Hernia (anatomy of femoral and inguinal)

Question 1

Describe the borders of the femoral triangle.

Answer 1

Inguinal ligament - free edge of the external oblique muscle fibres

Sartorius

Adductor longus

Question 2

What are the contents of the femoral traingle (lateral to medial)?

Answer 2

Femoral:

• Nerve
• Artery
• Vein

Question 3

What is the mid-inguinal point?

Answer 3

Halfway between the ASIS and the pubic symphysis

Question 4

Where is the femoral artery found?

Answer 4

Question 5

Where is the midpoint of the inguinal ligament? What is found here?

Answer 5

Halfway between the ASIS and pubic tubercle

Deep/internal ring is found here

Question 6

What is the posterior wall of the inguinal canal?

Answer 6

Inguinal ligament

Question 7

What are the muscles which surround the inguinal canal?

Answer 7

BLUE - External oblique muscle and its aponeurosis (runs down and forwards)

YELLOW - Internal oblique (runs perpendicular to the external oblique). It originates from the inguinal ligament then curves to form the roof over the spermatic cord/round ligament. This then curves further to form the posterior wall.

GREEN - Transverse abdominis (originates from lateral third of inguinal ligament) - some fibres run transversely to form the rectus sheath and others curve posteriorly over inguinal canal to help internal oblique form the roof of the inguinal canal

LIGHT GREEN - Transverse fascia is the layer between the transverse abdominis and the parietal peritoneum

Question 8

What are the walls of the inguinal canal?

Answer 8

Floor: Inguinal ligament and lacunar ligament medially;

Roof: Fibres of transversalis, internal oblique;

Anterior: External oblique aponeurosis + internal oblique for the lateral ⅓;

Posterior: Laterally, transversalis fascia; medially, conjoint tendon.

Question 9

What is the superficial inguinal ring and where is it found?

Answer 9

It is a defect in the external oblique aponeurosis. Thickened medially and laterally by the crura

Found supralateral to the pubic tubercle

Question 10

What passes through the inguinal canal?

Answer 10

Females - round ligament of the uterus

Males - spermatic cord. Males have a bigger inguinal canal.

Question 11

Where does an indirect inguinal hernia run?

Answer 11

THROUGH the inguinal canal e.g. with the spermatic cord

Question 12

What vessel helps distinguish between a direct and indirect inguial hernia?

Answer 12

Inferior epigastric artery - if hernia begins laterally then it is indirect, if immediately medial then direct hernia.

This is because direct hernias take a more direct route into the superficial inguinal ring i.e. they dont have to pass through deep inguinal ring

Question 13

How do you distinguish between a direct and indirect inguinal hernia on examination?

Answer 13

Try to manipulate the hernia back through the superficial and then deep inguinal ring

If pressing on the deep inguinal ring whilst asking the patient to cough keeps the hernia away then it is indirect. Pressing on deep inguinal ring will not stop a direct inguinal hernia.

Question 14

What are the borders of Hesselbach’s triangle?

Answer 14

• Inguinal ligament inferiorly
• Inferior epigastic vessels laterally
• Rectus abdominis medially

Question 15

What is the first lymph node of the femoral canal?

Answer 15

Lymph node of Cloquet

Question 16

What is the femoral canal and how long is it?

Answer 16

It is the smallest and most medial part of the femoral sheath. It is approximately 1.3cm long.

The femoral canal is an anatomical compartment located in the anterior thigh.

Question 17

What are the borders of the femoral canal?

Answer 17

• Medial border – lacunar ligament.
• Lateral border – femoral vein.
• Anterior border – inguinal ligament.
• Posterior border – pectineal ligament, superior ramus of the pubic bone, and the pectineus muscle

Question 18

What are the contents of the femoral canal? Why does it contain empty space?

Answer 18

• Lymphatic vessels – draining the deep inguinal lymph nodes.
• Deep lymph node – the lacunar node.
• Empty space - The empty space allows distension of the adjacent femoral vein, so it can cope with increased venous return, or increased intra-abdominal pressure.
• Loose connective tissue.

Question 19

Why might you get congenital indirect inguinal hernias?

Answer 19

Tunica vaginalis should wall-off the opening in the peritoneum that allows the testicle to descend embryologically. Howeveer sometimes the peritoneum doesn’t form = patent processus vaginalis (PPV)

However most indirect inguinal hernias are caused by weakness in the tunica vaginalis.

Question 20

Which hernia is more risky?

Answer 20

Femoral - high risk of strangulation or bowel obstruction

Question 21

Where are femoral and inguinal hernias in relation to the pubic tubercle?

Answer 21

Inferior and lateral to pubic tubercle = femoral hernia

Superior and medial = inguinal (as SIR is located here)

Question 22

Where does a direct inguinal hernia protrude through?

Answer 22

Protrusion of abdominal viscera through a weakness of the posterior wall of the inguinal canal medial to the inferior epigastric vessels, specifically through the Hesselbach’s triangle.