Surgical Technique

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Anatomy essentials for laparoscopic inguinal hernia repair

Xue-Fei Yang1, Jia-Lin Liu2
1
Department of Surgery, The University of Hong Kong-Shenzhen Hospital, the University of Hong Kong, Shenzhen 518053, China; 2Department
of Hepatobiliary Surgery, Shenzhen People’s Hospital & Second Clinical Medical College of Jinan University, Shenzhen 518020, China
Correspondence to: Jia-Lin Liu. Department of Hepatobiliary Surgery, Shenzhen People’s Hospital, No. 1017, North Dongmen Road, Luohu District,
Shenzhen 518020, China. Email: [email protected] or [email protected].

Abstract: Laparoscopic inguinal hernia repair is performed more and more nowadays. The anatomy of these
procedures is totally different from traditional open procedures because they are performed from different direction
and in different space. The important anatomy essentials for laparoscopic inguinal hernia repair will be discussed in
this article.

Keywords: Inguinal hernia; laparoscopic repair; anatomy

Submitted Aug 15, 2016. Accepted for publication Sep 01, 2016.
doi: 10.21037/atm.2016.09.32
View this article at: http://dx.doi.org/10.21037/atm.2016.09.32

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
(1,2). 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
acknowledge of the operation area under laparoscopic views
before they begin to perform these procedures, otherwise it
Figure 1 Representation of the myopectineal orifice.
will be very risky to cause complications such as bleeding,
nerve damage, insufficient repair and recurrence. The main
anatomic points are discussed as followed.
spermatic cord or the round ligament of the uterus runs
through the suprainguinal region, while the femoral nerve,
Myopectineal orifice the femoral artery, the femoral vein and the femoral canal
This anatomic region was originally coined by Dr. run through the subinguinal region. The deep layer of
Fruchaud, a French researcher, in 1956. Direct inguinal the myopectineal orifice is closed off by the abdominal
hernias, oblique inguinal hernias and femoral hernias are transverse fascia, which surrounds the spermatic cord, and
all caused by weakness of the abdominal transverse fascia the femoral sheath, which passes through the myopectineal
in myopectineal orifice (Figure 1). The inguinal ligament orifice. A single-side repair of the myopectineal orifice can
divides the myopectineal orifice into two regions: the simultaneously and completely repair the site of anatomical
suprainguinal region and the subinguinal region. The weakness for inguinal, direct and femoral hernias. This

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Page 2 of 7 Yang and Liu. Anatomy of laparoscopic repair of inguinal hernia

Figure 2 Schematic of the principle of adult laparoscopic inguinal hernia repair.

approach is also the principle of adult laparoscopic inguinal of patients). The space between the superficial and deep
hernia repair (Figure 2). transverse fascia is the parietal space. The superficial and
deep transverse fasciae extend to the inguinal region and
cover the blood vessels under the abdominal wall (both
Transverse fascia
sides). Then, they blend with the anterior abdominal wall
The transverse fascia is a complicated and contentious at the site lateral to the inferior epigastric blood vessels.
anatomical structure. Overall, it is a thin aponeurotic The lateral transverse fascia continues to ascend to the
membrane that lies between the rectus abdominis, the posterior lower edge of the inguinal ligament and then
deep layer of the transverse abdominal muscle, and the blends with the iliac fascia. The medial transverse fascia
peritoneum. Some researchers have described it as a two- is attached to the pubic bone, the pectineus muscle and
layer structure, while other researchers have described it Cooper’s ligament. The deep transverse fascia becomes
as a single-layer structure; some researchers have reported a funnel-shaped structure that extends downward to
that the transverse fascia is thick and dense in structure, cover the spermatic cord structures (the vas deferens, the
while other researchers have reported that it is thin in testicular vessels and the hernia sac of the oblique inguinal)
structure. In fact, the structure of the transverse fascia is at the internal inguinal ring and becomes the internal
not important in the TAPP approach or the IPOM repair; spermatic fascia entering the inguinal canal. Thus, the
therefore, the transverse fascia is often neglected. However, internal spermatic fascia must be incised during separation
the transverse fascia has important clinical relevance in the of the oblique inguinal hernia sac (Figure 5) to expose the
TEP patch repair; a correct understanding of the structure spermatic cord structures and the hernia sac.
of the transverse fascia can help ensure a smooth operation.
According to our clinical observations, the transverse fascia
Preperitoneal retropubic space and
can be divided into two layers in the majority of patients. To
extraperitoneal space posterior to the transverse
facilitate this description, the anatomical structures of the
fascia (space of Bogros)
lower anterior abdominal wall (especially with respect to the
transverse fascia) are defined as follows (Figure 3). These two spaces are potential non-natural cavities under
The transverse fascia in the lower anterior abdominal the lower anterior abdominal wall, and they lie in between
wall is divided into two layers (Figure 4). The superficial the superficial transverse fascia and the peritoneum
transverse fascia tightly covers the inner surface of the (Figure 6). They are created by blunt separation when
anterior abdominal muscles, but it is thin and has no performing a laparoscopic inguinal hernia repair.
clinical value in a hernia repair. The deep transverse The preperitoneal retropubic space is located in
fascia, beneath the superficial transverse fascia, covers the the midline of the lower abdomen with the superficial
parietal peritoneum and is relatively thick and dense in transverse fascia and the pubic bone anteriorly, the bladder
50% of patients (i.e., it is thin and loose in the other 50% posteriorly, the umbilicus level superiorly, the pelvic floor

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Annals of Translational Medicine, Vol 4, No 19 October 2016 Page 3 of 7

Bogros

Figure 3 Lower anterior abdominal wall, transverse fascia and spaces (the right lower anterior abdominal wall is taken as an example). The
surgical area refers to the main surgical field of a laparoscopic inguinal hernia repair.

Figure 5 Representation of the incised internal spermatic fascia.

muscles inferiorly, and the inferior epigastric arteries

laterally. It is filled with loose connective tissue and fat,
and there are no obvious blood vessels. The space is easily
separated; the pubic symphysis and the shiny Cooper’s
ligament are readily visible after slight blunt separation.
Figure 4 Representation of the superficial and deep transverse Usually, the preperitoneal retropubic space is considered to
fasciae. be equivalent to the space of Retzius. However, the space

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A B

Figure 6 The preperitoneal retropubic space and the space of Bogros.

laterally by the pelvic wall, and posteriorly by the psoas

muscle, the external iliac vessels and the femoral nerve.
During laparoscopic inguinal hernia repair, the space
of Bogros is explored to access the iliac fossa as well as
to make it easier to open the lateral mesh and lay it flat.
During surgery, after the preperitoneal retropubic space
is separated, care should be taken that the deep transverse
abdominal fascia is tightly attached to the anterior
abdominal wall at the site lateral to the inferior epigastric
blood vessels when separating the space of Bogros (Figure 7).
Thus, the deep transverse fascia should be incised at
the attachment site to enter the space of Bogros. The
separation is required to access the space of Bogros due to
Figure 7 The deep transverse abdominal fascia is tightly attached the relatively tight fusion of the transverse abdominal fascia
to the anterior abdominal wall at the site lateral to the inferior and the peritoneum.
epigastric blood vessel.

Important anatomic structures and landmarks

of Retzius originally referred to the space formed by the During laparoscopic inguinal hernia repair, it is important
fold of the tight fusion of the deep transverse fascia and the to recognize the following important structures in the
peritoneum between the bladder and the peritoneum, which abdominal cavity: the median umbilical fold, the medial
includes the bladder and is filled with loose connective umbilical fold, the lateral umbilical fold, Hesselbach’s
tissue. In fact, to obtain a more capacious preperitoneal triangle, the internal inguinal ring and the femoral ring.
retropubic space, the surgeon needs to incise the deep These structures are the landmarks for making a correct
transverse fascia that is attached to the pubic bone and diagnosis and performing accurate surgeries (Figure 8).
Cooper’s inguinal ligament and enter the visceral space. Other anatomical structures in the extraperitoneal space
Therefore, the preperitoneal retropubic space should that must be recognized include the pubic symphysis,
include the space of Retzius, a part of the visceral space and Cooper’s ligament, the corona mortis, the inferior
a part of the parietal space. epigastric vessels, the vas deferens/the round ligament of
The space of Bogros is located lateral to the space of the uterus, the testicular vessels, the iliopubic tract, the
Retzius and is bound anteriorly by the superficial transverse dangerous triangle (triangle of doom) and the triangle of
fascia, medially by the inferior epigastric blood vessels, pain (Figure 9).

