The Inguinal Canal

The path of descent of the testis carries it

obliquely through the anterior
abdominal wall, creating a passageway
Drawing of the inguinal
oriented in an inferomedial direction –
region, anterior view,
the inguinal canal. showing location of the
inguinal canal and
The entrance into the inguinal canal is the spermatic cord, from
deep inguinal ring, which can only be textboo
observed from the deep side of the
anterior wall.

The exit from the canal is through the

superficial inguinal ring which is seen on
the external side of the wall muscles.
In the male, the vas deferens and testicular vessels pass from one
end of the canal to the other. The covering layers of these
structures, the spermatic cord, forms from the abdominal wall
layers during descent.
 Building the Inguinal Canal
Transversalis fascia

Remember that the transversalis fascia Drawing of the transversalis

lies just outside of the parietal fascia layer, deep ring and
peritoneum. Descent pulls some of the internal spermatic fascia, from
textbook
transversalis fascia out as a tube,
covering the testis, vas deferens and
vessels. This is then the innermost
layer of the spermatic cord, the
internal spermatic fascia.

The internal end of the canal, the deep

ring, is therefore where the
transversalis fascia reflects out to form
the tube of internal spermatic fascia.
 Building The Inguinal Canal

Transversus abdominis
Drawing of the transversus
The testis skims under the inferior abdominis layer and its non-
edge of the transversus abdominis involvement in the spermatic
muscle and does not pick up this cord, from textbook
layer during descent. Therefore the
spermaric cord and testis coverings do
not include this layer.
 Building The Inguinal Canal
Internal oblique
During descent, the testis and pulls
out this layer as a tube which will lie
outside of the transversalis fascia Drawing of the internal
layer. This becomes the cremasteric oblique muscle and the
cremasteric fascia of the
fascia.
spermatic cord, from
Within this fascia is a substantial textbook
amount of muscle, the cremaster
muscle.
The cremaster mediates the reflex
retraction of the testis towards the
body in response to cold temperature
or cutaneous touch sensation.
Testing the cremaster reflex is
part of a complete physical exam
in the male.
 Building The Inguinal Canal
External oblique

The descending testis also pulls the

external oblique layer out as a tube
covering the deeper layers. This will Drawing of the external
become the external spermatic fascia. oblique muscle and the
The site of reflection of the external external spermatic fascia,
oblique onto the spermatic cord (i.e., from textbook
where the spermatic cord extends away
from the abdominal wall, toward the
scrotum) is the site of the superficial
inguinal ring.

The superficial ring is more or less

triangular shaped. Two sides of this
triangle are the medial crus and lateral crus
of the external oblique aponeurosis. This
relatively weak area of the aponeurosis is
spanned by intercrural fibers that keep the
crura from separating.
The Complete Inguinal Canal

Drawing of the dissected

inguinal canal formed from
individual layers of the
anterior abdominal wall,
from atlas
 Coverings of the Spermatic Cord and Testis
External spermatic fascia – derived from
the external oblique layer

Cremasteric fascia with the cremaster
muscles – derived from the internal
oblique layer
Internal spermatic fascia – derived from Drawing of the abdominal wall
contributions to the spermatic
the transversalis fascia
cord, from textbook
The transversus abdominis does not
contribute to the coverings. The parietal
peritoneum, as the parietal tunica
vaginalis, is normally isolated from the
main peritoneal sac and is not present in
the cord.
Important relationship – the deep ring
lies immediately lateral to the inferior
epigastric vessels
Descent of the Ovary and Female Inguinal Canal

Drawing of three steps in the

descent of the ovaries and
remnants of the gubernaculum in
females, from embryo textbook

The gubernaculum is attached to the ovary superiorly, to the labia majora inferiorly
and to the paramesonephric ducts.
The gubernaculum does not regress (due to a lack of androgen stimulus), so the
ovary only descends to the pelvic cavity.
The leftover gubernaculum becomes the round ligament of the uterus and round
ligament of the ovary.
The round ligament of the uterus passes through the inguinal canal, with a
rudimentary processus vaginalis.
Descent of the Ovary and the Female Inguinal Canal

The round ligament of the uterus

follows the same path as the vas
deferens through the deep ring,
inguinal canal and superficial ring, but Drawing of the female
inguinal region and
is NOT an homologous structure. uterus showing the
round ligaments of the
In dissection it is often very difficult to uterus and ovary, from
find the round ligament passing out of textbook
the superficial ring.
Inguinal Hernias and Hesselbach’s Triangle
A hernia is a protrusion of the
peritoneal sac (with or without
abdominal contents) through a
weakened area of the abdominal wall.
The inguinal region is an inherently Drawing of the internal side of
weak area of the abdominal wall and is inguinal region showing the deep
ring and Hesselbach’s triangle,
the most common site of abdominal
from textbook
hernias.

In addition to being painful, there is a

danger of strangulation of a portion
of the GI tract trapped in the hernial
sac.

