Evaluation of hernia of the male inguinal canal: sonographic method

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

Independent learning modules enhance student performance and understanding of anatomy

Didactic lessons are only one part of the multimodal teaching strategies used in gross anatomy courses today. Increased emphasis is placed on providing more opportunities for students to develop lifelong learning and critical thinking skills during medical training. In a pilot program designed to promote more engaged and independent learning in anatomy, self-study modules were introduced to supplement human gross anatomy instruction at Joan C. Edwards School of Medicine at Marshall University. Modules use three-dimensional constructs to help students understand complex anatomical regions. Resources are self-contained in portable bins and are accessible at any time. Students use modules individually or in groups in a structured self-study format that augments material presented in lecture and laboratory. Pilot outcome data, measured by feedback surveys and examination performance statistics, suggest that the activity may be improving learning in gross anatomy. Positive feedback on both pre- and post-examination surveys showed that students felt the activity helped to increase their understanding of the topic. In concordance with student perception, average examination scores on module-related laboratory and lecture questions were higher in the two years of the pilot program compared with the year before its initiation. Modules can be fabricated on a modest budget using minimal resources, making implementation practical for smaller institutions. Upper level medical students assist in module design and upkeep, enabling continuous opportunities for vertical integration across the curriculum. This resource offers a feasible mechanism for enhancing independent and lifelong learning competencies, which could be a valuable complement to any gross anatomy curriculum.

Anatomy education and classroom versus laparoscopic dissection-based training: a randomized study at one medical school

PURPOSE

Anatomy education on embalmed specimens is presumed to have added educational value. However, although embalmed specimens have been used for anatomy education for years, there is little evidence on the added educational value of dissection-based teaching. The objective of this randomized study is to examine the added value of dissection-based teaching, using models of the inguinal region in embalmed specimens.

METHOD

In 2011, medical students at Erasmus Medical Center, The Netherlands, were randomly assigned to three groups. Group I attended lectures, group II attended dissection-based training using laparoscopic dissection models, and group III attended lectures as well as dissection-based laparoscopic training. To assess the improvement of anatomical knowledge, all students had to complete a practical test before, immediately after, and two weeks after training. Data were analyzed with mixed modeling.

RESULTS

Forty-six students participated in this study. No significant difference in results was observed among the three groups before the start of training. Immediately after the course, groups II and III scored significantly higher than group I (P < .001; P < .001), and group II scored higher than group III (P = .009). The difference between group I and groups II and III persisted during follow-up (P = 012; P = .001). The difference between groups II and III disappeared.

CONCLUSIONS

Three-dimensional anatomy education with dissection models enhances anatomy learning by medical students. Students who received dissection-based training scored higher in the short- and long term compared with students who did not receive this type of education.

[Radical operations of inguinal hernias with the temporary translocation of inguinal nerves]

This article presents the results of anatomic researches of the innervations of the inguinal area, performed for studying an arrangement of the main nerves of the inguinal area in relation to the operation access and the area of plasty of the posterior wall of the inguinal canal. The method of temporary translocation of inguinal nerves is developed for their preservation at radical operations of inguinal hernias. Long-term experience of surgical treatment of inguinal hernias with the temporary translocation of inguinal nerves is summarized.

Medial circumflex femoral artery with different origin and course: a case report and review of the literature

The femoral artery (FA) and its branches play important roles in the arterial supply of the lower extremity. If the femoral artery is occluded, the circulation of the extremity is maintained by certain anastomoses. Therefore, identification of variations of these arteries is critical from a clinical and surgical point of view. During routine anatomical dissections for student education at the Department of Anatomy of the School of Medicine at Ondokuz Mayls University, a variation of the medial circumflex femoral artery (MCFA) was observed and photographed in a male, formalin-fixed cadaver aged 55 years. In this case, MCFA branched off from the posterolateral aspect of the FA, 32 mm distal to the inguinal ligament. A frequency rate of 17-26% has been reported regarding this variation. However, MCFA emerging from the postero-lateral aspect of the FA and its course, as in this case, is not that frequent. Knowledge of anomalies in the emergence and course of the arteries that join the cruciate anastomosis and are important in the arterial supply of the head and neck of the femur appear to be a critical component that requires caution during surgical interventions towards this region.

Anatomy of the reflected ligament of the inguinal region

BACKGROUND

There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy.

MATERIAL AND METHODS

Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured.

