Chapter 9 Abdominal Wall and Hernias

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HISTORY
The anatomic and surgical history of the abdominal wall is shown in Table 9-1.
Table 9-1. Anatomic and Surgical History of the Abdominal Wall and Hernias
Ebers Papyrus ca.
1552
B.C.
Earliest recorded reference to hernias: "When you judge a swelling on the surface of a belly. . . what comes out. . . [is] caused by coughing"
Herophilus of
Chalcedon (ca.
300 B.C.)
"The founder of anatomy." Ligated vessels for hemostasis.
Erasistratus of
Keos (ca. 330250 B.C.)
"The father of physiology." Performed hernia operations in Alexandria, Egypt.
Celsus (?-50
A.D.)
Author of De Medicina. Wrote detailed descriptions of hernia operations, and believed in preserving testicle during surgery. First to use term
'hydrocele,' as "a fluid (humour) which collects either between the scrotal tunica (vaginal hydrocele) or between the membranes which cover
the arteries and veins (hydrocele of the cord)."
Heliodorus (fl.
98-117)
Physician and surgeon during the Greco-Roman period. May have been the first to perform a celiotomy.
Galen (129199)
Most prominent physician of Greco-Roman period. Introduced concept of hernia caused by rupture of peritoneum and abdominal wall. Advised
ligature of sac and cord with orchiectomy. First to define processus vaginalis, "a duct descending to the testicle as a small offshoot of the
great peritoneal sac in the lower abdomen." First to recommend use of a seton for hydrocele drainage.
Paul of Aegina
(625-690)
Provided meticulous and accurate description of hernia surgery. For the treatment of hydrocele, he advocated cutting through scrotal wall
with a knife, destroying tunica vaginalis by cautery, and partial suturing of edges.
Albucasis
(936-1013)
Great Moorish surgeon and writer whose On Surgery and Instruments contains original surgical procedures using instruments of his own
design. The purpose of this book was to "revive the art of surgery as taught by the 'Ancients.'" Used seton and cautery for hydrocele repair.
Avicenna (9801037)
Used cautery to drain hydrocele fluid
William of
Salicet (12101277)
Innovator in surgery. First author after Celsus to propose redescent of testicle (rather than mutilation) during hernia operation: "And if you
were to be assured of this manner of opening, then permit the testicle to redescend to its place, and do not dream in any fashion of
extirpating it, as do some stupid and ignorant doctors who know nothing..."
Incised hydrocele with lancet and drained fluid through cannula.
Borgognoni of
Lucca (d.
1252)
Guy de
Chauliac
Proposed incising the hydrocele sac, plugging the cavity with "a lint," and treating the wound with arsenic powder
1363
Provided a more complete classification of hernias
Marcel
Cumanus (d.
1423)
Recommended orchiectomy for treatment of hydrocele
Par (15101590)
Advocated ligature of vessels and ligation of cord (often with a gold thread, as originated by Gualdus of Metz), and trusses for control of
hernias. Advised seton for hydrocele treatment.
Fallopius
(1523-1562)
Rejected surgical operation for repair of hydrocele. Suggested topical application of desiccating plaster for treatment.
Franco
1556
Described open method of surgery, which included cutting between strangulated hernia and external ring. In Trait des Hernies, Franco
advised against cutting spermatic cord or removing testicle.
Stromayr
1559
Practica Copiosa described first distinction between direct and indirect hernias. Advised orchiectomy only in cases of indirect herniation.
Lusitanus
1571
Supported acupuncture method of hydrocele repair; sac punctured with many needles, permitting fluid to diffuse into scrotal tissues
Hildanus
1610
Sutured sac, ligated cord and sac
Cheselden
(1688-1752)
Believed hydrocele to be a systemic disease originating in abdomen and extending to scrotum
Heister
1724
Successfully resected bowel of patient with strangulated hernia
Ruysch
1729
Stated that dilated spermatic vessels were cause of hydrocele
Richter
1778- Described partial strangulation of intestinal wall within hernial sac

