Anterior and Medial Thigh I.

Fibrous Structures of the Anterior Thigh

A. Femoral triangle
Is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. Has the floor , which is formed by the iliopsoas, pectineus, and adductor longus muscles. Its roof is formed by the fascia lata and the cribriform fascia. Contains the femoral n erve, a rtery, v ein, and l ymphatics (in the canal). A mnemonic NAVeL is used to remember the order of the structures, and the mnemonic NAVY is used to remember the structures from lateral to medial (n erve, a rtery, v ein, y ahoo!!!). The pulsation of the femoral artery may be felt just inferior to the midpoint of the inguinal ligament.

B. Femoral ring
Is the abdominal opening of the femoral canal. Is bounded by the inguinal ligament anteriorly, the femoral vein laterally, the lacunar ligament medially, and the pectineal ligament posteriorly

C. Femoral canal
Lies medial to the femoral vein in the femoral sheath. Contains fat, areolar connective tissue, and lymph nodes and vessels. Transmits lymphatics from the lower limb and perineum to the peritoneal cavity. Is a potential weak area and a site of femoral herniation , which occurs most frequently in women because of the greater width of the superior pubic ramus of the female pelvis.

cc 3.20
Femoral hernia: is more common in women than in men, passes through the femoral ring and canal, and lies lateral and inferior to the pubic tubercle and deep and inferior to the inguinal ligament; its sac is formed by the parietal peritoneum. Strangulation of a femoral hernia may occur because of the sharp, stiff boundaries of the femoral ring, and the strangulation interferes with the blood supply to the herniated intestine, resulting in death of the tissues.

D. Femoral sheath
Is formed by a prolongation of the transversalis and iliac fasciae in the thigh. Contains the femoral artery and vein, the femoral branch of the genitofemoral nerve, and the femoral canal. (The femoral nerve lies outside the femoral sheath, lateral to the femoral artery.) Reaches the level of the proximal end of the saphenous opening with its distal end.

E. Adductor canal
Begins at the apex of the femoral triangle and ends at the adductor hiatus (hiatus tendineus). Lies between the adductor magnus and longus muscles and the vastus medialis muscle and is covered by the sartorius muscle and fascia. Contains the femoral vessels, the saphenous nerve, the nerve to the vastus medialis, and the descending genicular artery.

F. Adductor hiatus (hiatus tendineus)

Is the aperture in the tendon of insertion of the adductor magnus. Allows the passage of the femoral vessels into the popliteal fossa.

G. Saphenous opening (saphenous hiatus) or fossa ovalis

Is an oval gap in the fascia lata below the inguinal ligament that is covered by the cribriform fascia , which is a part of the superficial fascia of the thigh. Provides a pathway for the greater saphenous vein.

III. Fasciae and Ligaments of the Anterior Abdominal Wall

Are organized into superficial (tela subcutanea) and deep layers; the superficial layer has a thin fatty layer (Camper's fascia ), and the deep layer has a membranous layer (Scarpa's fascia ).

A. Superficial fascia 1. Superficial layer of the superficial fascia (Camper's fascia)

Continues over the inguinal ligament to merge with the superficial fascia of the thigh. Continues over the pubis and perineum as the superficial layer of the superficial perineal fascia.

2. Deep layer of the superficial fascia (Scarpa's fascia)

Is attached to the fascia lata just below the inguinal ligament. Continues over the pubis and perineum as the membranous layer ( Colles' fascia ) of the superficial perineal fascia. Continues over the penis as the superficial fascia of the penis and over the scrotum as the tunica dartos which contains smooth muscle. P.182 May contain extravasated urine between this fascia and the deep fascia of the abdomen, resulting from rupture of the spongy urethra (see Chapter 6 , p. 241.).

B. Deep fascia
Covers the muscles and continues over the spermatic cord at the superficial inguinal ring as the external spermatic fascia. Continues over the penis as the deep fascia of the penis (Buck's fascia) and over the pubis and perineum the deep perineal fascia.

B. Linea alba
Is a tendinous median raphe between the two rectus abdominis muscles, extending from the xiphoid process to the pubic symphysis. Is formed by the fusion of the aponeuroses of the external oblique, internal oblique, and transverse muscles the abdomen.

cc 5.2
Epigastric hernia: is a protrusion of extraperitoneal fat or a small piece of greater omentum through a defect in the linea alba above the umbilicus and may contain a small portion of intestine, which may become trapped within the hernia, leading to strangulation or incarceration. Its symptoms include nausea, vomiting, and discomfort as a result of nerves and tissue being irritated or stretched.

