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Abstract
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.
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Serrat MA, Dom AM, Buchanan JT, Williams AR, Efaw ML, Richardson LL. Independent learning modules enhance student performance and understanding of anatomy. Anat Sci Educ 2014; 7:406-416. [PMID: 24616425 DOI: 10.1002/ase.1438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 12/18/2013] [Accepted: 02/03/2014] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Maria A Serrat
- Department of Anatomy and Pathology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
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ten Brinke B, Klitsie PJ, Timman R, Busschbach JJV, Lange JF, Kleinrensink GJ. Anatomy education and classroom versus laparoscopic dissection-based training: a randomized study at one medical school. Acad Med 2014; 89:806-810. [PMID: 24667502 DOI: 10.1097/acm.0000000000000223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Bart ten Brinke
- Dr. ten Brinke is a researcher, Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. Dr. Klitsie is a PhD candidate, Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. Dr. Timman is a statistician, Department of Psychiatry, Section of Medical Psychology and Psychotherapy and Institute of Medical Education Research Rotterdam (iMERR), Rotterdam, The Netherlands. Dr. Busschbach is professor of psychology, Department of Psychiatry, Section of Medical Psychology and Psychotherapy and Institute of Medical Education Research, Rotterdam (iMERR), Rotterdam, The Netherlands. Dr. Lange is professor of surgery, Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. Dr. Kleinrensink is professor of anatomy, Department of Neuroscience and Anatomy, Erasmus Medical Center, Rotterdam, The Netherlands
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Tsitsiura AP, Fetiukov AI. [Radical operations of inguinal hernias with the temporary translocation of inguinal nerves]. Vestn Khir Im I I Grek 2013; 172:91-93. [PMID: 23808236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
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.
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Rasmussen AO. [Fascia iliaca block]. Ugeskr Laeger 2010; 172:1393; author reply 1393. [PMID: 20455293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Ciftcioğlu E, Kale A, Kopuz C, Edizer M, Aydin E, Demir MT. Medial circumflex femoral artery with different origin and course: a case report and review of the literature. Folia Morphol (Warsz) 2009; 68:188-191. [PMID: 19722165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- E Ciftcioğlu
- Ondokuz Mayis University, School of Medcine, Department of Anatomy, Samsun, Turkey.
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Tubbs RS, McDaniel JG, Burns AM, Kumbla A, Cossey TD, Apaydin N, Comert A, Acar HI, Tekdemir I, Shoja MM, Loukas M. Anatomy of the reflected ligament of the inguinal region. Rom J Morphol Embryol 2009; 50:689-691. [PMID: 19942967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- R Shane Tubbs
- Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama 35233, USA.
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Brassier D, Elhadad A. [Classic and endoscopic surgical anatomy of the groin]. J Chir (Paris) 2007; 144 Spec No 4:5S5-5S10. [PMID: 18065911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- D Brassier
- Service de Chirurgie viscérale et thoracique, Hôpital R. Ballanger - Aulnay-sous-Bois.
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Favorito LA, Sampaio FJB. [Foundation for the realization of lymphadenectomy in penile cancer: applied anatomy of the inguinal-crural region]. Int Braz J Urol 2007; 33 Suppl 1:27-32. [PMID: 23634485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Affiliation(s)
- Luciano Alves Favorito
- Unidade de Pesquisa Urogenital, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.
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Sanjay P, Reid TD, Bowrey DJ, Woodward A. Defining the position of deep inguinal ring in patients with indirect inguinal hernias. Surg Radiol Anat 2006; 28:121-4. [PMID: 16636774 DOI: 10.1007/s00276-006-0105-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 11/28/2005] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- P Sanjay
- Royal Glamorgan Hospital, Llantrisant, CF72 8XR, S Wales, UK
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Stoppa R. Anthropometric characteristics of the public arch and proper function of the defense mechanisms against hernia formation. Hernia 2005; 9:400. [PMID: 16041560 DOI: 10.1007/s10029-005-0008-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 04/28/2005] [Indexed: 11/25/2022]
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Mirilas P, Colborn GL, McClusky DA, Skandalakis LJ, Skandalakis PN, Skandalakis JE. The history of anatomy and surgery of the preperitoneal space. ACTA ACUST UNITED AC 2005; 140:90-4. [PMID: 15655212 DOI: 10.1001/archsurg.140.1.90] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Petros Mirilas
- Centers for Surgical Anatomy and Technique, Emory University School of Medicine, Atlanta, GA 30322, USA
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Abstract
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.