1779
Morgagni
1761
Attributed hydrocele to rupture of hydatid cysts
Gimbernat
1793
Recommended division of lacunar ligament (which now bears his name) in cases of strangulated femoral hernia
Camper
1801
Described upper layer of superficial fascia of lower anterior abdominal wall and inguinal canal
Cooper
1804
Discovered bilaminar formation of transversalis fascia, transversus aponeurosis, and ligament that bears his name
Hesselbach
1806, Described triangle and ligament that now bear his name
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Hesselbach
1806, Described triangle and ligament that now bear his name
1814
Monteggia
1816
Scarpa (17521832)
Accurately described types and causes of hydrocele

Accurately described sliding hernia and deep layer of superficial fascia of lower abdominal wall and inguinal ligament
Wood
1863
Introduced subcutaneous ligature of sac for hernia repair
Demarquay
1863
Found microfilariae in hydrocele fluid
Bancroft
1876
Found live worms in hydrocele of spermatic cord
Annandale
1876
Often inaccurately attributed as being first to use Cooper's ligament in hernia repair. May have been first to introduce concept of
preperitoneal approach.
Marcy
1878
First to stress importance of high ligation of hernial sac and closure of dilated inguinal ring in repair of inguinal hernias. First to describe
transabdominal approach.
Warren
1884
Proposed concept of injection treatment
MacEwen
1886
Folded up peritoneal sac and fixed it around internal ring to act as a cork
Bassini
1887- Developed hernia repair operation which is basis of modern herniorrhaphy. Bassini repair consists of high ligation and resection of sac.
1890 Internal oblique and transversus abdominis muscles and transversalis fascia are sutured to ligament of Poupart. According to Bassini, his
technique was designed to "restore those conditions in the area of the hernial orifice which exist under normal circumstances."
Halsted
1889, Performed herniorrhaphy by placing spermatic cord above external oblique aponeurosis (Halsted I). Placed cord deep under repair (Halsted
1903 II). First to report relaxing incision over aponeurosis of rectus muscle.
Lucas-
1892
First to perform hernia repair with cord in intermediate position and imbrication between layers of external oblique aponeurosis
Socin
1893
Revived sac ligation and excision procedure after Lister introduced antisepsis, making possible operation on hernias other than those
immediately threatening life
Andrews
1895
Incorporated cord into imbrication of external oblique aponeurosis
von Mikulicz
1896
Used extrapleural osteochondral flap approach during resection
Lotheissen
1898
Used Cooper's ligament for repair of inguinal hernia
Ferguson
1899
Sutured internal oblique muscle and aponeurosis over spermatic cord. In 1889, he wrote, "Leave the cord alone for it is the sacred highway
along which travel vital elements indispensable to the perpetuity of our race."
Horwitz
1901
Treated hydrocele with excision and eversion of tunica vaginalis
Marwedel
1903
Resected stenosis through costal margin release procedure
Sauerbruch
1905
Advocated, but did not employ, two-incision approach (laparotomy and thoracotomy)
Wendel
1909
Employed two-incision technique (esophagostomy and gastrostomy)
Janeway and
Green
1910
First to suggest one-incision approach. Only employed two-incision technique.
Cheatle
1920- Described operation using median abdominal section without entering peritoneal cavity (preperitoneal approach)
1921
Huggins and
Entz, Rinker
and Allan
1931, By anatomic study, discovered cause of hydrocele

