Groin Anatomy

Inguinal Region
Inguinal region extends from ASIS to pubic tubercle
Important area anatomically and clinically
Structures exit and enter the abdomen and thigh
These are potential sites of herniation
o Due to inherent weakness of abdominal wall in the groin
(predestined to happen because of development)
Contains inguinal canal
o A slit like passage that extends in a downward and medial
direction
o Above and parallel to the medial half of the inguinal ligament
o Allows content of scrotum to communicate with abdominal
content
o Canal begins as a deep inguinal vein, continues for 4cm, into
your superficial inguinal vein
o The inguinal canal is an oblique passage
o The different flat muscles will have a contribution to the
development of this canal
E.g. external oblique, internal oblique, transversus
abdominis, transversalis fascia
o * Schematic sagittal section. See:
Inguinal ligament
Inguinal canal
Lies parallel and superior to your inguinal ligament
Spermatic cord in males
Round ligament in females
Contains blood and lymphatic vessels
o For dissection: peel off the inguinal area
Male cadaver: try to look for the superficial inguinal vein
Formation of Inguinal Canal in Males
o Fetus on its 7th week
Intraabdominal testes
Peritoneum
Gubernaculum
Fibrous structure that connects the primordial testes
to your anterolateral abdominal wall
Site of future deep inguinal ring of the inguinal canal
Processus vaginalis
A peritoneal diverticulum
Traverses your developing inguinal canal
 Will carry on with it muscle (the 3 flat muscles) and
fascia layer of anterolateral abdominal wall
th
o Fetus on 12 week
Testes will start to descend, and into the pelvis area
already
o Fetus on 7th month / 28th week
Testes will lie close to the deep inguinal ring
Testes will begin to pass through the inguinal canal, taking
three days to traverse the inguinal canal
Will carry on with it muscle (the 3 flat muscles) and
fascia layer of anterolateral abdominal wall
Ensheathed with the external fascia???
o Fetus on 8th month
Testes should have entered the scrotum
When this doesnt happen, an undescended testis
occurs
o 3% full term and 30% premature
o 95% occurs unilaterally
o Do
Formation of Inguinal Canal in Females
o Fetus on 2 months
Primordial ovaries
Develop in superior lumbar region
Relocated in lateral wall of pelvis
Processus vaginalis
Traverses the transversalis fascia at the site of the
inguinal ring
Protrudes to the labia majora
o Fetus 15 weeks
Gubernaculum
Fibrous cord that connects the ovary to the primary
uterus to the labia majora
No undescended ovaries! (why??)
Canal of Nuck
o Abnormal opening extending from the peritoneum to the labia
major
o Analogous to the patent processus vaginalis
o Extends to the anterior part of the round ligament
o Incomplete obliteration of processus vaginalis
o Results to an inguinal hernia or a hydrocele
Inguinal Canal
o Think of it like a box
Roof
 Conjoint tendon
Floor
Formed by incurving of the inguinal ligament, which
is part of the external oblique forming a gutter
Posterior wall
Formed by transversalis fascia throughout (as in
internal oblique on anterior side)
Reinforced by conjoint tendon on the medial side
o Made up of external oblique and transversus
abdominis aponeuroses
o Also called the inguinal falx
o Arches over the content of the inguinal canal,
where it also forms the roof of the canal
Contains deep inguinal ring (inferior side of the
abdominal wall)
o Situated more lateral (but still in the back)
o Particularly weak since the posterior wall is thin
and has no reinforcement except the conjoint
tendon
Anterior wall
Made up of external oblique muscle all through out
Reinforced by internal oblique muscle on the lateral
side
The transversus abdominis lies even more laterally
as part of the anterior abdominal wall
Contains Superficial inguinal ring
o Situated more medially
o Superior to the pubic tubercle
o Apex pointing superolaterally
o Exit by which spermatic cord and round
ligament exits inguinal canal
Lateral
Medial
o In males, the box transmits the spermatic cord
Groin
o Know how to do physical examination of the groin as well
Pressures in the inguinal canal
o Deep inguinal ring is closed off by the anterior wall
o Superficial inguinal ring is closed off by the posterior wall
o Weakness of walls causes direct or indirect hernias
Indirect hernia
Often congenital
 Failure of processus vaginalis to close off accounts for
nearly all inguinal hernias in childhood
A patent or partially patent processus vaginalis will
Passes through deep inguinal ring, through inguinal
canal, and goes down into scrotum
o From abdomen, testes will pass through deep
inguinal ring along with all its components
If stalk is not complete or partial, you can see a bulge
lateral or superior to inguinal area
Direct hernia
Within the floor of Hesselbachs triangle
o Hesselbachs triangle
Superolateral: inferior epigastric vessels
Medial: lateral part of rectus abdominis
Inferior: inguinal ligament
Often an acquired defect because of the mechanical
breakdown over the years
~1% lifetime risk of developing direct inguinal hernia
Differentiation
Indirect hernial sac is normally within spermatic
cord
Direct is separate and parallel from spermatic cord
Physical Examination
Perform with patient standing up
Inguinal occlusion test
o Palpate the deep inguinal ring and superficial
inguinal ring
Deep inguinal ring can be palpated as a
depression 3-4 cm superolateral to your
pubic tubercle.
Also superior to your inguinal
ligament
For this module
o no visible masses at inguinal area
o Majority of abdominal hernias occurs 75% in the inguinal canal
68% occurs in males
o Scrotal Hydrocele
Due to a persistent processus vaginalis (also known as
communicating or infantile hydrocele)
Also cause of inguinal hernia
Transillumination test
Shine a bright light
Trans-illumination = positive
 o Hematocele

