Lecture 8

Question 1

What is the most superficial layer?

Answer 1

Skin.

Question 2

What is the layer underneath the skin layer?

Answer 2

This layer is split up into two:

1. Fatty Superficial Fascia (Camper’s).
2. Membranous Superficial Fascia (Scarpa’s) - tend to find this fascia beneath the umbilicus.

Question 3

What is the layer underneath the deep fascia?

Answer 3

The three muscle layers:

1. External oblique (infero-medial).
2. Internal oblique (supero-medial).
3. Transversus abdominis.

Question 4

What is the layer underneath the muscle layers?

Answer 4

Transversalis fascia.

Question 5

What is the layer underneath the transversalis fascia?

Answer 5

Parietal peritoneum.

Question 6

What are the key bony landmarks?

Answer 6

1. ASIS.
2. Pubic symphysis.
3. Pubic tubercle - palpate with thumbs.
4. Pubic crest.
5. Pectineal line.

Question 7

Where does the inguinal ligament run from?

Answer 7

ASIS to pubic tubercle - it is formed from rolled edge of external oblique aponeurosis.

Question 8

Where does the lacunar ligament run from?

Answer 8

This ligament connects the inguinal and pectineal ligament - sharp edge (things can get trapped in here).

Question 9

Where does the pectineal ligament run from?

Answer 9

Pectineal line of the pubic bone.

Question 10

Describe the inguinal canal?

Answer 10

It is an oblique passage through the lower part of the abdominal wall - the oblique nature of the canal helps to prevent herniation of abdominal contents.

Question 11

How long is the inguinal canal?

Answer 11

In adults it is around 4cm long.

Question 12

Where does the inguinal canal extend from?

Answer 12

Deep inguinal ring to the superficial inguinal ring.

Question 13

What does the inguinal canal carry in males?

Answer 13

It carries structures to and from the testis and abdomen via the spermatic cord (and ilioinguinal nerve - not involved within the psermatic cord).

Question 14

What does the inguinal canal carry in females?

Answer 14

It carries the round ligament of the uterus from the pelvis to the labia majora (and ilioinguinal nerve).

Question 15

Describe the superficial inguinal “ring” (SIR)?

Answer 15

It is a triangular defect in the aponeurosis of the external oblique.

Question 16

Describe it’s reference to the pubic tubercle?

Answer 16

It is superior and lateral to the pubic tubercle.

Question 17

What do the margins (crura) of the SIR give rise toE?

Answer 17

External spermatic fascia (of the spermatic cord).

Question 18

Describe the deep inguinal “ring” (DIR)?

Answer 18

It is an oval opening formed in the transversals fascia.

Question 19

Describe the landmarks of DIR?

Answer 19

DIR is halfway between ASIS and pubic symphysis (mid-inguinal point). It is 1.5-2cm above the inguinal ligament. It is lateral to the inferior epigastric artery.

Question 20

What do the margins (crura) of the DIR give rise to?

Answer 20

Internal spermatic fascia (spermatic cord in men and round ligament fascia in women).

Question 21

What is between SIR (transversalis fascia) and DIR (external oblique)?

Answer 21

There are two more muscles that help to form the inguinal canal and spermatic fasciae:
1. Transversus Abdomens: This does not contribute to spermatic fascia.
2. Internal Oblique: This gives rise to the muscular layer - cremasteric muscle (of spermatic cord).
These two muscles will join medially to form a common tendon which attaches onto the pubic crest/pectineal line = Conjoint Tendon.

Question 22

What is the anterior inguinal canal borders?

Answer 22

Aponeurosis of external oblique muscle and internal oblique muscle (in lateral 1/3).

Question 23

What is the floor inguinal canal borders?

Answer 23

Inferior rolled edge of external oblique aponeurosis (inguinal ligament) and lacunar ligament (medial).
Looking from superior view, the inguinal ligament runs from AISS to Pub.Tub.

Question 24

What is the roof inguinal canal borders?

Answer 24

Fibres of internal oblique and transverses abdominis.

Question 25

What is the posterior inguinal canal borders?

Answer 25

Transversalis fascia and conjoint tendon (medial 1/3).

Question 26

Describe Hesselbach’s (Inguinal) Triangle?

Answer 26

This is a site where you typically get direct hernia. It pushes through weakened abdominal wall. It corresponds to weak anterior wall (superficial inguinal ring). It is the triangle between: inferior epigastric artery, inguinal ligament and lateral border of rectus abdominus.

Question 27

What is the spermatic cord?

Answer 27

This is a collection of structures which pass along the male inguinal canal to the testis. There are 3 concentric layers of fascia derived from the anterior abdominal wall. It begins at the deep inguinal ring and ends at the testis.

