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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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The posterior lamina of the rectus sheath is lined by transversus abdominal fascia, fascia
transversalis.
The superior epigastric a. a. epigastrica superioris, one of the terminal branches of thoracica
interna, which anastomosis with the inferior epigastric artery a. epigastrica inferior (branch of a.
iliaca externa) at the level of the umbilicus, both gives feeding branches to the posterior lamina of
the rectus sheath.
White line of the abdomen (The Linea alba):
It is a tendinous lamina formed by the intersection of the tendentious fibers of the aponeurosis of
the 3 pairs of the broad abdominal muscles & dividing the rectus abdominis muscle.
Extends from the xiphoid process towards the symphysis pubis across the median plane (30-40
cm) and getting broader along its way downwards. Width is different: at the xiphoid process - 0.5
cm, then it expands and at the level of the navel - 2-3 cm. Thickness above the navel - 1-2 mm,
below the navel - 3-4 mm.
White line hernias are more likely to occur above the navel, where the white line is thin and wide.
With prolonged increase in the volume of the abdominal cavity, the tendon fibers of the white line
can stretch and move apart, which leads to the formation of weak points.
The linea alba is among the weak points of the anterolateral abdominal wall, because:
1.It is a tendinous structure.
2.Not supported by any muscles,
3.It keeps the right and left abdominal muscles separated, shaped like an anchor which helps to
absorb force or pressure to the abdomen.
4. Pregnancy weakness the linea alba, as the uterus stretches the anterolateral abdominal, linea
alba separates. As a result, the linea alba loses elasticity and weakens.
5.Have no blood supply (bloodless field during incision) thus it has weak healing with high
probability of incisional hernia more than paramedian incisions.
Fig. 20: The Linea alba. Source [20].
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The inguinal region (Regio inguinalis):
Limits:
Superiorly, Interspinous line.
Laterally and inferiorly; The projection of the inguinal ligament.
Medially, The projection of the lateral border of the rectus abdominis.
1.Rectus abdominis muscle.
2.ASIS.
3.Pubic tubercle.
ABE- The inguinal region.
CDE- The inguinal triangle.
EF- The inguinal space.
BE-The inguinal ligament projection.
AE- The rectus abdominis lateral
border projection.
Fig. 21: The inguinal region. Source [21].
The inguinal triangle (Hesselbach’s triangle):
It is the part of the posterior wall, which is deep to the inferior epigastric vessels, through which
direct inguinal hernia descends.
Limits:
MENOMIC “MALT” (table 2):
M 1. Internal oblique Muscle.
2. Transversus abdominis Muscle.
A 1. External oblique Aponeurosis.
2. Internal oblique Aponeurosis.
L 1. Inguinal Ligament.
2. Lacunar Ligament.
T 1. Fascia Transversalis.
2. Conjoint Tendon.
Borders:
Menomin “RIP” (table 3):
R Rectus sheath Medially
I Inferior epigastric artery Laterally
P Poupart's ligament Inferiorly
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Fig. 22: The inguinal triangle (Hesselbach’s triangle). Source [22].
The retroinguinal space, (spatium retroinguinalis).
It is the space between the parietal peritoneum and the fascia transversalis, which corresponds to
the deep inguinal ring, filled with cellular tissue.
Limits:
Superiorly, Lower borders of the internus obliques and transversus muscle.
Inferiorly, inguinal ligament.
Medially, the external border of the rectus abdominis.
The inguinal canal:
Is formed during embryogenesis due to the descend of the gubernaculum; a cord like structure
which directs the migration of the testes from the posterior abdominal wall into the scrotum.
This descend is accompanied by a peritoneal covering called the processes vaginalis which
degenerates later on.
It is situated between the broad abdominal wall superiorly and the medial half of the inguinal
ligament.
It has oblique shape, directed superiorly downwards, from medial to lateral.
The length of the inguinal canal increases with age due to testicular descend in males.
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The length of the inguinal canal according to age in males (table 4):
t
Age Length
Newborn 0.7 cm.
s
Up to 1
year 1 cm.
1-2 years 1.3 cm.
2-6 years 1.5 cm.
6-12 years 2 cm.
Adults 4-5 cm.
N.B.
The inguinal canal in females; shorter and broader.
The inguinal canal has three passages; the deep inguinal ring superolaterally, the myopectineal
orifice in the middle, and the superficial inguinal ring (annulus superficialis) infromedially, where
their transverse locations improve its role in prevention of hernia formation.
Fig. 23: The inguinal canal. Source [23].
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Skeletopy of the inguinal region in relation to the pelvic skeleton:
The anterior border of the iliac bone, which presents from above to downward the anterior superior
iliac spine, inferior gluteal line; the anterior inferior iliac spine, the iliopubic eminence, and the
pectineal surface of the superior ramus of the pubic bone, which are bounded posteriorly by the
pecten of the pubis and medially by the pubic tubercle.
