Download - Surgical anatomy of inguinal hernia
Surgical anatomy of Inguinal hernia
Zeeshan
Hernia
• A condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it.
• Incidence: 25% in males and 2% in females
• 75% of hernias- groin hernias
• 2/3rd indirect and 1/3rd direct.
History of inguinal hernia
• Greek (hernios): bud
• or offshoot.
• Taxis for reduction of
incarcerated hernias
Inflating, inverting and shaking the patient
• Pt with strangulated inguinal hernia
• Purgatives / enemas of no avail
• Following use of “bellows” patient screams
“ YOU ARE BLOWING UP MY PURSE”
• Scrotum was distended with air
• Treatment of groin hernias are divided into 5 epochs.
• Oldest epoch- ancient era from ancient egypt till 15th century
• 19 – 20th century: Era of hernia repair under tension
- Antiseptic/aseptic precautions
- High ligation of hernial sac
- Narrowing of superificial inguinal ring
• Bassini : Repair of posterior wall of inguinal canal
• Shouldice : Imbrication of transverse fascia and strengthening of posterior wall of inguinal canal – 4 layer technique
• Currently – Era of tension free hernia repair.
Anterior abdominal wall
• External oblique aponeurosis:
- Origin:
• 8 fleshy strips from the outer surface and lower border of lower 8 ribs
- Insertion:
• Anterior half of outer lip of iliac crest
• Pubic tubercle
• Pubic crest and pecten pubis
• Linea alba
External oblique
Inguinal ligament
• Known as ?? Poupart’s ligament
- Thickened lower free border of external oblique aponeurosis
- Extent: Anterior superior iliac spine to pubic tubercle
Modifications of inguinal ligament
• Lacunar ligament (Gimbernat’s ligament)
• Pectineal ligament of Cooper
• Superficial inguinal ring
• Reflected part
Importance
• Lacunar ligament:
- Release of ligament required to reduce femoral hernias
• Pectineal ligament:
- Facilitates reconstruction of floor of inguinal canal
Superficial inguinal ring
• Opening in aponeurosis of external oblique above the pubic crest
• Triangular opening with superior and inferior crura
• Intercrural fibres cross over at the apex of the ring
Internal oblique abdominis
• Origin:
- Lateral 2/3rd of inguinal ligament
- Intermediate lip of ventral segment of iliac crest
- Thoracolumbar fascia at lateral border of quadratus lumborum
Internal oblique aponeurosis
• Insertion:
- Conjoint tendon to pubic crest and pectenpubis
- Linea alba
- Lower border of lower 4 ribs and costal cartilages
Cremastric muscle and fascia
• Derived from internal oblique aponeurosis
• Forms coverings of spermatic cord and testis
• Nerve supply: Genital branch of genitofemoralnerve (L1,2)
Transversus abdominis
• Origin:
- Lateral 1/3rd of inguinal ligament
- Anterior 1/3rd of inner lip of ventral part of iliac crest
- Thoracolumbar fascia
- Inner surface of lower six ribs and costal cartilage
• Insertion:
- Conjoint tendon to pubic crest and pectenpubis
- Linea alba
Conjoint tendon
• Formed by fusion of lower most fibres of internal oblique and transversus abdominus
• Inserts into pubic crest and medial part of pecten pubis
Fascia transversalis
• Lies between peritoneum and inner surface pftransversus abdominis
• Attaches to upturned part of inguinal ligament.
• Extends as internal spermatic fascia with the spermatic cord
Deep inguinal ring
• Opening in transversalis fascia
• Lies ½ an inch above midinguinal point
• Inguinal canal begins
• Medial relation : Inferior epigastric artery
Inguinal canal
• Musculo-aponeurotic tunnel
• From deep ring to superficial ring
• 4 cm long and 1 cm wide
Relations of inguinal canal
• Anterior wall:
- Aponeurosis of external oblique aponeurosis
- Internal oblique in lateral 1/3
- Superficial fascia
- Skin
• Posterior wall:
- Conjoint tendon (medial half)
- Transversalis fascia
- Extraperitoneal fat
- Peritoneum
• Roof:
- Arched fibres of
Internal oblique and transverse abdominusaponeurosis
• Floor:
- Inguinal ligament (upturned part)
Contents
• Spermatic cord (males)
• Round ligament (females)
• Ilioinguinal nerve ( Enters after piercing internal oblique and leaves through superficial inguinal ring)
Direct inguinal hernia
• Herniation through the posterior wall
• The inferior epigastric artery is found lateral to the neck of the hernial sac
• Can happen either medial or lateral to the medial umblical fold
Indirect inguinal hernia
• Congenital
• Inferior epigastric artery medial to sac.
Steps of hernia repair
Thank-you