Day Before yesterday March 19, 2015, 81 years old diabetic Egyptian patient complaining of bilateral painless swelling in the groin areas and marked scrotum swelling. Condition started 15 years ago. Patient also has right lower limb edema as a result of cardiac problem and Dyspnea as respiratory problem.
Both swelling increases during cough, visible and palpable but irreducible. Scrotum is full with intestinal contents. Scrotum is hot and red. The case most probably is bilateral indirect inguinal hernia. Shown On the pictures below
Definition of hernia: it is protrusion of viscera or viscus through a defect into sac characterized by expansile impulse on cough defined as hernia.
On physical examination, the internal ring test revealed no protrusion of contents during cough while ring is obstructed by index finger 1/2 inch above from mid inguinal point. When ring is free, contents come out during cough. The inguinal ring test positive indicates Indirect or oblique inguinal hernia. Characters of it, during cough contents pass upward, forward, and medially up to scrotum.
External ring test for it: after reduction of contents into abdomen, put your little finger in the external ring, the ring very narrow, it just admits your little finger then ask the patient to cough if the contents hit the tip of your finger, it is indirect inguinal hernia but if hit the medial side of your little finger, it is direct inguinal hernia.
what is internal ring, and why?
It is an opening point to transverse fascia of deep abdominal muscle, in where testes come out outside the abdomen through that ring like opening. So it forms a canal called inguinal canal. Inguinal canal contains spermatic cords and nerve fibers.
What is mid inguinal point? It is mid way between pubic tubercle and anterior superior iliac spine. 1/2 inch above it, the location of internal ring. Look at pictures down;
Abdominal muscles layers from superficial to deep in the inguinal area :
1. Skin,
2. Superficial fascia,
3. External oblique muscle,
4. Internal oblique muscle,
5. Transversus abdominis, and
6. Fascia transversalis. Then there is peritoneum. The contents protrude into ring through defect with peritoneum and form the peritoneal pouch within inguinal canal. Contents could be reduced but peritoneal pouch can not be reduced by clinically. Pictures..
Origins: from iliac crest, inguinal ligament, and ribs.
Insertion: to xiphoid process, linea alba, pubic tubercle and iliopectineal line. Remember all layers are fleshy fibers except superficial fascia and skin.
Halfway between pubis symphysis and ASIS is called midpoint of inguinal canal.
A point that is exactly at middle of inguinal ligament is termed 'midpoint of inguinal ligament. 1/2 inch above it, there is a ring called internal ring.
About inguinal canal: it has two openings deep and superior, any circular opening looks like a ring so it is called deep ring but it is in the inguinal area that is why its name is deep inguinal ring or internal ring and it has end second opening at superior is termed superior or external ring or openings.
Boundaries of inguinal canal:
The inguinal canal is made up of:
1. Anterior and posterior walls
2. Superficial and deep rings (openings)
3. Roof and floor (or superior and inferior walls)
We shall go through each component;
The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.
The posterior wall is formed by the transversalis fascia.
The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.
The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament. Look at the picture.
Development :
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The two openings to the inguinal canal are known as rings. The deep (internal) ring is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.
The superficial (external) ring marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening.
The inguinal canal is a short passage that extends inferiorly and medially, through the inferior part of the abdominal wall. It is superior and parallel to the inguinal ligament.
It acts as a pathway by which structures can pass from the abdominal wall to the external genitalia.
The inguinal canal also has clinical importance. It is a potential weakness in the abdominal wall, and therefore a common site of herniation.
Clinically it is important to note that the opening to the inguinal canal is located laterally to the inferior epigastric artery.
Development of the Inguinal Canal
In order to fully comprehend the anatomy of the inguinal canal, we must first look at its development, and the role the inguinal canal plays in the development of the genitalia. We shall explore the inguinal canal in the context of male development.
The descent and embryological development of the testes. Note that the processus vaginalis regresses after the descent of the testes
During development, the testes establish in the posterior abdominal wall, and descend into the scrotum. A fibrous cord of tissue called the gubernaculum attaches the inferior portion of the gonad to the future scrotum, and guides them during their descent.
The inguinal canal is the pathway by which the testes are able to leave the abdominal cavity and enter the scrotum. In the embryological stage, the canal is flanked by an outpocketing of the peritoneum, and the abdominal musculature. This outpocketing, the processus vaginalis, normally degenerates, but a failure to do so can result in an indirect inguinal hernia.
In women, there is also a gubernaculum, this attaches the ovaries to the uterus and future labia majora. Because the ovaries are attached to the uterus by the gubernaculum, they are prevented from descending as far as the testes, instead moving into the pelvic cavity. The gubernaculum then becomes the ovarian ligament, and round ligament of uterus.