D. Linea semilunaris
Is a curved line along the lateral border of the rectus abdominis.

E. Linea semicircularis (arcuate line)

Is a crescent-shaped line marking the inferior limit of the posterior layer of the rectus sheath just below level of the iliac crest.

F. Lacunar ligament (Gimbernat's ligament)

Represents the medial triangular expansion of the inguinal ligament to the pectineal line of the pubis. Forms the medial border of the femoral ring and the floor of the inguinal canal.

G. Pectineal (Cooper's) ligament

Is a strong fibrous band that extends laterally from the lacunar ligament along the pectineal line of the pubis.

H. Inguinal ligament (Poupart's ligament)

Is the folded lower border of the aponeurosis of the external oblique muscle, extending between the anteriorsuperior iliac spine and the pubic tubercle. Forms the floor (inferior wall) of the inguinal canal.

I. Iliopectineal arcus or ligament

Is a fascial partition that separates the muscular (lateral) and vascular (medial) lacunae deep to the inguinal ligament. The muscular lacuna transmits the iliopsoas muscle. The vascular lacuna transmits the femoral sheath and its contents, including the femoral vessels, a femoral branch of the genitofemoral nerve, and the femoral canal.

J. Reflected inguinal ligament

Is formed by certain fibers of the inguinal ligament reflected from the pubic tubercle upward toward the linea alba. Also has some reflection from the lacunar ligament.

K. Falx inguinalis (conjoint tendon)

Is formed by the aponeuroses of the internal oblique and transverse muscles of the abdomen and is inserted into the pubic tubercle. Strengthens the posterior wall of the medial half of the inguinal canal.

L. Rectus sheath (Figure 52)

Is formed by fusion of the aponeuroses of the external oblique, internal oblique, and trans verse muscles the abdomen. P.184 Encloses the rectus abdominis and sometimes the pyramidal muscle. Also contains the superior and inferior epigastric vessels and the ventral primaryrami of thoracic nerves 7 12.

1. Anterior layer of the rectus sheath

Above the arcuate line: aponeuroses of the external and internal oblique muscles. Below the arcuate line: aponeuroses of the external oblique, internal oblique, and transverse muscles.

2. Posterior layer of the rectus sheath

Above the arcuate line: aponeuroses of the internal oblique and transverse muscles. b. Below the arcuate line: rectus abdominis is in contact with the transversalis fascia.

IV. Inguinal Region

A. Inguinal (Hesselbach's) triangle
Is bounded medially by the linea semilunaris (lateral edge of the rectus abdominis), laterally by the inferior epigastric vessels, and interiorly by the inguinal ligament. Is an area of potential weakness and hence is a common site of a direct inguinal hernia.

B. Inguinal rings 1. Superficial inguinal ring

Is a triangular opening in the aponeurosis of the external oblique muscle that lies just lateral to the pubic tubercle.

2. Deep inguinal ring

Lies in the transversalis fascia, just lateral to the inferior epigastric vessels.

C. Inguinal canal
Begins at the deep inguinal ring and terminates at the superficial ring. P.185 Transmits the spermatic cord or the round ligament of the uterus and the genital branch of the genitofemoral nerve, both of which also run through the deep inguinal ring and the inguinal canal. An indirect inguinal hernia (if present) also passes through this canal. Although the ilioinguinal nerve runs through part of the inguinal canal and the superficial inguin ring, it does not pass through the deep inguinal ring. al Anterior wall : aponeuroses of the external oblique and internal oblique muscles. Posterior wall : aponeurosis of the transverse abdominal muscle and transversalis fascia. Superior wall (roof) : arching fibers of the internal oblique and transverse muscles.

Inferior wall (floor) : inguinal and lacunar ligaments.

cc 5.3
Inguinal hernia: is a condition in which a portion of intestine protrudes through a weak spot in the inguinal canal or in the inguinal triangle. Inguinal hernia occurs superior to the inguinal ligament and medial to pubic tubercle, occurs more in males than in females, and is derived from persistence of the processus vaginalis, which forms the tunica vaginalis (Figure 5-3 ). Reducible hernia is a hernia in which the contents of the hernial sac can be returned to their normal position. Incarcerated hernia is an irreducible hernia which the contents of the hernial sac are entrapped or stuck in the groin. Strangulated hernia is an irreducible hernia in which the intestine becomes tightly trapped or twisted; thus, the circulation is arrested, and gangrene (death of tissue) occurs unless relief (emergency operation) is prompt. This is life threatening, and emergency surgical repair is required.