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Affiliation(s)
- Shawn P Fagan
- Michael E. DeBakey Houston Veterans Affairs Medical Center, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Operative Care Line, 2002 Holcombe Boulevard, VA 112, Houston, Texas 77030, USA.
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López-Cano M, Munhequete EG, Hermosilla-Pérez E, Armengol-Carrasco M, Rodríguez-Baeza A. Anthropometric characteristics of the pubic arch and proper function of the defense mechanisms against hernia formation. Hernia 2004; 9:56-61. [PMID: 15517444 DOI: 10.1007/s10029-004-0282-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Accepted: 08/17/2004] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- M López-Cano
- Department of General Surgery, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.
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Abstract
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.
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Affiliation(s)
- Robert Bendavid
- Department of Surgery Hernia Clinic, Laniado General Hospital, Netania, Israel,
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- Charles A Perrott
- Department of General Surgery, University of Chicago, Illinois 60637, USA.
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Sudrania OP, Agrawal RK, Deb S, Khanna AK. Pubomyoaponeurotic foramen and posterior groin plait for groin hernia. Hernia 2003; 7:210-4. [PMID: 12923671 DOI: 10.1007/s10029-003-0154-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2002] [Accepted: 04/23/2003] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- O P Sudrania
- S3 BIMAS Research Academy, 201 Laxmi Building J. B. Nagar, 400 059 Mumbai, India
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Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol 2003; 189:1574-8; discussion 1578. [PMID: 14710069 DOI: 10.1016/s0002-9378(03)00934-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- James L Whiteside
- Department of Gynecology and Obstetrics/A81, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Jacobs CJ, Steyn WH, Boon JM. Segmental nerve damage during a McBurney's incision: a cadaveric study. Surg Radiol Anat 2003; 26:66-9. [PMID: 14625791 DOI: 10.1007/s00276-003-0189-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2002] [Accepted: 07/04/2003] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- C J Jacobs
- Section of Clinical Anatomy, Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, 0001 Pretoria, South Africa
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Abstract
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.
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Affiliation(s)
- Robert D Kugel
- Hernia Treatment Center, NW, 205 Lilly Road, Suite D, Olympia, WA 98532, USA.
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Peri D, Pirrone R, Ardizzone E, Gaglio S, Gerbino A, Cappello F, Farina F, Marcianò V, Palma A, Peri G. Three-dimensional geometrical models of the inguinal region. Towards a new stereology. Ital J Anat Embryol 2003; 108:223-30. [PMID: 14974505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
In this work we studied the inguinal-abdominal region and the inguinal canal using three-dimensional geometrical models. We built the models through computer aided geometric modeling techniques on the basis of observations during real dissections, operations and diagnostic medical imaging. The obtained models show in a complete modular synthesis and with a schematic iconology the structural organization of the anatomical districts in a logic sequence of layers and topographic and spatial relationships among its components. The models represent an amazing support to anatomy and clinical anatomy for teaching and research purposes on organogenesis, surgery and diagnosis.
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Affiliation(s)
- Daniele Peri
- Dipartimento di Ingegneria Informatica, Università degli Studi di Palermo, Italia
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Abstract
The aim of this paper was to assess if there is a standard technique for the repair of inguinal herniae in children and to establish if the inguinal canal should be routinely opened during this procedure in different age groups. A postal survey was conducted by sending questionnaires to 264 consultant surgeons who were surgical tutors or advisors to the Royal College of Surgeons of England. Information was sought using a multiple-choice tick-box questionnaire. The surgical techniques of surgeons working in specialist units were compared with those working in general units, and comparisons were also drawn between surgeons performing more operations than those doing only a few and also if the technique varied with the age of the patient. The response rate was 69%. Only 23% working in specialist units and 8% from general units performed more than 30 herniotomies per year. Overall, 15% of surgeons always performed the operation through the inguinal canal, 56% performed it superficial to the external ring, and 29% tended to do both. In children under the age of 2 years, most surgeons performed the operation superficial to the external ring, although a higher proportion of surgeons at specialist units opened the inguinal canal routinely. In the older age groups, the tendency to open the inguinal canal and/or divide the external ring was greater. However, surgeons at specialist paediatric units and those performing more than 30 herniotomies in a year were more likely to open the inguinal canal without dividing the external ring in all age groups. There was quite obviously no standard surgical technique for inguinal herniotomy in children in this survey, and there are only trends.