Inguinal hernias can occur in two

different ways. These are termed
direct and indirect inguinal hernias.
Inguinal Hernias and Hesselbach’s Triangle
Hesselbach's triangle is an important
landmark on the internal side of the
abdominal wall that is relevant to the
two types of inguinal hernias.
Drawing of the internal
The triangle is situated medial to side of inguinal region
inferior epigastric artery, lateral showing the deep ring
and Hesselbach’s
to the rectus abdominis and triangle (same as
superior to inguinal ligament. previous slide)

The deep ring passageway of the

vas deferens and testicular vessels,
or round ligament of the uterus, is
therefore lateral to Hesselbach’s
triangle. The iliac vessels pass
from the abdomen to the thigh
inferior to the triangle.
 Indirect Inguinal Hernia
Drawing of the internal side
of inguinal region showing
the deep ring and
Hesselbach’s triangle (same
as previous slide)
Drawing of section through
abdominal wall and scrotum
in a person with an indirect
hernia showing relation to the
inferior epigastric artery
[Google]

An indirect hernia pushes into the remnant of the processus vaginalis. This occurs
when the processus vaginalis does not completely close. This type of hernia is much
more common in males and because it is congenital shows up very often in
younger boys.
The peritoneal hernia sac and any abdominal contents passes through the deep ring
and so passes lateral to Hesselbach’s triangle. The hernia sac will be covered by
all layers of the spermatic cord.
Indirect hernias often traverses the entire inguinal canal and enter the scrotum
scrotum, still within processus vaginalis.
Indirect Inguinal Hernia

Drawing of an indirect hernia in a

dissected inguinal region, from
clinical anatomy atlas
 Direct Inguinal Hernia
Drawing of the dissected
inguinal region showing the
conjoint tendon with
Hesselbach’s triangle added
(same base image as slide 23)
Drawing of section through
abdominal wall and scrotum in a
person with an indirect hernia
showing relation to the inferior
epigastric artery (same style as
slide 28) [Google]

With age or injury, the aponeuroses of the lower abdominal wall muscles can
become weakened. This usually occurs within Hesselbach’s triangle, creating a
weak sport where a hernia sac simply pushes through the posterior wall of the
inguinal canal. The herniation either pushes all of the layers out as a bulge on
the abdominal wall or slips between the conjoint tendon and inguinal
ligament into the canal.
Most often, direct hernias are confined to the inguinal canal, but can sometimes
extend through the superficial ring. If it does so, it will be covered by only the
external spermatic fascia layer and lie medial to the rest of the spermatic cord.
 Other Abdominal Hernias

Drawing of umbilical, incisional, epigastric and Spigellian hernias ,

surface appearance and at the level of the abdominal wall muscles,
from clinical anatomy atlas

Umbilical hernias are located at or near the umbilicus. They can occur as a
developmental defect or be acquired later in life.
Congenital umbilical hernias are due to incomplete closure of the abdominal
wall after retraction of the midgut
Acquired umbilical hernias are more properly called paraumbilical hernias,
since they are ususally just above or below the umbilicus. These result from
weakening of the fascia around the umbilicus due to stretching of the wall
during pregnancy, obesity or accumulation of fluid in the abdomen.
 Other Abdominal Hernias

Drawing of umbilical, incisional, epigastric and Spigellian hernias ,

surface appearance and at the level of the abdominal wall muscles
(same as previous slide)

Hernia of the linea alba (epigastric hernia) – the hernia passes through a
weakened linea alba at some point between the xiphoid and umbilicus.

Spigelian hernia - the hernia passes under the arcuate line and between the
edge of the rectus abdominis and rectus sheath aponeuroses.

Incisional hernia – these can occur anywhere a surgical incision has left the
muscle layers weak.
 Femoral Hernias
The femoral canal is a space between the
lateral edge of the lacunar ligament
and the external iliac vein and inferior
to the inguinal ligament. Normally, this
space is filled with fat and lymphatic
vessels. Drawing of the internal side of
inguinal region showing the
A hernia sac of parietal peritoneum, with deep ring and Hesselbach’s
or without bowel, can be forced into the triangle (same base image as
slide 27) with the femoral canal
femoral canal and out into the upper
color-highlighted
thigh. A femoral hernia will be covered
only by peritoneum and transversalis
fascia.
Because females have a wider pelvis
and hence a larger femoral canal than
males, femoral hernias are most
common in middle-aged and elderly
women.
Abdominal Topography - Quadrants

Simple drawing of the

trunk with abdominal Photo of man with
contents and median and quadrants delineated and
transumbilical planes key organs ghosted in, from
drawn to demonstrate textbook
quadrants, from textbook

When referring to the abdomen and its contents, it is most common and useful to divide the
abdomen into four areas or quadrants: right upper, left upper, right lower and left lower.

The horizontal division passes through the umbilicus and the L3-4 intervertebral disc. The
vertical division is of course the median sagittal plane.

It is important to know what is typically found in each quadrant. As you progress in your
study of the abdomen, relate structures you learn to their quadrant. Realize that some organs
are variable in size and location or may be mobile within the abdominal cavity.
Abdominal Topography – Nine Regions

Another way of describing the

abdomen is to split it into nine regions.
The vertical divisions are made along Simple drawing of the trunk
the mid-clavicular lines. with abdominal contents
and the nine abdominal
The horizontal divisions are made at regions delineated, from
the subcostal plane (i.e., the bottom textbook
edge of rib cage) and intertubercular
plane (i.e., a line between the right and
left iliac tubercles).
Abdominal Topography – Nine Regions
The nine regions are:
Epigastric region
Right and left hypochondrium
Umbilical region
Simple drawing of the trunk
Right and left flank (lumbar with abdominal contents
region) and the nine abdominal
regions delineated (same
Pubic region (hypogastric region) as previous slide)
Right and left groin (inguinal
region)
Although the nine regions are not used as
often as simple quadrants, its still
worthwhile to know the regions and what
structures are found in them. In addition to
localizing structures, both quadrants and
the nine regions are used diagnostically in
interpreting referred pain.