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Clinical Anatomy oftheGroin: Posterior Laparoscopic Approach
the deep inguinal ring just through the ileo-pubic
tract and in 5% through the lacuna vasorum [9].
e femoral branch passes underneath the
inguinal ligament (ileo-pubic tract) traveling
adjacent to the external iliac artery and supplies
the skin of the upper, anterior thigh. In 58% of
the cases, two to ve branches are found, and in
73% the branches perforate the abdominal wall
2–5cm lateral to the deep inguinal ring. ere is
wide variation in the exit site with perforation of
the nerve below (30%), above (16%), or through
(54%) the ileo-pubic tract. In rare cases the nerve
may run near the anterior superior iliac spine or
through the inguinal canal [9]. e wide variation
of the number and course of sensory nerves that
traverse the preperitoneal space creates signicant potential for overlap with the genital branch,
femoral branch, lateral femoral cutaneous and
even ilioinguinal nerve, and a wide area in which
injury can occur. Respecting this proper dissection planes and knowledge of this neuroanatomy
will minimize contact and risk.
1.3 The Ileo-pubic Tract and
theMuscular/Vascular Lacuna
e ileo-pubic tract is one of the most important
landmarks of the groin. Whereas the inferior epigastric vessels divide the groin in a medial and a
lateral compartment, the ileo-pubic tract divides
the groin in an upper and lower part. e operation should always commence with identication
of the ileo-pubic tract cross-checking the anatomy with palpable surface features– an essential
step of the operation (
section is imperative below the tract because of
the important structures – vessels, cord, nerves
–that reside in this eld (trapezoid of disasters).
Above this line, typically only the epigastric vessels pose any risk. However, as noted in the prior
neuroanatomy section, some aberrant branches
of the genitofemoral and lateral femoral cutaneous nerve can perforate the abdominal wall up
to 1–2 cm above the tract. e ileo-pubic tract
corresponds to the anteriorly identied inguinal
ligament and is loosely connected with it when
visualized from outside. e ileo-pubic tract is a
thickened band of transversalis fascia bers that
curves over the external iliac vessels attached laterally to the iliac crest, arching across the front
. Fig. 1.21). Careful dis-
anatomy. Identifying the ileo-pubic tract (white line)
of the femoral sheath and inserting as a broad
attachment into the pubic tubercle and pectineal line. Furthermore, the tract is attached to the
ileo-pectineal arch which forms a septum which
subdivides the space deep to the inguinal ligament into a lateral muscular lacuna and a medial
vascular lacuna, the latter hosting the iliac vessels and the femoral nerve. e ileo-pubic tract
lies beneath the deep inguinal ring, forming the
entire aponeurotic order of that aperture [5]. It is
the ileo-pubic tract, not the lacunar ligament as
usually described, that denes the medial border
and roof of a normal femoral canal from the laparoscopic viewpoint, the place a femoral hernia
may develop (. Fig.1.22a, b) [5].
1.4 Conclusion
In-depth knowledge of the anatomy of the groin is
indispensable for safe and successful laparoscopic
hernia repair. e inferior epigastric vessels and
the ileo-pubic tract are the major landmarks that
dene the eld and facilitate identication of the
essential structures of the groin and the characteristics of the hernia. A thorough understanding of
the fascial architecture helps to identify the correct plane for an atraumatic dissection technique
when reducing the hernia sac and preparing the
pelvic oor for at mesh implantation. orough
knowledge of the course of the inguinal vessels
and nerves and their multiple variations are absolutely necessary to avoid serious complications.
17
. Fig.1.21 First laparoscopic view: cross-checking of
1
18
R. Bittner et al.
1
a
. Fig.1.22 a Indirect inguinal hernia above of the
ileo-pubic tract; femoral hernia below of the tract
(muscular lacuna). b Femoral canal (muscular lacuna,
Keep in mind: “A surgeon who is not familiar
with the anatomy, he will be like mole-what he
produces are nothing more than mounds of earth
(graves)” [23].
References
1. Cooper AP.The anatomy and surgical treatment of crural
and umbilical hernia. London: Longman; 1807. p.3–4.
2. Basssini E.Sulla cura radicale dell’ernia inguinale. Arch
Soc Ital Chir. 1987;4:380.