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Affiliation(s)
- K Ravi
- Department of General Surgery, Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield Derbyshire, S44 5BL, UK.
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28
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Abstract
BACKGROUND The traditional approach to pediatric inguinal pathologies has been the suprapubic transverse inguinal incision. Alternative incisions for better cosmetic results may be considered. MATERIALS AND METHODS The recently defined "low inguinal groove incision" was used in a consecutive series of 483 children having indirect groin hernias, hydroceles, and palpable undescended testes, etc. The neonates, infants, and children were operated on as elective day surgery cases. RESULTS All children ended with excellent cosmetic and functional results. There were no complications or morbidity apart from a recurrence of an inguinal hernia in a 7 year-old boy. In addition to the series of girls reported earlier, this novel surgical incision has further been employed in boys with excellent results.
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Affiliation(s)
- I H Gökçora
- Department of Pediatric Surgery, Ankara University School of Medicine, Turkey.
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29
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Abstract
This study reports the developmental anatomy of testicular descent and inguinal closure of the tammar wallaby (Macropus eugenii) from birth to maturity. In females the ovary migrated caudally between days 10 and 20 after birth. The gubernaculum differentiates into the round ligament in the abdomen and extra-abdominally as the ilio-marsupialis muscle of the mammary glands. In males the testes migrated to the internal inguinal ring by day 20 post partum (pp), coinciding with the enlargement of the gubernaculum, and from the internal inguinal ring to the scrotum between days 20 and 65 pp. During descent there was an increase in the hyaluronic acid concentration in cells of the gubernaculum and scrotum. Development of the cremaster muscle began by day 10 pp on the periphery of the gubernaculum and its basic structure was completed by day 60 pp. After descent the inguinal canal closed between days 50 and 60 pp, but a small irregular lumen persisted, somewhat similar to that seen in the congenital scrotal hydrocoele of humans. Tammars have a hopping mode of locomotion and, like humans, are essentially bipedal. We suggest that inguinal closure evolved in these two species because their upright posture may otherwise lead to a high incidence of inguinal hernias.
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Affiliation(s)
- Douglas Coveney
- Department of Zoology, The University of Melbourne, Victoria, Australia.
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30
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Hrabovszky Z, Di Pilla N, Yap T, Farmer PJ, Hutson JM, Carlin JB. Role of the gubernacular bulb in cremaster muscle development of the rat. Anat Rec 2002; 267:159-65. [PMID: 11997885 DOI: 10.1002/ar.10092] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The role of the gubernaculum during the inguino-scrotal phase of testicular descent remains controversial. Some authors propose involution and eversion while others suggest active migration, although the site of growth is unknown. We aimed to determine whether the gubernacular bulb is actively proliferating or regressing during inguino-scrotal testicular descent in the rat. Gubernacula were removed from Sprague-Dawley rats and congenitally-cryptorchid TS mutant rats. Animals (0, 3, 7, 10, and 11 days of age) were treated with bromodeoxyuridine (BUdR) 2 hr before they were killed. BUdR incorporation into newly synthesized DNA served as a marker of cell division. The gubernacula were histologically processed for hematoxylin-eosin (H&E) and immunoperoxidase staining. Four different areas within the gubernaculum were examined for BUdR-positive cells: area 1: plica gubernaculi (cord); area 2: pars infravaginalis gubernaculi (bulb); area 3: distal part of the cremaster muscle; and area 4: proximal part of the cremaster muscle. The rate of cell division for each of these areas was determined by counting the number of BUdR-positive cells per 100 cells. The highest rate of BUdR labeling in both types of rats was in area 2, which is the tip of the gubernacular bulb, and this was significantly greater (P < 0.0001) than in the gubernacular cord or developing cremaster muscle. The mitotic activity was also noted to be significantly greater (P < 0.0001) at the distal end of the cremaster muscle than at the proximal end. The amount of mitosis decreased significantly (P < 0.01) in areas 2 and 4 of the gubernaculum in Sprague-Dawley rats across the period studied. This trend was not observed in TS rats. Our results suggest that the bulb actively proliferates after birth, with possible differentiation into new cremaster muscle cells. We propose that the bulb is the growing end of the elongating gubernaculum, analogous to the growth of a limb bud.
