5 حسام أبو عوض - -Dr. Mohammad Muhtasib 1 P a g e
There are two types of inguinal hernia: direct and indirect. Hernia: protrusion of the small intestine or the greater omentum of the intra-abdominal organs through the weak points in the abdominal wall [e.g. deep inguinal ring in the transversalis fascia (considered a weak point because the spermatic cord passes through it), the inguinal triangle in elderly (the abdominal muscles become weak allowing for hernia to occur)] of the intra-abdominal wall. The inguinal hernia only occurs if there is a specific cause for it. An old person with chronic constipation or with chronic coughing due to smoking, for example, increase their intra-abdominal pressure and may result in opening of their weak point(s) allowing for hernia to occur. The hernia has content, sac, covering and a neck. Sac: the part in front of the small intestine/greater omentum that is being pushed by them the anterior abdominal wall layers all become in front of the sac which contains the herniated greater omentum content/ small intestine. The sac can get enlarged and extend till reaching the scrotum. The covering of the sac: begins from the anterior abdominal muscles (the defect is in the transversalis fascia), so the first layer (from outside to inside), made by the external oblique muscle, is the external spermatic fascia, the second, made by the internal oblique muscle, is the cremasteric fascia and muscle, the third layer, made by the transversalis fascia, is the internal spermatic fascia. More common than direct hernia and can be congenital (if congenital it would be bilateral). The hernial sac will be present and can arise from the prossus vaginalis (which is supposed to undergo fibrosis and get obliterated, if it didn t then it would remain open and would form the beginning of the sac of the hernia to be formed). The indirect hernia is lateral to the inferior epigastric vessels (remember the inferior epigastric vessels are some very important land-marks) while the direct hernia is medial to them in the inguinal triangle and both push the peritoneum (as the hernia is in the transversalis fascia). The indirect hernia begins in the deep ring, passes through the inguinal canal, passes through the superficial ring and may reach the scrotum 2 P a g e
(the indirect hernia is always next to the spermatic cord as it passes through the deep ring). The indirect hernia rarely reaches the labia majora in females because there only is a round ligament (the males have a spermatic cord that make the hernia more often reach the scrotum). The neck of the indirect hernia is usually in the deep ring. It is more common in males than females (20:1). It is more common in the right testis than the left (the right testis descends after the left testis). 15% of the direct hernia is in the inguinal region, is common in elderly due to the weakness of the abdominal muscles and it is bilateral. The hernial sac bulges forward in the direct hernia (in the inguinal triangle) and for its reduction we move it backwards. The direct hernia is not related to the inguinal canal (it occurs in the inguinal triangle in the forward-backward direction) so it never reaches the scrotum. The indirect hernia is lateral to the inferior epigastric vessels and its direction is downward, forward and medially and for its reduction we move it backwards, upwards and laterally. When the indirect hernia occurs a swelling in the anterior abdominal wall appears then disappears then re-appears and keeps increasing in size and might reach the scrotum. The patient here knows how to reduce the hernia. The indirect hernia, unlike the direct one, occurs in young patients and is unilateral unless it is congenital (then it is bilateral) and it may reach the scrotum. (We must be able to differentiate between direct and indirect inguinal hernias). 3 P a g e
Tests Superficial inguinal test: depends on the pulsation of the inferior epigastric with your index. Reduce the hernia through the superficial inguinal ring and then you place your index on the superficial ring. When we close the ring, if the hernia is direct, your finger moves backwards (to reduce the direct hernia) and the inferior epigastric vessels would be in the lateral direction to your index so you d feel the pulsation on the lateral side of your index. If it was indirect, then the vessels would come near the tip of your index after you reduce the hernia so you feel the pulsation on the tip of your index. Deep inguinal test: specific for the indirect inguinal hernia. We ask the patient to reduce the hernia by themselves, then we tell them to place their finger on the deep ring and then we ask them to cough. If it is an indirect hernia then there will be no bulge (the deep ring, from which the indirect hernia leaves is closed), but if it was a direct hernia then a bulge will be seen (the inguinal triangle is open). This test is more accurate than