1. By Prof. Saeed Abuel Makarem
Inguinal Region By
Prof. Saeed Abuel Makarem

2. GROIN OR INGUINAL REGION
The groin or the inguinal region, extending between the ASIS and pubic tubercle.
It is a very important area surgically and anatomically where structures enter and exit the abdominal cavity
It is a potential site for herniation.
In fact, the majority of all abdominal hernias, occur in this region in particular the Inguinal hernia, which account for % of all abdominal hernias.

3. Its length is about one & half inches (4 cm) in adult.
Inguinal Canal
It is an oblique intramuscular slit in the lower medial part of the Anterior Abdominal Wall.
It runs just above and parallel to the medial part of the inguinal ligament.
Its length is about one & half inches (4 cm) in adult.
Its gives a passage for the spermatic cord in male, or round ligament of the uterus in female.
Also it gives a passage for the Ilioinguinal nerve in both sexes.

4. Extends from the deep inguinal ring to the superficial inguinal ring
In the newborn child, the deep ring lies almost directly posterior to the superficial ring
The deep inguinal ring is an oval opening lies in the fascia transversalis
It lies ½ inch just above the midpoint of the inguinal ligament
Its margin gives attachment to the internal spermatic fascia.
Inguinal Canal

7. Deep inguinal ring
Superficial inguinal ring
External oblique
Medial
Lateral

8. Boundaries of the Inguinal canal
Ant. Wall: External oblique along whole length
Internal oblique along lateral half.
Post. Wall: Fascia Transversalis along whole length.
Conjoint tendon (inguinal falx) along
the medial part.
Reflected ligament along medial ¼.
Floor: Inguinal ligament supported medially by
Lacunar ligament.
Roof: Arching lower fibers of internal oblique.

9. The anterior wall is reinforced laterally 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
The posterior wall is reinforced medially by the conjoint tendon.
This wall is strongest where it lies opposite the weakest part of the anterior wall, that is superficial inguinal ring

10. Collection of structures that traverse the inguinal canal and pass to and from the testis
Covered by three layers of fascia derived from the layers of the abdominal wall
Begins at the deep inguinal ring, lateral to the inferior epigastric vessels, and ends at the testis
Spermatic Cord

11. Contents of the Spermatic Cord
1- Vas deferens:
Thick muscular tube transmitting sperms from the epididymis to the urethra
2- Arteries:
A -Testicular artery (branch of abdominal aorta)
B-- Cremasteric artery (branch of inferior epigastric artery)
C-- Artery of the vas deferens (branch of inferior vesical artery)
3- Veins:
Pampinioform plexus draining testis, continues as a single testicular vein, in the deep inguinal ring which drains into the inferior vena cava on right and into left renal vein on the left side

12. Contents of the Spermatic Cord
4- Lymphatics:
Draining testis, pass through inguinal canal and drain into para-aortic lymph nodes.
5- Nerves:
A. Autonomic nerves from renal and aortic plexuses, run with testicular artery
B - Genital branch of the genitofemoral nerve, which supplies the Cremasteric muscle
6- Remains of the
processus vaginalis

14. Coverings of the Spermatic Cord
Internal spermatic fascia, derived from the fascia transversalis
Cremasteric muscle and fascia: derived from the internal oblique muscle.
External spermatic fascia, derived from the external oblique aponeurosis

15. Male External Genitalia

16. Scrotum It is an out- pouch of the anterior abdominal wall
Formed of two pouches, fused in the midline
Contains testis, epididymis and lower part of the spermatic cord
Wall has following layers:
Skin
Dartos muscle
External spermatic fascia
Cremesteric fascia
Internal spermatic fascia
Tunica vaginalis
Scrotum

17. Scrotum Skin is thin & wrinkled
Superficial fascia continuous with the fatty & membranous layers of the abdominal wall
In the fatty layer, fat is replaced by dartos muscle, a smooth muscle supplied by sympathetic nerves and responsible for wrinkling of skin of the scrotum

18. Scrotum Tunica vaginalis: Membranous layer is called Colle’s fascia
It is continuous with the Scarpa’s fascia of the anterior abdominal wall
External spermatic fascia
Cremasteric muscle and fascia
Internal spermatic fascia
Tunica vaginalis:
Closed sac, derived from peritoneal cavity, covers the anterior, medial and lateral surfaces of testis

19. Testis Mobile primary sex organ, lies in the scrotum
Left usually lies at a lower level than right
Each testis is surrounded by tough fibrous capsule, the tunica albuginea
Septae extending from capsule dividing the testis into lobules, which contain seminiferous tubules
Tubules open into rete testis, which are connected to epididymis through efferent ductules
Testis

20. 20 feet long, coiled tube, embeded in connective tissue forming a firm structure
Lies posterior to testis and lateral to vas deferens
Has head, body and tail.
Tail continues with the vas deferens
Is separated from the testis laterally by a groove lined by visceral layer of tunica vaginalis, called sinus of epididymis
It is called sinus of epididymis
Epididymis is the storage and maturation space for the spermatozoa
Epididymis

21. Lymphatic Drainage of Scrotum & Its contents
Skin, fasciae ,and tunica vaginalis:
drain into superficial inguinal lymph nodes
Testis and epididymis: drain into lumbar (para-aortic) lymph nodes.

22. Clinical Notes Undescended testis
Anomalies of the processus vaginalis:
Hydrocele
Encysted Hydrocele
Hernias
Tapping of Hydrocele

23. Hernia is the protrusion of part of abdominal viscera beyond the normal confines of the abdominal walls
It has three parts:
The sac
Contents of the sac
Coverings of the sac
Hernia

24. Hernia: Types Inguinal: direct or indirect Epigastric
Umbilical: congenital (Omphalocele) or acquired
Inguinal:
direct or indirect
Femoral
Incisional
Semilunar
Hernia: Types

25. Hernia: Types Diaphragmatic or Hiatal Lumbar Or (Petit’s triangle)
Obturator

26. Herniation of the abdominal viscera (usually small intestinal coils) through the inguinal region
It is of two type:
Direct
Indirect
Inguinal Hernia

27. Indirect Or oblique Inguinal hernia
Most common form of hernia
Most common in children & young adults
About 20 times more common in male than in female
1/3rd are bilateral
More common on the right side

29. Indirect Inguinal hernia
Hernial sac:
Formed of remains of processus vaginalis
Enters inguinal canal through deep ring
Lies lateral to the inferior epigastric artery
Can be complete, extending to the scrotal sac, or incomplete, arrested in the inguinal canal
Indirect Inguinal hernia

30. Direct Inguinal hernia
About 15% of inguinal hernia,
Rare in females
Common in old men with weak abdominal muscles
Hernial sac:
Bulges directly through the posterior wall of the inguinal canal i.e.through the inguinal (Hasselbach’s) triangle. This triangle is bounded medially by lateral edge of rectus abdominis muscle, laterally by inferior epigastric artery, infeiorly by inguinal ligament.
Lies medial to the inferior epigastric vessels
Usually nothing more than a generalized bulge
Direct Inguinal hernia

32. DIRECT INGUINAL HERNIA OBLIQUE INGUINAL HERNIA

33. Femoral Hernia
Protrusion of abdominal viscera through the femoral ring into the upper part of the thigh
More common in women (wider femoral ring)
Neck of the sac lies below and lateral to the pubic tubercle

34. Relation of inguinal & femoral hernial sacs to pubic tubercle
sac lies above and medial to the pubic tubercle
Femoral:
sac lies below and lateral to the pubic tubercle

35. Management
Reduction of hernia (pushing the contents and the sac back to the abdominal cavity)
Repair of the weakness in the abdominal wall