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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 1
| Issue : 1 | Page : 24-31 |
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Laparoscopic view of surgical anatomy of the groin
Reinhard Bittner
Department of Visceral and General Surgery, Marienhospital Stuttgart, Germany, Hernia Center, Winghofer Medicum Rottenburg, Germany
| Date of Submission | 02-May-2018 |
| Date of Acceptance | 15-May-2018 |
| Date of Web Publication | 16-May-2018 |
Correspondence Address:
Reinhard Bittner
Supperstr. 19, 70565 Stuttgart
Germany
 Source of Support: None, Conflict of Interest: None  | 7 |
DOI: 10.4103/ijawhs.ijawhs_1_18
BACKGROUND: Deep knowledge of anatomy is essential for the success of any surgical intervention. This is especially true for inguinal hernia repair, due to the complex anatomical structure of the groin.
METHODS: Observation and documentation of the pathology of the groin in >15,000 laparoscopic inguinal hernia repairs and careful study of the literature describe the anatomy in cadaver preparation.
RESULTS: The large variability of the course of the nerves and the utmost importance of the bilaminar structure of the transversalis fascia for a precise dissection of the pelvic floor as well as for the placement of a large flat mesh are described in detail.
CONCLUSION: Competent knowledge of the anatomy of the groin facilitates the operative performance, enables a tissue-protective dissection, and may provide an uncomplicated postoperative course.
Keywords: Groin anatomy, inguinal hernia, laparoscopic hernia repair, surgical anatomy
How to cite this article:
Bittner R. Laparoscopic view of surgical anatomy of the groin. Int J Abdom Wall Hernia Surg 2018;1:24-31 |
| Introduction | |  |
In-depth knowledge of groin anatomy is essential for a successful inguinal hernia operation. Sir Astley Paston Cooper postulated in 1804, “No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its varieties.”[1] While Basssini helped to elucidate the anatomy of the anterior inguinal canal in 1884[2] ushering in the modern era of safe and effective hernia repair, understanding of the posterior canal remained limited. Lytle reported in 1945, “The operating surgeon knows little of the posterior wall of the inguinal canal, so well is it hidden from his view.”[3] In the early 1990s, laparoscopic approaches to the inguinal canal emerged. However, the posterior anatomy of the groin remained poorly understood and the laparoendoscopic view of this region was virtually unknown to most surgeons.[4] The adoption of this novel and exciting technique without a firm anatomic understanding resulted in several intra- and postoperative complications including vascular, visceral, and nerve injuries as well as high recurrence rates.The basic anatomical principles of laparoscopic herniorrhaphy were first described by Spaw AT and Spaw LP in 1991 based on human cadaveric dissections.[4] He coined the term “Triangle of Doom” delineating the region between the vas deferens and the spermatic vessels; however, he did not specifically consider the neuroanatomy of the preperitoneal space.[4] Rosser was the first to describe the inguinal neuroanatomy as it pertains to posterior inguinal hernia repair in 1994 roughly delineating the anatomical course of the inguinal nerves.[5] Seid and Amos provided a more precise description of the nerves,[6] postulating that the “Triangle of Doom” should be extended further laterally to the anterior superior iliac spine. The authors introduced the term “Trapezoid of Disaster,” describing also that nerves located lateral to the testicular vessels within the “Triangle of Pain” were also at risk.[7],[8] The most comprehensive analysis of the posterior inguinal anatomy was given by Annibali et al.[7],[8] including the fascial structures, vessels, and nerves. Recently, very detailed descriptions of the course of the nerves and their variations have been published by Rosenberger et al.,[9] Loeweneck,[10] and Reinpold et al.[11] adding to our understanding of this anatomy.
