Inguinal Region,Hernia And Scrotum 2024.pptyyyyyyyyyyx

Hematological principles

1. I n g uinal Region,Hernia And Scrotum Presnters : Belyo Yassin & Galiwango Henry Facilitator: Dr. Munabi Ian

2. I n g uinal region The inguinal region (groin) is the junction of the anterior abdominal wall and the anterior aspect of the thigh. It extends between the anterior superior iliac spine and the pubic tubercle. Clinically the inguinal region includes area along and around the inguinal ligament. This region is important both anatomically and clinically A natomically because it is the region where structures exit from and enter into the abdominal cavity and clinically because the pathways of exit and entry are potential sites of herniation. Majority of abdominal hernias occur in this region, e.g., inguinal and femoral hernias; only inguinal hernias account for 75% of all hernias of the body. The key structures in this region are the inguinal ligament, inguinal canal, and femoral canal. Hence, surgically it is the most important region

3. I n g uinal ligament The inguinal ligament is a thick, fibrous band extending from anterior superior iliac spine to the pubic tubercle. It lies beneath the fold of groin. It is formed by the lower-free border of the external oblique aponeurosis, which is thickened and folded backward on itself. Thus the lower aspect of the ligament is round while its upper aspect presents a groove. The grooved upper surface of inguinal ligament forms the floor of inguinal canal The strong deep fascia of the thigh(fascia lata ) is attached to the lower aspect of the entire length of the ligament, which makes it convex inferiorly by its pull.

4. E xtensions of the ligament Lacunar Ligament (or Gimbernat’s Ligament) From the medial end the deep fibers of the inguinal ligament curve horizontally backward to the medial part of the pecten pubis forming lacunar ligament. Pectineal Ligament (Ligament of Cooper) It is the extension of the posterior part of the lacunar ligament along the pecten pubis up to the iliopectineal eminence. . Reflected Part of Inguinal Ligament The superficial fibers from the medial end of the inguinal ligament expand upward and medially to form this ligament. It lies behind the superficial inguinal ring and in front of the conjoint tendon

5. Subin g uinal space (pelvifemoral space) . The space between the inguinal ligament and the hip bone is called pelvifemoral/subinguinal space. . This space is divided by the ilioinguinal ligament/arch into two parts: Large lateral part called lacuna musculorum. Small medial part called lacuna vasculorum. The fascial lining of the abdomen is prolonged into the thigh to enclose the upper 3.75 cm of the femoral vessels forming the femoral sheath.

6. In g uinal Canal Its an oblique intermuscular passage about 4 cm long lying above the medial half of the inguinal ligament. It extends from deep inguinal ring to the superficial inguinal ring. It is directed inferiomedially . The deep inguinal ring is marked 1.2 cm above the midinguinal point as an oval opening The centre of superficial inguinal ring lies 1 cm above and lateral to the pubic tubercle

7. Boundaries A nterior wall S kin S uperifical fasica and external obligue aponeuresis I nternal oblique fasica in the lateral one third R oof It is formed by the lower arched fibres of internal oblique and transversus abdominis muscles.

8. Boundaries contd…… P osterior wall F asica transeversalis in the whole extend C onjoint tendon in the medial 2/3 thirds R eflected part of the inquinal liagment in the medial most part Floor It is formed by: (a) Grooved upper surface of the inguinal ligament in the whole extent (b) Abdominal surface of the ligament at the medial end.

9. Contents In male : Spermatic cord and ilioinguinal nerve. In female : Round ligament of the uterus and ilioinguinal nerve

10. S permatic cord Spermatic Cord The spermatic cord is a collection of structures that pass to and from from testis through the inguinal canal. It extends from the deep inguinal ring to the posterior border of the testis and is covered by three fascial layers. Contents and structures include Ductus deferens, Three arteries: Testicular artery, Cremasteric artery (c) Artery to ductus deferens, 3.Veins, the pampiniform venous plexus. 4.Lymphatics Nerves, genital branch of genitofemoral nerve and sympathetic fibres Remains of processus vaginalis.

