The ‘Myopectineal Orifice of Fruchaud’
All groin (inguinofemoral) hernias originate in a single weak area called the myopectineal orifice. This oval, funnel-like, ‘potential’ orifice formed by the following structures, makes the ‘myopectineal orifice of Fruchaud’.-Henry Fruchaud
- Superiorly Internal oblique and transversus abdominis muscles.
- Inferiorly Superior pubic ramus.
- Medially Rectus muscle sheath.
The Peritoneal Landmarks
Median Umbilical Ligament:
This ligament ascends in the median plane from the apex of the bladder to the umbilicus. It represents the obliterated allantoic duct and its lower part is the site of the rare urachal cyst.
Medial Umbilical Ligament
This ligament represents the obliterated umbilical artery on each side and can be traced down to the internal iliac artery.
Lateral Umbilical Ligament
It is the ridge of peritoneum, which is raised by the inferior epigastric vessels.
These ligaments delineate the infraumbilical fossae
The Infraumbilical Fossae
These fossae are important for surgeons-
- Delineate the sites of groin herniation.
- An important landmark for orientation during hernia repairs.
The infraumbilical area between the median and medial umbilical
ligaments. This is the site for the origin of the supravesical hernia.
Medial Umbilical fossae
The infraumbilical area between the medial and lateral umbilical
ligaments. This is the site for the origin of the femoral and direct inguinal hernia.
Lateral Umbilical fossae
The infraumbilical area lateral to the lateral umbilical ligament. This is
the site for the origin of the indirect inguinal hernia.
Hesselbach’s Triangle (by Franz Caspar Hesselbach)
|1.||Superolateral boundary||Inferior epigastric vessels|
|2||Medial boundary||Rectus sheath|
|3.||Inferior boundary||Cooper’s ligament/
It is the site for direct hernia
The iliopubic tract is a thickened lateral extension of the transversalis fascia, which runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine. It is intimately associated with the inguinal ligament. It is anterior to the Cooper’s ligament and posterior to the inguinal ligament. The iliopubic tract separates the internal ring from the femoral canal. It is visualized as a fibrous (white) tract.
Transversalis Fascia (of Gallaudet)
This fascia is a two layered structure (bilaminar). The anterior layer is adherent to the rectus abdominis muscle. The posterior layer lies in between the anterior layer and the peritoneum. It divides this space into an anterior (vascular space) and a posterior (Space of Bogros). Medially it is continuous with the space of Retzius. One should work in the space of Bogros to prevent unnecessory oozing.
Prevesical space of Retzius
The preperitoneal space that lies deep to the supravesical fossa and the medial umbilical fossa is the prevesical space of Retzius (Described in 1858, by Swedish anatomist Anders Retzius). This space contains loose connective tissue and fat.
Important structures in this space are:
- External iliac artery
- Inferior epigastric artery and its branches
- External iliac vein
- Inferior epigastric veins
- Deep venous circulation
- Lateral femoral cutaneous nerve
- Genitofemoral nerve
- Femoral nerve
- Ilioinguinal nerve
- Iliohypogastric nerve
- Lymphatics and lymph nodes