Inguinal Region and Descent of the Testis

Question 1

What vertebral level corresponds to the bottom of the rib cage (last rib is 12) (name it)? What about the tubercles of the ilia? (name it)? What lines split the abdomen vertically?

Answer 1

1. L3, Subcostal Line
2. L5, Intertubercular line
3. Medclavicular/Midinguinal line on right and left side

Question 2

Using the 9 region terminology, what is the name of the center components of the abdomen, from most superior to most inferior? Why are these regions important?

Answer 2

1. Epigastrium (Plus right and left Hypochondrium), Umbilical (Plus right and left lumbar), Hypogastrium (Plus right and left inguinal)
2. Important since these are the regions (As in all 9) where we can reference pain

Question 3

How many layers are in the anterior abdominal wall? what are they?

Answer 3

1. Skin
2. Superficial fascia
   (Fatty Layer (Camper’s Fascia) and then Fibrous Layer (Scarpa’s fascia))
3. External Oblique layer (muscle then aponeurosis (Wide, flat TENDON for the muscle!!!!) then fascia, which covers the muscle and the apneurosis). Note that it runs in same direction as external oblique muscles
4. Internal oblique layer (muscle then aponeurosis (Wide, flat TENDON for the muscle!!!!) then fascia, which covers the muscle and the apneurosis)
5. Transversus abdominis layer (muscle then aponeurosis (Wide, flat TENDON for the muscle!!!!) then fascia, which covers the muscle and the apneurosis)
6. Transversalis fascia (covers entire surface of the abdomin, called endoabdominal fascia, but for INNER anterior wall)
7. Extraperitoneal layer (outside peritoneal layer)
8. Parietal peritoneum (most inner wall of the abdomin)

Question 4

What is significant about the extra peritoneal layer?

Answer 4

Nothing resides in it on the anterior wall, but on the posterior wall inside this layer, you will find a bunch of organs (aorta, adrenals, kidney AND testes)

Question 5

Describe migration pattern of the testes. What layer does the testes lack? Why?

Answer 5

From kidney region to the scrotum by invagination of dartos fascia. There is no fat in the scrotum (no Campers’ fascia. Just dartos fasica and colles fascia). Facilitates cooling (testes need to be below body temp for spermatogenisis)

Question 6

What layers do the testes cross during migration? Which layers are fused in the inguinal region? What does it do about the transversalis fascia. What is the lifeline of the testes, and what is the name of the hole created by the evanvination?

Answer 6

Transversalis fasia (endoabdominal fascia), transverse abdominus fascia, internal oblique layers, and then external oblique layer. Note that is started in Extraperitoneal layer with the kidneys. Stops between layers 2 and 3. Internal oblique (4) and transversalis abdominus (5) are fused. Upon migration, testes Evaginates Transversalis Fascia (now called Internal Spermatic Fascia). Drags spermatacord with it (it too is covered by transversalis fascia). Hole name is Deep Inguinal Ring (testicular artery, vein, lymphatics, nerve all enter this).

Question 7

What is the connection of the external oblique layer? What is this space called? How does testes pass through internal oblique (and transversus abdominus) layer?

Answer 7

Starts at iliac creest, attaches through anterior superiors iliac spine, and then attaches to pubic tubercal with apneurosis, but there is no bone between the last 2 (aka inguinal ligament).
External oblique layer creates origin point for internal oblique layer. The bottom 1/3 portion of the external oblique layer ITS NOT COVERED. THe internal oblique layer which lies directly underneath points downward in direction of external oblique layer. Creates tunnel called FALX INGUINALIS (lower most arching fibers). Testes travels through it. Ends at CONJOINT TENDON. Testes then evaginated the internal oblique fascia and internal oblique muscle (becomes cremaster muscle) as well.

Question 8

What is the job of the cremaster muscle? What is the job of Dartos Muscle? What is the job of the testicular artery?

Answer 8

Controls how far below the abdominal wall the testes is extended. Temperature controlled. Dartos muscle (smooth muscle) contracts to become MORE wrinkly, DECREASING surface area sides of scrotal wall and reducing amount of heat lost. Testicular arteries branch out in a plexus so that the veins are able to absorb the heat of the blood in the arteries. This lowers testes temp.

Question 9

How does the estes get through external oblique layer?

Answer 9

There is a hole in the external oblique aponeurosis called the superficial inguinal ligament. The testes still has to go through the fascia covering the aponeurosis by evaginating it. This fascia is called the external oblique fascia. Overall result through travel = inguinal canal.

