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Questions 1–20
Published in Anna Kowalewski, SBAs and EMQs in Surgery for Medical Students, 2021
Up to 15% of patients with hernias will present as an emergency in this way. They are more common on the right side. The contents of the inguinal canal in a male is as follows: cremasteric fascia and the internal spermatic fascia; the spermatic cord, the vas deferens and lymphatics, arteries to the vas deferens, cremaster and the testes; the pampiniform plexus and the genital branch of the genitofemoral nerve; finally, the ilioinguinal nerve passes through the superficial ring to descend into the scrotum, but is not technically part of the inguinal canal. Note that in the female it is the round ligament of the uterus and the ilioinguinal nerve.
Posterior Component Separation
Published in Jeff Garner, Dominic Slade, Manual of Complex Abdominal Wall Reconstruction, 2020
In the lower third of the dissection, the psoas muscles are encountered, marking the lateral extent of the dissection. The round ligament of the uterus in women and spermatic cord in men are also found and should be carefully dissected free; if necessary, the round ligament can be divided. The most inferior extent of the dissection exposes the pubic symphysis and Cooper's ligaments bilaterally, which are excellent as points of fixation for the inferior border of any reinforcing prosthetic. Placing a 2/0 slowly absorbable suture through these ligaments once they are encountered ensures they are ready for anchoring the prosthetic as soon as that stage is reached (Figure 12.8) – depending on the likely choice of prosthetic it may be necessary to leave the needle on the suture to drive through the mesh in due course.
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 supports of the uterus are extremely important. The lateral (or transverse) cervical ligaments condense around the uterine artery and run to the lateral pelvic wall. The uterosacral ligaments are primarily condensations of fascia running backwards from the cervix of the uterus past the rectum and attaching to the sacrum. The round ligament of the uterus is the female remnant of the embryonic gubernaculum which guides the testis to the scrotum in the male. It is a continuation of the ovarian ligament which is in the broad ligament attaching the ovary to the uterus. The round ligament then continues from the wall of the uterus in the anterior leaf of the broad ligament to the pelvic wall and then through the deep inguinal ring and inguinal canal to fade out into the labium majorum. It is important only in helping to hold the uterus in its usual anteverted, anteflexed position (i.e., the uterus tends to lie tipped forwards over the female bladder).
Image of the month: cyst of the canal of Nuck
Published in Acta Chirurgica Belgica, 2018
Banu Karapolat, Hatice Ayça Ata Korkmaz, Gulgun Kocak, Eser Bulut
Cyst of the canal of Nuck is a rare cause of the swellings occurring in the inguinal area in women. Homologous to the processus vaginalis in men, the canal of Nuck is a pocket-shaped evagination of the parietal peritoneum that follows the same path as the round ligament of the uterus in the inguinal ring. Normally, this canal obliterates at birth or early infant period and loses its connection with the peritoneal cavity, but sometimes it can remain patent. If it remains completely patent, it forms an avenue for an indirect inguinal hernia. Partial proximal obliteration with a patent distal portion causes a cyst of the canal of Nuck, which is also referred to as female hydrocele [1].
A Modification of Laparoscopic Type C1 Hysterectomy to Reduce Postoperative Bladder Dysfunction: A Retrospective Study
Published in Journal of Investigative Surgery, 2019
Wei Jiang, Meirong Liang, Douxing Han, Hui Liu, Ling Li, Meiling Zhong, Lin Luo, Siyuan Zeng
We disrupted the round ligament of the uterus at the middle-lateral one-third junction and incised the anterior leaf of the broad ligament and peritoneal reflection. The infundibulopelvic ligaments were detached and dissected at a high level. In cases where one ovary was preserved, we conducted incision of the proper ovarian ligament, followed by a biopsy and ectopic suspension of the ovary and salpingectomy contralaterally. The ureter was separated by resecting the posterior leaf of the broad ligament. After the incision of the uterorectal peritoneal reflection, we developed the rectovaginal space. The pararectal space was also developed between the uterosacral ligament and ureteral mesentery, sparing the inferior hypogastric nerve. In between the two spaces, the uterosacral ligament was dissected immediately adjacent to the rectal wall. The development of the paravesical space along the superior vesical artery to the top and posterior to the bladder was done to isolate the origin of the uterine artery, which was cauterized and divided centrifugally adjacent to the internal iliac artery. We developed the ureter tunnel according to established methods and cut the anterior leaf of the vesicocervical ligament. We then separated and laterally shifted the ureter. By extirpation of the superior fatty and lymph tissues, the DUV was isolated to where it emits the vesical and cervical branches, at which plane the paracervical space was developed. The posterior leaf of the vesicocervical ligament was cut, preserving the bladder branches of the DUV and the nervous tissues below. We cut the cervical branch of the DUV and the vascular portion of the cardinal ligament (CL) between the pararectal space and paracervical space. We also cut the vessels in the paracolpium and ligated them at the appropriate plane. After performing the same procedure on the opposite side, the uterus was amputated, leaving 3–4 cm of the vagina intact.