Femoral hernia. External oblique muscle of the abdomen and its aponeurosis

Date: 04.03.2020

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, and from the inside by the outer edge of the rectus abdominis muscle (Fig.).

The boundaries of the groin area (ABC), the inguinal triangle (GDV) and the inguinal space (E).

In the groin area is the 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 groin area is thin, mobile and forms an groin fold on the border with the thigh area; the superficial hypogastric artery and vein are located in the subcutaneous layer of the groin. The aponeurosis of the external oblique muscle of the abdomen, spreading between the anterior-superior spine of the ilium and the pubic tubercle, forms the inguinal ligament. The internal oblique and transverse abdominal muscles are located behind the aponeurosis of the external oblique muscle of the abdomen. 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 groin area are directed to the superficial inguinal lymph nodes, and from the deep layers to the deep inguinal and iliac lymph nodes. Innervation of the groin area is carried out by the ilio-hypogastric, ilio-inguinal and the branch of the genital-femoral nerve.

In the groin area, groin hernias are not uncommon (see), lymphadenitis arising from inflammatory diseases lower limbs, pelvic organs. Sometimes there are cold congestions descending from the lumbar spine with tuberculous lesions, as well as metastases to the inguinal lymph nodes with cancer of the external genital organs.

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

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

The structural features of the groin area in men are due to the process of lowering the testicle and the changes that the groin area undergoes during 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 the formation of the muscle that lifts the testicle (m. Cremaster) and its fascia. This defect is referred to in topographic anatomy as 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 muscles of the abdomen (i.e. transversus abdominis), below - the inguinal ligament, the medial-lateral edge of the rectus muscle.

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

The subcutaneous tissue looks like large fatty 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. Superficial arteries represented by the branches of the femoral artery (a. femoralis): superficial epigastric, superficial, circumflex iliac bone, and external pudendal (aa. epigastrica superficialis, circumflexa ilium superficialis and pudenda ext.). They are accompanied by the same veins flowing into the femoral vein or into the great saphenous vein (v. Saphena magna), and in the navel, the superficial epigastric vein (v. Epigastrica superficialis) anastomoses with vv. thoracoepigas-tricae and thus the connection between the axillary and femoral vein systems is carried out. Cutaneous nerves- branches of the hypochondrium, ilio-hypogastric and ilio-inguinal nerves (m. subcostalis, iliohypogastricus, ilioinguinalis) (printing. Fig. 1).

Rice. 1. On the 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. transversus 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 groin area, inguinal triangle and inguinal space: ABC - inguinal area; DEC - inguinal triangle; F - inguinal space.

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

The intrinsic fascia, which looks like a thin plate, is attached to the inguinal ligament. These fascial sheets prevent the inguinal hernia from dropping onto the thigh. The external oblique muscle of the abdomen (m. Obliquus abdominis ext.), Which has a direction from top to bottom and from outside to inside, does not contain muscle fibers within the groin area. Below the line connecting the anterior superior iliac spine with the navel (linea spinoumbilicalis) is the aponeurosis of this muscle, which has a characteristic pearlescent sheen. The longitudinal fibers of the aponeurosis are overlapped by the transverse ones, in the formation of which, in addition to the aponeurosis, the elements of the Thomson's plate and the abdominal fascia itself are involved. There are longitudinal slits between the fibers of the aponeurosis, the number and length of which varies greatly, as does 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 the 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 cases.

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

The most important from a practical point of view, the formation of the aponeurosis of the external oblique muscle is the inguinal ligament (lig. Inguinale), otherwise called the pipart, 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 scallop 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, pass the ilio-hypogastric and ilio-inguinal nerves. From the internal oblique muscle, as well as from the anterior wall of the sheath 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 abdominal muscle (m. Transversus abdominis), and between them, that is, in the second intermuscular layer, there are vessels and nerves: subcostal with the vessels of the same name, thin lumbar arteries and veins, branches of the ilio-hypogastric and ilio-inguinal nerves (the main trunks of these nerves penetrate into the first intermuscular layer), a deep artery that bends around the ilium (a. circumflexa ilium profunda).