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Affiliation(s)
- Zoltan Hrabovszky
- F. Douglas Stephens Surgical Research Laboratory, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia
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31
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Abstract
Groin dissection was performed in adult male post-mortem subjects to establish the prevalence of inguinal canal "lipoma." Thirty-six body halves (age range 24-92 years) were studied. Of these, 27 (75%) contained a discrete mass of fat within the inguinal canal. This mass was always continuous with the preperitoneal fat through the deep inguinal ring. Nineteen of these 27 masses (70%), displayed a characteristic pedunculated form with a bulbous distal end. Eighteen of the 36 dissections (50%), revealed a mass more than 4 cm in length. Six dissections showed extension of the mass beyond the superficial inguinal ring and three of these six (8% of the 36 groins studied) showed distortion of the proximal spermatic cord with a mass at the superficial inguinal ring. The masses submitted for histology comprised mature adipose tissue and all but two of these were reported as having an adherent capsule. No significant correlation was found between mass length and either subject age or body mass index (BMI) but a statistically significant correlation between the length of the fat mass on the left and right sides was shown. This study demonstrates that the inguinal canal "lipoma" is a common feature in an adult male population and may be of sufficient size to cause clinical misdiagnosis. The high prevalence, characteristic location and appearance of the "lipoma" suggest a developmental etiology.
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Affiliation(s)
- C Ann Heller
- Department of Anatomy and Histology, Institute for Biomedical Research, The University of Sydney, Australia.
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32
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Abstract
The aim of this study was to reinforce the importance of the pectineal ligament in laparoscopic surgery for groin hernia and female urinary incontinence, particularly its anatomical importance in the myopectineal region. A morphologic study was conducted on 44 pectineal ligaments from 23 embalmed and one fresh human cadavers, together with a radiological study on four volunteer patients. Anatomical and histological findings confirm the fact that the ligament of Cooper represents a thickening of the pectineal fascia rather than a thickening from the periosteum. The pectineal ligament provides a landmark in each approach, open or laparoscopic, anterior or posterior surgery.
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Affiliation(s)
- J P Faure
- Laboratoire d'Anatomie, Faculté de Médecine, 34, rue du jardin des plantes, F-86005 Poitiers, France.
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33
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Messina M, Garzi A, Ferrucci E, Meucci D, Carfagna L, Melissa B, Di Maggio G. Laparoscopic diagnostic exploration of the vaginal processus in the pediatric age. Preliminary experiences. MINERVA CHIR 2002; 57:23-7. [PMID: 11832854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Laparoscopic surgical procedures, employed even in the paediatric age, bearing both diagnostic and therapeutic value, are currently used in the evaluation of peritoneal-vaginal duct patency during surgery for controlateral inguinal hernia or other diseases requiring opening of abdominal wall. METHODS From January 1996 to December 2000, at the Department of Pediatric Surgery of the University of Siena a prospective study protocol has been performed to evaluate the effectiveness of laparoscopy versus traditional surgery in showing patency of peritoneal-vaginal duct. RESULTS From our study we have been able to see how this laparoscopic procedure is well tolerated by children and parents, and is lacking in clinical complications. Patency of peritoneal-vaginal duct has been pointed out in 21.73% of cases. This result is in line with the international literature; in fact, the majority of authors have found a negative controlateral exploration in 50-80% of patients examined, thus confirming the uselessness of routine surgical controlateral inguinal exploration in hernia cases. CONCLUSIONS The use of diagnostic laparoscopy in the study of peritoneal duct patency is a rapid and relatively easy technique, practically without intra- and peri operative risks. It allows an easy solution of the diagnostic doubt, without the need to necessarily perform a traditional explorative surgical procedure.
