hernia-inguinal canal
 Femoral hernia-femoral canal
 Obturator hernia
 Diaphragmatic hernia
 Lumbar hernia
 Spigelian
 Umbilical
 Epigastic hernia
 Gluteal hernia
 Incisional hernia

49. .

50. .

51. .

53. .

55. .

59. Skin fix to lnea alba

63. .

66. Thank you