Inguinal ligament attachment. The meaning of the ligament is lacunar in medical terms

The benefit of physiotherapy treatment lies in the direct effect on the affected area.

The main advantage is the beneficial effect on the focus of damage, as a result, the rest of the organs and systems remain intact (for tablet preparations, this effect is not typical).

An additional advantage is the focus of all physiotherapeutic methods of treatment on solving specific problems, as well as improving health in general. For example, when using hardware massage, not only the functions of the spine in the cervical region are improved, but the whole body is toned.

Although physiotherapy has some disadvantages. Such methods do not help and can even be harmful in severe pathology. For example, in the treatment of advanced osteochondrosis of the neck, vibromassage can provoke an increase in the gap in the fibrous ring.

The most common disease of the spine is osteochondrosis. Its cause is a sedentary, sedentary lifestyle, characteristic of the vast majority of urban residents. It affects all parts of the spine and causes severe pain, which has to be dealt with in different ways. One of the most effective ways is massage.

• Contraindications
• Types of massage for osteochondrosis
  • Classic massage
  • vacuum massage
  • Acupressure
• Lumbar-sacral massage technique for osteochondrosis
• Lumbar spine massage at home

Already after the first session, the intensity of pain decreases. At the same time, the body's resistance to osteochondrosis increases by strengthening the muscular corset and improving lymphatic drainage. This procedure allows you to remove a symptom characteristic of osteochondrosis - overstrain of the back muscles on one side.

Today we will talk about massage of the lumbosacral spine, but we will make a reservation right away, this is not a panacea. Relying on only one manual effect in the treatment of osteochondrosis is not worth it. Definitely need drug therapy.

Contraindications

As you know, osteochondrosis of the lumbosacral region proceeds differently in each patient. Therefore, doctors have to take into account all the features when prescribing courses of therapeutic massage. We are not even talking about an independent choice of methods of manual influence. It's just dangerous.

Before contacting a massage therapist, you need to undergo an examination with a vertebrologist. This specialist will determine if the patient can use back manipulation in the current phase of the disease.

As a rule, doctors prohibit massage of the lumbosacral region only to a small percentage of patients who have the following contraindications:

• The presence of tumor formations of various etiologies.
• The patient was diagnosed with hypertension of the third degree.
• There are many moles and birthmarks on the back of the patient.
• The patient has hypersensitivity of the skin.
• The patient has problems with the cardiovascular system.
• The presence of blood diseases.
• The patient has an infectious disease.
• The patient is in the active phase of tuberculosis.

With osteochondrosis of the lumbosacral region, three types of procedures are used. The doctor prescribes one or another type of manual exposure, taking into account the stage of the disease, the severity of the lesion and symptoms.

Osteochondrosis is a common disease of the degenerative-dystrophic type, in which the structure and function of the vertebrae and intervertebral discs are disturbed, which causes infringement of the roots of the intervertebral nerves and this causes symptoms. Osteochondrosis is a chronic pathology that occurs under the influence of a complex of causes - ranging from the evolutionary and anatomical features of the structure of the human skeleton to the influence of external factors, such as working conditions, lifestyle, excess weight, injuries, and others.

Symptoms

The defeat of the upper spine can be manifested by a mass of symptoms, depending on the location and severity of the dystrophic process, as well as on how seriously the radicular structures of the spine of the cervical region are affected. Often, patients' complaints are reduced to symptoms that at first glance are unrelated, which can make it difficult to diagnose and further treat the disease.

In general, the clinic of osteochondrosis of the cervical spine is the following series of syndromes:

• Vertebral, characterized by various types of pain in the back of the head and neck.
• Spinal, in which symptoms of disorders of motor and sensory innervation are observed, in addition, impaired trophism of the cervical zone causes gradual atrophy of the muscles of the shoulder girdle and arms.
• Radicular, expressed in pain symptoms in the region of the peritoneum and chest, which requires additional thorough diagnostics to differentiate osteochondrosis and diseases of internal organs.
• Syndrome of the vertebral artery in cervical osteochondrosis - vestibular disorders, manifested by headaches, hearing impairment, dizziness, up to loss of consciousness. These phenomena occur when the cause of cerebral ischemia is due to the infringement of the vertebral artery and the weakening of the blood supply.

Osteochondrosis of the cervical segment develops gradually, and patients usually seek treatment already at the stage of clinical manifestations that interfere with the quality of life during periods of exacerbation. How to treat osteochondrosis of the cervical spine, only the doctor decides after an appropriate diagnosis, self-medication in this case is unacceptable.

Treatment of osteochondrosis of the neck is aimed at eliminating pain, inflammation, partial or complete restoration of the affected tissue structures and preventing complications.

In advanced cases, at severe stages of development of neurological lesions and comorbidities, inpatient treatment of cervical osteochondrosis with the possibility of surgical intervention may be indicated.

Physiotherapy procedures have a beneficial effect on the discs and vertebrae in cervical osteochondrosis. In combination with medication, combined treatment helps to get rid of the symptoms of the disease. Procedures are carried out in a hospital or specialized rooms at polyclinics. Before starting the course, you need to consult a doctor, determine the duration of physiotherapy, types. It is strictly forbidden to pass it during an exacerbation.

Physiotherapeutic procedures for osteochondrosis of the cervical region:

• Magnetotherapy. A safe method of treatment, which consists in exposing damaged cells to a low-frequency magnetic field. It gives an analgesic effect, acts as an anti-inflammatory agent.
• Ultrasound. Favorably affects metabolic processes in the tissues of the cervical region, due to which puffiness is removed, pains go away.
• Electrophoresis. It should be applied using painkillers (anesthetics), which are injected under the skin by means of electronic pulses.
• Laser therapy. Improves blood circulation in the affected area, relieves tissue swelling, pain.

Symptoms

Distinctive features of osteochondrosis of the neck

Cervical osteochondrosis is a fairly common degenerative-dystrophic disease that occurs in the intervertebral discs. The primary symptoms of the disease begin to develop already at the age of twenty-five.

Against the background of osteochondrosis of the cervical region, the development of headaches and migraines is often observed. But before you start taking analgesics to eliminate such symptoms, you should determine the root cause of the pathology. Only after that, together with the doctor, you can select medication.

The following factors most often cause the formation of cervical osteochondrosis:

• sedentary lifestyle;
• malnutrition, during which the human body does not receive enough nutrients necessary for the proper functioning of the musculoskeletal, muscular system and cartilage;
• violation of metabolic processes;
• prolonged sitting at a computer or driving a car in the form of the main work.

In addition, the following can provoke the formation of osteochondrosis of the cervical region:

1. severe hypothermia;
2. the presence of progressive rheumatism;
3. hormonal imbalance in the body;
4. previous trauma of the spinal column, namely, the cervical region;
5. personal genetic predisposition.

