Laparoscopic anatomy of inguinal hernia

FOR GENERAL AND LAPAROSCOPIC SURGEONS

1. PRESENTED BY Dr.DONY DEVASIA UNDER GUIDANCE OF Dr. SHIV KUMAR BUNKAR(PROFESSOR AND UNIT HEAD) Dr. B.S.MEENA(A.P) Dr.DINESH YADAV(A.P) LAPAROSCOPIC ANATOMY OF INGUINAL HERNIA

2. Laparoscopic inguinal hernia repair is performed more and more nowadays because of its mini-invasive nature and demonstrated good results. Laparoscopic procedures are especially suitable for recurrent and bilateral inguinal hernia . The major procedures include intraperitoneal onlay mesh (IPOM) repair, transabdominal preperitoneal (TAPP) repair and total extraperitoneal (TEP) repair. The anatomy of these procedures is totally different from traditional open procedures because they are performed from different direction. Laparoscopic operations for inguinal hernia are carried out intraperitoneally or in preperitoneal space. Surgeons must understand important anatomic knowledge of the operation area under laparoscopic views before they begin to perform these procedures, otherwise it will be very risky to cause complications such as bleeding, nerve damage, insufficient repair and recurrence. The main anatomic points are discussed as followed. NEED TO LEARN ANATOMY:

3.     What is 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 It is separated from the anterior abdominal wall by the transversalis fascia and extends to the level of the umbilicus What is Bogros Space?  Also called retroinguinal space or Bogros' space It is an extraperitoneal space situated deep to the inguinal ligament It's limited by the fascia transversalis anteriorly, the peritoneum posteriorly and the iliac fascia laterally  This preperitoneal space communicates with prevesical space of Retzius.  It is divided into two compartments.  The medial compartment contains vasculature including the femoral artery and vein.  The lateral compartment allows for passage of the illiopsoas (primary hip flexor), allowing attachment to the femur, along with the femoral nerve.

4. Boundaries of the preperitoneal space Anteriorly - Anterior layer of the transversalis fascia ,Posteriorly - The peritoneum. Laparoscopic surgeon are employed in the preperitoneal space ie. In the posterior space of Bogros to avoid unnecessary oozing. Space of Bogros This ‘preperitoneal space’ is split into two by the posterior lamina from the transversalis fascia. The posterior compartment continues to be now termed as the ‘Space of Bogros (proper)’, described by French anatomist Bogros in 1923. The anterior space has been referred to as the ‘Vascular Space’. In some places the posterior lamina is deficient, there the peritoneum adheres towards the anterior lamina. Medially it's continuous with the space of Retzius. Prevesical space of Retzius The preperitoneal space that lies deep to the supravesical fossa and also the medial umbilical fossa may be the Prevesical space of Retzius (described in 1858, by Swedish anatomist Retzius). This space contains loose connective tissue and fat. Dissection of the space during a laparoscopic hernia repair is mandatory to enable proper mesh overlap from the hernial defect to aid in proper mesh placement/ fixation. Important vascular structures on this space are: Normal and aberrant obturator vessels Accessory pudendal vessels (10%)

5. Main difference between these two techniques is the sequence of gaining access to the preperitonial space. In the TEP approach, the dissection begins in the preperitoneal space using a baloon dissector. With the TAPP repair,the preperitonal space is accessed after initially entering the peritoneal cavity. TEP VS TAPP:

6. Median Umbilical Ligament This ligament ascends within the median plane in the 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 This ligament symbolizes the obliterated umbilical artery on both sides and can be traced down to the internal iliac artery. Lateral Umbilical Ligament It's the ridge of peritoneum, which is raised by the 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. THE PERITONEAL LANDMARKS

7. These ligaments delineate the next fossae Supravesical fossae:  The infra-umbilical area between the median and medial umbilical structures. This is actually the site for that source of the supravesical hernia. Medial Umbilical fossae:  The infra-umbilical 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 infra-umbilical area horizontal towards the lateral umbilical ligament. This is actually the site for the origins of the indirect inguinal hernia.