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

Preperitoneal tissue separates the peritoneum from the transverse fascia.

In this layer pass the lower epigastric artery (a.epigastrica inf.) And the deep artery that envelopes the iliac bone (a.circumflexa ilium prof.) - the 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 thoracic artery- a. thoracica int. From the initial section of the lower epigastric artery, the artery of the muscle that lifts the testicle (a. Cremasterica) departs. The diverting lymphatic vessels of the muscles and aponeuroses of the inguinal region run along the lower epigastric and deep enveloping iliac bone of the artery 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 groin area.

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

Located within the groin area, immediately above the inner half of the pupar ligament, the inguinal canal (canalis inguinalis) represents the gap between the muscles of the anterior abdominal wall. It is formed in men as a result of the movement of the testicle in uterine life and contains the spermatic cord (funiculus spermaticus); in women, there is a round ligament of the uterus in this gap. The direction of the canal 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 muscle of the abdomen, the posterior wall is the transverse fascia, the upper wall is the lower edges of the internal oblique and transverse muscles of the abdomen, the lower wall is the groove formed by the fibers of the inguinal ligament bent posteriorly and upward. 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 top wall- the lower edge of only the transverse abdominal muscle (Fig. 3).

Rice. 3. Diagram of the structure of the inguinal canal in healthy men (left) and in patients with inguinal hernia (right) on a 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 is formed by the transverse fascia, which at the same time constitutes the posterior wall of the inguinal canal. This wall from the medial side is strengthened by the inguinal sickle, or the connected tendon (falx inguinalis, s. Tendo conjunctivus) of the internal oblique and transverse muscles of the abdomen, 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 interwell ligament (lig. Interfoveolare), located between the inner and outer inguinal fossa.

In people with an inguinal hernia, the relationship between the muscles that make up the walls of the inguinal canal changes. The lower edge of the internal oblique muscle departs 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 abdominal muscle. With a significant height of the inguinal gap (over 3 cm), conditions are created for herniation. If the internal oblique muscle (most of all the elements of the anterior abdominal wall opposing 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 a third, deep (back) leg - lig. reflexum. Both legs at the apex of the gap they form are crossed by fibers running transversely and arcuately (fibrae intercrurales) and turning 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 in healthy men index finger... In women, the size of the superficial inguinal ring about 2 times less than that of men. At the level of the superficial inguinal ring, the medial inguinal fossa is projected.

The entrance to the inguinal canal is the deep (inner) 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 membrane of the spermatic cord and testicle is formed.

The deep groin ring in men and women has approximately the same diameter (1-1.5 cm), and most of it is filled with a lump of fat. The deep ring lies 1-1.5 cm above the middle of the pupar 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 lower medial part of the deep ring is strengthened by the intercellular ligament and fibers of the ilio-pubic cord, the upper lateral part is devoid of formations that strengthen it.

Above the spermatic cord and its membranes is the muscle that lifts the testicle with the fascia, and the fascia spermatica ext., Which is superficially the latter, is formed mainly due to the Thomson's plate and its own fascia of the abdomen. To the spermatic cord (in women, to the round ligament of the uterus) within the inguinal canal adjoins the ilio-inguinal nerve from above, from below - the branch of the inguinal-femoral nerve (ramus genitalis n. Genitofemoralis).

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

Inguinal ligament (lig.inguinale, Poupart) represents the lower, free edge of the aponeurosis of the external oblique muscle. It starts from the anterior superior iliac spine and attaches to the pubic tubercle. Slightly higher than the place of attachment, the lacunar (zhimbernatova) and twisted ligaments branch off from it (Fig. 41).

Lacunar ligament (lig. Lacunare, Gimbernat) It is a triangular expansion of the inguinal ligament in front of the place of its attachment to the pubic tubercle. It was first described by Antonio Zhimbernat in 1793. The ligament is attached to the pubic ridge: 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 a curved ligament, consists of aponeurotic fibers of the lower leg of the external inguinal ring. Connects top edge the pubic bone with the anterior wall of the sheath of the rectus abdominis muscle, limits the superficial inguinal ring from the medial side; extends up to the white line.

Internal oblique muscle. The relationship of the internal oblique muscle to other formations in the groin is a matter of controversy. C.B. McVay believed that the origin of the muscle is the fascia of the psoas-iliac muscle. The internal oblique muscle is not part of back wall inguinal canal, since 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 sheath wall of the rectus abdominis muscle.

The transverse abdominal muscle and its aponeurosis. The transverse muscle starts fromlumbar-iliac fascia, but not from

the inguinal ligament, and attaches to the superior pubic ligament (see Fig. 43). The integrity of the transverse abdominis muscle prevents hernias from forming, and thus the transverse abdominal muscle forms the most important layer of the abdominal wall in the inguinal canal. For inguinal hernia repair, 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 area of the inner inguinal ring, the internal oblique muscle is represented by muscle fibers, and the transverse muscle is aponeurotic (Fig. 44).

Joint tendon. By definition, the combined tendon is a plexus of fibers of the aponeuroses of the internal oblique and transverse muscles at the point of their attachment to the pubic tubercle and the superior branch 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 structures:

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

2. Henle's ligament (falx inguinalis) is a bundle of tendon fibers in the medial part of the inguinal space, separating from the aponeurosis of the transverse abdominal muscle and attaching to the tubercle and crest of the pubic bone.

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

4. Twisted bunch.

The joint tendon plays a key role in preventing groin hernia. Normally at

tension of the abdominal muscles is the tension and lowering of the combined tendon from top to bottom. At the same time, the inguinal gap is reduced, which prevents the formation of an inguinal hernia.

The space between the groin ligament and the joint tendon is called the groin gap. Distinguish between slit-oval and triangular forms of the inguinal gap (NI Kukudzhanov, 1949; Fig. 45). S.N. Yashchinsky (1894) describes 3 forms of it: triangular, spindle-shaped and slit-like. How more sizes the inguinal gap, which is usually observed with its triangular shape, the weaker the back 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.

Upper pubic ligament (lig.pectinale, Cooper) , or scallop 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 periosteumilio-pubictract, lacunar ligament and scallop fascia (Fig. 46).

Transverse fascia is part of the general fascia of the abdomen, which covers the muscles of the abdominal walls from the inside (Fig. 47). In the area of the lateral inguinal fossa, the transverse fascia forms a seal around the inner inguinal ring (Fig. 48). The deep inguinal ring (annulus inguinalis proiundus) is an incomplete ring consisting of thickenings in the form of two legs: a long front and a short back. The anterior leg attaches to the lower edge of the transverse abdominis muscle; back

- to the ilio-pubic tract. This whole complex looks like an inverted U. When the transverse muscle is tensioned, this seal is pulled and closes the inner groin 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 sheets. As part of the transverse fascia, there are ilio-pubic tract, which is an aponeurotic cord, stretching from the ilio-comb arc 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 transverse fascia. This tract forms the lower border of the inner inguinal ring, crosses the femoral vessels, forming the anterior edge of the femoral sheath (Fig. 50).

According to the anatomical studies of R.E. Condon (1995), the ilio-pubic tract is visible along the inferior border of the deep inguinal ring, but is partially overlapped by the inguinal ligament. R.E. Condon identified the ilio-pubic tract during deep dissection in 98% of operated patients. In the projection of the posterior wall of the inguinal canal (in its medial part) below the ilio-pubic tract, the transverse fascia is thinned, filled with adipose tissue. This area has an elliptical shape and is called pear-shaped fossa... It is limited: from above - by the ilio-pubic tract, from below - by the free edge of the inguinal ligament, medially - by the lacunar (gimbernatous) 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 straight and supravesical inguinal hernia. Therefore, many surgeons (Shouldice) attached great importance to the restoration of the transverse fascia during hernioplasty.