‘Mid-Inguinal Point’ and ‘Midpoint of the Inguinal Ligament’
These two terms are mentioned frequently in this article, and are often (mistakenly) used interchangeably.
The mid-inguinal point is halfway between the pubic symphysis and the anterior superior iliac spine. The femoral artery crosses into the lower limb at this anatomical landmark.
The midpoint of the inguinal ligament is exactly as the name suggests. The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine, so the midpoint is halfway between these structures. The opening to the inguinal canal is located just above this point.
The inguinal canal is the pathway by which the testes are able to leave the abdominal cavity and enter the scrotum.
In the embryological stage, the canal is flanked by an outpocketing of the peritoneum, and the abdominal musculature. This outpocketing, the processus vaginalis, normally degenerates, but a failure to do so can result in an indirect inguinal hernia.
In women, there is also a gubernaculum, this attaches the ovaries to the uterus and future labia majora. Because the ovaries are attached to the uterus by the gubernaculum, they are prevented from descending as far as the testes, instead moving into the pelvic cavity. The gubernaculum then becomes the ovarian ligament, and round ligament of uterus.
‘Mid-Inguinal Point’ and ‘Midpoint of the Inguinal Ligament’
These two terms are mentioned frequently in this article, and are often (mistakenly) used interchangeably.
The mid-inguinal point is halfway between the pubic symphysis and the anterior superior iliac spine. The femoral artery crosses into the lower limb at this anatomical landmark.
The midpoint of the inguinal ligament is exactly as the name suggests. The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine, so the midpoint is halfway between these structures. The opening to the inguinal canal is located just above this point.
Boundaries
The inguinal canal is made up of:
1. Anterior and posterior walls
2. Superficial and deep rings (openings)
3. Roof and floor (or superior and inferior walls)
We shall go through each component..
The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.
The posterior wall is formed by transversalis fascia.
The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.
The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament.
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The two openings to the inguinal canal are known as rings. The deep (internal) ring is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.
The superficial (external) ring marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening.
In men, the spermatic cord passes through the inguinal canal, to supply and drain the testes. In women, the round ligament of uterus traverses through the canal.
The walls of the inguinal canal are usually collapsed around their contents, preventing other structures from potentially entering the canal and becoming stuck.
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The walls of the inguinal canal are usually collapsed around their contents, preventing other structures from potentially entering the canal and becoming stuck.
Treatment: prevention is the most important, we prevent the risk factors e.g. COPD, smoking, anything that increases intra abdominal pressure.
Mainly surgical, either herniotomy, or hernioplasty, or herniorrhaphy. It depends on........
Both swelling increases during cough, visible and palpable but irreducible. Scrotum is full with intestinal contents. Scrotum is hot and red. The case most probably is bilateral indirect inguinal hernia. Shown On the pictures below
Definition of hernia: it is protrusion of viscera or viscus through a defect into sac characterized by expansile impulse on cough defined as hernia.
On physical examination, the internal ring test revealed no protrusion of contents during cough while ring is obstructed by index finger 1/2 inch above from mid inguinal point. When ring is free, contents come out during cough. The inguinal ring test positive indicates Indirect or oblique inguinal hernia. Characters of it, during cough contents pass upward, forward, and medially up to scrotum.
External ring test for it: after reduction of contents into abdomen, put your little finger in the external ring, the ring very narrow, it just admits your little finger then ask the patient to cough if the contents hit the tip of your finger, it is indirect inguinal hernia but if hit the medial side of your little finger, it is direct inguinal hernia.
what is internal ring, and why?
It is an opening point to transverse fascia of deep abdominal muscle, in where testes come out outside the abdomen through that ring like opening. So it forms a canal called inguinal canal. Inguinal canal contains spermatic cords and nerve fibers.
What is mid inguinal point? It is mid way between pubic tubercle and anterior superior iliac spine. 1/2 inch above it, the location of internal ring. Look at pictures down;
Abdominal muscles layers from superficial to deep in the inguinal area :
1. Skin,
2. Superficial fascia,
3. External oblique muscle,
4. Internal oblique muscle,
5. Transversus abdominis, and
6. Fascia transversalis. Then there is peritoneum. The contents protrude into ring through defect with peritoneum and form the peritoneal pouch within inguinal canal. Contents could be reduced but peritoneal pouch can not be reduced by clinically. Pictures..
Origins: from iliac crest, inguinal ligament, and ribs.
Insertion: to xiphoid process, linea alba, pubic tubercle and iliopectineal line. Remember all layers are fleshy fibers except superficial fascia and skin.
Halfway between pubis symphysis and ASIS is called midpoint of inguinal canal.
A point that is exactly at middle of inguinal ligament is termed 'midpoint of inguinal ligament. 1/2 inch above it, there is a ring called internal ring.
