Surgery Flashcards
Inguinal canal anatomy
- Location
- Walls
- Contains
Above, parallel and lower end of the inguinal ligament.
Starts at deep inguinal ring, extends to superficial
Walls:
- Anterior = external oblique aponeurosis
- Laterally= internal oblique
- Posterior= transversalis fascia
- Roof= transversalis abdominis and internal oblique
- Floor= medial 1/2 of inguinal ligament
In both sexes, contains:
- genitofemoral nerve
- ilio-ingunal nerve (L1)
In men
- Spermatic cord
In women
- Round ligament of the uterys
Deep inguinal ring
- Structure
- Location
Opening of the transversalis fascia, forming the beginning of the evagination for the spermatic cord or round ligament.
Located halfway between the anterior superior iliac spine and the pubic tubercle.
Lateral to the inferior epigastric artery
Superficial inguinal ring
- Structure
- Location
End of the inguinal canal.
- Traingular opening in the aponeurosis of the external oblique muscle.
Location
- Superior to the pubic tubercle
Spermatic cord
- Location
- Contents
- Fascia
Starts at deep inguinal ring, lateral to inferior epigastric vessels
Contains
- Vans deferens
- Branch of inferior epigastric artery (to ductus deferens)
- Testicular artery
- Pampiniform plexus of veins (testicular veins)
- Genital branch of genitofemoral (to cremaster muscle)
- Lymphatics
- Sympathetic and visceral afferent nerves
Fascia
- Deepest= internal spermatic fascia, from transversalis fascia. Attached to deep ring.
- Middle layer= cremasteric fascia, from cremaster muscle originating from internal oblique
- Covering= external spermatic fascia, from external oblique aponeurosis, attached to superficial inguinal ring
Inguinal hernia
- Definition
- Types
Passage of peritoneal tissue with/without abdominal contents, through the inguinal canal.
Indirect (congenital)
- Through the deep inguinal ring
- Due to processus vaginalis remaining patent (tunnel the testes migrate from)
- Lateral to inferior epigastric vessels
Direct
- Through posterior wall of inguinal canal
- Due to weakened abdominal wall
- medial to inferior epigastric vessels
Examination of inguinal hernia
Location
- Above the inguinal ligament
Feeling the upper edge of the lump= hernia
Reduction
- Applying pressure and reducing the hernia into the deep ring.
- This will remain reduced in indirect but reappear in direct.
Hesselbach’s triangle boundaries (RIP)
R- Rectus abdominis medially
I- Inferior epigastric, superior-laterally
P- Inguinal ligament, inferiorly
Presentation of inguinal hernia
Lump in the groin
Typically painless, reducible
- If painful, incarcerated (irreducible) or strangulated (obstruction/ blood supply compromised)
Intermittent
- Visible on straining or coughing
Management of inguinal hernia
Taxis
- Manually
- Analgesia
Surgery
- open or laparoscopic
Hydrocele
- definition
- Presentation
Passage of fluid through patent processus vaginalis
Presentation
- asymptomatic
- Lump in groin, may be blue
- May present during viral illness
- Larger in the evening/ when lying down
- Can palpate above the hydrocoele
Hydrocele management
Typically, resolves spontaneously as the patent processus vaginalis closes within months
Surgery considered when it persists > 2 years.
Varicocele
- definition
- Presentation
- Management
Swelling of the scrotal, testicular veins
Presentation
- Scrotum resembling ‘bag of worms’
- May present with dull ache,
- 90% are on the left side, 10% bilaterally
Management
- If <20% difference in size of testes, reassurance and observation
- If >20%, surgery required.
First line investigation for pyloric stenosis
Abdominal ultrasound
The most ‘classic’ biochemical profile for pyloric stenosis is…
Hypochloraemic, hypokalaemic metabolic acidosis
First line surgical procedure of pyloric stenosis
Ramstedt’s pyloromyotomy