11. C overings of the spermatic cord Internal spermatic fascia, derived from fascia transversalis. Cremasteric fascia consisting of loops of skeletal muscle fibres united by areolar tissue. The muscle fibres are derived from internal oblique muscle. External spermatic fascia, derived from aponeurosis of external oblique muscle.

12. I n g uinal canal and spermatic code

13. F emoral Sheath It is a funnel-shaped fascial sheath enclosing upper 3.75 cm of femoral vessels. The base of the sheath is directed upward toward the abdominal cavity and apex merges with the tunica adventitia of the femoral vessels The anterior wall of the femoral sheath is formed by the downward prolongation of the fascia transversalis and the posterior wall by the downward prolongation of the fascia iliaca

14. C ompartments And Contents Of The Sheath

15. F emoral Canal It is a short fascial tube (medial compartment of femoral sheath) The upper end of the femoral canal, which opens into the abdominal cavity is called femoral ring. A fatty areolar tissue called femoral septum normally closes it. Cloquet’s node is a lymph node situated in the femoral canal. The canal provides a dead space for the expansion of femoral vein during increased venous return

16. Boundaries Anterior : Inguinal ligament Medial : Sharp edge of the lacunar ligament Posterior : Pecten pubis Lateral : Femoral vein Below the inguinal ligament, the canal lies posterior to the saphenous opening and thin cribriform fascia, and anterior to the fascia covering the pectineus muscle.

17. I n g uinal triangle (Hasselbach triangle) B oundaries M edially L ower 5cm of the lateral boder of the rectus abdominis L aterally I nferior epigastric Artery I nferior M edial haif of the inquinal ligament The floor of the triangle is covered by the peritoneum, extraperitoneal tissue, and fascia transversalis.

18. C linical Correlates Femoral Hernia In g uinal Hernia

19. I n g uinal Hernias Accounts for 75% of abdominal hernias Occur in both sexes,86% occur in males cause of the passage of the spermatic cord through the canal Most are reducible 2 variants include Direct and Indirect inguinal hernias More than two thirds are indirect hernias

20. C lassification Of In g uinal Hernias Anatomical Classification Gilberts Classification Nyhus Classification A ccording To The Extend

21. Gilberts Classification Type 1 Indirect inguinal hernia(IIH)-tight deep ring Type 2 IIH deep ring admit 1 finger but less than 2 finger breadth Type 3 IIH deep ring more than 2 finger breadth Type 4 Direct hernia –entire posterior wall is defective Type 5 direct hernia-punched out hole/defect in transversalis fascia Type 6 Pantaloon/double hernia Type 7 Femoral hernia Type 6 & 7 are Robbin’s modification

22. N y hus Classification Type I-indirect hernia with normal deep ring Type II-indirect hernia with dilated deep ring without impengement on the floor of the inguinal canal Type III-post wall defect   direct   pantaloon hernia   femoral hernia 4. Type IV –recurrent hernia

23. A ccording To The Extend Incomplete Bubonocele -sac is confined to the inguinal canal 2. Funiclar -here the sac crosses the sup inguinal ring but does not reach the bottom of the scrotum Complete Sac descend to the bottom of the scrotum

24. Direct in g uinal Hernia The direct inguinal hernia occurs if the hernial sac enters the inguinal canal directly by pushing the posterior wall of the inguinal canal forward, medial to inferior epigastric artery through the Hesselbach’s triangle. The neck of hernial sac is wide. The direct inguinal hernias are common in elderly due to weak abdominal muscles. The direct hernia leaves the triangle through its lateral part or medial part, and therefore it is of two types: lateral direct inguinal hernia, and medial direct inguinal hernia.

25. E xamination of Hernia Test : Index finger on deep ring; middle finger on superficial ring and ring finger over saphenous opening—are placed after reducing the content. Patient is asked to cough and impulse is felt in finger corresponding to the existing hernia

26. I nvagination Test Done after reduction of hernia. Using little finger skin of the scrotum is invaginated from bottom up to pubic tubercle. The finger is then rotated and pushed up into the superficial inguinal Ring, the patient is asked to cough and if the impulse felt on the pulp of finger –direct ; if on tip- indirect.