3. Lytle WJ.Internal inguinal ring. Br J Surg. 1945;32:441–6.
4. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia
repair: the anatomical basis. J Laparoendosc Surg.
1991;1(5):269–77.
5. Rosser J.The anatomical basis for laparoscopic hernia
repair revisited. Surg Laparosc Endosc. 1994;4(1):36–
44. Review.
6. Seid AS, Amos E. Entrapment neuropathy in laparoscopic herniorrhaphy. Surg Endosc. 1994;8:1050–3.
7. Annibali R, Quinn TH, Fitzgibbons RJ Jr. Nerve injury in
the course of laparoscopic hernia repair: introducing
the “triangle of pain”. Clin Anat. 1993;6:370–1.
8. Annibali R. Anatomie der Leistenregion- transperitoneale (laparoskopische) Perspektive. In: Bittner R, editor.
Laparoskopische Hernioplastik. Stuttgart: Hippokratis
Verlag; 1995. S. 41–62.
9. Rosenberger RJ, Loeweneck H, Meyer G.The cutaneous nerves encountered during laparoscopic repair of
b
Pubic
bone
black triangle) after dissection of the peritoneum. Fatty
femoral hernia content is partially reduced
inguinal hernia: new anatomical ndings for the surgeon. Surg Endosc. 2000;14(8):731–5.
10. Loeweneck H. Neuroanatomie der Leistenregion bei
besonderer Berücksichtigung endoskopischer Operationstechniken. In: Bittner R, Leibl BJ, Ulrich M, editors.
Chirurgie der Leistenhernie. Basel: Karger Verlag; 2006.
S. 1–19.
11. Reinpold W, Schroeder AD, Schroeder M, Berger C,
Rohr M, Wehrenberg U. Retroperitoneal anatomy of
the iliohypogastric, ilioinguinal, genitofemoral, and
lateral femoral cutaneous nerve: consequences for
prevention and treatment of chronic inguinodynia.
Hernia. 2015;19(4):539–48.
12. Kingsnorth AN, Skandalakis PN, Colborn GL, Weidman
TA, Skandalakis LJ, Skandalakis JE.Embryology, anatomy, and surgical applications of the preperitoneal
space. Surg Clin North Am. 2000;80(1):1–24.
13. Fowler R.The applied surgical anatomy of the peritoneal fascia of the groin and the “secondary” internal
inguinal ring. Aust N Z J Surg. 1975;45(1):8–14.
14. Lampe EW.Special comment: experiences with preperitoneal hernioplasty. In: Nyhus LM, Condon RE,
editors. Hernia. Philadelphia: Lippincott; 1978.
p.242–7.
15. Colborn GL, Skandalakis JE. Laparoscopic inguinal
anatomy. Hernia. 1998;2:179–91.
16. Mirilas P, Mentessidou A, Skandalakis JE. Secondary
internal inguinal ring and associated surgical planes:
surgical anatomy, embryology, applications. J Am Coll
Surg. 2008;206(3):561–70.
17. Page B, O’Dwyer PJ.Anatomy and physiology. In: LeBlanc K, editor. Laparoscopic hernia surgery. London:
Arnold; 2003. p.41–6.
Corona
mortis
Clinical Anatomy oftheGroin: Posterior Laparoscopic Approach
19
1
18. Arregui ME.Surgical anatomy of the preperitoneal fasciae and posterior transversalis fasciae in the inguinal
region. Hernia. 1997;1:101–10.
19. Stoppa R, Diarra B, Mertl P.The retroparietal spermatic
sheath-an anatomical structure of surgical interest.
Hernia. 1997;1:55–9.
20. Mainik F, Quast G, Flade-Kuthe R, Kuthe A, Schroedl
F. The extraperitoneal loop in inguinal hernia repair
following the totally extraperitoneal technique. Hernia. 2010;14(4):361–7.
21. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ.Laparoscopic transperitoneal procedure for routine repair
of groin hernia. Br J Surg. 2002;89(8):1062–6.
22. Tamme C, Scheidbach H, Hampe C, Schneider C,
Köckerling F. Totally extraperitoneal endoscopic
inguinal hernia repair (TEP). Surg Endosc. 2003;17(2):
190–5.
