What are the relevant anatomic zones in laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

The inferior epigastric artery-vein complex lies on the rectus muscles bilaterally. Medial to these vessels but above the iliopubic tract is the external ring, which is not visible in patients without a direct hernia. The internal ring is lateral to the inferior epigastric vessels but is often obscured by them, even when a hernia is present. Its location can be approximated by locating the junction of these vessels and the cord structures. The femoral ring is inferior and lateral to the external ring and lies below the iliopubic tract just medial to the external iliac vessels.

The Cooper ligament is the name given to the periosteum of the superior pubic ramus. The pubic ramus can be easily palpated with a blunt grasper and is an excellent starting point for dissection.

Also deserving of careful recognition is the iliopubic tract (commonly referred to as the shelving edge of the inguinal ligament in open surgery). This aponeurotic stretch of tissue is located posterior to the inguinal ligament and extends from the anterior superior iliac spine to the superior pubic ramus. As a continuation of the transversus abdominis aponeurosis and fascia at the upper border of the femoral sheath, it passes medially to form the inferior border of the internal inguinal ring, crossing over the femoral vessels. [56, 57, 58]

The surgeon must be aware that the iliopubic tract forms the superolateral border of the so-called triangle of pain, an area bounded medially by the spermatic vessels (see the image below). In this area, tacking of the mesh is to be avoided because of the risk of injury to the femoral branch of the genitofemoral nerve or the lateral femoral cutaneous nerve. [53, 56, 57, 45]

Inguinal anatomy: triangle of pain. Inguinal anatomy: triangle of pain.

Another anatomic zone of which the surgeon must be aware is the so-called triangle of doom, which is bordered medially by the ductus deferens and laterally by the spermatic vessels, with its apex at the deep inguinal ring (see the image below). This area contains the external iliac artery and vein; thus, tacking of the mesh must be avoided within its boundaries, and dissection should be limited. [56, 58]

Inguinal anatomy: triangle of doom. Inguinal anatomy: triangle of doom.

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