RESULTS

83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 45 degrees angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 cm(2). There was no statistically significant difference between right or left sides or between genders.

CONCLUSIONS

The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

[Classic and endoscopic surgical anatomy of the groin]

Knowledge of the groin's anatomy is indispensable to understanding the pathological anatomy of hernias and their surgical treatment. Although classical anatomy provides an understanding of the techniques of open surgery, learning celioscopic techniques requires a new mental representation and specific training. The objective of this focus was to describe the anatomic approaches to inguinal hernias and compare them to those described during the celioscopic approach.

Defining the position of deep inguinal ring in patients with indirect inguinal hernias

A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.

The history of anatomy and surgery of the preperitoneal space

Preperitoneal (properitoneal) space is the space between the peritoneum and transversalis fascia. Bogros (1786-1825) described a triangular space in the iliac region between the iliac fascia, transversalis fascia, and parietal peritoneum. In the modern concept, this space lies between the peritoneum and posterior lamina of the transversalis fascia. In 1858, Retzius described the homonymous space, situated anterior and lateral to the urinary bladder (prevesical space). In 1975, Fowler reported that the preperitoneal fascia of the groin is distinct from the transversalis fascia. Preperitoneal herniorrhaphy may be subdivided into 2 approaches: transperitoneal and inguinal. We present herein the evolution of approaches to the preperitoneal space from use of the transperitoneal (or posterior) to use of the anterior preperitoneal and posterior preperitoneal approaches. As anatomic knowledge has increased, the evolution of laparoscopic surgery has paralleled that of open procedures.

Abdominal wall anatomy: The key to a successful inguinal hernia repair

Over the past century, there has been a significant increase in the understanding of abdominal wall anatomy as it relates to inguinal and ventral hernia repairs. Since the initial reports of successful primary inguinal herniorrhaphy, recurrence rates have dramatically decreased because of the improved understanding of the pathologic defect. This article will review the important nomenclature of the groin region, briefly review the bony and tissue anatomy of the groin, and describe the anatomic hole from which the pathologic hole (hernia) originates.

Anthropometric characteristics of the pubic arch and proper function of the defense mechanisms against hernia formation

In 33 inguinal regions, we determined the anthropometric characteristics of the pubic arch and the anatomic structures of the suprainguinal space and assessed whether there is a relationship between anatomic features and function of the defense mechanisms. There was a low position of the pubic arch (pubic tubercle and interspinal line distance >75 mm) in 23 cases. The low-pubic-arch group showed a significantly longer inguinal ligament and a greater angle made by the superior border of the suprainguinal space and the inguinal ligament at its medial insertion. The position of the pubic arch correlated significantly with the diameter of the internal ring, the length of the inguinal ligament, and the angle made by the superior border of the suprainguinal space and the medial insertion of the inguinal ligament. A low pubic arch would represent an unfavorable condition for an adequate function of the anatomic defense mechanism against hernia.

The unified theory of hernia formation

The perusal of surgical journals suggests that the etiology and the treatment of hernias are still based on the understanding of a simple mechanical defect, an idiopathic happenstance requiring a reliable hernia repair, preferably with a prosthetic mesh or device. The need for additional elucidation does not constitute an aim that is pervasive in the surgical community or with the corporate manufacturers of surgical implements. This may well be because surgeons are not trained scientists and laboratory workers. Fortunately, several disciplines are injecting a healthy dose of curiosity matched by ingenuity. Among these contributors, we can count anatomists, electron microscopists, biochemists, organic chemists, pathologists, geneticists, and molecular biologists, who have looked at collagen, enzymes, tobacco smoke, congenital diseases, and chromosomal defects. Every aspect of the researchers' work has identified and converged onto a final common organ: collagen. It is the pathological changes in collagen that set the stage for the development of a hernia. The multiple theories on mechanisms of hernia formation have, at last, melded into one single Unified Theory of hernia formation.

Surface marking of the deep inguinal ring

The surface marking of the deep inguinal ring (DIR) is commonly described as being located at either the middle of the inguinal ligament (MIL) or at the mid-inguinal point (MIP); there seems to be no consensus in previous studies in patients with inguinal hernias. The present study was carried out to determine a more accurate location of the DIR in individuals without inguinal hernias. Fifty-two cadavers without inguinal hernias were dissected and the positions of the DIR, MIL, MIP and femoral artery (FA) were determined. The mean distance from the anterior superior iliac spine (ASIS) to the DIR was 62 mm, where as the mean distance from the ASIS to the MIL, MIP, and FA were 55, 66, and 65 mm, respectively. The study showed that in individuals without inguinal hernias the DIR did not correspond to the MIL or MIP, but rather to an area between these two landmarks. The surface marking of the DIR may be best described as at the mid-inguinal region.

