Laparoscopic Inguinal Anatomy

Inguinal region Explored extensively by surgeons knowledge of anatomy improves the surgical repair

Conventional Anatomy Inguinal canal Oblique space, 4 cms, above the inguinal ligament bet superficial & deep inguinal rings Triangular in cross section Deep ing ring is opening in transversalis fascia at mid point of ing ligament Ext ring is small slit like opening in ext aponeurosis, above & lat to the pubic tubercle

Anatomy of ing canal Ant wall- ext oblique aponeurosis Lat wall- internal oblique & transversus abd arch over and forming roof and & lie on post aspect of medial half. Medial 2/3rd rectus abd sheath Post wall is formed by tranversalis fascia throughout the inguinal canal Shutter mechanism- prevents the herniation through the internal ring

Inguinal ligament Folded inf portion of ext oblique aponeurosis Ant sup iliac spine to pubic tubercle Bridge across iliopsoas muscle underneath and thigh compartment Iliac fascia anchors the ing ligament post and divide muscular & vascular compartment

Laparoscopic approach We approach anatomical structures from deep to superficial treating the peritoneum as the first layer The basic view from “inside out” capitalizes on many easily identified landmarks that must be familiar to anyone who wishes to learn the minimally invasive herniorrhaphy

Laparoscopic Anatomy Totally new view of anatomy Posterior layer to superficial layer Peritoneum Adipose Tissue Transversalis Fascia Transversus Abdominus Internal Oblique External oblique Scarpa’s Fascia Subcutaneous tissue Skin

Deep aspect of ant abd wall The parital peritoneum consists of monolayer of mesothelial cells supported by connective tissue It is interlaced with blood vessels & nerves It is translucent, closely adherent to post abd wall structures, many of them can be seen through it Some structures are prominent – thickened or gathered peritoneum around them called ligaments– accentuated by insuffalation.

Transversalis fascia 2 layers, Ant & post Identification of fascia transversalis & iliopubic tract are essential elements of a successful repair of hernia Imp structure in TEP 2 layers, Ant & post Ant layer is close to transverse abd. muscle and is inserted into rectus sheath medially and to cooper’s lig inferiorly Post layer merges sup with linea semilunaris, medially with linea alba and inf to the sup ramus of pubis Inf epigastric vessels are enveloped with in these two layers

symphysis post trans fascia arcuate

Inguinal Anatomy Before the reflection of peritoneum After the reflection of peritoneum

Structures Before Peritoneal Reflection Three ligaments Median umbilical ligament Medial umbilical ligament Lateral umbilical ligament

Medial Median Lateral

Structures Before Peritoneal Reflection Three fossa Supravesical Medial Inguinal fossa-direct hernia Lateral Inguinal fossa-indirect hernia

To familiarize the anatomy, advisable to identify these structures during other laparoscopic procedures like appendicectomy, cholecystectomy

Structures After Peritoneal Reflection Inferior epigastric vessels Iliopubic tract Cooper’s ligament Cord structures Femoral canal

Iliopubic Tract It is the aponeurotic band formed by condensation of ant layer of fascia transversalis blended with transverses abdominis aponeurosis Coursing from anterior superior iliac spine to pubic tubercle Runs parellel to inguinal ligament Attached to the pubic ramus as cooper’s Ligament

Cooper’s Ligament (Pectineal ligament) Shiny, thick, fibrous structure covering the superior pubic ramus Not a ligament in the true sense (Attachment of iliopubic tract to pubic ramus) Important landmark for fixation of mesh

Preperitoneal Space Space between parietal peritoneum & anterior layer of transversalis fascia Laterally up to the epigastric vessels Posteriorly on either side of the bladder molar tooth

Preperitoneal Space Medial part of space of Retzius Lateral part of space of Bogros

Retzius Bogras Retzius

Hasselbachs Triangle Medial - Rectus muscle Lateral - Inferior epigastric artery Inferior - Iliopubic tract

Triangle of Doom Described by Spaw in 1991 Vas and gonadal vessels Iliac vessels Femoral nerve

Lateral cutaneous nerve Femoral nerve (partially) Triangle of Pain Genitofemoral nerve genital branch (dysejaculation) femoral branch (hyperasthesia) Lateral cutaneous nerve Femoral nerve (partially)

Pain Doom

Corona Mortis Anastomotic branches from inferior epigastric artery & Obturator artery (abnormal OA) Iliopubic vein Retropubic vein

corona mortis

Square of Doom, Extended Square of Doom

Epigastric Medial Bladder

Before peritoneal reflection After peritoneal reflection

Myopectenial orifice of fruchaud all groin hernia emerge through this opening in the lower abdominal wall bounded by transverse abdominis and superior pubic ramus divided into ant. and post. by inguinal ligament allows passage of blood vessels, nerves, lymphatics, vas deference, muscle, tendon and fascia

Myopectineal Orifice of Fruchaud Medial: lateral border of rectus muscle Lateral: iliopsoas muscle Inferior: bony margin of pelvis Superior: transversalis fascia and internal oblique

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