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166
Conjoint
Conjoint tendon
Epigastric vessels
Inguinal ligament
abdominal oblique
abdominal oblique
Female
tendon
Fig. 17.9 The deep inguinal ring
Round ligament
of uterus
Fig. 17.10 The external inguinal ring
and hesselbach’s
ligament
Superficial
inguinal ring
Internal
External
Vaginal process
Fat
J. Loriau
17.5 Floor of the Channel:
the Inguinal Ligament
The inguinal ligament is one of the key elements
from the myopectineal orifice of Fruchaud. As a
strong structure, it divides the orifice in two
parts of frailty: the inguinal region and the femoral region. Made of the reinforcement of the
inferior edge of the external oblique aponeurosis, it also represents the floor of the inguinal
channel.
For anatomists, the “independance”& “constitution” of the inguinal ligament is for a long time
a subject of debate. In a paper from a decade,
Aclad R. [2] summarized all the conceptions
about that ligament that have been proposed by
anatomists (Table 17.1).
Streched between the anterior superior iliac
spine and public tubercle, its inferior part is generally considered neither totally free nor alone but
stretched in connection with the transversalis fascia and also to the femoral sheath by Thomson’s
band. The existence of Thomson’s band or iliopubic tract is another subject of debate but it can
be described as a fibrous structure running from
the pubic tubercle to the iliac fascia and in connection both with conjoint tendon and femoral
sheath. Thomson’s band is seen as transversalis
fascia reinforcement [10].
Table 17.1 Anatomical terms for the inguinal ligament used by noted anatomists of the late eighteenth and early
nineteenth centuries, and the structures to which each author applied the anatomical term(s)
Author Anatomical term(s) used Structure(s) described or understood to be included under the
anatomical term
Winslow [8] Ligament de Falloppe A structure distinct from the external oblique aponeurosis, to which
the lower edge of the external oblique aponeurosis is attached.
Gimbernat [9] Arcade crurale Superficial part: the in-turned lower border of the external
oblique aponeurosis. Deep part: the structure now recognized
as the medial part of the iliopubic tract.
Bichât [10] Ligament de Falloppe The folded lower border of the external oblique aponeurosis.
Bell [11] Ligament of the thigh
a
Poupart
Inguinal ligamenta Crural
a
arch
Ligament of Falloppius
Hesselbach [12] Aussere leistenband Innere
leistenband
a
Ligament of
a
A distinct ligament, independent of the external oblique
aponeurosis. Description corresponds largely to the structure
now known as the iliopectineal arch.
(1) “External inguinal ligament” formed by the lower edge
of the external oblique aponeurosis.
(2) “Internal inguinal ligament” formed by structures now
known as iliopectineal arch and transversalis fascia.
Cloquet [13] Ligament de Falloppe
Cooper [14] Poupart’s ligament
a
These terms were used synonymously by the named author
de Poupart
a
Arcade crurale
a
Ligament
a
a
Crural arch (Description indistinct) Understood the structure now known
The folded lower border of the external oblique aponeurosis.
as the iliopectineal arch to be part of the ligament.
17 Anatomy of the Inguinal Region
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167
Those anatomical debates might be considered
useless by surgeons in practice but one anatomical
point has to be known about vascular proximal
elements of the inguinal ligament. About 4 to
5 cm lateral to the pubic tubercle and just beneath
the inguinal ligament (& Thomson’s band) lays
the external iliac vein. It can be very easily injury
by an “unfair” stitching like in many groin hernia
procedures were the roof of the inguinal canal is
used as an inferior point of anchor.
17.6 Front Wall of the Inguinal
Canal: External Oblique
Aponeurosis
As we described before the aponeurosis of the
external oblique muscle is the most superficial
structure (after the superficial fascia) of the abdominal wall at the myopectineal orifice. As the lid of
Fruchaud’s myopectineal orifice, the external
oblique aponeurosis also covers the inguinal canal.
This layers contains the superficial inguinal ring
(see before) which is the exit of the inguinal canal.
17.7 Back wall of the Inguinal
Canal: Transversalis Fascia
However transversalis fascia is known due to its
presence and role of shutter of the myopectinral
orifice, it’s a structure extended from the lumbar
region to the spermatic cord (or round ligament
of the uterus).
Outside the inguinal region it’s only a thin
membrane but reaching this area it is much more
thicker and reinforced by some ligaments.
Medially the transversalis fascia ends as lining
the posterior surface of the rectus muscle. In
about half cases the fibers of the rectus muscle
extends laterally to the pubic tubercle in a reinforcement known as Henle’s ligament.
At its lower part it is connected to the
Thomson’s band that has been described before.
Anteriorly to the fascia lays the epigastric vessels and behind them, dividing the transversalis
fascia in a medial reinforcement stands the
Hesselbach’s ligament. Please note that the ligament also delimitates the Hesselbach’s triangle
which other limits are lateral border and sheath of
the rectus muscle and inguinal ligament. It is the
place of direct inguinal hernias.
Laterally the fascia is inserted at the iliac
fascia.
From the inferior margin of the transverse muscle to the pectineal ligament the transversalis fascia is the only structure supporting abdominal
pressure and supposed to contain it. The larger is
this area, due to the anatomic variations previously
described, and the weaker the transversalis fascia
is; the more easily a hernia can occur in those
regions. For this reason, reinforcement of the
transversalis is the CenterPoint of many hernia
repair techniques either using sutures or meshes.
The Peritoneum and the 3 inguinal depressions
Even if the peritoneum is not a topic of anatomic specific interest in the inguinal region; since
the development of the TAP laparoscopic repair the peritoneum has become of surgical anatomy
interest.
Looking from inside the abdomen, the peritoneum is subtended by fibro vascular structures
forming 3 depressions: supra vesical, medial inguinal fossa and lateral inguinal fossa.
Lateral to the epigastric vessels stands lateral inguinal fossa. It is the place for indirect hernia
outlet.
Between the epigastric vessels and the medial umbilical fold (umbilical artery) the area is
named middle inguinal fossa. It is the place for direct hernia outlet.
Medial to the medial umbilical fold and lateral to the median umbilical fold (remnant of the
urachus) stands the supra vesical fossa. Even if hernia sliding at this point is possible this
occurrence is very poor? Nevertheless several cases reports of bowel obstruction related to this
type of hernia have been published (Fig. 17.11) [11].
168
Fig. 17.11 Supravesical hernia
J. Loriau
17.8 Spermatic Cord and Vascular
Issues
Looking at the cord it is difficult to imagine how
complex is its constitution as it looks like a simple and single structure.
Indeed, the components of the cord are
wrapped in three different layers. The superficial
one is the external spermatic fascia which comes
from the external oblique muscle aponeurosis.
The second layer is the spermatic fascia formed
by fibers and aponeurosis of the internal oblique
and transverse muscle. Deeper lays the internal
spermatic fascia considered as an extension of
the transversalis fascia.
The cord contains itself two nerves: the genital branch of the genito femoral nerve (L1,L2)
innerving the cremaster muscle and testicular
nerves owning to the sympathetic system (T10L2). But the cord shares the inguinal canal with
another nerve running on it: the ilio-inguinal
nerve (L1). The “hot topic” of inguinal nerves
and their surgical “implication is treated below.
But the cord is also composed of vascular
structures; three arteries and three veins.
Testicular artery as a branch of the aorta arising just below the renal arteries supplies blood to
the epidydimis, tunica albuginea and testis.
The artery of the ductus deferens as a branch
of the superior of inferior vesical artery supplies
blood to the testis and epididymis
The cremasteric artery coming from the inferior epigastric artery, supplies the cremaster.
Fortunately (for the surgeon) anastomosis
exists between those arteries allowing blood supply even in case of their respective division. It is
estimated that ischemic testicular atrophy occurs
in only about 1% of cases. But due to the variability of those artery anastomoses caution must
be taken during dissection in order to avoid useless arterial division that in case of unknown anatomic variation could lead to ischemia.
As some blood supply to the testis is also
coming from the scrotal artery, inferior vesical
artery branches and prostatic artery it is advisable not to pull out the testis in incidental cord
division In order to let a chance to avoid testis
atrophy thanks to those collateral arteries that
could be pulled off.
The venous system included in the cord is a
complex network composed by numerous veins
of the testis and epididymis. Ascending in front
of the cord, the multiple veins composing the
Pampiniform venous plexus join themselves in
three or four veins along the inguinal canal. Then
going on these anastomotic process they stay
SPERMATIC CORD
pain in general visceral
vaginalis
ascia/muscle
17 Anatomy of the Inguinal Region
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(Cross section just beyond external inguinal ring)
Testicular artery
from aorta at L1,2
Sympathetics carrying
afferents to T9,10
dermatome
Cremasteric vessels
from inferior epigastric
Genital branch of
genitofemoral n (L2)
llioinguinal nerve
& lymphatics
Testicular vein
(pampiniform plexus) left to
renal vein; right to IVC
Processus
169
Lymphatics passing to
pars-aortics at L1,2 level
Artery & vein to/from vas
Internal spermatic fascia
from trasversalis fascia
Cremasteric f
from internal oblique &
transversus abdominis
Vas & lymphatics
External spermatic
fascia from external
oblique
Fig. 17.12 Components of the spermatic cord
only as two veins after deep inguinal ring and
and upper converge to give the genital vein
(Fig. 17.12).
In women, the round ligament attached to the
side of the uterus lays in the inguinal canal in
place of the cord. Vascular issues are of course
not the same and it can be divided without
consequences.
17.9 The Nerves of the Inguinal
10 to 54% (!!) of patients operated on for inguinal hernia present chronic inguinal pain [12–13].
The median accepted rate is around 10%.
This high rate, reported in the literature even if
unbelievable for each surgeon must lead to
develop every prevention measure. Even if the
Region: Turning Enemies
to Friends
cause of chronic pain is not unique nerve injury is
well recognized as one of the major and preventable cause.
In order to prevent chronic pain hernia surgery
guidelines [
14] recommend to systematically
identify the 3 nerves running the inguinal area during groin hernia surgery. Therefore knowing where
to find them makes surgery easier (and safer).
The llio hypogastric nerve (T12-L1) crosses the
transverse muscle and after divides in two branches.
Its lateral cutaneous branch pierces the external
oblique aponeurosis close to the anterior superior
iliac spine. It innervates the skin of the abdominal
wall around the pubis. This branch is more in danger in orthopedic surgery in case of bone from the
iliac crest retrieval than in hernia surgery.
Its anterior cutaneous branch goes anteriorly
after division and the crosses internal oblique and
external oblique aponeurosis above the superficial inguinal ring to innerve hypogastric region.
170
External oblique aponeurosis
Lateral cutaneousbranc
Obturator nerve
J. Loriau
It is one of the three nerves involved during groin
hernia surgery.
Ilio inguinal nerve (L1) innervates the internal
oblique muscle, crosses it and then lays on the inguinal canal on the side of the cord. It is not an element
of the cord as it is not included inside its different
fascia layers but stands outside. As it emerges from
the internal oblique muscle it can enter at a variable
place the inguinal canal. That is to say that it can’t be
normally found at the internal inguinal ring. It ends
at the superficial inguinal ring and distributes fibers
to innervate root of the penis, scrotum, skin of the
upper and medial part of the thigh
These two first nerves do have connections
Genital branch of genito femoral nerve (L1L2) can be found all along the inguinal canal as it
pierces the transversalis fascia to enter the deep
anal ring and follow to the cord in the canal to the
scrotum supplying fibers to the skin of the scrotum, the cremaster and dartos muscle. He is
responsible for the cremasteric reflex.
Subcostal nerve (T12) emerges through the
transversus abdominis passing between it and the
internal oblique. It then enters the rectus sheath
and becomes superficial halfway between the
pubic symphysis and the umbilicus.
The lateral cutaneous branch of the subcostal
nerve courses runs between the internal oblique
and the external oblique muscles , and emergies
superficial superior to the iliac crest. It innervates
the skin and the subcutaneous tissue of the gluteal
region and also the lateral side of the thigh, only as
far as the greater trochanter of the femur though.