The morphology of the pelvic skeleton has an important role in the occurrence of hernia, as there
is a direct proportion between increasing the value of the angle of Radojevic and hernia formation.
(Normal values 25-35°).
The myopectineal orifice is bounded superiorly by the conjoint tendon of internal oblique and
transverse muscles, inferiorly by the anteroinferior part of the coccyx, the horizontal part of pubic
bone, and is subdivided into two regions by the inguinal ligament into inguinal and femoral
regions, explaining the relationship between direct and femoral hernia, one pushing anteriorly and
the second one inferiorly.
The inguinal ligament lies inferior to the attachments of the myopectineal orifice, and it is widened
around a center constructed by autonomous fibers of the lower part of the external oblique muscle
aponeurosis. The iliopubic tract, (Iliopectineal bandelette, ligament of Gumbert) lies situated
posterior to the lower free margin of the inguinal ligament extending from its external one-third
and is parallel to the anterior aspect of the thigh and the anterior vascular sheath is also a fibrous
structure which is composed of condensations of the transversalis fascia reinforcing the internal
border of iliac, separating the femoral artery and the vein pass medially form the femoral nerve
laterally.
Furthermore, where the femoral septum, which is an inferior expansion of the transversalis fascia,
passes the lymphatics of the inferior extremities lies between the femoral vein and the ligament of
Gumbert, which clarify the role of the ligament of Gumbert in the strangulation of formal hernias
due to its resistant external border.
Cooper’s ligament (pectineal ligament), joins the inguinal ligament medially where it forms the
lacunar ligament of Gumbert, is composed of three layers: A superficial fibrous layer where the
vertical fibers of the aponeurosis of the pectineal muscle, transverse fibers that are running along
the innominate line of the pelvis overlap, a middle, muscular layer is formed by the fibers of the
pectineus muscle, a deep layer which is continuous with the periosteum of the superior pubic
ramus. The thickened medial parts of the Cooper’s ligament represent an extreme mechanical
resistance to hernia formation; Mc Vay procedure which automatically closes the inguinal and
femoral passages when the sutures are in place relies on the medial thickness.
The rectus abdominis muscle extends from the pubic symphysis to the pubic tubercle, represents
the internal border of the myopectineal orifice and is covered by the pyramidal muscle, which
extends from the middle part of the median line to the horizontal branch of the pubis. Surgical
significance: during hernia surgery; is its mobilization to be situated laterally and inferiorly either
to the inguinal ligament or to the Cooper’s ligament, which is more facilitated by Mc Vay incision.
The superior border of the myopectineal orifice is the conjoint tendon (tendo conjunctivus); which
is anteriorly made by the transverse fibers of the internal oblique muscle, posteriorly by the
transverse abdominis, extending from oneဨthird external part of the inguinal ligament to the
anterior face of rectus abdominis muscle.
The week sites in the myopectineal orifices are sites for hernia formations; were external (indirect)
hernias are formed outside the epigastric vessels, passes the spermatic cord where a patent
peritoneoဨvaginal canal exist, direct hernia develops between the umbilical artery and the
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epigastric vessels. Femoral hernias are encountered below the inguinal ligament, between the
vessels and the ligament of Gumbert while the very rare the internal oblique hernias may present
between the posterior face of the rectus abdominis muscle and the umbilical artery.
The superficial inguinal ring (Anulus inguinalis superficialis):
Oval in shape.
Length; 2-3 cm.
Width; 1-2 cm.
Is formed by the 2 crura of the external oblique aponeurosis; medial crus attached to pubis
symphysis and lateral attached to the pubic tubercle.
Sometimes there is third crus (Colles) lig. Reflexum passing to the contralateral external abdominal
oblique aponeurosis.
Surgical significance of the superficial inguinal ring:
Palpation of the inguinal in order to detect its type; direct or indirect.
1.The patient must be in standing position while the examiner is sitting to the side of the patient.
2.Using your fingertip, take a fold of the scrotal skin down to the superficial inguinal ring just
lateral to the pubic tubercle, with the left hand on the left side of the patient and vice-versa.
3.The patient is asked to cough in order to increase the intraabdominal pressure and induce hernia
protrusion.
A. If the bulge hits the tip of the finger, it is indirect hernia, protruding through the deep inguinal
ring due to a persistence process vaginalis, may extent to the base of the scrotum.
B. While if it hits the finger side, so it is direct hernia protruding medial to the inguinal ring due
to a weakness in the fascia transversalis, rarely extends to the scrotum.
C. In femoral hernia, the bulge hits the fingertip, but the pubic tubercle is felt above the hernial
sac.
Fig. 24: Determination of the type of inguinal hernia using fingertip. Source [24].
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Two ligaments reinforce the transversalis fascia; the ligament of Hesselbach (the interfoveolar
ligament) and the ligament of Henle, where the former is curved at the inferior border of the deep
inguinal ring. Medially, it begins from the arc of Douglas, passes under the deep inguinal ring and
ascends laterally to be vanished in the deep face of the transverse muscle toward the anterior
superior iliac spine.
