Pathology of femoral hernia
◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
#Hernia
#Surgery
◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
#Hernia
#Surgery
Surgical anatomy of the femoral ring
◼️Anteriorly it is bound by the inguinal ligament.
◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).
◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.
◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.
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◼️Anteriorly it is bound by the inguinal ligament.
◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).
◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.
◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.
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#Surgery
The box above highlights the essential aspects of femoral hernias.
Femoral hernias out of all hernias, are the most liable for strangulation mainly because of the narrowness of the neck "femoral canal is 1.25 cm only at its base which is directed up creating a funnel" and also because of the rigidity of the femoral ring.
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#Surgery
Femoral hernias out of all hernias, are the most liable for strangulation mainly because of the narrowness of the neck "femoral canal is 1.25 cm only at its base which is directed up creating a funnel" and also because of the rigidity of the femoral ring.
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#Surgery
Reduction en masse
Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.
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#Surgery
Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.
#Hernia
#Surgery
Femoral sheath and femoral canal
◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.
◼️It is divided by septa into compartments.
◼️The most medial compartment is called the femoral canal.
◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.
◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.
◼️It starts from the femoral ring and ends at the saphenous openings.
◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.
◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias
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#Surgery
◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.
◼️It is divided by septa into compartments.
◼️The most medial compartment is called the femoral canal.
◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.
◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.
◼️It starts from the femoral ring and ends at the saphenous openings.
◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.
◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias
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#Femoral_Triangle
◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.
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◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.
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#Surgery
Recurrence of Hernia after operation:
◼️Reports suggest that recurrence rate vary between 0.2% up to 15% depending on the technique used.
◼️Only by using meticulous technique principally concentrating on reinforcement of the posterior wall of inguinal canal with the shouldice technique or mesh hernioplasty can a recurrence rate of less than 2% be achieved.
◼️Only 50% of recurrences will become apparent within two years.
◼️In a few cases "false" recurrence occur, i.e another type of hernia occur - direct after indirect, femoral after inguinal. How ever to the patient it is recurrence!!
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#Surgery
◼️Reports suggest that recurrence rate vary between 0.2% up to 15% depending on the technique used.
◼️Only by using meticulous technique principally concentrating on reinforcement of the posterior wall of inguinal canal with the shouldice technique or mesh hernioplasty can a recurrence rate of less than 2% be achieved.
◼️Only 50% of recurrences will become apparent within two years.
◼️In a few cases "false" recurrence occur, i.e another type of hernia occur - direct after indirect, femoral after inguinal. How ever to the patient it is recurrence!!
#Hernia
#Surgery
Direct inguinal hernia
◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.
#Hernia
#Surgery
◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.
#Hernia
#Surgery
Repair of transversalis fascia and internal ring
◼️After exicion of the hernial sac, the deep ring may be found too stretched which risks recurrence of the hernia after operation.
◼️Repair techniques focus on simply narrowing the internal ring.
◼️One method is the Shouldice operation (shown in figure above) whereby the deep ring and transversalis fascia are incised and carefully seperated from the deep inferior epigastric vessels creating two flaps, the upper flap is pulled over the lower flap and connected together making the ring narrower.
◼️Another more simple method is the Lytle operation where by the spermatic cord is displaced laterally and the ring narrowed by sutures.
#Hernia
#Surgery
◼️After exicion of the hernial sac, the deep ring may be found too stretched which risks recurrence of the hernia after operation.
◼️Repair techniques focus on simply narrowing the internal ring.
◼️One method is the Shouldice operation (shown in figure above) whereby the deep ring and transversalis fascia are incised and carefully seperated from the deep inferior epigastric vessels creating two flaps, the upper flap is pulled over the lower flap and connected together making the ring narrower.
◼️Another more simple method is the Lytle operation where by the spermatic cord is displaced laterally and the ring narrowed by sutures.
#Hernia
#Surgery
Examination sequence for hernia
◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).
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#Surgery
◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).
#Hernia
#Surgery
Although the internal inguinal ring is thought of as a hole in transversalis fascia, it is actually not a hole but an invagination of the transversalis fascia to form the internal spermatic fascia of the spermatic cord, so a hernia passing though this ring would normally be deep to the internal spermatic fascia which is dissected at time of operation to expose the hernial sac
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#Inguinal_Triangle
◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?
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◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?
#Hernia
#Surgery
Types of indirect inguinal hernia
◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.
◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.
◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.
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#Surgery
◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.
◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.
◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.
#Hernia
#Surgery
Clinically an inguinal hernia can be differentiated from a femoral hernia by ascertaining the relationship between the neck of the hernia and the pubic tubercle i.e in inguinal hernia the neck is above and medial to the pubic tubercle while in a femoral hernia the neck is below and lateral to the pubic tubercle. (see figure above)
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Anatomy of inguinal canal
◼️In infants the internal and external rings almost oppose each other and the obliquity of the canal is slight.
◼️In adults the canal is about 3.75cm long extending from the internal to the external ring downwards and medially.
◼️In males the canal transmit the spermatic cord, ilioinguinal nerve and genital branch of genitofemoral nerve, in females the round ligament replaces the spermatic cord.
◼️The posterior wall is formed of the transversalis fascia (black arrow) and the conjoined tendon of internal oblique and transversus abdominis muscles (yellow arrow).
◼️The anterior wall is mainly formed of external oblique aponeurosis.
◼️The inferior boundery is the inguinal ligament.
◼️The superior boundery is formed by the conjoined muscles (internal oblique and transversus abdominis).
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◼️In infants the internal and external rings almost oppose each other and the obliquity of the canal is slight.
◼️In adults the canal is about 3.75cm long extending from the internal to the external ring downwards and medially.
◼️In males the canal transmit the spermatic cord, ilioinguinal nerve and genital branch of genitofemoral nerve, in females the round ligament replaces the spermatic cord.
◼️The posterior wall is formed of the transversalis fascia (black arrow) and the conjoined tendon of internal oblique and transversus abdominis muscles (yellow arrow).
◼️The anterior wall is mainly formed of external oblique aponeurosis.
◼️The inferior boundery is the inguinal ligament.
◼️The superior boundery is formed by the conjoined muscles (internal oblique and transversus abdominis).
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Surgical anatomy
◼️The deep inguinal ring is a U shaped condensation of the transversalis fascia, which is the fascial envelope of the abdomen it lies between the parietal peritoneum and the muscles of the abdominal wall(see figure above).
◼️The deep inguinal ring is about 1.25 cm above the inguinal ligament midway between the symphesis pubis and the anterior superior iliac spine.
◼️The competency of the deep inguinal ring greatly depends upon the integrity of the transversalis fascia.
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#Surgery
◼️The deep inguinal ring is a U shaped condensation of the transversalis fascia, which is the fascial envelope of the abdomen it lies between the parietal peritoneum and the muscles of the abdominal wall(see figure above).
◼️The deep inguinal ring is about 1.25 cm above the inguinal ligament midway between the symphesis pubis and the anterior superior iliac spine.
◼️The competency of the deep inguinal ring greatly depends upon the integrity of the transversalis fascia.
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Surgical anatomy
◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
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◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.
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#Surgery