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General Surgery
Published in Kristen Davies, Shadaba Ahmed, Core Conditions for Medical and Surgical Finals, 2020
Indirect inguinal hernias emerge through the deep inguinal ring along with the structures of the spermatic cord and are as a result lateral to the inferior epigastric vessels. Some indirect inguinal hernias occur due to a patent processus vaginalis, which usually obliterates in childhood. The deep inguinal ring can be found at the midpoint of the inguinal ligament (1 cm above and lateral to the femoral pulse at the mid-inguinal point).
Hernias
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
As part of the full examination, focus on: Does the patient have an ‘acute abdomen’ i.e. peritonitis, guarding?Assess the patient's nutritional and hydration status (skin turgor, mucous membranes and blood pressure).Where is the hernia and what type is it?If the hernia is in the groin, is it above and medial to the pubic tubercle (inguinal) or below and lateral (femoral)? This is important as femoral hernias are more likely to strangulate.Is the hernia reducible? Ask the patient to try and reduce it.If it is an inguinal hernia, attempt to differentiate between direct and indirect by reducing it and putting pressure on the deep inguinal ring (found above the midpoint of the inguinal ligament between pubic tubercle and anterior superior iliac spine). Then ask the patient to cough. If the hernia is indirect, pressure on the deep inguinal ring will stop it from protruding in most cases (although this is not always the case). A direct hernia will not be controlled by this pressure.
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
The deep inguinal ring is a hole in the transversalis fascia and lies a finger-breadth above the mid-point of the inguinal ligament (i.e., halfway between the anterior superior iliac spine and pubic tubercle). The superficial inguinal ring is a hole in the external oblique aponeurosis. The key to understanding the inguinal canal is to concentrate on the internal oblique layer which laterally forms the anterior wall of the inguinal canal. The internal oblique then arches over the top of the canal forming its roof and then blends with the transversus abdominus layer posteriorly and medially to form the conjoint tendon.
A preventable cause of transplant hydroureteronephrosis: inguinal herniation of the transplant ureter: case report and review of the literature
Published in Acta Chirurgica Belgica, 2021
Isabelle Bosmans, Veerle De Boe, Karl Martin Wissing, Marian Vanhoeij, Daniel Jacobs-Tulleneers-Thevissen
Before surgery, sirolimus was temporarily switched to cyclosporine. Surgical exploration was done using a midline laparotomy. We found an abdominal wall defect, medial to the deep inguinal ring, with the transplant ureter prolapsing through this defect anterior of the spermatic cord (Figure 1(C)). After opening the preperitoneal space, the ureter was reduced and the defect was closed primarily. The ureter was shortened to an appropriate length and re-implanted on the bladder over a ureteral stent using the Lich-Gregoir ureteroneocystostomy technique [5]. The nephrostomy tube was removed and a Prevena® (KCI, Inc., San Antonio, TX) dressing was used for optimal wound healing. Postoperatively, serum creatinine levels dropped to the patient’s baseline level (2.33 mg/dl) with discharge on the 5th postoperative day and ambulatory removal of the ureteral stent 6 weeks later. At that time, renal function was stable. Unfortunately, long-term outcome on hernia recurrence or renal function cannot be shown since the patient was lost to follow-up.
Unsatisfactory testicular position after inguinal orchidopexy: Is there a role for upfront laparoscopy?
Published in Arab Journal of Urology, 2020
Ahmed Abdelhaseeb Youssef, Mahmoud Marei Marei, Mohamed Hamed Abouelfadl, Wesam Mohamed Mahmoud, Atef Salaheldin Abdulaziz Elbarawy, Tamer Yassin Mohamed Yassin
Laparoscopy was initiated through an open Hasson technique using a supra-umbilically placed 5-mm cannula. Thereafter, the peritoneal cavity was insufflated with CO2 (pressure: 8–12mmHg). We used a 5-mm 30 °scope and two 5-mm working ports. With the patient in the Trendelenburg position and the ipsilateral side up, the lower abdomen and pelvis were inspected to identify the vas deferens and testicular vessels entering the deep (internal) inguinal ring and to note the adhesions at the deep inguinal ring (Figure 1). Two 5-mm instruments were placed in the midclavicular line on each side, slightly infra-umbilically. The peritoneal fold containing the testicular vessels was dissected free, starting from the deep inguinal ring upwards, reaching as high as possible (Figure 2(a,b)). Extreme care was exercised during dissection of scar tissue (often in the form of a fibrotic ring) present at and around the deep inguinal ring.
The Septum Inguinalis: A Clue to Hernia Genesis?
Published in Journal of Investigative Surgery, 2020
Giuseppe Amato,, Piergiorgio Calò,, Vito Rodolico,, Roberto Puleio,, Antonino Agrusa,, Leonardo Gulotta,, Luca Gordini,, Giorgio Romano,
Recognition of the septum inguinalis, and the fact that it may degenerate into oblivion from the compressive effect of advanced pantaloon hernia in the form of a combined hernia, allows a revision of the traditional anatomic concepts in relation to the inguinal canal. Classically the inguinal floor is described in 2 parts: Hesselbach’s triangle medial to the epigastric vessels and the deep inguinal ring laterally [15–19]. However, functionally this may not be correct. On the basis of the cases reported here and many others we have encountered in our clinical practice [3] we characterize the functional anatomy of the inguinal floor as follows:A medial aspect consisting of the fossa supravesicalis—fossa inguinalis media complex. These 2 zones, longitudinally divided by the medial umbilical fold and covered in the posterior aspect by the transversalis fascia, are tightly connected and often involved together in direct hernia protrusion.An intermediate aspect: the septum inguinalis that divides the medial from the lateral part of the inguinal floor. This comprises, anteriorly, the muscle bundles of the internal oblique and transverse, covered by the transversalis fascia and forming the medial border of the deep inguinal ring. Posteriorly is composed by the epigastric vessels and sheath. The latter may act as a protective shield as it is the last recognizable structure to disappear when a combined hernia converges into a single protrusion. Comprising more than just the inferior epigastric vessels, the septum inguinalis structure includes the lateral part of the fossa inguinalis media and the medial part of the internal ring.A lateral aspect that comprises the transversalis fascia and deep inguinal ring, its medial aspect being functionally connected with the septum inguinalis.