Transcript Anatomy of Inguinal Canal

Laparoscopic Inguinal Anatomy
Inguinal region
Explored extensively by surgeons
knowledge of anatomy improves
the surgical repair
Conventional Anatomy
Inguinal canal
Oblique space, 4 cms, above the inguinal
ligament bet superficial & deep inguinal rings
Triangular in cross section
Deep ing ring is opening in transversalis
fascia at mid point of ing ligament
Ext ring is small slit like opening in ext
aponeurosis, above & lat to the pubic
tubercle
Anatomy of ing canal
Ant wall- ext oblique aponeurosis
Lat wall- internal oblique & transversus abd
arch over and forming roof and & lie on post
aspect of medial half.
Medial 2/3rd rectus abd sheath
Post wall is formed by tranversalis fascia
throughout the inguinal canal
Shutter mechanism- prevents the herniation
through the internal ring
Inguinal ligament
Folded inf portion of ext oblique aponeurosis
Ant sup iliac spine to pubic tubercle
Bridge across iliopsoas muscle underneath
and thigh compartment
Iliac fascia anchors the ing ligament post and
divide muscular & vascular compartment
Laparoscopic approach
We approach anatomical structures from deep
to superficial treating the peritoneum as the
first layer
The basic view from “inside out” capitalizes
on many easily identified landmarks that
must be familiar to anyone who wishes to
learn the minimally invasive herniorrhaphy
Laparoscopic Anatomy
Totally new view of anatomy
Posterior layer to superficial layer
Peritoneum
Adipose Tissue
Transversalis Fascia
Transversus Abdominus
Internal Oblique
External oblique
Scarpa’s Fascia
Subcutaneous tissue
Skin
Deep aspect of ant abd wall
The parital peritoneum consists of
monolayer of mesothelial cells supported
by connective tissue
It is interlaced with blood vessels & nerves
It is translucent, closely adherent to post
abd wall structures, many of them can be
seen through it
Some structures are prominent – thickened
or gathered peritoneum around them called
ligaments– accentuated by insuffalation.
Transversalis fascia
Identification of fascia transversalis & iliopubic tract
are essential elements of a successful repair of hernia
Imp structure in TEP
2 layers, Ant & post
Ant layer is close to transverse abd. muscle and is
inserted into rectus sheath medially and to cooper’s lig
inferiorly
Post layer merges sup with linea semilunaris, medially
with linea alba and inf to the sup ramus of pubis
Inf epigastric vessels are enveloped with in these two
layers
symphysis
post trans
fascia
arcuate
Inguinal Anatomy
Before the reflection of
peritoneum
After the reflection of
peritoneum
Structures Before Peritoneal
Reflection
Three ligaments
Median umbilical ligament
Medial umbilical ligament
Lateral umbilical ligament
Medial
Median
Lateral
Structures Before Peritoneal Reflection
Three fossa
• Supravesical
• Medial Inguinal fossa-direct
hernia
• Lateral Inguinal fossa-indirect
hernia
To familiarize the anatomy,
advisable to identify these
structures during other laparoscopic
procedures like appendicectomy,
cholecystectomy
Structures After Peritoneal Reflection
Inferior epigastric vessels
Iliopubic tract
Cooper’s ligament
Cord structures
Femoral canal
Iliopubic Tract
It is the aponeurotic band formed by
condensation of ant layer of fascia
transversalis blended with transverses
abdominis aponeurosis
Coursing from anterior superior iliac
spine to pubic tubercle
Runs parellel to inguinal ligament
Attached to the pubic ramus as
cooper’s Ligament
Cooper’s Ligament
(Pectineal ligament)
Shiny, thick, fibrous structure covering
the superior pubic ramus
Not a ligament in the true sense
(Attachment of iliopubic tract to pubic
ramus)
Important landmark for fixation of mesh
Preperitoneal Space
Space between
parietal peritoneum &
anterior layer of
transversalis fascia
Laterally up to the
epigastric vessels
Posteriorly on either
side of the bladder
molar tooth
Preperitoneal Space
Medial part of space of Retzius
Lateral part of space of Bogros
Retzius
Bogras
Retzius
Hasselbachs Triangle
Medial - Rectus muscle
Lateral - Inferior epigastric artery
Inferior - Iliopubic tract
Triangle of Doom
Described by Spaw in 1991
Vas and gonadal vessels
Iliac vessels
Femoral nerve
Triangle of Pain
Genitofemoral nerve
genital branch (dysejaculation)
femoral branch (hyperasthesia)
Lateral cutaneous nerve
Femoral nerve (partially)
Pain
Doom
Corona Mortis
Anastomotic branches from inferior
epigastric artery & Obturator artery
(abnormal OA)
Iliopubic vein
Retropubic vein
corona
mortis
Square of Doom,
Extended Square of Doom
Epigastric
Medial
Bladder
Before peritoneal reflection
After peritoneal reflection
Myopectenial orifice of fruchaud
all groin hernia emerge through this
opening in the lower abdominal wall bounded
by transverse abdominis and superior pubic
ramus
divided into ant. and post. by inguinal
ligament
allows passage of blood vessels, nerves,
lymphatics, vas deference, muscle, tendon
and fascia
Myopectineal Orifice of Fruchaud
Medial: lateral border of
rectus muscle
Lateral: iliopsoas
muscle
Inferior: bony margin of
pelvis
Superior: transversalis
fascia and internal
oblique
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