the first one. The treatment for both hernias is surgical the hernia is reduced to the abdomen and then stitches are applied to strengthen the weak area (especially behind the conjoint tendon) from which the hernia had,مشد bulged. Other conservative treatments include using an abdomen but the surgical treatment is much better as other treatments may result in complications. In an indirect hernia the scrotum may reach the knee joint due to the continuously enlarging hernia. The Scrotum Originally, it is a single pouch, but then a septum appears forming two pouches, one for each testis. The wall of the scrotum is composed of the same exact layers as that of the abdominal layer. It s first layer is skin, which is pigmented and wrinkled. It is wrinkled because of the dartos fascia and the dartos muscle (in the abdomen it is camper s fascia). 4 P a g e
Then comes a membranous layer called the scarpa s facia in the abdomen and colles fascia in the scrotum. Then comes the layers covering the spermatic cord 1- External oblique external spermatic fascia 2- Internal oblique Cremasteric muscle and fascia 3- Transversalis Fascia Internal Spermatic fascia 4- Tunica Vaginalis (originally from prosessus vaginalis) gives two layers; parietal and visceral, and between them hydrocele, a fluid around the testes, may form. This hydrocele must be aspirated. In the scrotum, we have the testes. Above each testis we have the epididymis which forms the vas deferens which travels inside the spermatic cord. The innervation of the layers covering the scrotum is sympathetic. These sympathetic innervations come with the testicular artery. These sympathetic innervations are also sensory to the testis and the epididymis. The spermatic fascia surrounds the spermatic cord and ends in the testis as tunica vaginalis. The tunica vaginalis covers the anterior, the medial and the lateral surfaces of the testes (not the posterior) (normally, when the processus vaginalis gets obliterated it forms the tunica vaginalis). The parietal tunica vaginalis is made of connective tissue. The epididymis has a head, a body and a tail and from the tail the vas deferens begins. The cremasteric muscle is innervated by the genital branch of the genitofemoral nerve. This muscle moves the testes upwards in the winter and it relaxes in the summer and the testes drop downwards. This is important because the sperm is made at 2-3 degrees below the body temperature. If one gets testicular varicocele the temperature increases and so, the sperm die resulting in infertility. If such a patient comes you do some semen analysis and then you find that all the sperm are dead, then you 5 P a g e
see if the patient has a varicocele. The treatment is surgical in which most of the veins are cut and ligated and one or two veins are left to allow for venous drainage, this results in dropping the temperature and allowing the sperms to remain a live and remove the infertility problem. Testis The testis is a mobile organ found in the scrotum. Each testis is divided into lobules in which seminiferous tubules are found. In these tubules the sperms are made. In the seminiferous tubules, spermatogonia, which have 46 chromosomes, are present. These spermatogonia undergo meiosis I to form spermatocytes which contain 23 chromosomes each. These spermatocytes undergo meiosis II forming spermatozoa. In result, each spermatogonia gives 4 spermatozoa. In oogonia, at the end, we finish with only a single mature ovum (with 23 chromosomes). The sperm may have a sex chromosome of X or Y, while the ovum is always X the male determines the gender of the offspring. The testis is surrounded by a fibrous capsule called the tunica albuginea (it is the basement membrane on which the spermatogonia are present). The tunica albuginea gives septa to give lobules. From all the seminiferous tubules, the spermatozoa are collected in the rete testis. From there, the spermatozoa reach the epididymis via efferent ductules. The seminiferous tubules are very long. The epididymis is responsible for the maturation of the sperm which occurs in 14 days in which the sperm remain in the epididymis. Then the 6 P a g e
sperm enter the vas deferens in the spermatic cord. The vas deferens ends in the seminal vesicles. The seminal vesicles release nutritive materials that help in the maturation of the sperm. From the seminal vesicles, ejaculatory ducts emerge (one from the right side and one from the left side). The ejaculatory ducts end in the prostatic urethra. Then we have a membranous urethra and a penile urethra that moves the sperm out of the body. The vas deferens is 45 cm long. The blood supply of the testis is by the testicular artery coming from the abdominal aorta at the level of L2. The venous drainage is by the pampiniform plexus of veins (which is seen in the spermatic cord). This turns to a testicular vein at the deep ring of the inguinal canal. The testicular vein ends