8. 1= Bladder 2= Cooper Ligament 3= Medial Umbilical Ligament 4= Vas Defference 5= Deep Ring 6= Spermatic Vessels 7= Triangle of Pain 8= Triangle of Doom

9. Hesselbach’s (Inguinal) Triangle Franz Caspar Hesselbach’s (1759-1816) original descriptions from the inguinal triangle were as follows: Superolateral boundary Inferior Epigastric vessels Medially Rectus muscle sheath. Inferiorly Cooper’s ligament (Inguinal ligament in subsequent modification, to assist an ‘anterior’ approach surgeon.) HESSELBACH’S TRIANGLE:

10. In 1956, Henry Fruchaud espoused the theory that all groin (inguinofemoral) hernia originate in a single weak area called the Myopectineal orifice. This oval, funnellike, ‘potential’ orifice formed by the following structures, forms the ‘Myopectineal orifice of Fruchaud’. Superiorly Internal oblique and transverses abdominis muscles. Inferiorly Superior pubic ramus. Medially Rectus muscle sheath. Laterally Iliopsoas muscle. Weakness through this area leads to inguinofemoral hernia. Proper exposure of the area is essential during a preperitoneal (posterior) repair! To avoid missing small hernia in addition to To achieve adequate fixation. The orifice is divided through the Iliopubic tract and the inguinal ligament into an ‘inguinal’ defect and a ‘femoral defect’. THE ‘MYOPECTINEAL ORIFICE OF FRUCHAUD’

11. One or a number of anastomotic vessels between the inferior epigastric or the external iliac vessels and the obturator arteries or veins, namely, the corona mortis, can be visualized at the site 5 cm away from the pubic symphysis, arching over Copper’s ligament . The corona mortis includes arteries and veins, most of which travel alone and leave the pelvic cavity via the obturator canal. During surgery, significant hemorrhage may occur, and hemostasis may be difficult to achieve if the corona mortis vessels are accidentally cut because they may retract into the obturator canal. Therefore, the corona mortis is known as the “crown of death” to remind surgeons to be alert during a procedure such as a separation and fixation on Copper’s ligament. CORONA MORTIS:

12. The iliopubic tract is a thickened tendinous structure of the transverse abdominal fascia that connects the anterior superior iliac spine and the pubic tubercle and parallels the inguinal ligament . It arches medially across the front of the femoral vessels to insert via broad attachment onto the pubic tubercle and Cooper’s ligament. The iliopubic tract is the outer boundary of the triangle of pain. The lateral part of a mesh should be fixated at a spot just above the level of the iliopubic tract. ILLIOPUBIC TRACT:

13. The following three (3) nerves are at risk for injury at laparoscopic hernia repair- Lateral Femoral Cutaneous Nerve Femoral Branch from the Genito-Femoral Nerve Intermediate Cutaneous Branch of the Anterior Branch of the Femoral Nerve The next three (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 three nerves are in most risk in open hernia repairs. Ilioinguinal Nerve Iliohypogastric Nerve Genital Branch of Genito-femoral nerve NERVES TO BE LOOKED FOR:

14. During a laparoscopic inguinal hernia repair, the dangerous triangle (the triangle of doom) refers to a triangular area bound by the vas deferens, the testicular vessels and the peritoneal fold. Within the boundaries of this area, you can find the external iliac artery and vein. Separation in this area is risky in the setting of an external iliac vascular malformation or aneurysm. The triangle of pain is a triangular area located lateral to the dangerous triangle and bound by the iliopubic tract, the testicular vessels and the peritoneal fold. This area from lateral to medial includes the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve and the femoral nerve, which runs on the surface of the psoas muscle and the iliac muscle. Most of these nerves pass through the deep surface of the iliopubic tract to innervate the corresponding area of the perineum and thigh Trapezoid of disaster:

15. The pubic symphysis is the first exposed anatomical landmark at separation of the space of Retzius and is the medial reference line when placing mesh. Cooper’s ligament (also known as the pectineal ligament) is easier to identify because it is white, shiny and tough tendinous tissue. It is an extension of the lacunar ligament, running infero-laterally along the pectineal line and attaching to the pectineal line. Cooper’s ligament is a structure that can hold a mesh and tacks. COOPER’S LIGAMENT: