3.9 Inguinal Region

Question 1

Outline the nerve supply of structures in the inguinal region

Answer 1

1. Intercostal
2. Iliohypogastric
3. Ilio-Inguinal
4. Genitofemoral

Question 2

1. Intercostal

Answer 2

Lateral term branch
T11-12

ICN
Uppermost region

Question 3

2. Iliohypogastric

Answer 3

Branch L1
Anterior primary ramus
Occas T12

Div:

• Lateral
  upper gluteal
  lat abdo wall
• Ant pierce internal oblique
  supply upper medial aspect
  inguinal region
  above external inguinal ring

Question 4

3. Ilio-Inguinal

Answer 4

Arises from fusion of T12 and L1 roots

Emerges from lateral border
Psoas major

Provides Neural branches:

1 TA
2 Internal Oblique
3 Iliohypogastric N

Sensory Branches:
Pubic symphysis
Super and medial aspect femoral triangle

Root of penis and anterior scrotum

or Mons pubs and labia majora

Question 5

4. Genitofemoral

Answer 5

L1 + L2 Ventral Primary Rami
Fuse in Psoas Major
Form Nerve trunk

Divide into genital and femoral branch
Near inguinal ligament

Genital Branch gives motor supply
to cremaster muscle

Sensory to sperm cord / scrotum adjacent thigh

cutaneous sensation to labia majora and adjacent thigh in females

Femoral branch
proximal femoral triangle

Question 6

Technique adequate RA for a hernia repair under LA Alone

Answer 6

SLIMRAG

Ilio-hypogastric:
Blunted needle
2cm medial + inferior ASIS

Passage through External oblique aponeurosis
-> Click

Inject 5-8ml LA
aspirating
Minimal resistance

Question 7

Ilioinguinal

Answer 7

Needle advance further 1-2cm
Followed another click
crosses internal oblique

Further 5-8ml

Question 8

Neural branches

Answer 8

Fanwise infiltration
around ASIS
Block neural branches
ilio-inguinal / hypogastric
Improve efficacy block

Question 9

Gen-fem N

Answer 9

Fanwise injection around pubic tubercle
towards external ring

Block Genitofemoral

Often requires surgical top up

Question 10

Advantages of RA alone

Answer 10

1. Avoids GA severe comorbs
2. Analgesia and Anaesthesia
3. Early ambulation and d/c home
4. Cost effective
5. Reduce opiate req
   assoc complication

Question 11

Complications

Answer 11

1. Intravascular injection
2. Intraperitoneal injection +/- bowel or bladder injury
3. Failure
4. Fem Nerve block
   1-5%
   may require overnight admission