23. Voß H, Herrlinger R.Taschenbuch der Anatomie. Jena:
Gustav-Fischer-Verlag; 1955. Prämble.
21
Diagnostics ofInguinal
Hernias
BaukjeVan Den Heuvel
2.1 Part 1 How IDo It – 22
2.1.1 General – 22
2.1.2 Contralateral Side – 22
2.1.3 Dierentiation Between Medial andLateral – 23
2.2 Part 2 Statements andRecommendations – 24
References – 25
2
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_2
22
B. Van Den Heuvel
2.1 Part 1 How IDo It
an additional dynamic MRI can be initiated. e
advantage of MRI is that other groin pathologies
2.1.1 General
2
For generations, careful physical examination
of the groin in patients presenting with inguinal
pathology has been regarded as an essential surgical skill. Already in the eighteenth century, the
famous Dutch surgeon Petrus Camper emphasized:
“Among the defects of our body there are none
of any more concern therefore requiring precise
investigation, than hernias” [12]. In current surgical practice, the presence of an inguinal hernia can
be diagnosed quite accurately by history and physical examination, and additional diagnostic modalities are seldom needed [17, 28]. e presenting
symptom of a groin hernia is either discomfort or
pain in the groin in the majority of patients [10].
Approximately one third of all patients is asymptomatic at presentation and presents with the sign
of a non-tender bulge in the groin.
A patient with an inguinal hernia is usually
male and presents with a reducible bulge in the
groin. e bulge emerges during increased intraabdominal pressure such as sneezing, coughing,
straining, or laughing and resolves during rest or
lying down. At physical examination the inguinal
hernia can be provoked by instructing the patient
to blow at the back of his hand in an upright position. e intra-abdominal pressure increases and
typically the inguinal hernia emerges. is procedure is called the Valsalva maneuver. e hernia
can be reduced when intra-abdominal straining is
released or in supine position and diagnosis of an
inguinal hernia is conrmed. Hardly ever additional diagnostics are necessary.
However, not all patients with an inguinal
hernia present as abovementioned, and the different diagnosis and its according diagnostic
can be diagnosed accurately. Its specicity is 96%
and its sensitivity is 95% [26]. e most common
dierential diagnosis of a swelling in the groin
includes lymph node enlargement, varix, aneurysm, so tissue tumor, abscess, genital anomalies, and endometriosis.
Secondly, some patients present with a history of inguinal pain, but no bulging during
physical examination or Valsalva maneuver. In
these patients an extensive dierential diagnosis
applies such as adductor tendinitis, pubic osteitis,
hip artrosis, bursitis ileopectinea, irradiating low
back pain, or endometriosis. In these patients an
MRI should be requested. e MRI can dierentiate accurately and can show an early diagnosis of
dierent sport-related pathologies. A CT scan is a
reliable alternative to MRI in detecting an occult
hernia or other groin pathology but shows lower
sensitivity and specicity compared to MRI [26].
Consequently, in most hernia practices, CT scan
fullls no routine modality in the workup for an
inguinal hernia or inguinal pain.
Herniography used to be the standard imaging procedure since 1967 [21]. A herniography
comprises radiography of the pelvic area aer
intraperitoneal injection of radiopaque dye. It is a
cheap diagnostic modality with high sensitivity of
81–100% and specicity rate of 92–98%. However,
herniography is associated with a small risk of
complications such as contrast allergy, puncture
of the intestine, abdominal wall hematoma, and
short-lasting pain (0–4.3%) [11, 13, 19]. In addition, herniography has no value in diagnosing
other pathology in the groin apart from inguinal
hernias. It is therefore that herniography has no
routine use in diagnosing inguinal hernia in most
hernia practices.