| Methods and Results | | |
The aim of this article on groin anatomy is to translate this detailed knowledge of cadaveric anatomy and extensive clinical experience in >15,000 laparoscopic inguinal hernia repairs into relevant surgical anatomy that will optimize operative technique and outcomes of inguinal hernia repair:
| The first View to the Groin After Introducing the Laparoscope: Peritoneal Landmarks | | |
The initial laparoscopic view of the groin will identify five peritoneal folds (plicae) which serve as guiding landmarks when opening the peritoneum. The plica umbilicalis mediana (median umbilical ligament) found in the midline contains the obliterated urachus. It is less distinct but fortunately less clinically relevant to inguinal hernia repair. The medial umbilical plica (medial umbilical ligament) is the most prominent landmark seen on initial transabdominal inspection. This plica is easily recognized and contains the remnant umbilical vessels. The medial umbilical plica should not be routinely cut because the umbilical vessels may still be patent causing bleeding. The lateral umbilical ligament may be difficult to identify from this view, but its recognition is the most important of the plicae. This ligament contains the inferior epigastric vessels which divide the groin in a medial (space of Retzius) and a lateral (space of Bogros) compartment [Figure 1]; however, depending on the patient's body habitus and fat distribution, the lateral ligament may not be readily visualized laparoscopically. External palpation of the surface anatomy allows for precise localization of the anterior superior iliac spine and pubic tubercle, thereby delineating the iliopubic tract that divides the groin into an upper and a most critical lower part [Figure 1]. | Figure 1: Anatomy of the right groin showing the peritoneal folds, a direct hernia opening (D) and a femoral hernia (F)
Click here to view |
In addition to the five plicae, three flat fossae are recognizable on each side, corresponding with possible hernia defects. The lateral fossa, located in the triangle between the lateral umbilical ligament and the iliopubic tract, corresponds to the location of the internal ring from which a lateral (indirect) inguinal hernia originates [Figure 2]. | Figure 2: Anatomy of the right groin showing the peritoneal folds, a direct hernia opening (D) and an indirect hernia (I)
Click here to view |
The medial fossa is located between the lateral and the medial umbilical ligament and is inferiorly limited by the iliopubic tract. A direct hernia will be found in this region passing through Hesselbach's triangle [Figure 2] and [Figure 3]. The third fossa (vesicalis) is located medial to the medial umbilical ligament and cranial to the iliopubic tract, pubic bone, and urinary bladder. Rare defects in this point of weakness may be the origin of a so-called supravesical hernia. A fourth location where a hernia may develop is within the region of the femoral canal, the triangle below the iliopubic tract, medial to the femoral vein, and superior to the pubic bone and Cooper's ligament. A hernia present in this region can be more easily diagnosed by laparoscopy [Figure 1] compared to the totally extraperitoneal technique or open surgery. | Figure 3: Anatomy of the right groin after dissection of the peritoneal flap and exposing all important landmarks
Click here to view |
| Anatomic Structures of the Preperitoneal Space: View After Creation of the Peritoneal Flap in Transabdominal Preperitoneal or Totally Extraperitoneal Dissection Plane | | |
Transversalis fascia and preperitoneal space
The preperitoneal space lies between the peritoneum internally and the transversalis fascia externally. Within the preperitoneal space there is a variable quantity of adipose tissue, loose areolar connective tissue, and membranous tissue.[12] The transversalis fascia is perhaps the most important fascial structure in the groin as it is involved in both the development of a hernia as well as its treatment. Cooper originally described the transversalis fascia as a bilaminar structure with a strong anterior layer and a membranous deep layer [1] with the epigastric vessels lying between. However, the question whether the transversalis fascia is bilaminar or whether the deep/posterior lamina” is simply a significant regional condensation of extraperitoneal connective tissue (“extraperitoneal fascia”)[13],[14] is still unresolved.[15] Both structures appear strong and difficult to break through especially in the young patient with an indirect hernia. The deep membranous layer (extraperitoneal fascia) divides the preperitoneal space into a visceral and a parietal compartment. Mirilas et al.[16] describe this membranous septum as creating a second internal ring and separating the anatomical layers [Figure 4]. | Figure 4: Schematic representation of the planes of the abdominal wall in the inguinal region
Click here to view |
The parietal compartment contains the epigastric vessels and numerous small tributaries and may be associated with troublesome bleeding during dissection. The genitofemoral and lateral femoral cutaneous nerves also travel within this compartment, but when preserving the deep layer, these important structures are not touched neither when dissecting nor when implanting the mesh. The visceral compartment is avascular and dissection should proceed in this plane. Therefore, the visceral compartment is the right place for accommodation of the mesh. Understanding this anatomic distinction will greatly facilitate proper dissection, ease of developing the correct preperitoneal plane, and help to prevent vascular, nerve, and mesh complications.[17] Attention, despite numerous cadaveric studies, the nature of the transversalis fascia, is still a source of controversy for surgeons and anatomists.[17],[18] According to our clinical experience, there is a great individual variability in its topographic occurrence and strength which is much more better to recognize in clinical situation [Figure 5]. | Figure 5: Clearly demonstration of the deep layer of the transversalis fascia. After crossing the epigastric vessels medially showing a direct contact to the fatty tissue covering the rectus muscle due to the lack of the rectus sheath below of the arcuate line
Click here to view |
Therefore, according to our experience in >15,000 cases of transabdominal preperitoneal, it is easier to find and separate the correct plane (visceral compartment) for mesh placement, and it is recommended to start with the dissection of the groin at the lateral aspect at the level of the anterior superior iliac spine. After making a generous peritoneal incision, most of the preperitoneal dissection can be safely and efficiently performed by bluntly sweeping away the peritoneum and fatty tissue from the abdominal wall covered by the transversalis fascia [Figure 6]. | Figure 6: Entering the preperitoneal space from lateral just in front of the deep layer of the transversalis fascia
Click here to view |
However, when crossing the epigastric vessels to dissect the medial compartment, it is necessary to break through the deep layer to approach the rectus muscle and the symphysis.