27. Ring Occlusion Test Done after reduction of hernia This is a confirmatory test to differentiate an IIH from DIH A Thumb is pressed on the deep inguinal ring (1/2 inch above mid-inguinal point). Ask the patient to stand, the patient is asked to cough . A direct hernia will show a bulge medial to the occluding finger but an indirect hernia will not.

28. Direct and indirect hernia

29. M ain differences between the two hernias

30. Composition of a hernia As a rule, a hernia consists of three parts – the sac, the coverings of the sac and the contents of the sac. The sac The sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus. The neck is usually well defined but in some direct inguinal hernias and in many incisional hernias there is no actual neck. The diameter of the neck is important because strangulation of bowel is a likely complication when the neck is narrow , as in femoral and paraumbilical hernias.

31. The covering Coverings are derived from the layers of the abdominal wall through which the sac passes. In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each other

32. Contents These can be: • omentum = omentocele (synonym: epiplocele ); • intestine = enterocele ; more commonly small bowel but may be large intestine or appendix; • a portion of the circumference of the intestine = Richter’s hernia;

33. • a portion of the bladder (or a diverticulum) may constitute part of or be the sole content of a direct inguinal , a sliding inguinal or a femoral hernia; • ovary with or without the corresponding fallopian tube; • a Meckel’s diverticulum = a Littre’s hernia ;

34. Treatment Herniotomy H erniotomy and hernioraphy(Macvay , desardas ,Modified Bassini and Shouldice ) H ernioplasty( Lichtenstein, Rives, Gilbert, Stopa, TEP,T APP )

35. ANATOMY OF THE SCROTUM,TESTES AND EPIDIDYMIS Galiwango Henry

36. TESTES- EMBRYOLOGY Testes develop from the gonadal ridge, formed by the proliferation of the coelomic epithelium and condensation of underlying mesoderm on the medial side of the mesonephros. In the 6 th week the primordial germ cell from the yolk sac reach the gonadal ridge, and become incorporated into the developing gonad.

37. EMBRYOLOGY

38. EMBRYOLOGY CONT’D At first the testes and mesonephros lie in the posterior abdominal wall attached by the urogenital mesentery. As the testes enlarges, its cranial end degenerates and the remaining portion of the organ lies in a more caudal position. Most of the mesonephros atrophies. Derivatives of the mesonephric tubules include the vas efferentia and parapididymis .

39. EMBRYOLOGY CONT’D.. In the male the mesonephric duct forms the canal of the epididymis, vas deferens, ejaculatory duct and the appendix of the epididymis. Gubernaculum, a condensation of the mesodermal cells connects the lower pole of the testes to the region of the anterior abdominal wall that later forms the scrotum. It traverses the site of the future inguinal canal; which is formed by the developing abdominal m uscels

40. EMBRYOLOGY CONT’D… A sac of peritoneum; processus vaginalis , protrudes down the inguinal canal anterosuperior to the gubernaculum. By the 7 th month the testes lies in the inguinal canal and rapidly descends to lie in the scrotum before birth. As the testis descends, it is accompanied by the processus vaginalis , projecting into its distal part to form the tunica vaginalis . The rest of the sac gets obliterated.

41. CLINICAL CORRELATES Pantent Processus Vaginalis ; persistency of the whole or proximal part of the processus vaginalis . Hydrocele of the cord ; persistence of an intervening segment of the processus . Cryptorchidism ; failure of descend of the testes from the abdominal cavity Undescended testes ; arrest of testes along path of descent

42. Scrotum and Testes

43. SCROTUM A cutaneous fibromuscular sac that contains the testes and the lower part of the spermatic cord; found below the pubis symphysis in between the anteromedial surfaces of the thighs Consists of the following layers -skin - dartos muscle -external spermatic fascia -cremasteric fascia -Internal spermatic fascia

44. Scrotum Cont’d… The internal spermatic fascia is loosely attached to the parietal layer of tunica vaginalis . The scrotum is divided into left and right halves by the cutaneous raphae which continues ventrally up to the inferior penile surface and dorsally along the midline of the perineum to the anus. It indicates the bilateral origin of the scrotum from the genital swellings. The left scrotum is usually lower because the left spermatic cord is longer

45. Scrotum Cont’d… Scrotal skin is thin, pigmented and rugose, with scanty hair whose roots can be seen through the skin. Has sebaceous gland whose secretion has a distinct ordour , numerous sweat glands, and nerve endings; which are sensitive to the mechanical stimulation from the hairs and skin and to various temperatures. Has no subcutaneous adipose tissues. External appearance varies with temperature, being smooth elongated and flaccid when warm, and short, corrugated and closed applied to the testes when its cold.

46. Scrotum The dartos muscle is a thin smooth muscle layer continous with superficial inguinal and perineal fasciae. It extends to the scrotal septum; which connects the raphae to inferior penile radix. It contains all the scrotal wall layers apart from the skin. Dartos muscle is connected to the skin but loosely connected to the other layers. Scrotal ligament; fibromuscular sheath extending from the dartos sheet to the inferior testicular pole. It plays a role in testicular thermoregulation.

47. Scrotum- Blood supply External pudendal branches of femoral artery Scrotal branches of the internal pundendal artery. Cremasteric branch of the inferior epigastric artery. Dense subcutaneous plexus carry substantial blood flow, which facilitates heat loss. There are prominent arteriovenous anastomoses which are simple but of a high calibre . Veins follow the corresponding arteries

48. Blood supply

49. Lymphatic drainage Lymphatics follow the external pudendal vessels to drain into the superficial inguinal nodes.

50. Nerve supply Anterior one third- illioinguinal and and genital branch of the genitofemoral nerve (L1) Posterior two thirds- perineal nerve and perineal branch of the posterior femoral cutaneous nerve of the thigh (S3) The ventral axial line of the lower limb passes between these areas which means that a spinal anaesthetic must be injected much higher to anaesthetize the anterior region.

51. TESTES

52. TESTES Primary reproductive organs in the male. Ovoid in shape. Both reproductive (sperm production) and endocrine (testosterone). Average testicular dimensions are 5 cm (length), 2.5 cm (breadth), 3 cm ( anteroposterior diameter). Suspended in the scrotum by dartos muscle and spermatic cords. Left testes usually lies lower than the right.

53. TESTES Lie obliquely with the upper pole tilted anterolaterally and the lower posteromedially . Anterior aspect is convex while posterior one is flat, with spermatic cord attached to it. The testes are covered by three layers which from outside inward; tunica vaginalis tunica albuginea tunica vasculosa

54. Testes cont’d… Anterior, lateral and medial surfaces and both poles are covered by the visceral and parietal layers of the serosal tunica vaginalis and the scrotal tissues, while the posterior surface is partly covered by the serosa and has the epididymis adjoined to it laterally The testes are separated by a fibrous septa called the median raphae which is deficient superiorly.

55. Blood Supply

56. Vascular Supply Testicular arteries; branches of the aorta, run in the spermatic cord, give off branches to the epididymes , on reaching the back of the testes, they divide into the medial and lateral branches. These penetrate the substance of the organ. In the region of the epididymis there is an anastomosis between the testicular, cremasteric and ductal arteries; but these cannot sustain supply if the main artery is divided, and can lead to atrophy rather than necrosis.

57. Vascular Supply Venules pass the mediastinum from which several veins pass upwards as a mass of intercommunicating veins called the pampiniform plexus surrounding the testicular artery. I n the inguinal canal, the plexus separate into about 4 veins which join to from two which leave the deep inguinal ring becoming a single vein that runs on the psoas major The left vein invariably drains into the left renal vein at a right angle, while the right testicular vein drains into the inferior vena cava at an acute angle.

58. Lymphatic Drainage Move along the testicular arteries to drain into the para-aortic lymph nodes, which lie along the aorta at the level of the origin of the testicular arteries (L2) just above the umbilicus.

59. Nerve Supply Sympathetic innervation; most of the connector cells lie in the T10 segment of the cord, passing in the lesser splanchnic nerve to the Coeliac ganglion. Postganglionic grey fibres reach the testes along the testicular artery. Sensory fibres share the same pathway in the direction of the spinal cord .

