5. Inguinal Hernia & Surgical Anatomy.pptx

Anatomy of the inguinal hernia
anatomy of the inguinal area

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: Congenital forms of indirect hernia occur because the processus vaginalis fails to undergo regression. 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.

9. 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.

10. Complications : Incarceration. Strangulation. Obstruction.

11. Surgical Anatomy

12. ASIS

13. 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

14. Nerves : There are three known nerves that pass within the structures of the inguinal canal: T he ilioinguinal nerve . The genitofemoral nerves. Iliohypogastric nerve.

15. 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.

16. 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.

17. 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. 

18. 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/