Medially, both laminae of the transversalis fascia insert inferiorly on the ligament of Cooper. Laterally, its course is less clear. Around the internal inguinal ring, the deep fibers may envelop the cord structures and contribute at least partially to the spermatic sheath as extensively described by Stoppa et al.[19] The morphology of the spermatic sheath is triangular with an anterior apex at the deep aspect of the inner inguinal orifice and a posterior medial base. The vas deferens makes up its medial border while the spermatic vessels delineate the lateral border. The base of the sheath disappears beneath the retracted peritoneal sac when parietalization is performed.[19] In addition, the spermatic sheath covers the external iliac vessels which reside just deep to the triangle. Although the origin of this sheath it is not clearly defined either a prolongation of the urogenital fascia as Stoppa et al.[19] suggested or a continuation of the deep layer of transversalis fascia – for the surgeon it is of essential importance to recognize this sheath and not to violate it when dissecting the pelvic floor, except at the level of the internal inguinal ring anteriorly [Figure 7] and [Figure 8]. | Figure 7: Continuation of the deep layer of the transversalis fascia into the spermatic sheathvessels
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 | Figure 8: Detachment of the adhesions between the spermatic sheath and the cord structures respectively the hernia sac
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With an indirect hernia, the sheath is opened at the ring to identify and reduce the hernia sac as well as when parietalizing the cord structures [Figure 8].
According to Stoppa et al.,[19] the posterior part of the spermatic sheath (deep layer of the transversalis fascia) should be preserved during separation from the hernia/peritoneal sac (parietalization) because it protects the external iliac vessels and the nerves that are lying beneath [Figure 9]. The surgeon must preserve this important fascial layer for two reasons: (1) to avoid an injury to the vessels or the nerves during dissection and (2) to avoid direct contact between the nerves and mesh which may produce pain in the later postoperative period due to perineural scarring. For the same reason, implantation of a slitted mesh cannot be recommended as the integrity of the fascia will be destroyed and the nerves, spermatic vessels, and vas are all placed at risk. | Figure 9: Detachment of the anterior layer of the spermatic cord medially from the vas deference
Click here to view |
Preperitoneal space and the vessels
The location and the course of the vessels remain fairly constant with a few common variations and identification is typically straightforward. The inferior epigastric vessels are perhaps the most important landmark in the myopectineal orifice and are easily recognized even in obese patients. It is important to recognize that in case a large hernia sac or a lipoma is present, the vessels may be dislocated medially. The epigastric vessels originate from the external iliac vessels and may be surrounded by fatty tissue as well as lymph nodes. This tissue must be respected and not removed when dissecting the groin. The same consideration applies to the iliac vessels which are protected by the spermatic sheath. The iliac artery, located at the bottom of the pelvis and in the middle of the preperitoneal space, may be identified by following the epigastric downward toward their origin. The iliac vessels may be accompanied by fatty tissue and lymph nodes and over-dissection may lead to bleeding, potential nerve injury, or lymphatic leakage. Preservation of the spermatic sheath will avoid these issues. The iliac vein is located posterior and slightly medial to the artery. It may be visualized during dissection of the groove (red line) in the triangle between the lower branch of the pubic bone, the iliac vessels, and the wall of the urinary bladder [Figure 10].