Question 10

What is a hernia? What is the most common version of an abdominal hernia? What’s an indirect inguinal hernia? What’s a direct inguinal hernia? Where would direct inguinal hernias tend to end up? What artery is lateral to the direct hernia?

Answer 10

Hernia: structure should be inside a containing wall, and is no longer is. Inguinal hernia is most common abdominal hernia. Indirect: loop of bowl that go through the deep inguinal ring enter the inguinal canal, and emerge at superficial inguinal ring. Follows a pathway that ALREADY EXISTS (covered by the same layers of fascia). A direct inguinal hernia fundamentally follows a non-preformed pathway by tearing through a wall. Normally ends up where the wall is the weakest (superficial inguinal ring of external). Tears through the layers beside it. Both direct and indirect end up normally in superficial ring. Direct hernia will not be covered by said layers…only the external spermatic fascia. Direct hernias pass medially to the inferior epigastric artery

Question 11

What is the name of the area direct inguinal hernias pass through? What are it’s borders? How do you figure out what kind of injuinal hernia you are dealing with in surgery?

Answer 11

1. Inguinal (Hesselbach’s) Triangle (lateral border of rectus abdominus muscle, inguinal ligament, inferior epigastric vessels)
2. Take finger and push abdominal components through the the superficial ring until you feel pulse of INFERIOR EPIGASTRIC ARTERY. If you push the pulse of the artery and the pulse is LATERAL (NOT MEDIAL) to the deep ring, it was a direct hernia.

Question 12

How would you determine (1) if there was an inguinal hernia and (2) whether it is direct or indirect?

Answer 12

1. Determine location of anterior superior iliac spine and the pubic tubercle (the span is the inguinal ligament). Place finger at superior inguinal ring and have patient cough. If you feel somrhting bump finger, you have inguinal hernia. Now, to determine the type, place finger where deep inguinal ring, compress it, and have patient cough again. If you still feel bump where first finger was, you have a direct hernia. If you do not, you have an indirect hernia. Cough increases abdominal pressure, which will push out a hernia if present. Compressing the superficial ring stops the abdominal mass from moving through it.

Question 13

How do femoral hernias emerge? How do you tell difference between femoral hernia and inguinal hernia? Which is more common in which gender?

Answer 13

Abdominal components enter though femoral canal. Shows up as bulge on groin. Inguinal hernias will appear above pubis tubercle. Femoral hernias will appear below the pubis tubercle. Inguinal (men), femoral (female)

Question 14

What is the point of the tunica vaginalis? What happens if processus vaginalis does not fuse? WHat happens if it fuses only partially in the canal?

Answer 14

Innermost layer double layer inside of the internal spermatic fascia. BEFORE the testes goes down inguinal canal, parietal peritonium forms evagination called processes vaginalis. Testes follows its track down the canal. AFTER the testes descends, most to the processes vaginalis fuses, cutting off abdominal opening. If it does not fuse (persistent processus vaginalis), indirect hernias easily form. (congenital are always indirect). Upon partial fusion, it creates a bubble (cyst) called the Hydrocele of the Spermatic Cord

Question 15

Outline the name changes of testes fascia.

1. Skin =
2. Scarpa’s fascia =
3. External oblique fascia =
4. Internal oblique fascia =
5. Transversalis fascia =
6. Parietal peritoneum =
7. Testes =

Answer 15

1. Skin
2. Dartos fascia
3. External spermatic fascia
4. Cremasteric fascia
5. Internal spermatic fascia
6. Tunica vaginalis (double layer, where parietal is most outer and visceral makes contact with the testes)
7. Testes

Question 16

What is the difference between males and females with sexual development? What passes through the canal in females?

Answer 16

Females have all the same layers up to and including the superficial inguinal ring. After which, females have the Round Ligament of the Uterus, which leads to labium majus. Fold of scrotum = labioscrotal fold in females. Ligament connecting gonnad (ovaries) to labioscrotal fold = caudal genital ligament. The ligament is the only thing that stays in the inguinal canal. There is no descending, so the ovaries and gonadal artery stay up in the abdomin region.

Question 17

Name comparable features between male and female -->
1. Gonad
2. Caudal genital ligament
3. Gonadal artery (vessel)
 supply
4. Labioscrotal fold

Answer 17

1. Male testes
2. Male gubernaculum
3. In Male spermaticord
4. Male scrotum
5. Ovary
6. Round ligament (and Ovarian ligament)
7. In Suspensoral ligament
8. Labia majora