Transverse muscle contraction stretches the Hesselbach’s ligament resulting in narrowing of the
deep inguinal ring resisting the herniation of visceral organs. While the latter is composed of fibers,
which leave the external border of the rectus abdominis muscle and cover the internal part of the
inguinal ligament. Inferiorly, it is continuing with the ligament of Gumbert
The deep inguinal ring (anulus inguinalis profundus):
It is situated 1-1.5 cm superior to the medial part of the inguinal ligament.
It is not a real opening but it is a protrusion of fascia transversalis in the inguinal canal created
during testicular descend from the posterior abdominal wall downwards the scrotum during
embryogenesis.
This protrusion extends to become fascia spermatica interna which envelopes ductus deferens and
all other elements of the future spermatic cord reaching the scrotum in males and the round
ligament of the uterus in females.
It corresponds to the lateral inguinal fossa (in the peritoneal cavity) and the medial to the initial
part of the inferior epigastric artery.
CONTETNTS OF THE INGUINAL CANAL:
1.Ilioinguinal nerve:
Sensory innervation of the genitalia.
Doesn't pass through the hole length of the inguinal canal, as it exits the canal before passing
through the deep inguinal ring.
2. Genital branch of the genitofemoral nerve:
Supplies the cremasteric muscle and scrotal skin in males, the round ligament the skin of the
mons pubis and labia majora in females.
Pass through the hole length of the inguinal canal and pass through the deep inguinal ring.
3.Spermatic cord in males or round ligament in females.
Coverings:
1. External spermatic
fascia.
2. Cremasteric fascia. 3. Internal spermatic
fascia.
Fig.25: Coverings of the spermatic cord. Source [25].
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Contents:
Mnemonic;
Papers Don't Contribute To A Good Specialist Level. 3 arteries, 3 nerves, 3 fascias, 3 other
things.
x 3 arteries: artery of the ductus deferens, testicular artery, cremasteric artery
x 3 nerves: genital branch of the genitofemoral nerve, parasympathetic and sympathetic
nerve fibers
x 3 fascias: external spermatic fascia, cremasteric fascia, internal spermatic fascia
x 3 other things: ductus deferens, pampiniform plexus of veins, lymphatic vessels.
OR…
Partying Doesn’t Contribute To A Good Social Life
1. Pampiform Plexus
2. Ductus Deferens
3. Cremasteric Artery
4. Testicular Artery
5. Artery of the Ductus Deferens
6. Genital Branch of Genitofemoral Nerve
7. Sympathetic Nerve Fibers
8. Lymphatic Vessels.
Fig.26: Contents of the spermatic cord. Source [26].
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The Descent of the testicle, (descendus testiculorum):
¾ 3rd month; iliac fossa.
th
¾ 7
month; deep inguinal ring.
¾ 8th month; superficial inguinal ring.
¾ 9th month; upper part of the scrotum.
¾ At birth; lower part of the scrotum.
Fig. 27: Testicular descend. Source [27].
Failure of normal testicular descent:
The failure of normal testicular descend will results in either undescended or ectopic testes.
Various locations of undescended and ectopic testes (table 5):
Undescended testes Ectopic testes
1. Abdominal.
2. Inguinal.
3. Suprascrotal.
1. Prepenile.
2. Superficial ectopic.
3. Transverse scrotal.
4. Femoral.
5. Perineal.
Fig. 28: Failure of normal testicular descent. Source [28].
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Complications of the failure of normal testicular descent (table 6):
y
Undescended testes Ectopic testes
Mnemonics TESTIS
T-Tumor
E- Epididymoorchitis.
S-Seminoma.
T-Torsion.
Testicular cancer.
Testicular torsion.
Testicular trauma.
Inguinal hernia.
I-Inguinal hernia.
S-Sterilit
.
The round ligament:
Within the inguinal canal the round ligament of the uterus is covered by a fascial membrane which
extends from the fascia transversalis. After leaving the inguinal canal, the round ligament becomes
attached to the labia majora and to the pubis. Like spermatic cord in males, the round ligament
pierces the processes vaginalis, which if left patent will lead to the formation of a congenital hernia
formation; Hernia of the canal of Nuck (Nuck’s canal, canalis Nucku).
Fig. 29: Canal of Nuck. Source [29].
The arterial supply of the superficial layer of the groin is by the superficial iliac circumflex vessels
and the superficial epigastric vessels; while for the deep layers is through the deep circumflex iliac
artery, the epigastric artery and its branches, obturatriceဨepigastric anastomoses connected to the
descending branch of the epigastric artery. Venous drainage is by veins in the subcutaneous
adipose tissue which are drained by join the saphenous vein inferiorly. The lymphatic drainage is
by inguinal lymph nodes. The external pudendal arteries emerging from the femoral artery supplies
the femoral region, which is drained by inferior epigastric vein which in turn is drained by the
femoral vein.
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