Inguinal hernias: room for a better understanding

Inguinal hernias are a common problem but often present with diagnostic dilemmas, in part as a result of the complex anatomy of the region. A simplified analogy is put forward in the hope of increasing the understanding of the anatomy and some guidance given in an endeavor to differentiate direct and indirect hernias, with significance to their possible complication rates.

Pubomyoaponeurotic foramen and posterior groin plait for groin hernia

Sir Astley Paston Cooper stated in 1804 that a sound knowledge of proper anatomy of hernia is vital. But even in the succeeding two centuries, the confusion has only multiplied by varied and overly enthusiastic descriptions, some speculative and others real, by different workers. An attempt has been made to highlight the size of the controversies surrounding the anatomical structures forming the inguinal canal and groin. The inguinal and femoral hernias should be viewed collectively as one entity and together be called groin hernias. Therefore, the passage for their superficial emergence through the anterior abdominal wall is redefined and is called pubomyoaponeurotic foramen. It is uniformly accepted that the strong posterior wall of the groin area is the only preventive factor towards the emergence of hernia; it has been renamed as posterior groin plait. Therefore, proper understanding of its structure towards effective repair and reinforcement is the only safe method, whether the procedure is carried out by anterior or posterior route or laparoscopically. Hence, an attempt has been made to elucidate its true structure. In spite of so many descriptions, the exact anatomy of hernia is yet to be resolved.

Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions

OBJECTIVE

The purpose of this study was to map the course of the ilioinguinal and iliohypogastric nerves.

STUDY DESIGN

The courses of iliohypogastric and ilioinguinal nerves from 11 fresh frozen cadavers were mapped from their lateral emergence on the anterior abdominal wall to their midline termination in reference to fixed bony landmarks. Bivariate fit ellipses were generated for each nerve and compared with sites of standard abdominal surgical incisions.

RESULTS

Thirteen iliohypogastric and 16 ilioinguinal nerves were identified and mapped. On average, the proximal end of the ilioinguinal nerve entered the abdominal wall 3.1 cm medial and 3.7 cm inferior to the anterior superior iliac spine, then followed a linear course to terminate 2.7 cm lateral to the midline and 1.7 cm superior to pubic symphysis. The iliohypogastric nerve entered the abdominal wall on average 2.1 cm medial and 0.9 cm inferior to the anterior superior iliac spine, which followed a linear course to terminate 3.7 cm lateral to the midline and 5.2 cm superior to pubic symphysis.

CONCLUSION

Abdominal wall surgical sites below the level of the anterior superior iliac spine have the potential for ilioinguinal or iliohypogastric injury.

Segmental nerve damage during a McBurney's incision: a cadaveric study

Injury to the ilioinguinal and iliohypogastric nerves after a McBurney's incision have been reported to cause paralysis of the conjoint tendon that may lead to the development of an indirect inguinal hernia. This study reports on the incidence of ilioinguinal and iliohypogastric nerve sectioning after the performance of a classic McBurney's incision as well as the distance and relationship of the ilioinguinal and iliohypogastric nerves to the anterior superior iliac spine and a classic McBurney's incision. The right iliac fossa and lumbar region of 33 cadavers were dissected for the uncovering of the ilioinguinal and iliohypogastric nerves after a correct McBurney's incision was made. Injury to the ilioinguinal and iliohypogastric nerves was recorded. The mean distance between the ilioinguinal nerve and the incision line was 41.89 mm and 34.63 mm between the iliohypogastric nerve and the incision line. The ilioinguinal and iliohypogastric nerves were found to be 6.69 mm and 12.08 mm from the anterior superior iliac spine, respectively. No ilioinguinal or iliohypogastric nerve was injured during all 33 McBurney's incisions.

The Kugel repair for groin hernias

The Kugel repair is a minimally invasive but nonlaparoscopic preperitoneal hernia repair. It has certain advantages over other repairs, but will require a little additional effort initially to learn the repair and the associated anatomy encountered in this approach. This anatomy has not, historically, been well taught in medical schools. This repair is an attempt to achieve the fastest recovery possible after groin hernia surgery while assuring a very low risk of recurrence.