Cervical osteochondrosis is characterized by the development of the following symptoms:

• repeated pain in the neck, shoulders and arms, aggravated by physical exertion, coughing and sneezing syndrome;
• the appearance of a strong crunch in the cervical region, growing during head movements;
• often numb hands (especially fingers) and the interscapular region;
• a headache appears, localized in the occipital region and gradually diverging into the temporal region;
• there is a feeling of a lump in the throat, which is accompanied by muscle spasm of the larynx and neck;
• there is a predisposition to fainting, dizziness with sudden movements of the head.

In addition, with osteochondrosis in the neck, it is sometimes possible to experience a noise effect in the ears, deafness, impaired visual function, and nagging heart pain. Patients diagnosed with this disease often complain of continuous exhaustion and lethargy.

Complications

Among all forms of osteochondrosis, the most dangerous is the pathology of the cervical region. Damaged segments of the ridge in the neck, where there are numerous vessels that supply food to the brain.

In the neck, there is a tight fit of the segments to each other. Therefore, even minor changes in them can provoke infringement and even displacement of the nerve roots and blood vessels.

In the absence of appropriate treatment of cervical osteochondrosis using physiotherapeutic procedures, the progression of the disease begins, which can contribute to the development of some complications:

1. Violation of visual function.
2. formation of hypertension.
3. Violation of cardiac functions.
4. Development of vegetovascular dystonia.
5. The coordination of movements is disturbed due to damage to the blood circulation in the brain.

Osteochondrosis of the cervical region in an advanced form can lead to the formation of complications in relation to the vertebral artery, which can cause a patient to develop a spinal stroke. This ailment favors the loss of motor ability, which is associated with disorders in the nerve fibers.

The sooner the patient begins to use physiotherapeutic procedures as therapeutic actions, the greater the likelihood of complete recovery, stopping degenerative processes in bone and cartilage tissue. If even minor symptoms of pathology are found, you should consult a doctor to determine therapeutic actions.

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Femoral hernias account for 5-8% of all hernial formations. They are often infringed, and after performing a surgical intervention, they often recur. Femoral hernias occur much more often in women, due to the large size of the pelvis and femoral ring.

The vascular and muscular lacunae and gaps in the lacunar ligament can serve as hernia gates of femoral hernias. In most cases, a femoral hernia exits through the medial part of the vascular lacuna filled with fatty tissue, which, in the presence of a hernia, turns into a femoral canal. Femoral hernias can also be located anterior or posterior to the sheath of the femoral vessels: hernia femoralis and hernia retrovascularis. A hernia of the vascular lacuna passes through a gap in the lacunar ligament. Hernias in the area of ​​the femoral nerve in the muscle gap ( hernia hesselbachi) are rare.

The direction of the hernial sac, as a rule, is downward. However, sometimes the hernial sac can go up and be located above the inguinal ligament, as well as on the anterior surface of the pectineal muscle (Cloquet's hernia). Often, the hernial sac in men penetrates into the scrotum, and in women - into the labia majora.

As a rule, the clinical course of femoral hernias is asymptomatic. Even with the development of infringement, the patient often notes the appearance of pain in the abdominal cavity than in the thigh area. Thus, the resulting pain syndrome with infringement and acute intestinal obstruction are one of the first clinical manifestations of the disease. Local clinical manifestations of a femoral hernia depend on its size; with its small size, it can be determined only as a small bulge just below the inguinal ligament.

Differential diagnosis of femoral hernia is carried out with varicose veins of the great saphenous vein, aneurysm of the femoral artery and lymphadenopathy of the thigh.

Surgical treatment of femoral hernias

The proposed methods of surgical treatment of femoral hernias do not provide complete and reliable closure of the femoral canal. The narrowness of the femoral canal, the close proximity of the femoral vein, the atypical location of the obturator artery determine the technical difficulties in operating this type of hernia. Surgical interventions for femoral hernias are performed mainly in an open way. Depending on the access to the hernial orifice, there are femoral, inguinal and intraperitoneal methods of operation. When carrying out plastics, it is possible to additionally use synthetic explants, which are used in the form of a “patch” (“plug”). Surgery is usually performed under local or spinal anesthesia.

Local anesthesia is carried out from four points:
1) 4 cm below the superior anterior iliac spine;
2) at the level of the pubic tubercle;
3) 5 cm above the hernial protrusion;
4) 5 cm below the hernial protrusion.

During anesthesia, conduction along the ilioinguinal and iliohypogastric nerves is interrupted. The skin and subcutaneous tissue are anesthetized along the incision line. After the hernial sac is exposed, the anesthetic solution is injected additionally along the medial, upper and lower sides of the hernial sac. Due to the proximity of the femoral vein, it is not recommended to inject the solution from the lateral side of the hernial sac. Fascia and pectineus muscle are additionally anesthetized.

Bassini femoral method

This operation is the simplest in its technique and is used especially widely. A skin incision 8-10 cm long is performed parallel and immediately below the inguinal ligament. The inguinal ligament, the lower part of the aponeurosis of the external oblique muscle of the abdomen and the hernial sac are exposed. The hernial sac should be exposed as high as possible. To do this, its front wall is freed from fatty tissue and surrounding fascial membranes, which are especially pronounced closer to the neck. The shells of the bag are the cribriform plate and the transverse fascia. Their identification is facilitated by the introduction of a 0.5% solution of novocaine into the area of ​​​​the neck of the hernial sac. The selection of the hernial sac from the lateral side, where the femoral vein is closely adjacent to it, must be carried out with extreme caution. When isolating the hernial sac, it should be remembered that the bladder may be located on the medial side, and the great saphenous vein below. Careful hemostasis should be carried out, coagulating and ligating the tributaries of the femoral and great saphenous veins passing in this area.

If the hernial orifice needs to be expanded, they are dissected medially, crossing the lacunar ligament. Any other direction threatens to injure the femoral vessels or inguinal ligament. Some anomalies in the location of the vessels in the area of ​​the femoral canal are also of great practical importance in isolating the hernial sac. First of all, it is necessary to remember about the atypical origin of the obturator artery from the inferior epigastric artery in 20-30% of patients. In these cases, the obturator artery can intimately adjoin the neck of the hernial sac, covering it in front, medially and partly behind. This anatomical anomaly is known as corona mortis("crown of death"). Damage to the obturator artery can lead to dangerous bleeding. The tactics of layer-by-layer dissection of tissues with constant visual control protects against possible injury to this artery, and in case of accidental damage, it facilitates stopping bleeding and ligation of the vessel.

After opening the hernial sac and repositioning the contents into the abdominal cavity, the neck of the hernial sac is circularly released from the inner surface of the hernial orifice, sutured, bandaged, and the sac itself is cut off. With a sliding hernia of the bladder, the neck of the bag is sutured from the inside with a purse-string suture without piercing the bladder wall. The stump of the hernial sac is moved with anatomical tweezers beyond the hernial orifice towards the abdominal cavity.

Before proceeding with the hernioplasty, it is necessary to thoroughly clean the inguinal, superior pubic and lacunar ligaments with the help of a small tight gauze tupfer, remove fatty tissue from the femoral canal and be sure to see the femoral vein. The deep opening of the femoral canal is narrowed by suturing the posterior and lower edges of the inguinal ligament to the superior pubic ligament. This requires steep atraumatic needles and non-absorbable strong synthetic threads. The femoral vein is protected from possible needle damage during blunt hook suturing. In case of accidental puncture of a vein with a needle, press the bleeding area with a gauze tupfer and hold until the bleeding stops completely (usually 5-7 minutes). When the wall of the femoral vein is ruptured, accompanied by massive and dangerous bleeding, it is necessary to expose the vein well throughout, take it on tourniquets and close the defect in the wall with a vascular suture.

When plasty of the hernial ring, it is better to apply the lateral suture first, do not tie it, and grab both ends of the thread with a clamp. To do this, at a distance of 1 cm or a little less from the femoral vein, the inguinal ligament is stitched, which is then pulled upwards with a second hook to expose and firmly grab the upper pubic ligament into the seam. Further, subsequent sutures are placed in the medial direction. In total, 2-4 similar sutures are applied at a distance of 0.5-1.0 cm from each other. Before tying seams by provisional tightening, the quality of these seams is checked. Good closure of the hernial orifice is checked by straining the patient. At the same time, attention should also be paid to the fact that the lateral suture does not compress the femoral vein.

The second row of sutures (3-4 sutures) connects the falciform edge of the wide fascia of the thigh and the scalloped fascia and thereby strengthens the superficial opening of the femoral canal. The applied sutures should not compress the great saphenous vein. Next, the wound is sutured in layers.

The main disadvantage of the Bassini method is the difficulty of high ligation of the hernial sac and suturing the deep opening of the femoral canal. A typical mistake is suturing the inguinal ligament not with the superior pubic ligament, but with the pectineal fascia. In such a case, the likelihood of a hernia recurrence is very high.

Inguinal method Rugi-Parlavekyo

The inguinal method of treating a femoral hernia allows you to more reliably identify and strengthen the hernial orifice. This method of plastic surgery should be especially used in men, since in 50% of cases they develop an inguinal hernia simultaneously with a femoral hernia.

For the first time, the inguinal method of radical treatment of a femoral hernia was described in detail by G. Ruggi (1892). In 1893, another Italian surgeon Parlavecchio, in addition to narrowing the femoral hernial orifice, proposed to simultaneously close the inguinal hernial orifice as well. Subsequently, this method has also been modified by many authors.

An incision of the skin and subcutaneous tissue is carried out in the same way as with an inguinal hernia, above the inguinal ligament. The aponeurosis of the external oblique muscle of the abdomen is dissected along its fibers. The spermatic cord or round ligament of the uterus is released from the surrounding tissues, taken on a holder and taken upward. The posterior wall of the inguinal canal is examined in order to identify concomitant inguinal hernias. Then the transverse fascia is dissected above the inguinal ligament parallel to it from the medial edge of the deep inguinal ring to the pubic tubercle. Thus, they enter the peritoneal space, where the peritoneum is covered with more or less pronounced preperitoneal fatty tissue. Carefully pushing the fiber up with a gauze ball, the neck of the hernial sac is found and isolated, which is taken on a provisional holder.

The hernial contents are pushed into the abdominal cavity by pressing on the hernial protrusion. Sipping on the neck of the bag and crossing the existing adhesions with the walls of the femoral canal, the bag is transferred to the inguinal region. Then the bag is stitched, tied up with synthetic thread as high as possible and cut off. The gauze ball releases the upper pubic, lacunar and inguinal ligaments, as well as the vagina of the femoral vessels. The hernial ring is closed by suturing the lower edge of the internal oblique and transverse muscles, as well as the upper edge of the dissected transverse fascia with the superior pubic and inguinal ligaments. To reduce the load on the tissues, a laxative incision is made in the vagina of the rectus abdominis muscle. With a wide deep inguinal ring, it is sutured to normal size, applying additional sutures to the transverse fascia. The spermatic cord or round ligament of the uterus is placed on the muscles. The edges of the dissected aponeurosis of the external oblique muscle of the abdomen are sutured edge to edge with a continuous suture.

Reeves' inguinal method

With atrophy and cicatricial degeneration of the internal oblique and transverse muscles and rupture of the transverse fascia, the effectiveness of the Ruggi-Parlavekyo method becomes doubtful. In this situation, tension-free plasty using a synthetic mesh prosthesis can be successfully applied.

Isolation and treatment of the hernial sac is carried out in the same way as with the Ruggi-Parlavecchio method. The transverse fascia is widely exfoliated from the peritoneum to accommodate a mesh prosthesis in this space. The lower part of the polypropylene mesh is tucked behind the Cooper's ligament and fixed in the same way as with the Liechtenstein method. The upper part of the mesh prosthesis is placed in the preperitoneal space behind the transverse fascia and fixed with through transmuscular U-shaped sutures.

B.C. Saveliev, N.A. Kuznetsov, S.V. Kharitonov

Inguinal ligament (lig. inguinale, Poupart) represents the lower, free edge of the aponeurosis of the external oblique muscle. It originates from the anterior superior iliac spine and inserts on the pubic tubercle. Slightly above the point of attachment, the lacunar (gimbernato) and twisted ligaments branch off from it (Fig. 41).

Lacunar ligament (lig. lacunare, Gimbernat) is a triangular extension of the inguinal ligament in front of its attachment to the pubic tubercle. It was first described by Antonio Gimbernat in 1793. The ligament is attached to the pubic crest: its lateral edge meets the proximal edge of the superior pubic (Cooper) ligament. It limits the vascular lacuna from the medial side (Fig. 42).

Twisted ligament (lig. reflexum, Colles), or bent ligament, consists of aponeurotic fibers of the lower leg of the external inguinal ring. Connects the upper edge of the pubic bone with the anterior wall of the vagina of the rectus abdominis muscle, limits the superficial inguinal ring from the medial side; extends upward to the white line.

Internal oblique muscle. The relationship of the internal oblique muscle to other structures in the groin is a matter of controversy. C.B. McVay believed that the beginning of the muscle is the fascia of the lumboiliac muscle. The internal oblique muscle is not part of the posterior wall of the inguinal canal because it does not attach to the superior pubic (Cooper) ligament (Fig. 43). The aponeurosis of the internal oblique muscle is formed from two intertwining layers - anterior and posterior. These two layers, together with the aponeuroses of the other two muscles, form the lower part of the anterior wall of the sheath of the rectus abdominis.

The transverse abdominal muscle and its aponeurosis. The transverse muscle starts fromlumboiliac fascia, but not from

inguinal ligament, and is attached to the superior pubic ligament (see Fig. 43). The integrity of the transversus abdominis prevents hernia formation, and thus the transversus abdominis forms the most important layer of the abdominal wall in the region of the inguinal canal. For plastic surgery of inguinal hernias, it is convenient to use the arch of the transverse abdominal muscle. It is formed from the free aponeurotic and muscular lower edge of this muscle. Medially, the arch is an aponeurosis; closer to the inner ring, it becomes mixed muscular-aponeurotic. In the region of the internal inguinal ring, the internal oblique muscle is represented by muscle fibers, and the transverse muscle is represented by aponeurotic (Fig. 44).

United tendon. By definition, the united tendon is a plexus of fibers of the aponeuroses of the internal oblique and transverse muscles at the point of attachment to the pubic tubercle and the superior ramus of the pubis (see Fig. 44). Such anatomical formation is very rare: in 3–5% of cases (W.H. Hollinshead, 1956; R.E. Condon, 1995). It consists of the following anatomical formations:

1. The lower edge of the transverse abdominal muscle, which has an aponeurotic structure.

2. Ligament of Henle (falx inguinalis) - a bundle of tendon fibers in the medial part of the inguinal gap, separated from the aponeurosis of the transverse abdominal muscle and attached to the tubercle and crest of the pubic bone.

3. Interfoveal ligament (lig. interfoveolare, Hesselbachi) - tendon bundles of the transverse and internal oblique muscles of the abdomen; strengthens the transverse fascia in the groin.

4. Twisted link.

The united tendon plays a key role in preventing the occurrence of an inguinal hernia. Normal at

Tension of the abdominal muscles causes tension and lowering downwards of the joint tendon. This reduces the inguinal gap, which prevents the formation of an inguinal hernia.

The space between the inguinal ligament and the joint tendon is called the inguinal gap. There are slit-oval and triangular shapes of the inguinal gap (N.I. Kukudzhanov, 1949; Fig. 45). S.N. Yashchinsky (1894) describes its 3 forms: triangular, spindle-shaped and slit-like. The larger the size of the inguinal gap, which is usually observed with its triangular shape, the weaker the posterior wall of the inguinal canal is strengthened and the more anatomical prerequisites for the formation of a direct inguinal hernia, since the inguinal gap corresponds in most cases to the medial inguinal fossa.

Superior pubic ligament (lig. pectinale, Cooper) , or the comb ligament, is a branch of the lacunar ligament located on the crest of the superior branch of the pubic bone (see Fig. 41). It consists of the periosteum of the pubic bone attached to the periosteumiliopubica path, a lacunar sheaf and a comb fascia (fig. 46).

transverse fascia is part of the general fascia of the abdomen, covering the muscles of the abdominal walls from the inside (Fig. 47). In the region of the lateral inguinal fossa, the transverse fascia forms a seal around the internal inguinal ring (Fig. 48). Deep inguinal ring (annulus inguinalis proiundus) is an incomplete ring consisting of thickenings in the form of two legs: a long anterior and a short posterior. The front leg is attached to the lower edge of the transverse abdominal muscle; rear

- to the iliac-pubic tract. This entire complex looks like an inverted U. When the transverse muscle is tensed, this seal is stretched and closes the internal inguinal ring,

which is hidden under the lower edge of the internal oblique muscle. In the region of the inguinal canal, the transverse fascia has two leaves. The transverse fascia contains iliopubic tract, which is an aponeurotic cord stretching from the iliac crest to the superior branch of the pubic bone (Fig. 49). It forms the lower edge of the deep musculoaponeurotic layer, consisting of the transverse abdominal muscle and the transverse fascia. This tract forms the lower border of the internal inguinal ring, crosses the femoral vessels, forming the anterior edge of the femoral sheath (Fig. 50).

According to anatomical studies by R.E. Condon (1995), the iliopubic tract is visible along the lower border of the deep inguinal ring, but is partially covered by the inguinal ligament. R.E. Condon revealed the iliopubic tract with deep dissection in 98% of operated patients. In the projection of the posterior wall of the inguinal canal (in its medial part) below the iliopubic tract, the transverse fascia is thinned and filled with fatty tissue. This area has an elliptical shape and is called piriform fossa. It is limited: from above - by the iliac-pubic tract, from below - by the free edge of the inguinal ligament, medially by the lacunar (gimbernate) ligament, laterally by the femoral sheath (see Fig. 49). It is through the pear-shaped fossa that the protrusion of the hernial sac occurs during the formation of a direct and supravesical inguinal hernia. Therefore, many surgeons (Shouldice) attached great importance to the restoration of the transverse fascia in hernioplasty.

The posterior wall of the inguinal canal is formed by the aponeurosis of the transverse abdominal muscle and the transverse fascia. However, part of the posterior wall (approximately 1/3–1/4) is not covered by the transversus abdominis aponeurosis. It is this part that is located above the upper pubic (Cooper) ligament and the site

transition of the iliac-pubic tract to the lacunar (gimbernato) ligament. Anatomically, this zone is a weak point of the posterior wall of the inguinal canal.

Another weak spot in the groin area is myopectineal foramen, described in detail by H. Fruchaud (1956). The musculoskeletal opening is bounded from above by the aponeurotic arch of the internal oblique and transverse abdominal muscles, laterally by the lumbar muscle, from below by the pubic bone of the pelvis, medially by the outer edge of the sheath of the rectus abdominis muscle. The inguinal ligament divides this opening into upper and lower spaces: the spermatic cord passes above the ligament, below the femoral vessels (Fig. 51).

The peritoneum in the inguinal region is loosely connected to the transverse fascia, except for the internal inguinal ring, where the connection is more dense. From the inside, the posterior surface of the inguinal region, lined with the peritoneum, has three pits (Fig. 52).

1. lateral fossa- located lateral to the lower epigastric arteries, corresponds to the projection of the internal inguinal ring and is the exit point of oblique inguinal hernias (Fig. 53).

2. Medial fossa - located between the lower epigastric arteries and the medial umbilical ligaments (obliterated umbilical arteries), corresponds to the projection of the superficial inguinal ring and is the exit point of direct inguinal hernias (see Fig. 53).

3. Suprapesic fossa- located between the median ligament (Urachus) and the medial umbilical ligaments, is the site of the exit of supravesical hernias (see Fig. 53). In the supravesical fossa there is a triangle of Hesselbach, the boundaries of which are: the lower epigastric vessels, the edge of the rectus abdominis muscle and the inguinal ligament (Fig. 54). This triangle was described by F.K. Hesselbach in 1814 and noted that in this zone there is a weak spot in the inguinal

anterior abdominal wall, through which direct and supravesical hernias can exit.

The French anatomist Bogros described a triangular space in the iliac region, which is located between the parietal peritoneum and the iliac fascia, and is bounded above by the transverse fascia. This space is filled with loose adipose tissue, which contains the venous plexus formed from the iliopubic, lower epigastric, retropubic, and communicating veins. Surgeons must clearly know the location of the Bogros space, since manipulations in this area can lead to damage to the veins and serious bleeding.

Thus, the inguinal canal (canalis inguinalis) is an oblique slit located in the lower part of the anterior wall of the abdomen (Fig. 55). It is well expressed only in the presence of a hernial protrusion, usually the spermatic cord (funiculus spermaticus) passes through the inguinal canal in men, and the round ligament of the uterus (lig. teres uteri) in women. In the inguinal canal, 4 walls and 2 holes, or rings, are conditionally distinguished - superficial and deep. The lower wall of the inguinal canal is formed by the groove of the inguinal ligament; the upper wall is the joint tendon and the free lower edges of the internal oblique and transverse abdominal muscles; anterior wall - aponeurosis of the external oblique muscle of the abdomen; back - transverse fascia. The size of the inguinal canal is individual. The greater the distance from the lower edges of the internal oblique and transverse abdominal muscles to the inguinal ligament, the wider the inguinal canal. In women with a wider pelvis, the width of the inguinal canal is smaller and longer than in men, and the inlet (deep) and outlet (external, or superficial) openings of the inguinal canal are far from each other. In men, the inguinal canal is shorter and wider - usually 4.5-5 cm; deep and

surface holes are located closer to each other. Therefore, inguinal hernias are more common in men than in women. In children of the first years of life, the canal is very short due to the fact that the inlet and outlet inguinal openings are actually opposite each other. In the inguinal canal in men, in addition to the spermatic cord, there is the ilioinguinal nerve and the pudendal branch of the femoral-pudendal nerve. The spermatic cord is formed by the vas deferens, blood, lymphatic vessels and nerves of the duct and testis. The veins of the cord are a powerful pampiniform plexus.

V.V. Yakovenko (1963) notes two extreme forms of the external structure of the venous formations of the spermatic cord. With one of them, the pampiniform plexus is a powerful peculiar reservoir of venous blood, consisting of many complexly intertwined veins connected by abundant anastomoses both among themselves and with other venous formations of the spermatic cord and veins of the pelvis. With this form, a vein-anastomosis is well expressed, connecting the veins of the pampiniform plexus with veins lying outside the vaginal membrane; it is characteristic of the veins of the left spermatic cord. In another form, the pampiniform plexus consists of a small number of separate venous trunks with a small number of anastomoses between them. In this case, the vein-anastomosis is single, there is no connection with the veins of the scrotum. More often this form of a structure is observed on the right. The spermatic cord is covered with a vaginal membrane common with the testicle, on top of which lies m. cremaster.

A.S. Obysov (1953), who studied the relative position of some anatomical formations of the inguinal canal, notes that in men, in the region of the superficial and deep rings, the vas deferens is located most medially, and m. cremaster. Venous plexus and testicular artery

areas of the superficial inguinal ring lie in front, superficially, between the vas deferens and m. cremaster.

During surgery, the surgeon sees the structure of the inguinal region as follows: after dissection of the aponeurosis of the external oblique muscle of the abdomen and opening the inguinal canal, the view opens elliptical zone. Its bottom is the transverse fascia; superomedial edge - united tendon; inferolateral border - inguinal ligament, iliopubic tract and superior pubic ligament; the medial pole of the ellipse is the lacunar ligament; the lateral pole is the inner inguinal ring.

The physiological role of the inguinal canal consists in two main and, at first glance, essentially opposite functions. On the one hand, the inguinal canal provides free exit from the abdominal cavity of the elements of the spermatic cord, which are responsible for the normal function of the testicle. On the other hand, it is necessary to prevent the exit of other abdominal organs through this natural weak spot: with an increase in intra-abdominal pressure and tension in the abdominal muscles, a coordinated mutual displacement of the muscular-aponeurotic structures occurs, which reliably closes the inguinal gap. With constant intense, prolonged loads, accompanied by a significant increase in intra-abdominal pressure, this mechanism is violated, which leads to the occurrence of an inguinal hernia.

Causes of inguinal hernias.

In the occurrence of inguinal hernias, two main reasons play the main role: 1) features of embryogenesis and development of the gonads; 2) certain dystorfic changes in the musculoaponeurotic tissues of the inguinal region, due to both

the influence of various factors (great physical exertion, straining, beriberi, malnutrition, etc.), and congenital defects.

The occurrence of oblique inguinal hernias is often associated with the mechanism of testicular descent during embryogenesis. In the first months of intrauterine development of the fetus, the testicles are located in the retroperitoneal space, on the side of the spine, at the level of II-III lumbar vertebrae, adjacent to the primary kidney. The peritoneum covers the testicles on three sides. At the 3rd month of fetal development, the testicles begin to descend from the retroperitoneal space down, along the so-called conductor (gubernaculum testis). The gubernaculum testis is a mesenchymal cord that develops from the caudal end of the primary kidney (mesonephros). In parallel with the process of lowering the testicle, even preceding it, the parietal peritoneum forms a protrusion - the so-called vaginal process of the peritoneum (processus vaginalis peritonei), which gradually protrudes forward the transverse fascia and the remaining layers of the anterior abdominal wall, contributing to the final formation of the inguinal canal and scrotum. Thus, the testicle makes a further journey along the finished anatomical tract. By the 4-6th month, it lies at the inner inguinal ring, during the 7th month it passes the inguinal canal, by the 8th month it reaches its outer opening. On the 9th month, it descends into the scrotum, reaching its bottom by the time the child is born. Together with the testicle and its appendage (epididimis), the vas deferens (ductus deferens), the arteries and veins of the testicle, forming a dense arteriovenous plexus and lymphatic vessels, pass into the inguinal canal. All these elements, surrounded by a single shell (fascia spermatica externa), form the spermatic cord. Together with him in the inguinal canal are the terminal sections of the nerves (n. ilioinguinalis, n. genitalis, n. genitifemoralis). To the moment

the birth of a child testicular conductor atrophies. In the normal course of embryogenesis, the vaginal process of the peritoneum is obliterated, with the exception of the area immediately adjacent to the testicle. That part of the process that covers the testicle is called the visceral leaf (lamina visceralis), and the other wall of the gap formed is called the parietal (lamina parietalis).

In women, the ovary in the process of development is sent to the pelvic cavity; the vaginal process (Nuk's diverticulum) is a rudimentary formation, it is located in the inguinal canal and may not be obliterated.

The following factors can influence the process of testicular descent (S.Ya. Doletsky, A.B. Okulov, 1978):

1. Perversion of genetic information.

2. Teratogenic effects (physical, chemical, biological, etc.).

3. Deficiency of differentiating hormones of the mother and fetus,

regulating the process of testicular migration.

The consequence of these factors is a lag in the development of mesenchymal structures of the inguinal region (muscles, aponeuroses, ligaments), a delay in the descent of the testicle or its deviation from the normal path, as well as varying degrees of severity of violations of the processes of obliteration of the vaginal process of the peritoneum. In the event that the vaginal process remains completely intact, its cavity freely communicates with the peritoneal cavity.

Diagnosis of inguinal hernias.

Depending on the place of exit of the hernial sac in relation to the lower epigastric vessels, direct and oblique inguinal hernias are distinguished. With a direct hernia, the hernial gates are located medially from these vessels, and with an oblique hernia - outwards. In

The iliac-inguinal region has the shape of a right triangle. Its lower outer side is formed by the inguinal ligament, the upper one is a line drawn between the anterior superior iliac spines, the inner one is the outer edge of the rectus abdominis muscle. The lower part of the ilio-inguinal region is occupied by the inguinal triangle. The upper side of the triangle is a horizontal line connecting the point between the outer and middle thirds of the inguinal ligament with the lateral edge of the rectus abdominis. In the lower often ilioinguinal region in the aponeurosis of the external oblique muscle of the abdomen is the outer ring of the inguinal canal.

The aponeurosis of the external oblique muscle of the abdomen, wrapping inwards, forms the inguinal (pupart) ligament. The latter is located between the anterior superior iliac spine and the pubic tubercle. Attached to the pubic tubercle, the pupart ligament continues into a dense fibrous layer covering the upper surfaces of the pubic bones. This is the so-called upper pubic ligament of Cooper (lig. pubicum, superius Cooperi). In the inguinal ligament itself, superficial and deep parts are distinguished. The deep part forms the iliac-pubic cord. It is firmly soldered to the transverse fascia of the abdomen. Two bundles of fibers of the inguinal ligament do not reach the pubic tubercle. One of them goes up, inside, weaving into the white line of the abdomen (twisted ligament, Kolesi's ligament, lig. reflexum, lig. Collesi), the other goes down to the pecter ossis pubis (lacunar ligament, ligament of gimbernates, lig. Gimbernati).

Located behind the aponeurosis of the external oblique muscle of the abdomen, the internal oblique and transverse abdominal muscles are tightly connected to each other, but do not adhere to the pupart ligament along their entire length. The space bounded from above by the lower edge of the internal oblique and transverse abdominal muscles, from below by the pupart ligament, from the medial side by the outer edge of the rectus abdominis muscle, is called the inguinal gap. It can be triangular, round, oval or slit-shaped. The probability of formation of inguinal hernia is directly proportional to the size of the inguinal gap.

Deeper than the transverse muscle is the transverse fascia. At the outer edge of the rectus abdominis muscle, it is more compacted due to lig. Henle, In the region of the inguinal triangle, the strength of the transverse fascia is increased by aponeurotic fibers (lig. Hesselbachi) woven along the medial and lower edges of the deep inguinal ring. In the lowest part of the inguinal gap in the area parallel to the deep part of lig. pubicum, in the transverse fascia, a seal up to 0.8-1 cm wide is determined (ilio-pubic cord). At the internal opening of the inguinal canal, the transverse fascia, bending, passes to the spermatic cord, forming the vaginal membrane of the spermatic cord and testis.

On the inner surface of the anterior abdominal wall there are five folds of the peritoneum, two paired and one unpaired. Between the peritoneal folds there are three fossae: between the median and medial vesico-umbilical folds from the sides and the upper part of the bladder from below lies fossa supravesicaiis; between the medial and lateral folds - fossa inguinalis medialis; outward from plica umbilicalis lateralis - fossa guinalis lateralis. Fossa supravesicaiis is the site of supravesical hernia formation. The path of this hernia is usually straight, however, unlike a typical direct hernia, the neck of the hernial sac is longer and narrower, which is associated with the hernia bending around the edge of the rectus abdominis muscle. Fossa inguinalis medialis lies on the same vertical with the external inguinal ring and serves as an exit point for direct inguinal hernias. Fossa inguinalis lateralis is projected onto the anterior abdominal wall above the middle of the inguinal ligament 1-1.5 cm above it. Through fossa inguinalis lateralis oblique inguinal hernias fall out.

The main structural formation of the ilio-inguinal region is the inguinal canal. In healthy individuals, the inguinal canal is not expressed. It is a slit-like space containing the spermatic cord in men and the round ligament of the uterus in women. The canal runs in an oblique direction from top to bottom from outside to inside to the inguinal ligament, the length of the inguinal canal in men is 3-4.5 cm. It has four walls and two rings (internal and external). The anterior wall of the canal is formed by the aponeurosis of the external oblique abdominal muscle, the posterior one by the transverse fascia of the abdomen, the upper one by the lower edge of the internal oblique and transverse abdominal muscles, and the lower one by the pupart ligament.

The inguinal region (ilio-inguinal) is bounded from above by a line connecting the anterior-superior spines of the iliac bones, from below by the inguinal fold, from the inside by the outer edge of the rectus abdominis muscle (Fig.).

Borders of the inguinal region (ABV), inguinal triangle (GDV) and inguinal gap (E).

In the inguinal region there is an inguinal canal - a slit-like gap between the muscles of the anterior abdominal wall, containing in men, and in women - a round ligament of the uterus.

The skin of the inguinal region is thin, mobile, and forms an inguinal fold on the border with the thigh region; in the subcutaneous layer of the inguinal region are the superficial hypogastric artery and vein. The aponeurosis of the external oblique muscle of the abdomen, spreading between the anterior superior iliac spine and the pubic tubercle, forms the inguinal ligament. Behind the aponeurosis of the external oblique abdominal muscle are the internal oblique and transverse abdominal muscles. The deep layers of the anterior abdominal wall are formed by the transverse abdomen, located medially from the muscle of the same name, preperitoneal tissue and parietal peritoneum. The inferior epigastric artery and vein pass through the preperitoneal tissue. The lymphatic vessels of the skin of the inguinal region are directed to the superficial inguinal lymph nodes, and from the deep layers to the deep inguinal and iliac lymph nodes. The innervation of the inguinal region is carried out by the ilio-hypogastric, ilio-inguinal and branch of the pudendal nerve.

In the inguinal region, inguinal hernias are not uncommon (see), lymphadenitis that occurs with inflammatory diseases of the lower limb, pelvic organs. Sometimes there are cold swellings descending from the lumbar region with tuberculous lesions, as well as metastases to the inguinal lymph nodes with cancer of the external genitalia.

Inguinal region (regio inguinalis) - part of the anterior-lateral abdominal wall, the lateral part of the hypogastrium (hypogastrium). The boundaries of the region: from below - the inguinal ligament (lig. inguinalis), the medial-lateral edge of the rectus abdominis muscle (m. rectus abdominis), from above - a segment of the line connecting the anterior superior iliac spines (Fig. 1).

In the inguinal region there is an inguinal canal, which occupies only its lower medial section; therefore, it is advisable to call this entire area the ilioinguinalis (regio ilioinguinalis), highlighting in it a department called the inguinal triangle. The latter is limited from below by the inguinal ligament, by the medial-lateral edge of the rectus abdominis, from above by a horizontal line drawn from the border between the lateral and middle third of the inguinal ligament to the lateral edge of the rectus abdominis.

The structural features of the inguinal region in men are due to the process of testicular descent and the changes that the inguinal region undergoes in the embryonic period of development. A defect remains in the muscles of the abdominal wall due to the fact that part of the muscle and tendon fibers went to form the muscle that lifts the testicle (m. cremaster) and its fascia. This defect is called in topographic anatomy the inguinal gap, which was first described in detail by S. N. Yashchinsky. The boundaries of the inguinal gap: at the top - the lower edges of the internal oblique (m. obliquus abdominis int.) and the transverse abdominal muscles (t. transversus abdominis), below - the inguinal ligament, the medial-lateral edge of the rectus muscle.

The skin of the inguinal region is relatively thin and mobile, at the border with the thigh it is fused with the aponeurosis of the external oblique muscle, as a result of which the inguinal fold is formed. The hairline in men occupies a larger area than in women. The skin of the scalp contains many sweat and sebaceous glands.

Subcutaneous tissue has the appearance of large fat lobules, collected in layers. The superficial fascia (fascia superficialis) consists of two sheets, of which the superficial one passes to the thigh, and the deep one, more durable than the superficial one, is attached to the inguinal ligament. The superficial arteries are represented by branches of the femoral artery (a. femoralis): superficial epigastric, superficial, envelope of the ilium, and external pudendal (aa. epigastrica superficialis, circumflexa ilium superficialis and pudenda ext.). They are accompanied by the veins of the same name, flowing into the femoral vein or the great saphenous vein (v. saphena magna), and in the umbilical region, the superficial epigastric vein (v. epigastrica superficialis) anastomoses with vv. thoracoepigas-tricae and thus a connection is made between the systems of the axillary and femoral veins. Cutaneous nerves - branches of the hypochondrium, iliac-hypogastric and iliac-inguinal nerves (m. Subcostalis, iliohypogastricus, ilioinguinalis) (printing. Fig. 1).

Rice. 1. Right - m. obliquus int. abdominis with nerves located on it, on the left - m. traasversus abdominis with vessels and nerves located on it: 1 - m. rectus abdominis; 2, 4, 22 and 23 - nn. intercostales XI and XII; 3 - m. transverse abdominis; 5 and 24 - m. obliquus ext. abdominis; 6 and 21 - m. obliquus int. abdominis; 7 and 20 - a. iliohypogastricus; 8 and 19 - n. ilioinguinalis; 9-a. circumflexa ilium profunda; 10 - fascia transversalis et fascia spermatica int.; 11 - ductus deferens; 12-lig. interfoveolare; 13 - falx inguinalis; 14 - m. pyramidalis; 15 - crus mediale (crossed); 16-lig. reflexum; 17 - m. cremaster; 18 - ramus genitalis n. genitofemoral.

Rice. 1. Borders of the inguinal region, inguinal triangle and inguinal gap: ABC - inguinal region; DEC - inguinal triangle; F - inguinal gap.

The draining lymphatic vessels of the skin are directed to the superficial inguinal lymph nodes.

Own fascia, which looks like a thin plate, is attached to the inguinal ligament. These fascial sheets prevent the lowering of inguinal hernias on the thigh. The external oblique muscle of the abdomen (m. obliquus abdominis ext.), having a direction from top to bottom and from outside to inside, does not contain muscle fibers within the inguinal region. Below the line connecting the anterior superior iliac spine with the navel (linea spinoumbilicalis), is the aponeurosis of this muscle, which has a characteristic mother-of-pearl luster. The longitudinal fibers of the aponeurosis overlap with the transverse ones, in the formation of which, in addition to the aponeurosis, elements of the Thomson plate and the proper fascia of the abdomen participate. Between the fibers of the aponeurosis there are longitudinal fissures, the number and length of which varies greatly, as well as the severity of the transverse fibers. Yu. A. Yartsev describes the differences in the structure of the aponeurosis of the external oblique muscle (Fig. 2 and color. Fig. 2), which determine its unequal strength.

Rice. 2. On the right - the aponeurosis of the external oblique muscle of the abdomen and the nerves passing through it, on the left - superficial vessels and nerves: 1 - rami cutanei lat. abdominales nn. intercostales XI and XII; 2 - ramus cutaneus lat. n. iliohypogastrici; 3-a. et v. circumflexae ilium superficiales; 4-a. et v. epigastricae superficiales, n. iliohypogastricus; 5 - funiculus spermaticus, a. et v. pudendae ext.; 6 - crus mediale (pulled up); 7-lig. reflexum; 8 - ductus deferens and surrounding vessels; 9 - ramus genitalis n. genitofemoralis; 10-n. ilioinguinalis; 11-lig. inguinale; 12 - m. obliquus ext. abdominis and its aponeurosis.

Rice. 2. Differences in the structure of the aponeurosis of the external oblique muscle of the abdomen (according to Yartsev).

A strong aponeurosis, which is characterized by well-defined transverse fibers and the absence of cracks, can withstand a load of up to 9 kg and is found in 1/4 of observations.

A weak aponeurosis with a significant number of gaps and a small number of transverse fibers can withstand loads up to 3.3 kg and occurs in 1/3 of cases. These data are important for evaluating various methods of plasty in inguinal hernia repair.

From a practical point of view, the most important formation of the aponeurosis of the external oblique muscle is the inguinal ligament (lig. inguinale), otherwise called pupart, or fallopian; it is stretched between the anterior superior iliac spine and the pubic tubercle. Some authors consider it as a complex complex of tendon-fascial elements.

Due to the aponeurosis of the external oblique muscle, lacunar (lig. lacunare) and twisted (lig. reflexum) ligaments are also formed. With its lower edge, the lacunar ligament continues into the comb ligament (lig. pectineale).

Deeper than the aponeurosis of the external oblique muscle is the internal oblique, the course of the fibers of which is opposite to the direction of the external oblique: they go from bottom to top and from outside to inside. Between both oblique muscles, that is, in the first intermuscular layer, the ilio-hypogastric and ilio-inguinal nerves pass. From the internal oblique muscle, as well as from the anterior wall of the vagina of the rectus abdominis muscle and in about 25% of cases, muscle fibers depart from the transverse abdominal muscle, forming the muscle that lifts the testicle.

Deeper than the internal oblique muscle is the transverse muscle of the abdomen (m. transversus abdominis), and between them, that is, in the second intermuscular layer, there are vessels and nerves: the hypochondrium with the same vessels, thin lumbar arteries and veins, branches of the ilio-hypogastric and ilio-inguinal nerves (the main trunks of these nerves penetrate the first intermuscular layer), the deep artery that envelops the ilium (a. circumflexa ilium profunda).

The deepest layers of the inguinal region are formed by the transverse fascia (fascia transversalis), preperitoneal tissue (tela subserosa peritonei parietalis) and parietal peritoneum. The transverse fascia is connected to the inguinal ligament, and in the midline is attached to the upper edge of the symphysis.

Preperitoneal tissue separates the peritoneum from the transverse fascia.

In this layer, the lower epigastric artery (a. epigastrica inf.) and the deep artery that envelops the ilium (a. circumflexa ilium prof.) pass - branches of the external iliac artery. At the level of the navel a. epigastrica inf. anastomoses with the terminal branches of the superior epigastric artery (a. epigastrica sup.) - from the internal mammary artery - a. thoracica int. From the initial section of the inferior epigastric artery, the artery of the muscle that lifts the testicle (a. cremasterica) departs. The efferent lymphatic vessels of the muscles and aponeuroses of the inguinal region run along the inferior epigastric and deep circumflex iliac arteries and are directed mainly to the external iliac lymph nodes located on the external iliac artery. There are anastomoses between the lymphatic vessels of all layers of the inguinal region.

The parietal peritoneum (peritoneum parietale) forms a number of folds and pits in the inguinal region (see. Abdominal wall). It does not reach the inguinal ligament by about 1 cm.

Located within the inguinal region, immediately above the inner half of the pupart ligament, the inguinal canal (canalis inguinalis) is a gap between the muscles of the anterior abdominal wall. It is formed in men as a result of the movement of the testicle in utero and contains the spermatic cord (funiculus spermaticus); in women, the round ligament of the uterus is located in this gap. The direction of the channel is oblique: from top to bottom, from outside to inside and from back to front. The length of the canal in men is 4-5 cm; in women it is several millimeters longer, but narrower than in men.

There are four walls of the inguinal canal (anterior, posterior, upper and lower) and two holes, or rings (superficial and deep). The anterior wall is the aponeurosis of the external oblique abdominal muscle, the posterior one is the transverse fascia, the upper one is the lower edges of the internal oblique and transverse abdominal muscles, the lower one is a gutter formed by the fibers of the inguinal ligament bent backwards and upwards. According to P. A. Kupriyanov, N. I. Kukudzhanov and others, the indicated structure of the anterior and upper walls of the inguinal canal is observed in people suffering from inguinal hernia, while in healthy people the anterior wall is formed not only by the aponeurosis of the external oblique muscle, but also by the fibers of the internal oblique, and the upper wall - the lower edge of only the transverse abdominal muscle (Fig. 3).

Rice. 3. Scheme of the structure of the inguinal canal in healthy men (left) and in patients suffering from inguinal hernia (right) on the sagittal section (according to Kupriyanov): 1 - transverse abdominal muscle; 2 - transverse fascia; 3 - inguinal ligament; 4 - spermatic cord; 5 - internal oblique muscle of the abdomen; 6 - aponeurosis of the external oblique muscle of the abdomen.

If you open the inguinal canal and displace the spermatic cord, then the above-mentioned inguinal gap will be revealed, the bottom of which forms the transverse fascia, which at the same time constitutes the posterior wall of the inguinal canal. This wall is strengthened from the medial side by the inguinal sickle, or the connected tendon (falx inguinalis, s. tendo conjunctivus) of the internal oblique and transverse abdominal muscles, closely connected with the outer edge of the rectus muscle by discrepancies - inguinal, lacunar, scallop. From the outside, the bottom of the inguinal gap is reinforced with an interfoveal ligament (lig. interfoveolare), located between the inner and outer inguinal fossae.

In people suffering from an inguinal hernia, the ratio between the muscles that form the walls of the inguinal canal changes. The lower edge of the internal oblique muscle extends upward and, together with the transverse muscle, forms the upper wall of the canal. The anterior wall is formed only by the aponeurosis of the external oblique muscle of the abdomen. With a significant height of the inguinal gap (over 3 cm), conditions for hernia formation are created. If the internal oblique muscle (the most of all elements of the anterior abdominal wall that counteracts intra-abdominal pressure) is located above the spermatic cord, then the posterior wall of the inguinal canal with a relaxed aponeurosis of the external oblique muscle cannot withstand intra-abdominal pressure for a long time (P. A. Kupriyanov).

The outlet of the inguinal canal is the superficial inguinal ring (anulus inguinalis superficialis), formerly called the external, or subcutaneous. It is a gap in the fibers of the aponeurosis of the external oblique muscle of the abdomen, forming two legs, of which the upper (or medial - crus mediale) is attached to the upper edge of the symphysis, and the lower (or lateral - crus laterale) - to the pubic tubercle. Sometimes there is also a third, deep (back), leg - lig. reflexum. Both legs at the top of the gap they form are crossed by fibers that run transversely and arcuately (interpeduncular fibers - fibrae intercrurales) and turn the gap into a ring. Ring sizes for men: base width - 1-1.2 cm, distance from base to top (height) - 2.5 cm; it usually misses the tip of the index finger in healthy men. In women, the size of the superficial inguinal ring is approximately 2 times smaller than in men. At the level of the superficial inguinal ring, the medial inguinal fossa is projected.

The entrance to the inguinal canal is the deep (internal) inguinal ring (anulus inguinalis profundus). It represents a funnel-shaped protrusion of the transverse fascia, which is formed during the embryonic development of the elements of the spermatic cord. Due to the transverse fascia, a common sheath of the spermatic cord and testis is formed.

The deep inguinal ring has approximately the same diameter in men and women (1-1.5 cm), and most of it is filled with a fatty lump. The deep ring lies 1-1.5 cm above the middle of the pupartite ligament and about 5 cm above and outward from the superficial ring. At the level of the deep inguinal ring, the lateral inguinal fossa is projected. The inferomedial section of the deep ring is reinforced by the interfossular ligament and fibers of the iliac-pubic cord, the upper lateral section is devoid of formations that strengthen it.

On top of the spermatic cord and its membranes there is a muscle that raises the testicle with fascia, and more superficially than the latter is fascia spermatica ext., Formed mainly by the Thomson plate and the abdominal fascia itself. The ilioinguinal nerve adjoins the spermatic cord (in women, the round ligament of the uterus) within the inguinal canal, and the branch of the inguinal-femoral nerve (ramus genitalis n. genitofemoralis) from below.

Pathology. The most frequent pathological processes are congenital and acquired hernias (see) and inflammation of the lymph nodes (see Lymphadenitis).