1. Laparoscopic Inguinal Anatomy

2. Inguinal region Explored extensively by surgeons
knowledge of anatomy improves the surgical repair

3. 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

4. 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

6. 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

9. 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

10. 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

11. 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.

12. Transversalis fascia 2 layers, Ant & post
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

13. symphysis
post trans
fascia
arcuate

16. Inguinal Anatomy Before the reflection of peritoneum
After the reflection of peritoneum

17. Structures Before Peritoneal Reflection
Three ligaments
Median umbilical ligament
Medial umbilical ligament
Lateral umbilical ligament

18. Medial
Median
Lateral

19. Structures Before Peritoneal Reflection
Three fossa
Supravesical
Medial Inguinal fossa-direct hernia
Lateral Inguinal fossa-indirect hernia

24. To familiarize the anatomy, advisable to identify these structures during other laparoscopic procedures like appendicectomy, cholecystectomy

25. Structures After Peritoneal Reflection
Inferior epigastric vessels
Iliopubic tract
Cooper’s ligament
Cord structures
Femoral canal

26. 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

28. 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

29. 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

30. Preperitoneal Space Medial part of space of Retzius
Lateral part of space of Bogros

31. Retzius
Bogras
Retzius

32. Hasselbachs Triangle Medial - Rectus muscle
Lateral - Inferior epigastric artery
Inferior - Iliopubic tract

34. Triangle of Doom Described by Spaw in 1991 Vas and gonadal vessels
Iliac vessels
Femoral nerve

35. Lateral cutaneous nerve Femoral nerve (partially)
Triangle of Pain
Genitofemoral nerve
genital branch (dysejaculation)
femoral branch (hyperasthesia)
Lateral cutaneous nerve
Femoral nerve (partially)

36. Pain
Doom

38. Corona Mortis
Anastomotic branches from inferior epigastric artery & Obturator artery (abnormal OA)
Iliopubic vein
Retropubic vein

39. corona
mortis

40. Square of Doom, Extended Square of Doom

41. Epigastric
Medial
Bladder

43. Before peritoneal reflection
After peritoneal reflection

44. 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

45. Myopectineal Orifice of Fruchaud
Medial: lateral border of rectus muscle
Lateral: iliopsoas muscle
Inferior: bony margin of pelvis
Superior: transversalis fascia and internal oblique

46. Thank You