at the right in the inferior vena cava and at the left side it ends in the left-renal vein. This is why at the left side the testicular vein is perpendicular resulting in more varicocele in the left side. The lymphatic drainage for the testis and the epididymis is the paraaortic lymph nodes in the abdomen at the level of L1 and L2 (also known as lumbar lymph nodes). The lymph drainage of the scrotum and its skin goes to the superficial inguinal lymph nodes (MSS system). If a tumor occurs in the testes the enlargement is seen in the para-aortic lymph nodes, but if the tumor was in the skin of the scrotum then the enlargement is seen in the superficial inguinal lymph nodes in the femoral triangle. The nervous supply here is autonomic, especially the sympathetic, which is found around the testicular artery and innervates the testis and the epididymis. More importantly, the sensory nerves (sympathetic too) (afferent) (orchitis = inflammation in the testes) which carries sensation and pain (e.g. in orchitis). The genital branch of the genitofemoral nerve innervates the cremasteric muscle. The cremasteric reflex is when one itches on the upper medial region of the thigh resulting in contraction of the 7 P a g e
cremasteric muscle raising the testes (and the scrotum) upwards. This is because the femoral branch of the genitofemoral nerve innervates that area and it is sensory, so when scratching occurs the stimulation goes to L1 and L2 and the reflex goes to the genital branch, which innervates the cremasteric muscle, causing the aforementioned effect. Clinical Notes Varicocele: dilatation and tortious of pampiniform plexus which causes testicular varicocele. Vasectomy: cutting and ligating the vas deferens. This is not common in our country, what is more common in case the couple no longer want to give birth to offspring is tubal ligation (ligation and cut of the fallopian tubes), but for infertility to occur both of the fallopian tubes must be ligated. In other countries vasectomy is also done, there the vasectomy must be done on both sides for infertility to occur. Processus Vaginalis: It is supposed to get obliterated (fibrosis) after birth. If it persisted then bilateral congenital indirect inguinal hernia occurs. Sometimes, the processus vaginalis gets narrowed causing congenital hydrocele. Other times, obliteration might occur in the upper and lower parts while the middle part remains open, then in that open area insisted hydrocele accumulates there. If hydrocele is present then the testis would be pressurized and tapping of hydrocele (removal by aspiration) must be done. Sometimes this hydrocele is idiopathic, other times it is inflammatory or maybe due to a trauma. For the aspiration, a needle is inserted in the scrotum crossing all the layers till reaching between the parietal and visceral layers of the 8 P a g e
tunica vaginalis, then the hydrocele will get absorbed to the needle and with aspiration the entire hydrocele is removed. Usually the treatment is successful and the hydrocele doesn t come back. Congenital Anomalies of the Testes Cryptorchidism: We said that the testes move from posterior abdominal wall at the level of L1 and L2 and move through the deep ring, the inguinal canal and the superficial ring reaching the scrotum by the help of the processus vaginalis and the gubernaculum. The descending of the testes may stop in the abdominal cavity at the deep ring, in the inguinal canal, in the superficial ring or in the upper part of the scrotum. That s why the pediatrists now come in the following day of birth to ensure that the testes are in the scrotum, if they were not an investigation is done to know their place then an operation must be done to get them to their correct place. Maldescent: This is when the testes stop in an abnormal position out of their usual route, e.g. the root of the penis, the superficial fascia, perineum, the thigh, etc. The maldescent is more difficult than the cryptorchidism because you need to extend the spermatic cord and pull it to get the testes to the normal position. Previously, it was said that before the age of 6 the operation must be done and the testes must be put in the scrotum because at the age of 6, usually, the testes begin releasing testosterone (before that it releases nothing) which is necessary for the maturation of the genital organ. Now, we say that the operation must be done as soon as possible, e.g. if after one year the kid can tolerate the operation we do it, but we must never leave it later than 6 years after birth. If the testes remain in an abnormal position after 6 years they could become carcinogenic and turn into cancer cells or the testes may undergo atrophy or inflammation. Therefore, if the testes were found in an abnormal position for a patient older than 6 years old they are removed to avoid cancer and other complications (they must be remove not returned to their position). 9 P a g e