steps should be understood. Firstly, some patients
present with a history of an intermittent bulge or
vague localization of the bulge, but no bulging can
2.1.2 Contralateral Side
be conrmed during physical examination and
Valsalva maneuver. In that case an ultrasound is
helpful. An ultrasound is a noninvasive dynamic
modality with which possible herniation through
the inguinal canal (indirect) or through an insufcient abdominal wall (direct) can be evaluated
quite correctly. In a clinical nonevident groin
hernia, the specicity of ultrasound in relation to
surgical exploration is 81–100%, and its sensitivity is 33% [26]. If an ultrasound is inconclusive,
When a patient presents with a unilateral inguinal hernia, the contralateral side should always be
routinely examined. A contralateral inguinal hernia is not seldom found. e contralateral hernia
in that case is oen asymptomatic as the patient
presents with a unilateral hernia. It is very likely
according to the publications on the long-term
results of Fitzgibbons etal. and O’Dwyer etal. that
an asymptomatic inguinal hernia will eventually
Diagnostics ofInguinal Hernias
23
2
become symptomatic over the years [6, 8, 9, 20].
Both groups of authors designed a randomized
controlled trial in which male patients with a
minimal symptomatic or asymptomatic inguinal
hernia were randomized for either surgical repair
or for watchful waiting. In their series 50–72% of
the male patients in the watchful waiting group
developed symptoms requiring repair. It was also
shown that few hernia accidents occurred in the
watchful waiting group requiring emergency
repair. It should be discussed with the patient that
a minimal symptomatic or asymptomatic inguinal
hernia on the contralateral side is likely to develop
symptoms over the years requiring repair but that
the incidence of hernia accidents is low and a conservative policy is safe. A bilateral repair however
can be proposed.
Another prevailing phenomenon is the accidental nding of an occult inguinal hernia on
the contralateral side during laparoscopic repair
while indication for surgery was a symptomatic
unilateral hernia. e “free” inspection of the
contralateral side is considered one of the advantages of laparoscopic inguinal repair. In 8–51% of
the patients who present with a unilateral inguinal hernia, an occult contralateral defect is found
during laparoscopic intra-abdominal inspection
[29]. When a laparoscopic unilateral inguinal hernia repair is scheduled, the surgeon should always
discuss with the patient prior to surgery what to
do when an asymptomatic occult contralateral
defect is found. As mentioned above Fitzgibbons
and O’Dwyer showed that a hernia accident is
unlikely to occur, but most minimal or asymptomatic inguinal hernias do develop symptoms
over the years. An immediate repair of such an
occult defect can be easily undertaken, prolonging the laparoscopic repair by 7–25 additional
minutes [29], requiring an additional mesh, while
convalescence and morbidity remains the same.
2.1.3 Dierentiation Between
Medial andLateral
Dierentiation by physical examination in types
of inguinal hernia, direct (medial) or indirect
(lateral), is considered inaccurate and irrelevant
by many. Dierentiation might be challenging
by additional diagnostic modalities as well [4,
22, 23]. Knowledge of the type of hernia seldom
inuences the indication to perform surgery or
the surgical approach. However, with the development of minimally invasive procedures, the surgical possibilities to correct an inguinal hernia have
greatly extended. During laparoscopic posterior
repair of an inguinal hernia, evident dierences in
complexity are experienced between repairing a
direct and an indirect inguinal hernia, while these
dierences are not present in an open anterior
approach. Laparoscopic dissection of a direct hernia consists simply of the separation of two distinct planes, the hernia sac entailing peritoneum
and the insucient transversal fascia. As these
planes have no relation to each other, separation
is performed without diculty. e laparoscopic
dissection of an indirect hernia however can be
technically challenging, as scar tissue of the obliterated vaginal process results in peritoneal xation to the funicular structures. e peritoneal sac
is most closely related to the funicular structures.
Indierent dissection of the peritoneum inevitably leads to the risk of damage to the vas deferens
and the vascular funicular structures. e laparoscopic repair of an indirect hernia requires welldeveloped endoscopic surgical skills and may
be time-consuming when performed with the
essential caution, while the laparoscopic repair of
a direct hernia is generally far less challenging and
takes less time. Consequently, preoperative differentiation of the type of inguinal hernia results
in useful information, both in training programs
and in preoperative planning.
