Laparoscopic Anatomy of Inguinal Region

Dr.S.EaswaramoorthyMS FRCS (Eng) FRCS (Glas) Hon FRCS (Edin)

Consultant surgeon, Lotus hospital, Erode, TNEC Member, IAGES South Zone

“ No disease of the human body, belonging to theProvince of the surgeon, requires in its treatment, A better combination of accurate anatomical knowledgeWith surgical skill than hernia in all its variants”

Sir Astley Paston Cooper, 1804

TAPP Vs TEP

TAPP: 9 Key Landmarks

Median Umbilical ligamentMedial Umbilical LigamentLateral Umbilical ligament

VasGonadal vesselsDeep ring

Supravesical fossaMedial inguinal fossaLateral inguinal fossa

A: Median Umbilical ligamentB: Medial Umbilical ligamentC: Lateral Umbilical ligament

Medial Umbilical Ligament

• Obliterated Umbilical artery• Medial end of dissection

Lateral Umbilical LigamentInferior Epigastric artery

• Direct/Indirect hernia• Hesselback’s triangle• Risk of bleeding

C

Hesselback’s Triangle

Triangle of Doom

Vas/round ligamentGonadal vessels

Deep Ring

Trapezoid of Disaster (Rt Side)

Triangle of Doom Triangle of Pain

4. Vas5. Deep ring6. Spermatic vessels7. Triangle of pain8.Triangle of Doom

After Peritoneal Reflection12 Landmarks to Recognize

3 Vessels• Inferior epigastric artery• Iliac vessels• Corona Mortis

3 Nerves• Genitofemoral N• Lateral femoral cutaneous N• Femoral N

3 TrianglesHesselbeck’sTriangle of DoomTriangle of Pain

3 LigamentsCooper’s LigamentLacunar ligamentIlio Pubic tract

Importance of Inferior Epigastric Artery

Corona Mortis

Transversalis Fascia

• Deep Ring• Iliopubic tract• Bilaminar membrane

– Vascular space– Preperitoneal space

• Space of Bogros• Space of Retzius

Iliopubic tract

Importance of Ilio Pubic tract

No staples please…

Triangle of Pain

• Lateral Femoral Cutaneous N• Femoral Br of GFN• Femoral N

We don’t seeIlio hypogastric NIlio inguinal N

Lateral Femoral Cutaneous N

Meralgia paraesthetica

Left Femoral ring and Femoral hernia

• Black arrow: Femoral ring• Black line: Ilio pubic tract• Straight arrow: In Epi A• Curved arrow: Deep ring• V: External iliac vein• aa: External iliac artery

Space of Bogros

TEP

Anatomy of Rectus sheath

Space of Retzius

Cooper’s Ligament

Cooper’s Ligament‘Light House’ during TEP!

TEP

Direct Hernia: Pseudosac Indirect Hernia

Pseudo sac of Direct Defect

Myopectineal Orifice of Fruchand

Lateral: Ilio Psoas muscleMedial : Rectus muscleInferior: Bony margin of PubisSuperior: Arching fibres of

In.oblique and transversus

Suffice to say…

“I know more than hundred surgeons whom I wouldcheerfully allow to remove my gallbladder but onlyone to whom I should like to expose my inguinalcanal.” – Sir Heneage Ogilvie

British Surgeon1887-1991