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

transition of the ilio-pubic tract into the lacunar (zhimbernatova) ligament. Anatomically, this area is the weak point of the posterior wall of the inguinal canal.

Another weak point in the groin area is foramenus muscle, described in detail by H. Fruchaud (1956). The crestal orifice 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 rectus sheath. The inguinal ligament divides this opening into upper and lower spaces: the spermatic cord passes above the ligament, and the femoral vessels below (Fig. 51).

The peritoneum in the groin is loosely connected to the transverse fascia, except for the inner inguinal ring, where the connection is more dense. Inside, the posterior surface of the groin area, lined with the peritoneum, has three fossae (Fig. 52).

1. Lateral fossa- is located lateral to the lower epigastric arteries, corresponds to the projection of the inner inguinal ring and is the exit site 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. Supravesical fossa- is located between the median ligament (Urachus) and the medial umbilical ligaments, is the exit site of supravesical hernias (see Fig. 53). In the supravesical fossa is the Hesselbach triangle, 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 area there is weakness inguinal

the anterior abdominal wall, through which direct and supravesical hernias can come out.

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

Thus, the inguinal canal (canalis inguinalis) is an oblique slit located in the lower part of the anterior abdominal wall (Fig. 55). It is well expressed only in the presence of a hernial protrusion, usually in the inguinal canal in men passes the spermatic cord (funiculus spermaticus), in women - the round ligament of the uterus (lig. Teres uteri). In the inguinal canal, 4 walls and 2 holes, or rings, are conventionally 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 abdominal muscle; back - transverse fascia. The dimensions of the inguinal canal are 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 the length is greater 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 inguinal inlet and outlet are actually opposite each other. In the inguinal canal in men, in addition to the spermatic cord, is the iliac 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 testicle. The veins of the cord are a powerful lobe-shaped 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 plexus plexus is a powerful kind of reservoir venous blood, consisting of many complex intertwining veins connected by abundant anastomoses both among themselves and with other venous formations of the spermatic cord and pelvic veins. With this form, the vein-anastomosis is well expressed, connecting the veins of the aciniform plexus with the veins lying outside the vaginal membrane; it is characteristic of the veins of the left spermatic cord. In another form, the aciniform 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 structure is observed on the right. The spermatic cord is covered with a common vaginal membrane with the testicle, on top of which lies m. cremaster.

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

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

During surgical intervention The surgeon sees the structure of the inguinal region as follows: after dissecting the aponeurosis of the external oblique muscle of the abdomen and opening the inguinal canal, the survey opens elliptical zone... Its bottom is the transverse fascia; superior medial edge - joint tendon; inferior lateral edge - inguinal ligament, ilio-pubic 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 of two main and, at first glance, essentially opposite functions. On the one hand, the inguinal canal provides a free exit from abdominal cavity elements of the spermatic cord responsible for normal function testicles. On the other hand, it is necessary to prevent the exit of other organs of the abdominal cavity through this natural weak point: with an increase in intra-abdominal pressure and tension of the abdominal muscles, a coordinated mutual displacement of the musculo-aponeurotic structures occurs, which sufficiently reliably closes the inguinal gap. With constant intense, prolonged loads, accompanied by a significant increase in intra-abdominal pressure, this mechanism is disturbed, which entails the occurrence of an inguinal hernia.

The causes of inguinal hernias.