The subcostal nerve supplies the transversus
abdominis, rectus abdominis, and the pyramidalis, along with some fibers to the peritoneum. It
can be damaged during orthopedic surgery involving the iliac crest but also in case of trocart placement close to the superior anterior iliac crest.
Knowing these anatomical considerations is
mandatory for every surgeon who’d like to experience hernia surgery whatever an open or a laparoscopic one. As written before, systematically
identifying the three main nerves is recommended
in open hernia surgery. But as there is a high variability of the nerves situation it is difficult and might
be impossible to delimitate a “safe area” where
nerve damage can be avoided for stapling a mesh
during laparoscopic approach. The classical and
historical “triangle of doom” delimitated by the vas
deferens and the spermatic vessels even defining a
zone of high vascular injury risk is not large enough
to include the other potential nerve damage zones.
The only place where fixation could avoid
nerve damage is the Cooper ligament but one
must keep in mind that small anastomotic arteries
like the anastomotic pubic branch might take
place in this area (Fig. 17.13).
Fig. 17.13 Anatomy of the inguinal region
of iliohypogastric nerve
Lateral cutaneous
nerve of the thigh
Femoral nerve
Femoral branch of the
genitofemoral nerve
Genital branch of the
genito femoral nerve
Internal oblique muscle
Iliohypogastic nerve
Ilio-inguinal nerve
lliac muscle
h
Ventral cutaneousbranch
of ilihypogastric nerve
Spermatic Cord
Pubic branch of the
iliohypogastric nerve
Genital branch of
iliohypogastric and
ilioinguinal nerves
Guber
17 Anatomy of the Inguinal Region
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Surgical Take home message about the anatomy of Inguinal Region
– It is the upper part of the myopectineal orifice of Fruchaud
– The wider is the myopectineal orifice, the more the fascia transversalis is left “alone” to
contain abdominal pressure
– Considering the inguinal canal; its borders entry and exit in a 3D approach and as a volume
in space is the key for understanding both physiopathology and surgery principles
– In open surgery it is recommended to know and systematically identify the 3 nerves of the inguinal
region during the procedures that are: illio hypogastric, illio inguinal, genital branch of genito femoral nerve.
– In laparoscopic approach high variability of nerve situation leads to recommend minimal mesh
fixation and maybe, if needed, limited to the Cooper ligament.
– The Retropubic area
– Any hernia surgeon,wether he (she) is or not a laparoscopist couldn’t ignore what’s beyond
the transversalis fascia!
– Once that fascia is opened from an anterior approach or the peritoneum reclined from a
laparoscopic approach, we enter a space of fatty tissues in connection with the retropubic
Retzius space.
– Let’s remember that in its description of the space he gave his name AJ. Bosgros mentioned
the existence of an important venous system involving inferior epigastric vein, iliopubic
vein, rectusial vein, retropubic vein, communicating rectusio epigastric vein.
– Due to that venous network avoiding hazardous digital exploration or blind mesh stiching in
that area might be wise… (Fig. 17.14)
171
Testis
Peritoneal
cavity
Penis
naculum
testis
Inguinal canal
Fig. 17.14 The deep inguinal venous vasculature with in the space
Deferent duct
B
A
172
vein
Rectusio-epigastric
1st
2nd
t
J. Loriau
17.10 Inguinal Canal: Some
Notions of Embryology
(Fig. 17.15)
The migration of the testis from the lumbar area
to the future scrotum begins around the 12th week
of gestation.
This migration is a result of the action of
gumernaculum testis and hormonal influences.
Gimbernaculum testis raise up from the low gimbernaculum (future scrotum) after the involution
of the mesonephros abouth the 7th week and cranialy is inserted at the testis itself.
During that time (from the 7th to the 12th
week), peritoneum evaginates downward laterally to the gimbernaculum creating the vaginal
process and accompanying the testis migration
through the inguinal canal.
Fibers from the different layers of muscles
from the inguinal region are also involved in that
process and this will lead to the formation of the
different layers wrapping the cord. (see upper.).
Vas deferens and vessels are also pulled through
the canal during the same process.
At the 8th month the testis is located around
the superficial inguinal ring and moves to the
scrotum at our close to the birth.