About inguinal canal: it has two openings deep and superior, any circular opening looks like a ring so it is called deep ring but it is in the inguinal area that is why its name is deep inguinal ring or internal ring and it has end second opening at superior is termed superior or external ring or openings.
Boundaries of inguinal canal:
The inguinal canal is made up of:
1. Anterior and posterior walls
2. Superficial and deep rings (openings)
3. Roof and floor (or superior and inferior walls)
We shall go through each component;
The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.
The posterior wall is formed by the transversalis fascia.
The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.
The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament. Look at the picture.
Development :
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The two openings to the inguinal canal are known as rings. The deep (internal) ring is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.
The superficial (external) ring marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening.
The inguinal canal is a short passage that extends inferiorly and medially, through the inferior part of the abdominal wall. It is superior and parallel to the inguinal ligament.
It acts as a pathway by which structures can pass from the abdominal wall to the external genitalia.
The inguinal canal also has clinical importance. It is a potential weakness in the abdominal wall, and therefore a common site of herniation.
Clinically it is important to note that the opening to the inguinal canal is located laterally to the inferior epigastric artery.
Development of the Inguinal Canal
In order to fully comprehend the anatomy of the inguinal canal, we must first look at its development, and the role the inguinal canal plays in the development of the genitalia. We shall explore the inguinal canal in the context of male development.
The descent and embryological development of the testes. Note that the processus vaginalis regresses after the descent of the testes
During development, the testes establish in the posterior abdominal wall, and descend into the scrotum. A fibrous cord of tissue called the gubernaculum attaches the inferior portion of the gonad to the future scrotum, and guides them during their descent.
The inguinal canal is the pathway by which the testes are able to leave the abdominal cavity and enter the scrotum. In the embryological stage, the canal is flanked by an outpocketing of the peritoneum, and the abdominal musculature. This outpocketing, the processus vaginalis, normally degenerates, but a failure to do so can result in an indirect inguinal hernia.
In women, there is also a gubernaculum, this attaches the ovaries to the uterus and future labia majora. Because the ovaries are attached to the uterus by the gubernaculum, they are prevented from descending as far as the testes, instead moving into the pelvic cavity. The gubernaculum then becomes the ovarian ligament, and round ligament of uterus.
‘Mid-Inguinal Point’ and ‘Midpoint of the Inguinal Ligament’
These two terms are mentioned frequently in this article, and are often (mistakenly) used interchangeably.
The mid-inguinal point is halfway between the pubic symphysis and the anterior superior iliac spine. The femoral artery crosses into the lower limb at this anatomical landmark.
The midpoint of the inguinal ligament is exactly as the name suggests. The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine, so the midpoint is halfway between these structures. The opening to the inguinal canal is located just above this point.
The inguinal canal is the pathway by which the testes are able to leave the abdominal cavity and enter the scrotum.
In the embryological stage, the canal is flanked by an outpocketing of the peritoneum, and the abdominal musculature. This outpocketing, the processus vaginalis, normally degenerates, but a failure to do so can result in an indirect inguinal hernia.
In women, there is also a gubernaculum, this attaches the ovaries to the uterus and future labia majora. Because the ovaries are attached to the uterus by the gubernaculum, they are prevented from descending as far as the testes, instead moving into the pelvic cavity. The gubernaculum then becomes the ovarian ligament, and round ligament of uterus.
‘Mid-Inguinal Point’ and ‘Midpoint of the Inguinal Ligament’
These two terms are mentioned frequently in this article, and are often (mistakenly) used interchangeably.
The mid-inguinal point is halfway between the pubic symphysis and the anterior superior iliac spine. The femoral artery crosses into the lower limb at this anatomical landmark.
The midpoint of the inguinal ligament is exactly as the name suggests. The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine, so the midpoint is halfway between these structures. The opening to the inguinal canal is located just above this point.
Boundaries
The inguinal canal is made up of:
1. Anterior and posterior walls
2. Superficial and deep rings (openings)
3. Roof and floor (or superior and inferior walls)
We shall go through each component..
The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.
The posterior wall is formed by transversalis fascia.
The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.
The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament.
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The two openings to the inguinal canal are known as rings. The deep (internal) ring is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal.
The superficial (external) ring marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening.
In men, the spermatic cord passes through the inguinal canal, to supply and drain the testes. In women, the round ligament of uterus traverses through the canal.
The walls of the inguinal canal are usually collapsed around their contents, preventing other structures from potentially entering the canal and becoming stuck.
During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the inguinal canal. To prevent herniation, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal.
The walls of the inguinal canal are usually collapsed around their contents, preventing other structures from potentially entering the canal and becoming stuck.
Treatment: prevention is the most important, we prevent the risk factors e.g. COPD, smoking, anything that increases intra abdominal pressure.
Mainly surgical, either herniotomy, or hernioplasty, or herniorrhaphy. It depends on........
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