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CASE 3.1 INDIRECT INGUINAL HERNIA

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Patient Presentation

During a routine physical examination, a small, round swelling was noted in the left groin of a 12-year-old male.

Relevant Clinical Findings History

The patient reported that he had noted the swelling some time ago, but that it was not painful. The bulge seemed to change in size depending on his body position and time of day. Early in the morning it was barely noticeable, but later in the day or after exercise the enlargement was more obvious. The patient has had no prior major illnesses or surgeries.

Physical Examination

The following findings were noted on physical examination:

  • Testes of normal size and position for patient's age

  • Small palpable mass in left groin, just lateral and superior to pubic tubercle

  • Mass is easily reducible

Laboratory Tests
Table Graphic Jump Location
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Test Value Reference value
Erythrocytes (count) 5.3 4.3–5.6 × 106/mm3
Leukocytes (count) 8.2 3.54–9.06 × 103/mm3
Imaging Studies
  • Ultrasonography of the left groin showed an abnormal mass.

Clinical Problems to Consider
  • Enlarged superficial inguinal lymph nodes

  • Hydrocele

  • Direct inguinal hernia

  • Indirect inguinal hernia

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LEARNING OBJECTIVES

  1. Describe the anatomy of the inguinal region.

  2. Describe the anatomy of the spermatic cord.

  3. Describe the development of the male inguinal canal.

  4. Define the anatomy of the inguinal triangle.

  5. Explain the anatomical basis for the signs and symptoms associated with this case.

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RELEVANT ANATOMY

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Inguinal Region
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The inguinal (groin) region is the antero-inferior area of the anterior abdominal wall. Three flat muscles of the abdominal wall (external oblique, internal oblique, and transversus abdominis) contribute to the anatomy of this region. Each of these muscles has an aponeurosis (flat tendon). The inferior margin of the external oblique aponeurosis forms the inguinal ligament, a thickened band that stretches from the anterior superior iliac spine to the pubic tubercle.

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Inguinal Canal
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The inguinal canal is an oblique passageway through the inferior part of the anterior abdominal wall (Fig. 3.1.1). The canal is approximately 5 cm in length and is directed inferomedially. In males, it serves as a passageway for the spermatic cord, which contains structures coursing to and from the testis. In females, the round ligament of the uterus passes through the canal.

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Figure 3.1.1

Antero-inferior abdominal wall (anterior view) showing anatomy of the inguinal region.

Graphic Jump Location
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The boundaries of the inguinal canal are formed by muscles and fascia of the abdominal wall (Table 3.1.1).

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Table Graphic Jump Location
Table 3.1.1Boundaries of the inguinal canal.

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