Dissection of this region should be performed with special caution looking for the presence of a corona mortis, a vascular connection between the epigastric and obturator vessels. This variant, found in 20-30% of patients, is important because intraoperative bleeding from disruption can be difficult to control due to the dual vascular supply from the obturator and iliac vessels (corona mortis). Moreover, in this region, there may be several variants of anastomosing vascular branches between the pubic artery/vein and the epigastric and obturator vessels. These small vascular tributaries may form a network investing the pubic bone, Cooper's ligament, and the direct and femoral spaces [Figure 11]. These vessels and the underlying pubic bone are covered by a very thin membrane (deep layer of the transversalis fascia) which should not be disrupted.
The correct plane of dissection will preserve this membranous layer and blunt dissection may be used to push away the urinary bladder developing the retropubic space for mesh placement. When dissecting downward to the urogenital space, special care should be paid to the umbilical artery originating from the internal iliac artery. Attention, the vas, traverses directly over the artery. Furthermore, the surgeon should be aware that the umbilical artery may be patent and, in the case of injury, bleeding may be profuse and difficult to control.
The testicular vessels are easily identifiable but can be most clearly defined at their caudal aspect between the external iliac vessels and the psoas muscle and course from caudal-lateral to cranial-medial. The testicular vessels meet the vas deferens at the apex of the triangle immediately at the entrance to internal ring [Figure 3], [Figure 8], and [Figure 10]. The vas deferens travels downward crossing the iliac vessels medially, following the “preperitoneal loop” (deep layer of the transversalis fascia [20]) but then changes its direction like a knee and dives down to urogenital space to join the prostate gland. To complete the parietalization, it is important to cut this “preperitoneal loop” [Figure 9] and [Figure 10].
Preperitoneal space and topographic anatomy of the nerves
The anatomy of the nerves located in the groin is extensively described by Rosser,[5] Seid and Amos,[6] Annibali et al.,[7],[8] Rosenberger et al.,[9] Loeweneck,[10] and recently by Reinpold et al.[11] In total, six nerves are of interest in laparoscopic inguinal hernia repair and this neuroanatomy should be well understood by all surgeons. Anatomically, the nervus hypogastricus and the nervus ilioinguinalis are not involved in the dissection and repair planes utilized by laparoscopic hernia repair. These nerves have typically exited the retroperitoneum and entered into the anterior abdominal wall and inguinal canal lateral and superior to the anterior superior iliac spine. However, as a rule to the lumbar plexus neuroanatomy, there is a tremendous anatomic variability, especially progressing distally along the branches away from the spinal origin. In about 32% of cases, the course of the ilioinguinal nerve may be within the operating field and may be at risk during the placement of staples in the neighborhood of the anterior superior iliac spine.[9]
The femoral nerve, which arises from the dorsal branches of the ventral rami of the second, third, and fourth lumbar nerves, is located just lateral to the iliac vessels and lateral and beneath the testicular vessels. This is usually well protected by the psoas tendon, surrounding fatty and lymphatic tissue, and spermatic sheath or iliac fascia. Therefore, injury to this nerve is extremely rare during laparoscopic hernia repair. Reported injury to the obturator nerve is rare and anecdotal as it shares the same origin as the femoral nerve and is well hidden deep in the triangle between the pubic bone and the iliac vessels behind the vessels. The more common nerve injuries seen with laparoscopic inguinal repairs are lesions of the genitofemoral nerve [Figure 12] and lateral femoral cutaneous nerve. However, in total in large series, the frequency of damage to these nerves is not higher than 0.3%.[21],[22] Nevertheless, each of these complications should be taken seriously as it can have disastrous consequences for the patient. Intractable pain may arise when nerves are injured, clipped, tacked, or scarred to mesh. Therefore, precise knowledge of the topography of these nerves is essential to perform a high-quality repair with optimal patient outcomes. While the course of the obturator and femoral motor nerves is largely predictable and constant, the course of the sensory nerves (genitofemoral and lateral femoral cutaneous) demonstrates great variability [Figure 13] and [Figure 14]. | Figure 13: Variation of nervus genitofemoralis (N. g-f.; 3 branches) and nervus cutaneous femoris lateralis (N.c.f.l.)