After birth the vaginal process closes progressively from its medial part to the extremities
forming rings (Ramonede’s rings) and dilatations
that will involve. At the top the peritoneal extremity will close and give the lateral inguinal fossa.
If not it is one of the way of hernia constitution.
At the lower extremity the canal wrappes the testis and becomes the tunica vaginalis testis.
In female there is also a peritoneal migration
forming the canal of Nuck that ends in the major
labia. After birth like in male the canal closes with
the same process. Persistence of the canal leads to
inguinal hernia but as unattended ovarian migration in the canal can occur division of it specially
in young women must be done with caution.
a
communicating v.
Inferior epigastric
Fig. 17.15 (a) Venous network in the inguinal region. (b) venous network variations
Iliopubic vien
Deep circumflex
iliac vein
Int. ring
vein
Femoral vein
Obturator vein
Pubic tubercle
Rectusial v.
Cooper’s lig Retropubic
branch
branch
Lateral margin of
rectus abdominis
Pre-peritoneal fa
Inguinal ligament
External ring
Spermatic cord
17 Anatomy of the Inguinal Region
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b
173
Fig. 17.15 (Continued)
References
1. Fruchaud H. Anatomie chirurgicale des hernies de
l’aine. Paris: G.Doin; 1956.
2. Acland RD. The inguinal ligament and its lateral
attachments: correcting an anatomical error. Clin
Anat. 2008;21(1):55–61.
3. Winslow JB. Exposition Anatomique de la Structure
du Corps Humain. Paris: Desprez; 1732. p. 172.
4. Gimbernat DA. Nuevo Método de Operar en la Hernia
Crural. Madrid: Ibarra; 1793. p. 26.
5. Bichat X. Anatomie Générale: Appliquée à la Physiologie
et à la Médecine. Paris: Brosson, Gabon; 1801. p. 140–5.
6. Bell J, Bell C. The Anatomy and Physiology of the
Human Body. 6th ed. London: Longmans; 1826.
p. 349–57.
7. Hesselbach FC. Neueste Anatomisch-pathologische
Untersuchungen über den Ursprung und das
Fortschre'iten der - Leisten- und Schenkelbrüche.
Würzburg: Stahel; 1814. p. 11–3.
8. Cloquet H. Traité d'Anatomie Descriptive. Paris:
Crochard; 1816. p. 488, 489
9. Cooper A. The Anatomy and Surgical Treatment of
Abdominal Hernia. London: Longman; 1827. p. 5, 6
10. Teoh LS, Hingston G, Al-Ali S, Dawson B, Windsor
JA. The iliopubic tract: an important anatomical landmark in surgery. J Anat. 1999;194(Pt 1):137–41.
11. Jerraya H, Zenaïdi H, Dziri C. Supra-vesical hernia presenting as intestinal obstruction. J Visc Surg.
2014 Jun;151(3):235–6.
12. Callesen T, Bech K, Kehlet H. Prospective study of
chronic pain after groin hernia repair. Br J Surg. 1999.
Dec;86(12):1528–31.
13. Poobalan AS, Bruce J, King PM, Chambers WA,
Krukowski ZH, Smith WC. Chronic pain and quality of life following open inguinal hernia repair. Br J
Surg. 2001;88(8):1122–6.
14. Simons MP, Aufenacker T, Bay-Nielsen M,
Bouillot JL, Campanelli G, Conze J, de Lange D,
Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J,
Morales-Conde S, Nordin P, Schumpelick V,
Smedberg S, Smietanski M, Weber G, Miserez
M. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia.
2009;13(4):343–403.
Ambulatory Hernia Surgery
R.Lorenz
18
18.1 Denition
Even the ambulatory surgery terminology shows
some differences internationally. In many countries,
the term ambulatory surgery means the following:
The patient spends the night before and
after the operation at home.