In the occurrence of inguinal hernias the main role there are two main reasons: 1) features of embryogenesis and development of the gonads; 2) certain dystorphic changes in the musculoaponeurotic tissues of the groin area, caused by both

the influence of various factors (great physical exertion, straining, vitamin deficiency, 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, to 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 intrauterine development of the fetus, the testes begin to descend from the retroperitoneal space downward, along the so-called conductor (gubernaculum testis). Gubernaculum testis is a mesenchymal strand arising 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 bulge - the so-called processus vaginalis peritonei, which gradually protrudes forward the transverse fascia and the rest of the layers of the anterior abdominal wall, contributing to the final formation of the inguinal canal and scrotum. Thus, the testicle makes a further path along the finished anatomical tract. By the 4th to 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. At the 9th month, it descends into the scrotum, reaching its bottom by the time the baby is born. Together with the testicle and its epididymis (epididimis), the vas deferens (ductus deferens), 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, the testicular conductor atrophies. In the normal course of embryogenesis, the processus vaginalis of the peritoneum is obliterated, with the exception of the area immediately adjacent to the testicle. The part of the process that covers the testicle is called the visceral leaf (lamina visceralis), and the other wall of the formed gap is called the parietal (lamina parietalis).

In women, the ovary in the process of development is sent to the pelvic cavity; the processus vaginalis (Nuka's diverticulum) is a rudimentary formation, it is located in the inguinal canal and may not obliterate.

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

1. Perversion of gene information.

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

3. Deficiency of differentiating hubbubs of mother and fetus,

regulating the process of testicular migration.

The consequence of these factors is a lag in the development of the mesenchymal structures of the groin area (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 disturbance in the processes of obliteration of the vaginal process of the peritoneum. In the event that the processus vaginalis remains completely open, its cavity communicates freely with the peritoneal cavity.

Inguinal hernia diagnostics.

Depending on the exit site 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 inwardly from these vessels, and with an oblique hernia, outward. In

The benefits of physical therapy are the direct effects 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 (this effect is not typical for tablet preparations).

An added benefit is that all physiotherapy treatments are focused on solving specific problems and improving overall health. For example, when using hardware massage, not only the functions of the spine in the cervical region are improved, but the whole body is also toned.

Although physiotherapy has some disadvantages. Such methods do not help and can even harm in case of pathology in severe form... For example, in the treatment of advanced osteochondrosis of the neck, vibration massage can provoke an increase in the rupture in the annulus fibrosus.

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

Contraindications
Types of massage for osteochondrosis
- Classic massage
- Vacuum massage
- Acupressure
Lumbosacral massage technique for osteochondrosis
Lumbosacral massage at home

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

Today we will talk about massage of the lumbosacral spine, but let's make a reservation right away, this is not a panacea. You should not rely on only one manual effect in the treatment of osteochondrosis. Necessarily needed drug therapy.

Contraindications

As you know, osteochondrosis of the lumbosacral region occurs in each patient in different ways. 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 masseur, you need to be examined by a vertebrologist. This specialist will determine if the patient can use manual impact on the back in the current phase of the disease.

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

The presence of tumor formations of various etiologies.
The patient is diagnosed with third-degree hypertension.
There are many moles and birthmarks on the patient's back.
Patient hypersensitivity skin.
The patient has problems with cardiovascular system.
The presence of blood diseases.
The patient has infection.
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 influence, taking into account the stage of the disease, the severity of the lesion and the 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 thereby causes the symptoms. Osteochondrosis is a chronic pathology that arises under the influence of a complex of reasons - 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, trauma and others.

Symptoms

Defeat upper section the spine can manifest itself with a mass of symptoms, depending on the localization and severity of the dystrophic process, as well as on how seriously the root structures of the spine of the cervical region are affected. Often, patients' complaints are reduced to symptoms that at first glance are not related to each other, which can complicate the diagnosis and further treatment of the disease.

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

Vertebral, characterized by various types of pain in the occiput and neck.
Spinal, in which symptoms of impaired motor and sensory innervation are observed, in addition, the disturbed trophism of the cervical zone causes gradual atrophy of the muscles of the shoulder girdle and arms.
Radicular, expressed in pain symptoms in the area of the peritoneal organs and chest, which requires additional careful diagnostics to differentiate osteochondrosis and diseases of internal organs.
Vertebral artery syndrome 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 due to infringement of the vertebral artery and 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, decides only the doctor after the appropriate diagnosis, self-medication in this case is unacceptable.

