Inguinal Region – Anatomy, Peritoneal Landmarks, Infraumbilical Fossae

Anatomy of the Inguinal Region

The ‘Myopectineal Orifice of Fruchaud’

Henry Fruchaud
Henry 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

Boundaries

  • Superiorly Internal oblique and transversus abdominis muscles.
  • Inferiorly Superior pubic ramus.
  • Medially Rectus muscle sheath.
Myopectineal orifice of Fruchaud
Myopectineal orifice of Fruchaud

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 ligaments
The infraumbilical ligaments

The Infraumbilical Fossae

These fossae are important for surgeons-

  1. Delineate the sites of groin herniation.
  2. An important landmark for orientation during hernia repairs.

Supravesical fossae:

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 boundaryInferior epigastric vessels
2Medial boundaryRectus sheath
3.Inferior boundaryCooper’s ligament/
Inguinal ligament

It is the site for direct hernia

Hesselbach’s triangle
Hesselbach’s triangle

Iliopubic Tract

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:

Arteries

  1. External iliac artery
  2. Inferior epigastric artery and its branches

Veins

  1. External iliac vein
  2. Inferior epigastric veins
  3. Deep venous circulation

Nerves

  1. Lateral femoral cutaneous nerve
  2. Genitofemoral nerve
  3. Femoral nerve
  4. Ilioinguinal nerve
  5. Iliohypogastric nerve
  6. Lymphatics and lymph nodes

Advantages of Laparoscopic Hernia Repair and Difficulties

Advantages Laparoscopic Hernia Repair

Level 1A evidence

  1. Lower incidence of wound infection and hematoma formation.
  2. Lesser pain & discomfort. Immediate postoperative pain and delayed pain is reduced.
  3. Shorter hospital stay.
  4. Early resumption of normal daily activities and work.

Level 1B evidence

  1. Incidence of recurrence as low as with Lichtenstein’s repair.
  2. Cost-effective when QALY (quality-adjusted life-year) is taken into consideration.

Level 4 evidence

  1. Deep repair of inguinal hernia addresses the issue of repair at the ‘point of origin’ rather than at the ‘point of presentation’. This gives a mechanical advantage over the onlay/ anterior mesh placement.
  2. Covering the entire myopectineal orifice of Fruchaud, the deep repair deals with all the potential sites at risk for herniation in the groin.
  3. Other co-existing diseases like cholelithiasis can be tackled in the same sitting.
  4. Larger mesh can be placed comfortably when compared to that in open technique.
  5. Reduces the chance of infection (mesh and wound) as wound is minimal & mesh is deep inside.
  6. Preferred in recurrence after anterior approach as preperitoneal space is untouched and dissection is easy.

Difficulties – Laparoscopic Hernia Repair

Level 1A evidence

  1. Longer operation time.

Level 2B evidence

Steeper learning curve.
A safe and successful outcome of any surgical procedure is dependent upon the clear understanding of the surgical anatomy of the relevant area. The laparoscopic view of the groin anatomy is quite different from that during open surgery. The laparoscopic view is essentially a posterior approach view. Most surgeons are well versed to the anterior approach. Changing to laparoscopic approach needs additional knowledge. Certain structures that are clearly visible during the open approach like the ilioinguinal nerve and the inguinal ligament are not as clearly visible with the laparoscope. It is not mandatory to visualize them as you rely on median, medial & lateral infraumbilical ligaments, inferior epigastric vessels, pubic symphysis, pubic arch, iliopubic tract, external iliac vessels, cord structures etc.

Level 4 evidence

  1. The laparoscopic view is a ‘virtual view’ with a ‘2- dimensional’ handicap. There is the additional loss of tactile feedback.
  2. Hand-eye coordination is the key as in any other laparoscopic procedure.
  3. The procedure may be difficult if preperitoneal space is dissected during prior surgeries.

Introduction to Hernia

Repair of inguinal hernia is one of the commonest surgical procedures performed worldwide. The lifetime risk for men is 27% and for women, it is 3 %.

“No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its variants.”

Sir Astley Paston Cooper, The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, Cox, London, 1804.

“I know more than hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal.”

Sir Henage Ogilvie

History of Hernia Repair

YearProponent and Procedure details
1884Edoardo Bassini
Introduced the modern era of herniorrhaphy.
Bassini’s method relies on a musculoaponeurotic repair to reconstruct the inguinal canal.
1945Edward Earle Shouldice
Four layer repair
1958Francis C. Usher
Used polypropylene as first successful synthetic prosthesis.
1964Irving L. Lichtenstein
Tension free open mesh repair. Till now it is the standard evidence-based operation.
1973Rene Stoppa
GPRVS (Giant Prosthetic Reinforcement of Visceral Sac) / Open preperitoneal mesh repair (Significantly reduced recurrence rate for multi-recurrent groin hernias). He reiterated the advantages of posterior approach.
1982Ralph Ger
The first laparoscopic hernia repair by approximating the internal ring with stainless steel clips.
1992Maurice E. Arregui and Yves Marie Dion TAPP(Transabdominal preperitoneal repair)
1992Ferzli et al., Dulucq, Himpens, and McKernan & Laws, TEP(Total extraperitoneal repair)

Both the techniques of laparoscopic hernia repair reproduce the concept of Stoppa, by placing a large mesh in the preperitoneal space to cover half of the abdominal wall and all the weak areas (Myopectineal orifice of Fruchaud) including area of internal ring, Hasselbach’s triangle and the femoral ring with/without obturator opening. Both TAPP and TEP are now accepted as evidence based treatment for inguinal hernias equivalent to Lichtenstein’s procedure.

Laparoscopic Hernia Repair

Section 1

Section 2

Section 3

  • Laparosopic repair-the technique
  • Transabdominal preperitoneal repair of inguinal hernia
  • Total extra peritoneal repair
  • Two port TEP.
  • Laparoscopic ventral hernia repair
  • Diaphragmatic hernias in adult
  • Laparoscopic hiatus hernia repair
  • Pediatric hernia repair

Laparoscopic Hernia Repair - How to Learn at Ease
By
Dr. R. Padmakumar
Dr. Madhukar Pai & Dr. Farish Shams

Section 4

  • Difficulties encountered during laparoscopic hernia repair
  • Complications
  • Frequent queries and answers from experts

Section 5

  • Hernia in general