In the English-speaking world, the term usually has a broader meaning and often comprises
postoperative care for up to 24h. The following
terms and synonyms are used (Table18.1):
Table 18.1 Ambulatory surgery terminology [1]
Terminology Synonym and denition
Day surgery Ambulatory surgery, same-day
Extended
recovery
Short-stay
surgery
Outpatient <24h in hospital
Inpatient >24h in hospital
surgery, day case surgery, outpatient
surgery
23h, overnight stay, single night
24–72h in hospital
18.2 History
Ambulatory surgery is much older than surgery
performed in hospitals. As far back as antiquity,
there were numerous accounts of operations performed on outpatients. In the Middle Ages, the socalled rupture cutters always plied their trade on
an ambulant basis, often in the marketplace. Since
the late nineteenth century, operations have also
been performed in hospitals because of improved
asepsis and the development of anaesthesia [2].
The rst outpatient surgery centre was founded in
Phoenix, Arizona in 1970 [2]. In 2011, the number of outpatient surgery centres in the USA was
5174, nearly attaining the number of hospitals [3].
The rst publication about the advantages of
outpatient inguinal hernia surgery with faster
mobilisation, high patient satisfaction and lower
costs appeared in 1955 [4].
18.3 Ambulatory Hernia Surgery
Evidence
Thanks to medical progress, most hernia operations today can be performed as outpatient procedures. This is due especially to:
R. Lorenz
Hernia Center 3+CHIRURGEN, Berlin, Germany
e-mail: lorenz@3chirurgen.de
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_18
175
176
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– New and less traumatic surgical
procedures
– Better anaesthesia methods
– Better pain medications for intra- and
postoperative treatment
– Fast-track surgery with faster convales-
cence and earlier increased loading
Outpatient inguinal hernia operations are
regarded as safe today. There were no deaths
after outpatient inguinal hernia operations, and
the rate of readmission to hospital after outpatient operations is also very low [5–7].
There are numerous studies that recommend outpatient inguinal hernia operations without restriction even over the age of 65years [8–13]. Obesity
too is not an obstacle to outpatient surgery [14].
Ambulatory inguinal hernia operations can be performed even in the presence of comorbidities [8].
The advantages of performing inguinal hernia
surgery under local anaesthesia are reported
repeatedly [10, 14, 15]. The use of local anaesthesia has the advantage of the fastest recovery postoperatively. Lack of urinary retention was probably
related to the small IV infusion volumes [15].
Numerous studies conrm that endoscopic
inguinal hernia operations can be performed as
outpatient surgery in most unselected cases
[16–18]. Logistic regression analyses show that
“age”, “bilateral procedures” and “comorbidities”
affect the complication rate. “Age” and “recurrent
inguinal hernia” are risk factors for an increased
need for analgesic medication. Furthermore, we
present an actual distribution of day case vs. inpatient surgeries in inguinal hernia repair based on
data from the Herniamed registry [19].
R. Lorenz
The European Hernia Society guidelines, rst
published in 2009, recommend outpatient inguinal hernia surgery, regardless of method, in all
patients with ASA classication I and II [20]. In
the update of the European guidelines published
in 2014, this even applies for many patients with
ASA class III [21]. In the more recent HerniaSurge
guidelines, too, this is recommended for the
majority of inguinal hernias if appropriate home
care is ensured (Fig.18.1).
Key Question 9.a: Which inguinal hernias
can be safely repaired in day surgery?
More recent studies point to further possibilities for additionally improving the outcome of
outpatient surgery. These include, for example,
intraoperative noise reduction to reduce surgical
site infections (SSI) [23] and the use of a TAP
block with local anaesthesia to reduce postoperative pain [24].
18.4 International Comparison
Outpatient inguinal hernia surgery has become
increasingly popular internationally in recent
decades [25, 26]. In many European countries,
there has been a steady rise in the proportion of
outpatient inguinal surgery operations [27]. The
cost savings are regarded as a crucial advantage
of day surgery [28].
In a global comparison, however, there are
still considerable differences in the proportion of
inguinal hernia operations performed as day surgery (Fig.18.2).
Key Question 9.a: Which inguinal hernias can be safely repaired in day surgery?
Day surgery is recommended for the majority of
Recommendation
Fig. 18.1 HerniaSurge recommendations for outpatient surgery [22]
groin hernia patients provided adequate aftercare
is organized.
X X X
Strong
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