Peritoneal Cavity

Peritoneum
Introduction
o Smooth glistening transparent lining the abdominal cavity
o Provides pathway for blood vessels and lymph
Review of structures
o Rectus
o 3 flat muscles
o Transversalis fascia
Deep to this is the peritoneum
Layers
o Parietal
o Visceral
Same nerve supply as the viscera it invests
Pain is poorly localized, but can feel stretch and chemical
irritation
o Both layers consist of simple low cuboidal mesothelium???
Two main groups of abdominal viscera
o Intraperitoneal
Completely covered by the visceral peritoneum (e.g.
jejunum)
Stomach
Spleen
Liver
o Retroperitoneal
SADPUCKER
Only covered by peritoneum on their anterior surface
2 groups of organs
Primarily retroperitoneal
o Develop in the body wall
o Never had a mesentery
o Esophagus kidney rectum
Secondarily retroperitoneal
o Initially suspended in a cavity
o But later fused with the body wall
o Ascending and descending colon
Peritoneal cavity
o Space between visceral and parietal layers
o Normally contains peritoneal fluid
o Peritoneal folds and ligaments suspend the intraperitoneal
organs
o When the peritoneum doubles up, it becomes an omentum
o An omentum that attaches to the body wall is a mesentery
o Greater omentum
Composed of fat, blood vessels, lymphatic tissue
POLICE MAN OF THE ABDOMEN
Can migrate to infected viscera!!! To localize infection
o Lesser omentum
Gastrohepatic omentum
Also connect the stomach to a triad of organs
This is where you find the hepatoduodenal ligament
Hepatogastric ligament
o Peritoneal ligaments
6?
Double layered folds of peritoneum that connects viscera
to abdominal wall
o Greater Sac
Supracolic and infracolic compartments, depending on
location relative to transverse colon
On the side you have the paracolic gutters located in the
posterolateral abdominal wall, lateral to the ascending and
descending colon
These gutters connect both supra- and infracolic
compartments
Ovarian Cancer Spread
Intraperitoneal dissemination is the most common
cause of metastasis
It can spread up using the paracolic gutters,
eventually reaching the diaphragm
o Peritoneal Recess
Are of clinical importance in connection with the spread of
pathological fluid such as pus
The recesses determine the extent and direction of spred
of fluids tha may enter the peritoneal cavity whena
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Subphrenic recess
Anterior and posterior
Right and left
Duodenal recess
Close to the duodenojejunal junction
Cecal recess
o Lesser Sac
 Omental bursa lies posterior to the stomach and the lesser
omentum
Allows stomach to move freely against structures inferior
and posterior to it
Opening is the epiploic foramen of Winslow
Site of internal herniation via the epiploic foramen of
Winslow
o Diaphragm
Shaped like a parachute
Origin:
Sternal part
Costal part
Vertebral part
Also arises from lateral and medial arcuate ligament
(aside from median)
Medial: Thickened fascia of the psoas muscle
Lateral: upper part of the quadratus lumborus
Extends from tip of transverse process of L1 into the
lower border of 12th rib
Insertion: central tendon, which fuses with fibrous part of
the pericardium
Openings:
Caval hiatus, passes through central tendon at level
of T8, right of the median plane, most superior of the
three diaphragmatic apertures
Esophageal hiatus, more superior and to the left of
aortic hiatus, at the level of T10, transmitting
esophagus, anterior and posterior vagal trunk, and
esophageal trunk of left gastric vessels
Aortic hiatus, found at the T12 level, transmits aorta
and azygos vein
o Aortic hiatus does not change in aperture, in
contrast to caval hiatus, wherein it widens
during inspiration
Blood supply
Mainly via inferior phrenic
Secondarily:
o Musculophrenic?
o 2 more
Innervation
Phrenic nerves (right and left)