INGUINAL

REGION
with question

Asso Prof Dr G M
Kibria
UPNM6
17/2/17
9/20/17 1
 Learning objectives
At the end of this session you should be able to
1. describe the inguinal ligament.
a. Formation
b. Bony attachments
c. Importance
2. describe the inguinal rings & their surface markings.
3. describe the inguinal canal.
a. Location, extension
b. Floor, roof, anterior wall, posterior wall
c. Contents/ spermatic cord, spermatic fascia
d. Mechanism of inguinal canal
4. describe the inguinal hernia.

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 Understanding for the inguinal canal

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 1
ve INGUINAL LIGAMENT
cti
je
Ob

Formation: Lower border of

external oblique aponeurosis.
Attached to anterior-superior iliac
spine & to pubic tubercle.
Forms the floor of inguinal canal.

Femoral vessels & nerve pass deep

to this ligament.
Inguinal
ligament
Internal oblique & transversus Ex. Oblique
abdominis take origin from its aponeurosis
lateral part.

? Mid-inguinal point
?Midpoint of inguinal ligament
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 1
ve
cti
je
Ob

Q. How the inguinal ligament is formed?

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 1
ve
cti
je
Ob

Lacunar ligament & pectineal

ligament are the extensions
of inguinal ligament
Q. How the inguinal
ligament is formed?
Q. What are its bony
attachments?

Inguinal lig.
Lacunar lig. Pectineal lig.
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 al

2
ui n
ve
ep Inf
cti
In g iga eri
str or
je

ial ic a
Ob

c rte
e rf ry
Su p i n gs
nd r
p a

g
e in p
De rin
g u ee
al
In D
al al
in ci
g
rin
f
gu r
In upe
S

Deep inguinal ring:

In fascia transversalis, immediately lateral to inferior epigastric artery.
Internal spermatic fascia is the extension of fascia transversalis.
Surface marking: Situated 1.2 cm above mid-inguinal point.
Superfcial inguinal ring:
In external oblique aponeurosis. External spermatic fascia is its extension.
Surface marking: Situated just above the pubic tubercle.
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 3
ve Inguinal canal
cti
je
Ob

Passage situated just above

the medial half of inguinal
ligament.
From deep inguinal ring to
superfcial inguinal ring. Deep inguinal ring

Length: 4 cm long
Superficial
In infants: canal is shorter, inguinal ring
less oblique & both the
rings almost overlaps.
So inguinal hernia is
common in infant.
In male the canal is wider
than in female, & thus
inguinal hernia is more in
male than in female.
9/20/17
(Remember the layers in the abdominal wall)8
 Ob
Ductus deferens

je
Genital branch of GF nerve

cti
ve
Testicular vessels

3
Fs. Transversals

Ex Ob
Aponeurosis

Contains of inguinal canal:

spermatic cord (or round
ligament in female) & its
covering fascia
genital branch of
genitofemoral nerve
ilioinguinal nerve. Testis

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Q. Superficial inguinal ring is the opening in _____ _____
Q. Deep inguinal ring is the opening in _____ _____
Q. What is the location of superficial inguinal ring in
relation to the pubic tubercle?
Q. What is the location of deep inguinal ring in relation to
the inguinal ligament?

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 e3
Ob
jec
ti v
Boundary of inguinal canal
Anterior wall:

e
bliqu
Skin

nal o
Superfcial fascia
Co

Inter
n
External oblique aponeurosis of joint
i
tra ntern tendo
Internal oblique muscle nsv al
ers ob. n

Arc rnal s abd

Tra
us &

Int vers
reinforces the lateral part of a b.

he obl om
e
ns

d f iqu in
anterior wall.

be e & is
u

rs
Posterior wall:

of
Parietal peritoneum
Extraperitoneal tissue
Fascia transversalis

Conjoint tendon of internal oblique & transversus

abdominis reinforces the medial part.
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 3
Rela
ve
abd x
om ation o
cti
inal
je
f
Ob

mu
scle
Roof:
Arched fbres of
internal oblique &
transversus abdominis
muscles
Floor: Con
Inguinal ligament abd tracti
om
inal on of
Lacunar ligament mu
scle

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 3
cti
je
ve Mechanism of inguinal canal during increased
intra-abdominal pressure
Ob

Deep & superfcial rings do not overlap in adult. Consequently,

increased intra-abdominal pressure presses the posterior wall of
the canal against the anterior wall.
Contraction of external oblique approximates the anterior wall
to the posterior wall. It also increases tension on medial &
lateral crura resisting the dilation of superfcial ring.
Contraction of the arched musculature of the roof of the canal
makes the roof descend, constricting the canal.