cc 5.4
Indirect inguinal hernia: passes through the deep inguinal ring, inguinal canal, and superficial inguinal and descends into the scrotum. The hernia lies lateral to the inferior epigastric vessels. Indirect inguinal hernia is found more commonly on the right side in men and is more common than direct inguinal hernia. congenital (present at birth), associated with the persistence of the processus vaginalis, and covered by peritoneum and the coverings of the spermati cord. c Direct inguinal hernia: occurs directly through a weakened area of the abdominal wall muscles (posterior wall of the inguinal canal), lateral to the edge of the conjoint tendon, in the inguinal triangle but does not descend into the scrotum. The hernia lies medial to the inferior epigastric vessels and protrudes forward (rarely through) the superficial inguinal ring. It is acquired (develops after birth), associated with weakness in the posterior wall of the inguinal canal lateral to the falx inguinalis, and has a sac that is formed by the peritoneum and occasionally the transversalis fascia.

V. Spermatic Cord, Scrotum, and Testis

A. Spermatic cord (Figure 5-3)
Is composed of the ductus deferens; testicular , cremasteric, and deferential arteries; pampiniform plexus testicular veins; genital branch of the genitofemoral and cremasteric nerves and the testicular sympathetic plexus; and lymph vessels. These are all conjoined by loose connective tissue. Has several fasciae: External spermatic fascia , derived from the aponeurosis of the external oblique muscle. Cremasteric fascia (cremaster muscle and fascia), originating in the internal oblique muscle. Internal spermatic fascia , derived from the transversalis fascia.

C. Fetal structures
Is the fetal ligament that connects the bottom of the fetal testis to the developing scrotum. Appears to be important in testicular descent (pulls the testis down as it migrates). Is homologous to the ovarian ligament and the round ligament of the uterus.

C. Scrotum (see p. 247)

Consists of a thin pigmented skin and dartos fascia, a layer of smooth muscle fibers; when contracted, it wrinkles to regulate the temperature. Is innervated by genital branch of the genitofemoral, anterior scrotal branch of the ilioinguin al, posterior scrotal branch of the perineal, and perineal branch of the posterior femoral cutaneous nerves. Receives blood from anterior scrotal branches of the external pudendal artery and posterior scrotal branches of the internal pudendal artery and drains lymph initially into the superficial inguinal nodes.

D. Testes (see p. 260)

Are surrounded by the tunica vaginalis in the scrotum, and produce sperms in the seminiferous tubules and testosterone by interstitial (Leydig) cells. Are innervated by the autonomic nerves, drain lymph into the deep inguinal nodes and to the lumbar and preaortic nodes, receive blood from the testicular arteries arising from the aorta, and drain venous blood testicular veins, which empty into the inferior vena cava on the right and the renal vein on the left.

VI. Inner Surface of the Anterior Abdominal Wall (Figure 5-4)

A. Supravesical fossa
Is a depression on the anterior abdominal wall between the median and medial umbilical folds of the peritoneum. P.187

B. Medial inguinal fossa

Is a depression on the anterior abdominal wall between the medial and lateral umbilical folds of the peritoneum. It lies lateral to the supravesical fossa. Is the fossa where most direct inguinal hernias occur.

C. Lateral inguinal fossa

Is a depression on the anterior abdominal wall, lateral to the lateral umbilical fold of the peritoneum.

D. Umbilical folds or ligaments 1. Median umbilical ligament or fold

Is a fibrous cord, the remnant of the obliterated urachus , which forms a median umbilical fold of peritoneum. Lies between the transversalis fascia and the peritoneum and extends from the apex of the bladder to the umbilicus.

2. Medial umbilical ligament or fold

Is a fibrous cord, the remnant of the obliterated umbilical artery , which forms a medial umbilical fold and extends from the side of the bladder to the umbilicus.

3. Lateral umbilical fold

Is a fold of peritoneum that covers inferior epigastric vessels and extends from the medial side of the deep inguinal ring to the arcuate line.

E. Transversalis fascia
Is the lining fascia of the entire abdominopelvic cavity between the parietal peritoneum and the inner surface of the abdominal muscles. Continues with the diaphragmatic, psoas, iliac, pelvic, and quadratus lumborum fasciae. P.188 Forms the deep inguinal ring and gives rise to the femoral sheath and the internal spermatic fascia. Is directly in contact with the rectus abdominis below the arcuate line.