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Affiliation(s)
- M Messina
- Department of Pediatric Surgery, University of Siena, Siena, Italy
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34
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Abstract
The groin region is subdivided into two distinct anatomic areas: the inguinal canal and the femoral triangle. A series of cross-sectional imaging cases illustrate that a good understanding of the local anatomic characteristics of the groin allows confident characterization of groin pathologic conditions. Such conditions can be classified into five major groups: congenital abnormalities, noncongenital hernias, vascular conditions, infectious or inflammatory processes, and neoplasms. Congenital entities include hernias, cysts, undescended testis, and retractile testes. Ultrasound (US) is useful in depicting these conditions. In the second group, noncongenital hernias, US allows visualization of bowel loops in peristalsis within the hernia. Herniography, computed tomography (CT), and magnetic resonance (MR) imaging are also helpful in diagnosis. Among vascular conditions, false aneurysms may be detected from the turbulent flow through the tract at Doppler US. The characteristic venous flow of varicoceles is best diagnosed with US during the Valsalva maneuver. Infectious or inflammatory conditions include, among others, hematomas, which appear hyperattenuating at CT and have variable appearances, depending on the age of the blood products, at MR imaging. The origins of neoplasms may be assessed at CT and MR imaging, although appearances of solid tumors are relatively nonspecific.
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Affiliation(s)
- C L Shadbolt
- Department of Radiology, University of California, Irvine, Medical Center, 101 The City Dr, Orange, CA 92868, USA
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35
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Abstract
The aim of this study was to compare the inguinal area, known as "Hessert's triangle", in patients undergoing surgical treatment for inguinal hernia with the area in fresh cadavers without hernia. The 73 cadavers, which were not fixed in formalin, were examined within 15 h post mortem. A total of 132 measurements were made in these cadavers and compared with 130 measurements in 115 hernia patients. The average age was 44.2 years for patients and 32.7 years for cadavers. The mean height and weight were 1.68 m and 69.9 kg for hernia patients and 1.67 m and 70.0 kg for the cadavers, respectively. The mean area of Hessert's triangle was 8.97 cm2 (range 2.28-29.62 cm2) in the hernia patients and 2.95 cm2 (range 1.37-5.92 cm2) in the cadavers. This difference was statistically significant (P < 0.00). A larger triangle is created by a higher intersections of the internal oblique and transversus muscles and its aponeurosis to the rectus sheath. When these muscles contract, they move toward the inguinal ligament to occlude the triangle, but with a larger triangle, the occlusion is incomplete. Our anatomical measurements verified that the size of Hessert's triangle is an important factor in the etiology of inguinal hernia.
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Affiliation(s)
- R Z Abdalla
- Department of Surgery, Hospital Sirio Libanes, Sao Paulo, SP, Brazil.
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36
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Rosenberger RJ, Loeweneck H, Meyer G. The cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new anatomical findings for the surgeon. Surg Endosc 2000; 14:731-5. [PMID: 10954819 DOI: 10.1007/s004640000137] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND With an incidence rate of 2%, injury to the nerves of the lumbar plexus is the most common complication of laparoscopic hernioplasty, particularly when the transabdominal preperitoneal (TAPP) technique is used. METHODS The course of the genitofemoral nerve, lateral femoral cutaneous nerve, and ilioinguinal nerve within the operation site was investigated in 53 adult dissecting-room bodies. Their relationship to the deep inguinal ring, iliopubic tract, and anterior superior iliac spine was also examined. RESULTS Both the femoral and genital branches of the genitofemoral nerve may penetrate the abdominal wall lateral to the deep ring and cranial to the iliopubic tract. The lateral femoral cutaneous nerve and the ilioinguinal nerve may run immediately lateral to the anterior superior iliac spine. CONCLUSION Contrary to the previously accepted opinion, dissection and the placement of staples either cranial to the iliopubic tract or lateral to the anterior superior iliac spine can result in injury to the nerves.
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Affiliation(s)
- R J Rosenberger
- Department of Anatomy, Ludwig Maximilian University, Pettenkoferstrasse 11, D-80336 Munich, Germany
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37
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Abstract
The purpose of this paper is to give an overview of the anatomy of the inguinal region, and to discuss the value of various imaging modalities in the diagnosis of groin hernias. After description of the gross anatomy of the groin, attention is focused on the anatomic features of conventional herniography, US, CT, and MRI. Advantages, disadvantages, and accuracy of each technique is discussed briefly.