Treatment of osteochondrosis of the neck has the goal of eliminating pain, inflammation, partial or complete restoration of the affected tissue structures and prevention of complications.

In advanced cases, at severe stages of development of neurological lesions and concomitant pathologies, it can be shown hospital treatment cervical osteochondrosis with the possibility of surgical intervention.

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

Physiotherapy procedures for cervical osteochondrosis:

Magnetotherapy. A safe method of treatment, which consists in the effect on the damaged cells of a low-frequency magnetic field... It gives an analgesic effect, acts as an anti-inflammatory agent.
Ultrasound. It has a beneficial effect on metabolic processes in the tissues of the cervical spine, due to which swelling is removed, pains go away.
Electrophoresis. It should be used with the use of pain relievers (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 neck osteochondrosis

Cervical osteochondrosis is a fairly common degenerative-dystrophic disease that occurs in the intervertebral discs. The primary symptomatology of the disease begins to develop 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 similar symptoms, you should determine the root cause of the pathology. Only after that, together with the doctor, you can select drug treatment.

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

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

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

severe hypothermia;
the presence of progressive rheumatism;
violation of hormonal levels in the body;
trauma suffered spinal column, namely, the cervical region;
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 stress, cough and sneezing syndrome;
the appearance of a strong crunch in the cervical region, increasing during head movements;
hands (especially fingers) and interscapular region often go numb;
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 larynx and neck;
there is a predisposition to fainting, dizziness with sudden head movements.

In addition, with osteochondrosis in the neck, sometimes a noise effect in the ears, deafness, impaired visual function, pulling heart pains are possible. Patients diagnosed with this condition often complain of continuous exhaustion and lethargy.

Complications

Among all forms of osteochondrosis, the most dangerous is the pathology of the cervical region. The segments of the ridge in the neck are damaged, where there are numerous vessels supplying nutrition 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 with the use of physiotherapeutic procedures, the progression of the disease begins, which can contribute to the development of some complications:

Visual impairment.
The formation of hypertension.
Cardiac dysfunction.
Development of vascular dystonia.
Coordination of movements is impaired due to damage to blood circulation in the brain.

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

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

Treatment of the vessels of the stump. Typically, amputations are performed under a tourniquet. This makes it possible to cross all soft tissues without blood. At the end of the operation, before removing the tourniquet in the stump, all large vessels, and the arteries are ligated with two ligatures, the lower of which must be stitched: one of the ends of the ligature is threaded into a needle, with which both walls of the artery are stitched. This additional fixation insures against slipping of the ligature. As a suture material, many surgeons prefer catgut, because when using silk, the formation of a ligature fistula is possible. The ends of the ligatures are cut off only after removing the tourniquet. Smaller vessels are ligated with stitching of the surrounding tissues.

Operations on the vessels of the lower extremity

Puncture of the femoral artery according to Seldinger. The puncture is carried out with the aim of introducing a catheter into the aorta and its branches, through which it is possible to carry out contrasting of the vessels,

to bed the cavity of the heart. The injection of a needle with an inner diameter of 1.5 mm is carried out immediately below the inguinal ligament along the projection of the femoral artery. Through the lumen of the needle inserted into the artery, a guidewire is first inserted, then the needle is removed and instead of it a polyethylene catheter with an outer diameter of 1.2-1.5 mm is put on the guidewire. The catheter together with the guidewire is advanced along the femoral artery, the iliac arteries into the aorta to the desired level. Then the guidewire is removed, and a syringe with a contrast agent is attached to the catheter.