60. STRUCTURE OF TESTES

61. STRUCTURE OF THE TESTES Upper pole of epididymis is attached to the posterolateral aspect of the testes H ere is the mediastinum testes ; a fibrous mass from which the septa radiate to reach the tunica albuginea . Septa divide the testes into about 200-300 lobules, each with 1-4 highly convulated seminiferous tubules. These opens into the rete testes , a network of intercommunicating channels within the mediastinum testes.

62. STRUCTURE CONT’D From the rete; 12-20 vas efferentia enter the commencement of the canal of the epididymis, thus connecting it to the testes. Seminiferous tubules have different cell layers; Spermatogonia ; the outermost layer. These divide into the primary spermatozoa, which divide into the secondary spermatozoa, which also divide almost immediately into spermatids. These undergo morphogenesis to form the spermatozoa. The whole process is Spermatogenesis.

63. STRUCTURE CONT’D Sustencular cells (of Sertoli ): germ cells which secrete Androgen Binding Protein (ABP), which maintains a high testosterone concentration in the germ cell environment. Interstitial cells (of Leydig ) : scattered among the connective tissue in between the tubules. These secrete testosterone. Testes contribute a small amount to semen.

64. Clinical correlates Testicular torsion: T he testis and epididymis are usually fixed to their surrounding tissues. In cases where this this fixation may be insufficient, the structures are able to twist within the tunica vaginalis . This is termed testicular torsion and normally results in severe scrotal pain, which is a surgical emergency. T he testicular appendix ( hydatid of Morgagni ) and the appendix epididymis can twist; torsion of these structures may also result in scrotal pain.

65. EPIDIDYMIS AND VAS DEFERENS

66. EMBRYOLOGY The whole length of a single tube consisting of the epididymis and vas is a persistent and much elongated part of the mesonephric ( Wolffian ) duct of the embryo, which recieves the efferent tubules of the mesonephros. When the mesonephros is replaced by the metanephros and disappears, some tubules persist tubules and attach to the developing testes to form the vasa efferentia

67. EMBRYOLOGY CONT’D Some tubules persist without any function and end in blind tubes, the vasa aberrantia . Their blind ends may form small swellings, an upper one is relatively constant, the appendix of the epididymis. Above the epididymis, at the lower end of the spermatic cord, mass of tubules blind at each end persist as the paradidymis (organ of Giraldes ).

68. EMBRYOLOGY CONT’D Cysts formed from the aberrant blind tubule will contain spermatozoa and therefore opalescent whilst a cyst formed from a tubule of the paradidymis will not and thus will be clear. The paramesonephric ( Mullerian ) duct will disappear in the male at its two ends, the upper end persisting as the appendix of the testes while the conjoined lower ends of the two ducts as the prostatic utricle ( utricus masculinus ).

69. ANATOMY OF EPIDIDYMIS Epididymis is a firm structure attached behind the testis with the vas deferens medial to it. It’s a single highly coiled tube packed with fibrous tissue. Has a head, body and tail. Head is attached to the upper pole of the testes by the vas efferentia while the tail to lower pole by loose connective tissue. The body is separated from the testis by a recess which is open laterally, the sinus of the epididymis. The sinus is lined by the tunica v aginalis which also covers the lateral surface.

70. ANATOMY OF THE VAS DEFERENS Vas deferens is a direct continuation of the tail of the epididymis, with a thick wall of smooth muscle that passes up medially. It enters the spermatic cord, passes through the inguinal canal, across the pelvic side wall just under the peritoneum and crosses the pelvic cavity. It pierces the prostate and opens up into the prostatic urethra by the ejaculatory duct.

71. EPIDIDYMIS AND VAS DEFERENS Blood and nerve supply; same as for the testes. Structure: epithelial lining is made of columnar cells with long microvilli called Stereocillia . The wall is thin and has one layer of circular smooth muscle cells.

72. CLINICAL CORRELATES Vasectomy: The spermatic cord containing the firm tubular vas is palpated between the thumb and fingers at the top of the scrotum and a transverse incision made so that the vas can be dissected out and a small length of it removed. Each remaining cut end is turned back on itself and ligated, and the same procedure is then carried out on the opposite side.

73. Enjoy anatomy & Thank you for listening!!