groin swellings- introduction

Dr.B.Selvaraj MS;MCh;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

GROIN SWELLINGS

INTRODUCTION

Must to know core clinical problems

1.Acute RLQ pain2.Acute RUQ pain3.Acute epigastric pain4.Acute LLQ pain5.Dysphagia6.Abdominal lumps7.Upper GI haemorrhage8.Lower GI haemorrhage9.Obstructive Jaundice

10.Breast lumps, mastalgia & nipple discharge 11.Neck swellings- Thyroid & non thyroidal12.Groin swellings13.Scrotal swellings14.Limb ischemia- Acute & Chronic15.Varicose veins16.Renal & ureteric colic17.Hematuria18.Acute retention of urine

Groin swellings- Introduction

Causes of groin swellings Anatomy of inguinal canal Anatomy of femoral canal Embryology of testicular descend Algorithm to clinch the correct diagnosis

Causes of Groin swellings

Inguinal hernia- Indirect & direct Femoral hernia Undescended testis Inguinal lymphadenitis Lipoma of spermatic cord Encysted hydrocele Saphena varix Femoral artery aneurysm Psoas abscess Femoral nerve neuroma

Anatomy- Inguinal canal

Inguinal canal is about 4cm in length extending from deep inguinal ring to the superficial inguinal ring.

Superficial inguinal ring: is an inverted v-shaped defect in the external oblique aponeurosis immediately superior to the pubic tubercle.

Deep inguinal ring: It is ½" or 1.25cm above the mid-inguinal point-the midpoint between the symphysis pubis and anterior superior iliac spine. It is U-shaped defect in transversalis fascia.

Anatomy- Inguinal canal

Anteriorly- external oblique aponeurosis and fleshy fibres of the origin of internal oblique in its lateral 1/3rd.

Posteriorly—Fascia transversalis along the whole length of the canal. In the medial half there are conjoint tendon and reflected part of the inguinal ligament.

Superiorly—There are arched fibres of internal oblique and transversus abdominis before they fuse to form the conjoint tendon.

Inferiorly—Inguinal ligament and the lacunar ligament on the medial side (Gimbernat’s ligament).

Anatomy- Inguinal canal

Anatomy- Inguinal canal

Myopectineal orifice of FruchaudPosterior Laparoscopic view

Anatomy- Femoral canal

Femoral Canal: It extends from the femoral ring above to the saphenous opening (fossa ovalis) below, being the innermost compartment of the femoral sheath.

Length – 2cm, shape: It looks like the inverted truncated cone, the upper end being the femoral ring

Contents of the femoral canal 1. Fibrofatty tissue 2. Lymph nodes and lymphatics. Lymph node situated at the ring

is known as Cloquet’s node.

Anatomy- Femoral ring

Femoral Ring: Boundary Anterior—Inguinal ligament Posterior—Iliopectineal ligament and pubis. Medially—Crescentic edge of the lacunar ligament Laterally—Fibrous septum separating the canal from the

femoral vein (Silver fascia). The ring is closed above by the septum crurale – a

condensed extraperitoneal tissue pierced by the lymphatic vessels.

Anatomy- Femoral canal

Embryology of testicular

Descend Primitive gonad in urogenital ridge turns

into testis by gene in short arm of Y chromosome. Early testis 3 hormones

Testosterone from Leydig cells CSL regression

Mullerian inhibiting substance from Sertoli cells Mullerian duct regression

Insulin-like3 hormone shortening of gubernaculum relative descend of testis

8 to 15 wks gestation- Transabdominal phase

Embryology of testicular

Descend At 25 wks Processus vaginalis

elongates into gubernaculum Distal end of gubernaculum reach

scrotum between 30 to 35 Wks Then testis descend through PPV TestosteroneGFN CGRP

Migration of gubernaculum along with testis to scrotum

28 to 35 wks gestation- Inguinoscrotal phase

Algorithm for Groin Swellings

https://www.youtube.com/watch?v=YXsCUv6dj3M