Operations for varicose veins of the lower leg and thigh. At

varicose veins of the lower limb (v. saphena magna and v. saphena parva) due to insufficiency of the venous valves, the blood stagnates in the lower parts of the leg, as a result of which trophic tissue is disturbed, trophic ulcers develop. This is also facilitated by the insufficiency of the valves of the perforating veins, due to which in superficial veins there is a discharge of blood from deep veins. The purpose of operations is to eliminate blood flow through the superficial veins (with full confidence in the patency of deep veins!). Previously used operations to ligate the great saphenous vein at the place of its confluence with the femoral vein (in particular, the Troyanov-Trendelenburg operation) proved to be insufficiently effective. The most radical operation is the complete removal of the great saphenous vein according to Babcock. The principle of the method is to remove a vein using a special flexible rod with a clavate head inserted into it through a small incision under the inguinal ligament to the level of the knee joint, where venesection is also performed through a small incision. The conductor is taken out through this hole, the club-shaped head is replaced with a venextractor (metal cone with sharp edges). By pulling the extractor out by the guidewire at the upper incision, the vein is removed from the subcutaneous tissue. By the same principle, the distal part of the vein on the lower leg is removed.

The femoral canal is formed only in the process of protrusion of the peritoneum when the femoral hernia passes through the weak spot of the lower abdominal wall - the medial section of the vascular lacuna, limited:

In front - the inguinal ligament;

Behind - a comb ligament (Cooper's ligament), lying on the crest of the pubic bone;

Medially - lacunar ligament, attaching to the pubic tubercle and the crest of the pubic bone;

Laterally - the iliac-comb arch.

The femoral vessels pass through the vascular lacuna, and the vein lies medial to the artery (Fig.22A). In the medial corner of the vascular lacuna there is a femoral ring, which, in the presence of a hernia (Fig.22B), limits from above femoral canal.

Femoral ring boundaries:

The anterior, posterior and medial borders coincide with the same borders of the vascular lacuna;

Lateral border - femoral vein pliable, and can be pushed outward by a hernial sac.

The distance between the lacunar ligament and the femoral vein is on average 1.2 cm in men and 1.8 cm in women. The larger this distance, the more likely it is to develop a femoral hernia, so they are much more common in women than in men (5: 1).

Rice. 23. Vascular and muscle lacunae of the right groin area.

A: 1 muscle lacuna -; 2 - ilio-comb arch; 3 - inguinal ligament;

4 - femoral artery; 5 - femoral vein; 6 - vascular lacuna; 7 - femoral ring; eight - lymph node Pirogov-Rosenmüller; 9 - lacunar ligament; 10 - spermatic cord; 11 - comb muscle; 12 - obturator neurovascular bundle; 13 - femoral nerve; 14 - iliopsoas muscle.

B: - GM - hernial sac femoral hernia.

The femoral ring from the side of the abdominal cavity is covered with a transverse fascia, here called the "femoral septum". Within the femoral ring, in the vascular lacuna between the femoral vein and the lacunar ligament, there remains a gap filled with loose tissue, in which the Pirogov-Rosenmüller lymph node is located.

During the passage of the hernia, the walls of the femoral canal are formed:

Front - wide fascia of the thigh;

Posterior - comb ligament;

Lateral - femoral vein (Fig.22B).

The length of the femoral canal is 1-3 cm, depending on the level of attachment of the upper horn of the crescent edge to the inguinal ligament or to the deep plate of the fascia lata on the comb muscle.

From below, the femoral canal ends with a subcutaneous fissure, limited:

Laterally - with a crescent edge;

Above and below - with the upper and lower horns.

The subcutaneous fissure is covered in front by the ethmoid fascia.

The femoral ring can bend around the obturator artery anteriorly and medially in the case of its divergence from the external iliac artery or the obturator branch of the inferior epigastric artery. This variant of the obturator artery discharge is called the "crown of death", since blind dissection of the lacunar ligament with a strangulated femoral hernia often led to damage to this vessel and fatal bleeding.