Question 28

Describe the spermatic cord layers?

Answer 28

The spermatic cord arises from a peritoneal diverticulum called the processes vaginalis - it pushes through the abdominal wall taking a tubular sheath from each layer: 1. Transversalis fascia (DIR) = Internal Spermatic Fascia. 2. There is no covering form the transverses abdominis. 3. Internal Oblique = Cremaster muscle. 4. External Oblique (SIR) = External Spermatic Fascia. Peritoneal out-ouching eventually pinches off leaving a closed off sac - tunica vaginalis (as a remnant).

Question 29

What are the arteries in the spermatic cord?

Answer 29

1. Testicular artery - branches off at L2 from the abdominal aorta. 2. Artery of Vas Deferens (Deferential artery). 3. Cremasteric artery.

Question 30

What are the nerves in the spermatic cord?

Answer 30

1. Genital branch of genitofemoral nerve - L1-2. 2. Sympathetic nerves - from testicular plexus. 3. (Ilioinguinal nerve - L1) - (Doesn’t travel in the cord - piercing through roof of canal).

Question 31

What are the three other structures in the spermatic cord?

Answer 31

1. Vas Deferens. 2. Lymphatics. 3. Tunica Vaginalis.

Question 32

What is the venous plexus of the spermatic cord?

Answer 32

Pampiniform plexus.

Question 33

What does the testicular artery supply?

Answer 33

Testes and epididymis.

Question 34

What is the Vas Deferens?

Answer 34

It is the muscular duct which transports spermatozoa from the epididymis to the urethra.

Question 35

Describe the vas deferens artery?

Answer 35

it accompanies vas deferens and is important for vasectomy (often damaged during vasectomy).

Question 36

What does the paminiform plexus do?

Answer 36

It helps with temperature regulation - it forms a single vein at the deep inguinal ring.

Question 37

What does the genital branch of the genitofemoral nerve innervate?

Answer 37

It innervates the cremaster muscle (M) and skin of scrotum (S) - why it sits outside the cremaster muscle.

Question 38

Where do the lymphatics drain?

Answer 38

They drain to the para-aortic nodes at L2 (origin of the testicular arteries).

Question 39

What is testicular torsion?

Answer 39

This is where the spermatic cord twists round, cutting off the blood supply - causing ischaemia. Surgical emergency - window of 6 hours.

Question 40

What are the symptoms of testicular torsion?

Answer 40

1. Acute and severe testicular/scrotal pain. 2. Pain is also referred to groin and lower abdomen. 3. Symptoms may be similar to other conditions affecting this anatomical region e.g. epididymitis. 4. Absent/decreased cremasteric reflex. 5. Nausea/vomiting. 6. Redness and pyrexia.

Question 41

Describe the cremasteric reflex?

Answer 41

1. Stroke the superior medial thigh. 2. This will stimulate sensory fibres of the femoral branch of genitofemoral nerve and ilioinguinal nerve (L1-2 origins). 3. This is turn stimulates motor fibres of genital branch of genitofemoral nerve - cremaster muscle contracts on ipsilateral side, raising the testis.

Question 42

What happens to the cremasteric reflex if testicular torsion has occurred?

Answer 42

The reflex is not present (method is not infallible - if there is no reflex is does not mean that it is torsion). Ultrasound confirmation is very reliable - it distinguishes torsion from epididymitis by showing lack of blood flow to testis. There is a 6 hour window of opportunity - the chance of saving the testis drops significantly after this time.

Question 43

What are the type of hernias?

Answer 43

1. Direct Inguinal. 2. Indirect Inguinal. 3. Femoral.

Question 44

Describe inguinal hernias?

Answer 44

It is the protrusion of the abdominal contents through the inguinal canal.

Question 45

Describe indirect inguinal hernias?

Answer 45

Hernias that go through the DIR and through the entirety of the inguinal canal into the scrotum within the spermatic cord. It is lateral to the inferno epigastric artery. it is often seen in juveniles - oblique passage of canal has not yet formed (DIR is overlaid by SIR). It can be a congenital defect.

Question 46

Describe direct inguinal hernias?

Answer 46

Herniation through the weak spot in the fascia of posterior wall of inguinal canal - hesselbach’s triangle. It is medial to the inferior epigastric artery. males are 10 times more likely to have direct inguinal hernia than women. Middle aged to elderly are far more likely to get them than the young.

Question 47

Describe femoral hernias?

Answer 47

It occurs within the classification of “Groin Hernias” along with inguinal hernias. However, the herniation occurs through the femoral canal below the inguinal ligament. It is an uncommon hernia type. Most likely to occur in females due to wider pelvis.