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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.
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,
Figure 8 Bilateral inguinal area under laparoscopy.
can be visualized at the site 5 cm away from the pubic
symphysis, arching over Copper’s ligament (Figure 10). 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.
The separation continues laterally along Cooper’s
ligament and the dark blue external iliac vein; the white,
elastic, pulsating external iliac artery can be seen after
passing the corona mortis. The slightly thin inferior
Figure 9 Important anatomic landmarks in the extraperitoneal epigastric arteries and veins can be seen at the top of
space. the external iliac vessels. Most of the inferior epigastric
arteries are branches of the external iliac arteries or veins.
The inferior epigastric artery usually runs with two veins
along the back of the rectus abdominis muscle toward the
umbilicus. The identification of the inferior epigastric
vessels is very important before accessing the space of
Bogros. Separating between the inferior epigastric vessels
and the deep transverse abdominal fascia is the only
approach to correctly gain access to the space of Bogros
(Figure 11). Otherwise, it is easy to accidentally damage the
inferior epigastric vessels or pierce the peritoneum, which
may cause difficulties while performing laparoscopic surgery
or even require conversion to open surgery.
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
Figure 10 Corona mortis. vessels and the peritoneal fold. Within the boundaries of

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Page 6 of 7 Yang and Liu. Anatomy of laparoscopic repair of inguinal hernia

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
(Figure 12). The femoral nerve is 6 cm above the inguinal
Figure 11 Correct access to the space of Bogros. ligament and is not easily injured because it is covered by
the psoas muscle. The lateral femoral cutaneous nerve
runs just below the iliac fascia and enters the thigh in the
1- to 4-cm-wide region infero–medial to the anterior
superior iliac spine under the iliopubic tract. During
separation of the space of Bogros, avoiding piercing the
iliac fascia and exposing the nerves is one of the most
effective methods to reduce the incidence of postoperative
chronic neuropathic pain. Clinical data have shown that
the lateral femoral cutaneous nerve and the femoral
branch of the genitofemoral nerve are more commonly
damaged. Minor damage can result in abnormal sensation
in the area innervated by these nerves. Such symptoms
can resolve spontaneously in 2–4 weeks. However, these
Figure 12 Lateral femoral cutaneous nerve and genitofemoral
abovementioned nerves can suffer major damage or
nerve.
entrapment when performing separation or fixation or when
controlling bleeding, which may cause abnormal sensation
in the nerve-innervated area, especially chronic neuropathic
pain, and may even cause motor disorders in the lower
extremity. It is extremely difficult to manage or improve
these symptoms.
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 (Figure 13). 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. The white
iliopubic tract can be seen at the lower edge of a direct
hernia ring or below an internal inguinal ring. However,
the degree of development of the iliopubic tract may vary
Figure 13 Representation of the right Cooper’s ligament, the individually; the iliopubic tract in other areas may not be
iliopubic tract and the inguinal ligament. easy to recognize under the laparoscope. The simplest

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Annals of Translational Medicine, Vol 4, No 19 October 2016 Page 7 of 7

method to identify the iliopubic tract is to touch and Footnote

press the projected spot of the stapler head on the body
Conflicts of Interest: The authors have no conflicts of interest
surface when using a stapler to staple the lateral part of a
to declare.
mesh; the feel of the stapler head indicates that the stapler
head is located above the iliopubic tract. Otherwise, the
Informed Consent: Written informed consent was obtained
stapler head is likely located below the iliopubic tract, and from the patient for publication of this manuscript and any
stapling may cause nerve damage. accompanying images.
The vas deferens/the round ligament of the uterus and
testicular blood vessels can be completely exposed only when
the internal spermatic fascia is incised and the hernia sac or References
the peritoneal fold is separated to the cephalad direction. 1. Pisanu A, Podda M, Saba A, et al. Meta-analysis and review
of prospective randomized trials comparing laparoscopic
and Lichtenstein techniques in recurrent inguinal hernia
Acknowledgements
repair. Hernia 2015;19:355-66.
Funding: This work was supported by the Shenzhen 2. Pahwa HS, Kumar A, Agarwal P, et al. Current trends in
government funding for scientific and technical research laparoscopic groin hernia repair: A review. World J Clin
and development (JCYJ20140414092023238). Cases 2015;3:789-92.

Cite this article as: Yang XF, Liu JL. Anatomy essentials
for laparoscopic inguinal hernia repair. Ann Transl Med
2016;4(19):372. doi: 10.21037/atm.2016.09.32

© Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(19):372