Groin swellings- Introduction

Groin swellings is one of the common problems in Surgery. Common causes are Inguinal hernia, femoral hernia and Undescended testis. In this slide presentation I discuss the applied anatomy of the groin region.

1. Dr.B.Selvaraj MS;MCh;FICS Professor of Surgery Melaka Manipal Medical college Melaka Malaysia 75150 GROIN SWELLINGS INTRODUCTION

2. Must to know core clinical problems 1. Acute RLQ pain 2. Acute RUQ pain 3. Acute epigastric pain 4. Acute LLQ pain 5. Dysphagia 6. Abdominal lumps 7. Upper GI haemorrhage 8. Lower GI haemorrhage 9. Obstructive Jaundice 10. Breast lumps, mastalgia & nipple discharge 11. Neck swellings- Thyroid & non thyroidal 12.Groin swellings 13.Scrotal swellings 14 . Limb ischemia- Acute & Chronic 15. Varicose veins 16. Renal & ureteric colic 17. Hematuria 18. Acute retention of urine

3. Groin swellings- Introduction Causes of groin swellings Anatomy of inguinal canal Anatomy of femoral canal Embryology of testicular descend Algorithm to clinch the correct diagnosis

4. Causes of Groin swellings Inguinal hernia- Indirect & direct Femoral hernia Undescended testis Inguinal lymphadenitis Lipoma of spermatic cord Encysted hydrocele Saphena varix Femoral artery aneurysm Psoas abscess Femoral nerve neuroma

5. Anatomy- Inguinal canal Inguinal canal is about 4cm in length extending from deep inguinal ring to the superficial inguinal ring . Superficial inguinal ring: is an inverted v-shaped defect in the external oblique aponeurosis immediately superior to the pubic tubercle. Deep inguinal ring: It is ½" or 1.25cm above the mid-inguinal point-the midpoint between the symphysis pubis and anterior superior iliac spine. It is U-shaped defect in transversalis fascia.

6. Anatomy- Inguinal canal Anteriorly - external oblique aponeurosis and fleshy fibres of the origin of internal oblique in its lateral 1/3rd . Posteriorly —Fascia transversalis along the whole length of the canal. In the medial half there are conjoint tendon and reflected part of the inguinal ligament . Superiorly —There are arched fibres of internal oblique and transversus abdominis before they fuse to form the conjoint tendon . Inferiorly —Inguinal ligament and the lacunar ligament on the medial side ( Gimbernat’s ligament).

7. Anatomy- Inguinal canal

8. Anatomy- Inguinal canal Myopectineal orifice of Fruchaud Posterior Laparoscopic view

9. Anatomy- Femoral canal Femoral Canal : It extends from the femoral ring above to the saphenous opening (fossa ovalis ) below, being the innermost compartment of the femoral sheath. Length – 2cm, shape: It looks like the inverted truncated cone, the upper end being the femoral ring Contents of the femoral canal 1. Fibrofatty tissue 2. Lymph nodes and lymphatics. Lymph node situated at the ring is known as Cloquet’s node.

10. Anatomy- Femoral ring Femoral Ring: Boundary Anterior—Inguinal ligament Posterior— Iliopectineal ligament and pubis. Medially—Crescentic edge of the lacunar ligament Laterally—Fibrous septum separating the canal from the femoral vein (Silver fascia ). The ring is closed above by the septum crurale – a condensed extraperitoneal tissue pierced by the lymphatic vessels.

11. Anatomy- Femoral canal

12. Embryology of testicular Descend Primitive gonad in urogenital ridge turns into testis by gene in short arm of Y chromosome. Early testis  3 hormones Testosterone from Leydig cells CSL regression Mullerian inhibiting substance from Sertoli cells Mullerian duct regression Insulin-like3 hormone shortening of gubernaculum  relative descend of testis 8 to 15 wks gestation- Transabdominal phase

13. Embryology of testicular Descend At 25 wks P rocessus vaginalis elongates into gubernaculum Distal end of gubernaculum reach scrotum between 30 to 35 Wks Then testis descend through PPV Testosterone GFN  CGRP Migration of gubernaculum along with testis to scrotum 28 to 35 wks gestation- Inguinoscrotal phase

14. Algorithm for Groin Swellings

15. https://www.youtube.com/watch?v=YXsCUv6dj3M