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Q. How the floor, roof, anterior wall & posterior wall of
inguinal canal are formed?
Q. What are the contents of inguinal canal?
Q. What is the clinical importance of inguinal canal?
Q. Explain the mechanism of inguinal canal.
How does it help to prevent the hernia?

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 3
ve
cti
Coverings of spermatic cord
je
Ob

Internal spermatic fascia: extension from fascia

transversalis
Cremasteric fascia: extension of muscle fbers from lower
part of internal oblique muscle
External spermatic fascia: extension from external
oblique aponeurosis

Q. What are the contents of spermatic cord?

Q. What are the coverings of the spermatic cord?

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 3
ve
Cremasteric reflex
cti
je
Ob

Lightly stroking the skin on the medial aspect of upper

thigh Contraction cremaster muscle & elevation of testis.
Sensory supply of this area of thigh is by Ilioinguinal nerve
(L1) & femoral branch of genitofemoral nerve (L1-2).
Cremaster motor supply is by genital branch of
genitofemoral nerve (L1-2).
This reflex is extremely active in children.

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 4
ve Inguinal hernia
cti
je
Ob

Abnormal protrusion of parietal peritoneum & abdominal

viscera into inguinal canal.
More common in male than in female.
Commonly associated with frequent increased intra-
abdominal pressure.

Two types: Direct & indirect inguinal hernia. Two third are
indirect hernia.
Viscera that herniate is called the content.
The peritoneal covering is the hernial sac.
Other layers lying external to sac are the coverings of hernia.

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 4
ve
Direct hernia Indirect hernia
cti
je
Ob

Inferior epigastric

ct
ire
ct
vessels

d
e

In
Dir

Peritoneal
bulge

Peritoneal sac
lateral medial

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 Ob
jec
Coverings of inguinal tiv
e4
hernia
Indirect hernia:
peritoneum & all three
spermatic fascia,
superfcial fascia, skin.

Direct hernia:
peritoneum, fascia
transversalis, cremasteric
fascia &/or external
spermatic fascia,
superfcial fascia, skin.

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 Ob
jec
Difference between direct & indirect hernia tiv
e4

Direct inguinal hernia: Indirect inguinal hernia:

Acquired, incidence is to .
Due to weakness of anterior
abdominal wall, e.g., distended
superfcial ring, narrow conjoint
tendon, attenuated aponeurosis.
Common in old male (>40yrs).
Passes through posterior wall of
inguinal canal (medial part).
Congenital, incidence is to
(Moore).
Due to patency of processus
vaginalis.
In infant inguinal canal is less
oblique & 2 rings almost
overlap each other, so this
hernia common in young
male.
Passes through deep
inguinal ring, whole length
of canal.

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Difference (contd.)
Direct inguinal hernia:
Coverings: peritoneum,
fascia transversalis, outer
one or two fascial
coverings of spermatic
cord.
Rarely enters scrotum.
9/20/17
Ob
jec
tiv
e4
Indirect inguinal hernia:
Coverings: peritoneum & all
three spermatic fascia.
Exit via superfcial ring,
commonly passing into scrotum
(complete hernia).
Funicular hernia: contents lie above
the testis.
Bubonocele: hernia confned to the
inguinal canal.
22
Questions.
1. What is hernia?
2. Inguinal hernia is common in ______
3. Why inguinal hernia is more in male than in female?
4. What are the 2 types of inguinal hernia?
5. What are the difference between direct & indirect
inguinal hernia?
6. Why indirect inguinal hernia in more in infant?
7. How the hernial sac is formed?
8. What are the coverings of direct & indirect inguinal
hernia?

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 ?

TQ

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