When dierentiation in type of hernia is
desired, the surgeon can reduce the inguinal hernia and press his ngers to the expected location
of the deep inguinal ring. e patient is instructed
to perform a Valsalva maneuver, and the inguinal
hernia either appears immediately, indicating that
the hernia is a direct type, or appears aer releasing pressure of the surgeon’s ngers, indicating an
indirect hernia. is method, the so-called nger
occlusion method, appears indeed to be inaccurate [5, 14, 17, 18, 22, 23]. e overall accuracy
diagnosing an indirect hernia with physical examination ranges from 72% to 92% and 55% to 65%
for direct hernias. Subsequently, the European
Hernia Society guidelines on the treatment of
inguinal hernia in adult patients state that dierentiation of hernia types by physical examination
is unreliable [26]. e most plausible explanation
for the inaccuracy in dierentiating between the
types of hernia in present literature is the diculty of determining the exact location of the deep
24
Anterior
superior
iliac Spine
B. Van Den Heuvel
. Fig.2.1 Location of the
deep inguinal ring
Inguinal Occlusion Test
2
Deep
inguinal
ring
FEMORAL
ARTERY
inguinal ring. During physical examination, the
deep inguinal ring cannot be palpated, so its exact
location can only be derived from anatomic landmarks. Four anatomical landmarks are of importance in assessing the location of the deep inguinal
ring: the anterior superior iliac spine, the femoral
artery, the inferior epigastric artery, and the pubic
tubercle (see . Fig.2.1). It is oen suggested that
the deep inguinal ring is located midway between
the anterior superior iliac spine and the pubic
tubercle or slightly lateral to it. However, many
reports contradict on the exact location of the
deep internal ring and inguinal pathology might
alter its location [1, 7, 15, 24, 25]. Protrusion of
an indirect hernia is likely to push the location
of the deep inguinal ring more medially and vice
versa [24]. In this way, some of the indirect hernias, emerging through a dislocated deep inguinal
ring, will protrude medial from the mid-inguinal
point (and the occluding nger of the examiner)
and thereby might be diagnosed as a direct hernia.
More accurate localization of the deep inguinal ring results therefore in an improved accuracy
in preoperative dierentiation of hernia type. e
deep inguinal ring is with few exceptions located
lateral from the inferior epigastric vessels both in
the normal groin as well as in the groin with hernia pathology. A recent study of Tromp etal. [27]
showed that aer localization of the inferior epigastric vessels by a handheld Doppler device, the
deep inguinal ring could be located much more
accurately. Preoperative dierentiation was accurate in 79% of the direct hernias and 93% of the
Inferior
epigastric
artery
Hesselbach’s
triangle
Pubic
tubercle
indirect hernias [5] comparable to the accuracy
of ultrasound in dierentiating between hernia
types [2, 3, 16, 30].
2.2 Part 2 Statements and
Recommendations
Statements
Ultrasonography and MRI have high sensitivity and specicity in diagnosing a clinical
unclear inguinal hernia.
Level of evidence: moderate
MRI has high sensitivity and specicity in
revealing other inguinal pathology.
Level of evidence: moderate
Herniography has high sensitivity and
specicity in unclear diagnosis of an inguinal
hernia and has a low incidence of complications but is infrequently used in current
hernia practice.
Level of evidence: moderate
An occult contralateral inguinal hernia is
often found during laparoscopic exploration,
and its incidence varies between 8% and 51%.
Level of evidence: low
Preoperative dierentiation in type of
hernia is possible with the nger occlusion
test following localization of the inferior
epigastric artery with high sensitivity and
specicity.
Level of evidence: low
Diagnostics ofInguinal Hernias
Recommendations
In case of an evident clinical inguinal hernia,
no additional imaging diagnostics are
indicated.
Weak
When an inguinal hernia is suspected but
clinical ndings are uncertain, the rst
diagnostic imaging modality is dynamic
ultrasonography, followed by dynamic MRI.
Weak
The contralateral side in patients
presenting with a unilateral inguinal hernia
should be routinely physically examined to
assess presence of an occult contralateral
defect.
Weak
When a laparoscopic repair is initiated for
a unilateral inguinal hernia, the contralateral
side should be routinely visualized to assess
presence of an occult contralateral defect.
Weak
Preoperative dierentiation in inguinal
hernia type can be accurately done after
localization of the inferior epigastric artery
with Doppler device followed by the nger
occlusion test.
Weak
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2
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2
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27
Classication ofInguinal
Hernia
VolkerSchumpelick
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3
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_3