Laparoscopic Inguinal Hernia Repair- Surgical Anatomy

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Median Umbilical Ligament

Apex of the bladder towards the umbilicus. It represents the obliterated allantoic duct and its lower part may be the site from the unusual urachal cyst.

Medial Umbilical Ligament

Obliterated umbilical artery on both sides and can be traced down to the internal iliac artery.

Lateral Umbilical Ligament

Has Inferior Epigastric artery and its companion two veins because they course around the medial border from the internal inguinal ring after which pass upwards into the posterior rectus sheath.



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Myopectineal orifice of Fruchaud

It is a potential weak area in the lower abdominal wall through which groin hernias occur. It is bounded:

  • Above by conjoint tendon
  • Below by the pectineal line of the superior pubic ramus
  • Laterally by the iliopsoas muscle 
  • Medially by the lateral border of the rectus muscle. 

This serves as the passage for blood vessels, nerves, lymphatics, muscles and tendons between the abdomen and the lower limb.

This is the site for direct, indirect and femoral hernias.

All the three can be repaired by a single piece of mesh by covering this orifice

Iliopubic Tract

The Iliopubic tract is really a thickened lateral extension from the transversalis fascia, that runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine.

Important Nerves in Laparoscopic Hernia Repair

The following 3 nerves are at risk for injury at laparoscopic hernia repair :-

1) Lateral Femoral Cutaneous Nerve
2) Femoral Branch from the Genito-Femoral Nerve
3) Intermediate Cutaneous Branch of the Anterior Branch of the Femoral Nerve

The next 3 nerves are usually not in danger at laparoscopic hernia repair but could be injured if excessive pressure is applied during mesh fixation, compressing the muscles enough to permit the staples to reach the nerve. It is interesting to notice that conversely the below 3 nerves are in most risk in open hernia repairs.

1) Ilioinguinal Nerve
2) Iliohypogastric Nerve
3) Genital Branch of Genito-femoral nerve

Laparoscopic Inguinal Hernia Repair- Surgical Anatomy
Image Courtesy: Gateway Clinics, Coimbatore (https://www.facebook.com/gatewayclinics.coimbatore)

Triangle of Pain

The “triangle of pain” is an inverted “V” shaped area with its apex at the internal (deep) inguinal ring. It is bound anteriorly by the iliopubic tract / inguinal ligament and by the testicular (spermatic) vessels posteromedially.

Laparoscopic Inguinal Hernia Repair- Surgical Anatomy
Image Courtesy: Gateway Clinics, Coimbatore (https://www.facebook.com/gatewayclinics.coimbatore)

Triangle of Doom

The “triangle of doom” is an inverted “V” shaped area with its apex at the internal (deep) inguinal ring. The “triangle of doom” is bound laterally – gonadal vessels, & medially – vas deferens in the male, or the round ligament of the uterus in the female

Laparoscopic Inguinal Hernia Repair- Surgical Anatomy
Image Courtesy: Gateway Clinics, Coimbatore (https://www.facebook.com/gatewayclinics.coimbatore)

The corona mortis

This refers to an anatomical variation – a vascular anastomosis between the obturator and the external iliac vascular systems that passes over Cooper’s pectineal ligament and posterior to the lacunar (Gimbernat’s) ligament. (Fig: Corona Mortis on Left Side)

Laparoscopic Inguinal Hernia Repair- Surgical Anatomy
Image Courtesy: Gateway Clinics, Coimbatore (https://www.facebook.com/gatewayclinics.coimbatore)

Space of Retzius and Bogros (Read More Here)

Retzius Space: Also called Retropubic space, Prevesical space or cave of Retzius. It is an extraperitoneal space located posterior to the pubic symphysis and anterior to the urinary bladder

Bogros Space: Also called retroinguinal space or Bogros’ space. It is an extraperitoneal space situated deep to the inguinal ligament


Related posts:

LAPAROSCOPIC EXTRAPERITONEAL INGUINAL HERNIA REPAIR IS USUALLY PERFORMED IN WHICH OF THE FOLLOWING SPACE?

SURGICAL ANATOMY OF INGUINAL CANAL

LAPAROSCOPIC INGUINAL HERNIA REPAIR- SURGICAL ANATOMY

THE HIPPO TRIAL: COMPARISON OF SELF-GRIPPING MESH AND SUTURED MESH IN LICHTENSTEIN HERNIOPLASTY (RANDOMIZED DOUBLE BLIND TRIAL)

NAMED AND UNCOMMON VARIETIES OF INGUINAL HERNIAS

WHAT IS VARICOCELE AND HOW IT IS MANAGED?

https://worldsurgeryforum.net/2016/05/what-is-varicocele-and-how-it-is-managed.html


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