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 | Figure 14: Variation of nervus cutaneous femoris lateralis (N.c.f.l.; 2 branches)
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Most at risk during laparoscopic hernia repair are the lateral femoral cutaneous nerve (58.2% of all nerve lesions) and the femoral branch of the genitofemoral nerve (31.2% of all nerve lesions). Injury to the genital branch of the genitofemoral nerve comprises 4.7% of all published nerve lesions. The lateral femoral cutaneous nerve arises from the dorsal divisions of the second and third lumbar nerves. It emerges from the lateral border of the mid-psoas muscle and crosses the iliacus muscle obliquely traveling toward the anterior superior iliac spine. It then passes under the inguinal ligament, through the lacuna musculorum and then over the sartorius muscle into the thigh, where it divides into an anterior and a posterior branch. The anterior branch becomes superficial about 10 cm below the inguinal ligament and divides into branches which are distributed to the skin of the anterior and lateral parts of the thigh reaching as far as the knee.
The posterior branch supplies the skin from the level of the greater trochanter to the middle of the thigh. Intraoperatively, the surgeon should be aware that the lateral femoral cutaneous nerve will typically cross the middle of the operating field, but the majority (57%) demonstrate variability from the normal course. Single (44%), double (23%), or multiple nerve trunks may be identified [Figure 14].
The point of exit where the nerve penetrates the abdominal wall is typically lateral to the field 2 to 4 cm medial to the anterior superior iliac spine at the level of the iliopubic tract. However, this exit point also demonstrates significant variability and may be found up to 6 cm medially (only 3 cm lateral to the inner inguinal ring) and in 7% of the cases may even exit lateral and cranial to the anterior superior iliac spine.[9] The genitofemoral nerve arises from the upper L1–L2 segments of the lumbar plexus. It passes downward and emerges from the anterior surface of the psoas major muscle. The nerve continues on the surface of the psoas muscle progressing caudally toward the inguinal canal and divides into two branches, the genital branch and the femoral branch.
In men, the genital branch continues down and supplies the scrotal skin. In women, it accompanies the round ligament and supplies the mons pubis and the labia majora. Wide variation in the course of this nerve is seen. In contrast to classically described anatomy, the genital branch runs through the inguinal canal in only 14% of cases. In 44% of cases, it consists of 2–5 branches, in 49% of the cases, the nerve perforates the abdominal wall 1–3 cm lateral to deep inguinal ring just through the iliopubic tract, and in 5% through the lacuna vasorum.[9]
The femoral branch passes underneath the inguinal ligament (iliopubic tract) traveling adjacent to the external iliac artery and supplies the skin of the upper, anterior thigh. In 58% of the cases, 2–5 branches are found, and in 73%, the branches perforate the abdominal wall 2–5 cm lateral to the deep inguinal ring. There is a wide variation in the exit site with perforation of the nerve below (30%), above (16%), or through (54%) the iliopubic tract. In rare cases, the nerve may run near the anterior superior iliac spine or through the inguinal canal.[9] The wide variation of the number and course of sensory nerves that traverse the preperitoneal space creates significant 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.
| The Iliopubic Tract and the Muscular/vascular Lacuna | | |
The iliopubic 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 iliopubic tract divides the groin in an upper and lower part. The operation should always commence with identification of the iliopubic tract cross-checking the anatomy with palpable surface features – an essential step of the operation [Figure 1]. Careful dissection is imperative below the tract because of the important structures – vessels, cord, and nerves – that reside in this field (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. The iliopubic tract corresponds to the anteriorly identified inguinal ligament and is loosely connected with it when visualized from outside. The iliopubic tract is a thickened band of transversalis fascia fibers that curve over the external iliac vessels attached laterally to the iliac crest, arching across the front of the femoral sheath, and inserting as a broad attachment into the pubic tubercle and pectineal line. Furthermore, the tract is attached to the iliopectineal 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. The iliopubic tract lies beneath the deep inguinal ring, forming the entire aponeurotic order of that aperture.[5] It is the iliopubic tract, not the lacunar ligament as usually described, that defines the medial border and roof of a normal femoral canal from the laparoscopic viewpoint, the place a femoral hernia may develop [Figure 1].[5]
| Conclusion | | |
In-depth knowledge of the anatomy of the groin is indispensable for safe and successful laparoscopic hernia repair. The inferior epigastric vessels and the iliopubic tract are the major landmarks that define the field and facilitate identification 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 floor for flat mesh implantation. Thorough knowledge of the course of the inguinal vessels and nerves and their multiple variations is absolutely necessary to avoid serious complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
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