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Affiliation(s)
- J C van den Berg
- Department of Diagnostic Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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38
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Abstract
An approach to the acetabulum is described. This approach consists of an anterior and a posterior part. The anterior part is nearly identical with the ilioinguinal approach. The posterior part resembles Kocher's (Gibson, J Bone Joint Surg 1950;32B:183-186) original description in that the plane of dissection passes between the motor territories of the superior gluteal nerve anterolaterally and the inferior gluteal nerve posteromedially. Two modifications have been introduced, however. First, the incision is a transverse one; superior and inferior fasciocutaneous flaps are elevated. Second, the gluteus maximus is not only disinserted from the fascia lata and the gluteal tuberosity at the upper end of the femur but from the iliac crest as well. After ligating the superficial branch of the superior gluteal artery to the gluteus maximus, the muscle itself is reflected posteromedially. We have used this approach to explore the lumbosacral plexus and its branches, particularly the sciatic nerve at the greater sciatic notch. Due to the excellent exposure of both columns of the acetabulm, this approach may be equally used in fractures of the acetabulum.
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Affiliation(s)
- S Amr
- Department of Orthopaedics and Traumatology, Cairo University, Manial, Egypt
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39
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Abstract
This review provides a brief history of groin dissection, including studies on anatomical considerations and technique. A groin dissection for complete ablation of the node-bearing areolar tissue in the inguinal and iliac regions and with negligible morbidity requires careful attention to the pathophysiology of cancer in lymphatics, pre- and postoperative care, and surgical technique, including coordinated use and general, plastic, vascular, and orthopedic surgical principles.
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Affiliation(s)
- J Spratt
- Department of Surgery, James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky 40202, USA.
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40
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Palot JP, Avisse C. [Inguinal, femoral and umbilical hernia. Physiopathology, diagnosis, complication, treatment]. Rev Prat 1999; 49:1242-8. [PMID: 10416359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
MESH Headings
- Diagnosis, Differential
- Fascia/anatomy & histology
- Female
- Hernia, Femoral/complications
- Hernia, Femoral/diagnosis
- Hernia, Femoral/pathology
- Hernia, Femoral/physiopathology
- Hernia, Femoral/surgery
- Hernia, Inguinal/complications
- Hernia, Inguinal/diagnosis
- Hernia, Inguinal/pathology
- Hernia, Inguinal/physiopathology
- Hernia, Inguinal/surgery
- Hernia, Umbilical/complications
- Hernia, Umbilical/diagnosis
- Hernia, Umbilical/pathology
- Hernia, Umbilical/physiopathology
- Hernia, Umbilical/surgery
- Humans
- Inguinal Canal/anatomy & histology
- Male
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Affiliation(s)
- J P Palot
- Service de chirurgie générale et digestive, centre hospitalier universitaire Robert-Debré, Reims
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41
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Valenti G, Testa A, Capuano G. [Anthropometric measurements of the male inguinal canal]. MINERVA CHIR 1998; 53:715-8. [PMID: 9866937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND A problem in the use of a prosthesis in the treatment of inguinal hernia is the form and dimension the mesh should have. There are no precise indications in the international literature and manufactured pre-cut prostheses available are not always suitable for all patients. In this study some measurements within the male inguinal canal have been compared with the patients' physical characteristics, such as weight, height and body mass index, and with inguinal hernia too. The purpose was to look for a relation between these data, in order to establish the form and size of the ideal mesh prosthesis for every patient before operation. A "list" of different prosthesis sizes could help both the surgeon and the manufacturers. METHODS The study was carried out on 150 male patients who underwent surgery for inguinal hernia. RESULTS The analysis of the results does not demonstrate a relationship between the data examined. CONCLUSIONS The conclusion is drawn that there could be two solutions to the problem of mesh size: one being the expensive prepacking of meshes of various sizes, and the cheaper one being to find out a method which, not considering the internal ring variability, will not influence the production of a universal mesh.
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Affiliation(s)
- G Valenti
- Divisione di Chirurgia Generale, Ospedale S. Pietro, Fatebenefratelli, Roma
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42
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Guarnieri A. [Original procedure of functional plasty of primary inguinal hernias]. Chirurgie 1998; 122:534-8. [PMID: 9616901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe a novel autoplasty method we developed for primary inguinal hernia repair and report our results in nearly 150 operations. The method is based on novel principles: priority given to an individual stato-dynamic conception of the inguinal region; effect on physiological defense mechanisms of the inguinal canal; absence of tension on the sutures by autoplastic repair.
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43
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Stoppa R, Van Hee R. Surgical anatomy of the groin region. Acta Chir Belg 1998; 98:124-6. [PMID: 9689972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- R Stoppa
- Department of Abdominal Surgery, Centre Hospitalier Universitaire d'Amiens, France
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44
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Abstract
BACKGROUND The role of the gubernaculum in descent of the testis is controversial. The mechanism of testicular descent has been studied in the rat, because inguino-scrotal descent occurs postnatally in this species. Several authors have claimed that the cremasteric sac forms by eversion of the gubernacular cone, whereby regression of the extra-abdominal part of the gubernaculum creates a space into which the gubernacular cone everts to form the processus vaginalis within the scrotum. This postulated lack of any gubernacular migration phase contrasts with the situation in the human, where gubernacular migration appears to be an integral component of testicular descent. This study was designed to determine in the rat whether there is any gubernacular migration toward the scrotum during testicular descent, or whether eversion of the cremasteric sac alone could account for the extension of this sac into the bottom of the scrotum. METHODS Oblique sagittal sections of the inguino-perineal region were taken from rats aged 21 days of gestation and days 1, 3, 4, 6, 8, and 10 days postnatally. Histological sections were examined and the following measurements were obtained: gubernacular cone height, gubernaculum-scrotum distance, processus vaginalis length, and pubic symphysis-anus distance. RESULTS The gubernaculum was not in close proximity to the developing scrotum at any age. After 21 days of gestation, there was little evidence of a substantial gubernacular bulb distal to the processus vaginalis. At all ages the gubernacular cone height was significantly less than the distance from the gubernaculum to the scrotum. CONCLUSIONS These results show that the gubernaculum does not develop in close proximity to the developing scrotum. Even if complete eversion of the gubernaculum takes place, the gubernaculum would still fail to reach the bottom of the scrotum. It is proposed that gubernacular eversion is more apparent than real and that some degree of gubernacular migration is needed for complete extension of the cremasteric sac to the bottom of the scrotum.
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Affiliation(s)
- S K Lam
- F. Douglas Stephens Surgical Research Laboratory, Royal Children's Hospital, Parkville, Victoria, Australia
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45
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Abstract
BACKGROUND Most adult anatomical texts state that the deep inguinal ring is situated midway between the anterior superior iliac spine and the pubic tubercle. The aim of this study was to determine if this was true in prepubescent children. METHODS A total of 107 inguinal ligaments and canals were measured during inguinal operations in 80 children (68 boys, age range 1-118 months). RESULTS The length of the inguinal ligament increased from a median of 4.3 cm (range 3.6-6.8) at less than 1 year of age to 7.5 cm (range 6.7-10.1) at over 4 years of age. The internal ring was situated medial to the midpoint of the inguinal ligament throughout childhood. The ratio of internal ring to public tubercle over inguinal ligament length was 42% (range 27-58) at less than 2 years; and 34% (range 25-46) at over 4 years. The inguinal canal remained short (median 1 cm (range 0.7-1.1) at less than 2 years, and median 1.1 cm (range 0.7-2.3) at over 4 years) suggesting that growth of the inguinal region in this age group occurs outside the canal. CONCLUSIONS These results have implications for the siting of incisions, and question the necessity of opening the inguinal canal in children.
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Affiliation(s)
- S J Parnis
- Russell Howard Department of General Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
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46
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Hay JM. [Treatment of inguinal hernias: methods]. Rev Prat 1997; 47:262-7. [PMID: 9122599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
After a short description of the anatomy of the inguinal area, especially of muscular walls and rings, weaken areas through which hernia could appear, we describe surgical procedures, using or not prosthesis, to strength the posterior wall. The most usual procedures using no prosthesis are Bassini's, Mac Vay's and Shouldice's techniques. The procedures using prosthesis are Lichtenstein's, plug's, Stoppa and Rive's, and Pouliquen's techniques. Finally, we describe coelioscopic procedures (intra- and extraperitoneal approach). We conclude that actually, the best technique employing nonprosthesis is the Shouldice repair. Concerning techniques employing a prosthesis, we do not know, at the present time, which is the best. Clinical trials are on run to answer this question.
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Affiliation(s)
- J M Hay
- Service de chirurgie générale et digestive hôpital Louis-Mourier, Colombes
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47
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Abstract
There are a number of important structures to be avoided in suturing or stapling during laparoscopic inguinal herniorrhaphy, not all of which are easily identifiable at laparoscopy. This is particularly so of the ductus deferens. Measurements were taken of the angle made by the ductus deferens with testicular vessels, and of the thickness of tissue in the vicinity of the internal ring into which sutures or staples are likely to be inserted. The angle (mean +/- SD) made by the ductus with testicular vessels was 38.6 degrees +/- 4.4 degrees on the right, and 48.6 degrees +/- 7.2 degrees on the left (P < 0.05) (measurements for right and left sides taken from different cadavers). Thickness of tissue around the ring (peritoneum, transversalis fascia and intervening connective tissue) varies at different sites, being greatest lateral to the testicular vessels (2.2 +/- 0.4 mm) and least over the ductus (0.2 +/- 0.1 mm). The angle measured constitutes the apex of the "triangle of doom" (Spaw et al., 1991. J. Laparoendoscopic Surg. 1:269-277) and with its use the position of the ductus deferens may be predicted and the underlying external iliac vessels avoided when stapling during herniorrhaphy.
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Affiliation(s)
- K J O'Malley
- Department of Anatomy, Royal College of Surgeons in Ireland, Dublin, Ireland
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48
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Metternich FU, Claeys LG, Koebke J. The anatomic structure of the preperitoneal tissue (PPT) of the inguinal canal. Acta Chir Belg 1997; 97:19-22. [PMID: 9079139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Anatomical examinations of the inguinal canal exist in many forms. The preperitoneal tissue, the structure directly adjacent to the transverse fascia, was examined in 62 cadavers. The left side of the inguinal abdominal wall was studied with special interest in the transverse fascia and the adjacent preperitoneal tissue. In 75% of the cases the transverse fascia and preperitoneal tissue built a continuous layer. A differentiation was difficult in cadavers with cachexia or an average nutritive state. The tissues could be differentiated without difficulty in individuals with adipositas. In these cases no connection between the two layers was detected. In the medial part of the inguinal abdominal wall the tissue thickness was larger than in the lateral part. However in 32% of the cases the tissue thickness was reverse. As a consequence, the isolated suture of the transverse fascia in inguinal hernia repair is anatomically virtually impossible, if both tissues build one continuous layer.
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Affiliation(s)
- F U Metternich
- Department of Head and Neck Surgery, Academic Teaching Hospital, University of Cologne
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49
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Abstract
Abdominal wall hernias are usually asymptomatic, discovered incidentally on physical examination. Emergency physicians, however, may be called on to deal with the potential life-threatening complications of abdominal wall hernias. This article discusses the anatomy, pathophysiology, and specific types of hernias in the adult and pediatric patient populations. Also covered are the complications of hernias, emergency interventions for hernia reduction, and urgent surgical consultation.
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MESH Headings
- Diagnosis, Differential
- Emergency Service, Hospital
- Hernia, Inguinal/diagnosis
- Hernia, Inguinal/etiology
- Hernia, Inguinal/physiopathology
- Hernia, Inguinal/surgery
- Hernia, Ventral/classification
- Hernia, Ventral/diagnosis
- Hernia, Ventral/etiology
- Hernia, Ventral/physiopathology
- Hernia, Ventral/surgery
- Humans
- Inguinal Canal/anatomy & histology
- Male
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Affiliation(s)
- J J Mensching
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia, USA
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50
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Redman JF. Applied anatomy of the cremasteric muscle and fascia. J Urol 1996; 156:1337-40. [PMID: 8808866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Although the cremasteric muscle is a prominent structure of the inguinal canal, specific details of its anatomy are seldom discussed in either anatomical or surgical texts. Therefore, a detailed description of the anatomy of the cremasteric muscle and fascia is provided, followed by descriptions of new applications of this knowledge for operations on the inguinal canal. MATERIALS AND METHODS Observations are described based on more than 1,000 operations on the inguinal canal conducted during a 15-year period. Magnification of 3.5 x was used in all dissections. RESULTS Careful dissections of the cremasteric muscle and fascia allowed for development of new approaches to enhance exposure of the inguinal canal and internal ring, and to mobilize the spermatic cord and testes. CONCLUSIONS Knowledge of the anatomy of the cremasteric muscle and fascia, and techniques for dissection are adjuncts to surgery of the inguinal canal, including inguinal hernia repair and orchiopexy.
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Affiliation(s)
- J F Redman
- Department of Urology, University of Arkansas College of Medicine, Little Rock, USA
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