Abdomen- groin Flashcards
Layers surrounding testis on their descent into scrotum
Layers from in to out:
Processus vaginalis (diverticulum/invagination of parietal peritoneum)
Transversalis fascia
Internal oblique
External oblique
Skin
- there is no layer from the transversus abdominis as the processus vaginalis passes under the arching fibers of this abdo wall muscle
The content of inguinal canal
- Ilioinguinal nerve
- spermatic cord (in men)
- Round ligament (in women)
Remember the genital branch of the genitofemoral nerve passes within either the spermatic cord or the round ligament
Inguinal canal anterior wall
External oblique aponeurosis
Internal oblique more laterally
And Transversus abdominis even more laterally
Inguinal canal posterior wall
Transversalis fascia
Conjoint tendon (medial one third)
Conjoint tendon
formed from the lower part of the common aponeurosis of the internal oblique muscle and the transversus abdominis
Roof of inguinal canal
Internal oblique
Transversus abdominis
Floor of inguinal canal
Also known as the inferior wall, the floor is made of the:
- Inguinal ligament, which is reinforced by the
- Lacunar ligament
Boundaries of deep inguinal ring
Superolaterally: tranversalis fascia
Inferomedially- inferior epigastric
Contents of spermatic cord
3 layers of fascia:
* Internal spermatic fascia (transversalis fascia)
* Cremasteric fascia (internal oblique)
* External spermatic fascia (external oblique)
3 Arteries:
* Testicular artery (aorta - L1 - Genital ridge commences here to form and descend testes/ovaries)
* Cremasteric artery (inferior epigastric vessel)- can bleed during hernia repair.
* Artery to the vas (inferior vesical branch of the internal iliac) - can lead to atrophic testicle if damaged in hernia repair.
3 Veins:
* Testicular vein (Pampniform plexus - right - IVC/Pampniform plexus - left - renal vein)
* Cremasteric vein
* Vein to the vas
3 Nerves:
* Sympathetic pain afferents T10/T11 - can cause referred pain to abdomen in renal colic/epididymitis.
* Genital branch of genitofemoral nerve (L1/L2) - cremaster muscle
* Ilioinguinal nerve (not part of the cord itself!)
- 3 nerves can be cause of post of pain in hernia repair
3 other structures:
* Vas deferens
* Lymphatic (drain to para-aortic nodes - testicular cancer mets)
* Processus vaginalis - patent in indirect hernias
Origin of Vas (ductus) deferens artery
The vas (ductus) deferens is usually supplied by a branch of the **superior vesical artery **but is occasionally supplied by a branch of the inferior vesical artery (internal iliac)
Drainage of pampiniform plexus
testicular vein
Right testicular vein drains into IVC
Left testicular vein drains into Left renal vein
Origin of cremasteric vessels
Inferior epigastric vessels (from external iliac)
Origin of testicular artery
abdominal aorta
Spermatic cord fascia covering
External spermatic fascia (external oblique)
Cremasteric fascia (internal oblique)
Internal spermatic fascia (transversalis fascia)
Cremasteric reflex Afferent and Efferent nerves
Afferent: ilio-inguinal at upper medial thigh skin
Efferent: genital of genitofemoral to cremasteric muscle
https://www.youtube.com/watch?v=eVvInQNyXIU
Which level of spinal cord does the cremasteric reflex check
L1/L2
Indirect inguinal hernia
Peritoneal sac herniates through patent processus vaginalis THROUGH THE DEEP RING
Site of direct inguinal hernia
Through posterior wall of inguinal canal
Hesselbach’s triangle
Borders of Hesselbach’s triangle
Lateral: ingerior epigastric artery
Medial: rectus abdominis
Inferior: inguinal ligament
How to differentiate between direct and indirect inguinal hernias
Direct: medial to epigastric artery
Indirect: lateral to epigastric artery
Differentiating between femoral and inguinal hernia
Inguinal: above pubic tubercle
Femoral: below and lateral
Femoral canal content
Fat
Lymph node of femoral canal or cloquets gland
Mid point of inguinal ligament
Halfway between ASIS and tubercle
Which structure associated with mid point of inguinal ligament
Deep inguinal ring
Mid inguinal point
Half way between symphysis and ASIS
Which structure associated with mid inguinal point
femoral artery
Between which layers of the abdominal wall does the inferior epigastric artery sit
Transversus abdominis and peritoneum
Surface marking for inguinal canal
Deep inguinal ring 1.5cm above midpoint of inguinal ligament
Superficial ring 1cm above and medial to pubic tubercle
Ischio-rectal fossa boundaries
Superior- levator ani
Lateral- obturator internus
Inferior- Perineal skin
Deep perineal pouch content
Membranous urethra
Sphincter m
Bulbourethral gland
Deep transverse perineal muscles
Internal pudendal vessels
Dorsal nerve of penis
What landmark does the surgeon use to identify the superficial inguinal ring?
The intercrural fibers that run at right angles across the aponeuroses of the external oblique
Spigelian hernias occur where?
Along the line of the semilunaris (i.e the lateral border of the rectus abdomninus muscle) at the level of the arcutae line
A persistent processus vaginalis in women forms the canal of ____.
The ____ procedure for direct inguinal hernias involves the fixation of a mesh to the reflected surface of the inguinal ligament.
Nuck
Lichtenstein
In the male the inguinal canal transmits the ____ and the ____
In the female the inguinal canal is much smaller and transmits the ____ and the ____
Male: Spermatic cord and the Ilioinguinal nerve (L1)
Female: Round ligament of the uterus and the ilioinguinal nerve (L1)
Remember testicular nerves, blood vessels and lymphatics drain descend from the abdominal aorta at the level of the testicular arch (L1) - hence why lymph vessels can often be enlarged in a testicular cancer at the para-aortic nodes.
Define the mid inguinal point? (.ie where the femoral artery can be palpated)
Halfway between the ASIS and the pubic SYMPHYSIS (cartilagenous joint)
Note it does NOT correspond to mid point of the inguinal ligament which lies between the ASIS and the pubic tubercle
Spermatic cord transverse section
Remember only the structures within the internal spermatic fascia are considered to be stricly part of the spermatic cord
Layers of the scrotum
A handy mnemonic to recall the layers of the scrotum is:
Some Damn Englishman Called It The Testes
Mnemonic
S: skin
D: dartos fascia and muscle
E: external spermatic fascia
C: cremasteric fascia (continuous with aponeurosis of internal oblique)
I: internal spermatic fascia
T: tunica vaginalis
T: tunica albuginea