1951
Henry
1936
Revitalized preperitoneal procedure
Brock
1942
First successful esophagogastrotomy in Europe
McVay
1942- Popularized use of Cooper's ligament for hernia repair by repeatedly publishing articles about it
1949
Shouldice,
Obney, Ryan
1950- Performed multiple layer repair of posterior inguinal wall under local anesthesia (Shouldice technique)
1953
Solomon, Lord
1955, Developed radical cure of hydrocele by plication of tunica vaginalis without mobilization of hydrocele sac
1964
Nyhus
1959
Fasana
1973, Modified radical cure for hydrocele irrespective of size of sac and involvement of tunica vaginalis
1982
Ger
1982
Described "intraabdominal approach" for repair of abdominal wall hernias. Believed to be first to perform laparoscopic inguinal herniorrhaphy
in a human.
Stoppa
1984
Devised procedure for reinforcing peritoneum using large unslit prosthesis
Lichtenstein
1986
Introduced tension-free repair by reconstructing floor of inguinal canal using prosthetic material
Gilbert
1989
Devised technique for sutureless repair of inguinal hernia using prosthesis through internal inguinal ring or for repair of posterior inguinal
wall
Condon
1989
Studied iliopubic tract anatomically and used it for repair
Rutkow
1993
Modified mesh-plug repair
Championniere
Described iliopubic tract repair of direct and femoral hernia by preperitoneal approach. In 1989, Nyhus wrote: "I am convinced that all
recurrent groin hernias must be approached posteriorly and the fascial repair buttressed by prosthetic material."
History table compiled by David A. McClusky III and John E. Skandalakis.

References
Bendavid R. Prostheses and Abdominal Wall Hernias. Austin: RG Landes, 1994.
Fasana F. Hydrocele in the Temperate and Tropical Countries. Boca Raton: CRC Press, 1983.
Nyhus LM, Harkins HN (eds). Hernia. Philadelphia: JB Lippincott, 1964.
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Nyhus LM, Condon RE (eds). Hernia (3rd ed). Philadelphia: JB Lippincott, 1989.
Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB Lippincott, 1995.
Robbins AW, Rutkow IM. The mesh-plug hernioplasty. Surg Clin North Am 1993;73:501-512.
Warren R. Surgery. Philadelphia: WB Saunders, 1963.
EMBRYOGENESIS
Normal Development
During the 6th week of gestation, mesoderm from the myotomes which lie on either side of the vertebral column invades the somatopleure (primitive wall of
the abdomen). This area is occupied by the body stalk and the open midgut. The mesoderm forms a sheetlike embryologic entity. After migrating laterally
and ventrally, it differentiates to form the right and left rectus muscles. Around the 12th week, they approximate in the midline, closing the body wall.
A majority of embryologists (among them Wolff 2 and Duhamel3) state that this closure proceeds simultaneously from cranial, caudal, and lateral directions.
However, Klippel4 suggested that closure proceeds from the middle to the periphery.
Around the middle of the 7th week, the main body of the mesodermal sheet splits into 3 layers, forming the three flat muscles ventrally and the serratus
muscle group dorsally. Therefore, all abdominal wall muscles can be recognized around the 7th week.
The lower abdominal wall is formed by a mesodermal layer, the so-called "secondary mesoderm." It envelops and invades the cloaca, thereby separating
ectoderm from endoderm cranial to the cloaca.
The reader should remember that embryology is a speculative science full of "perhaps," "maybe," and "most likely." The word "necessity" is used in this
chapter for a possible embryologic explanation. Two giants of the past used this word: Aristotle and John Hunter. Hunter wrote about the stimulus of
"necessity" in his writings about collateral circulation.
We present the following overview of the possible embryology of the inguinofemoral area from Skandalakis et al.5:
The embryologic phenomenon of the formation of spaces above and below the inguinal ligament is the result of two necessary developments.
Necessity One, the space above the inguinal ligament, is the well known inguinal canal which is the testicular pathway from the retroperitoneal space
to the scrotum. Necessity Two consists of the spaces below the inguinal ligament which permit the exodus of the muscles, nerves, and vessels which
are destined to provide for the lower extremity. The question is: What is the reason for the formation of the enigmatic femoral canal?...
The embryology of the inguinal canal is peculiar. In a highly synergistic way, the skin, parietal peritoneum, and embryologic and anatomic entities
between them produce the future pathway for the testes. The skin will form the scrotum (scrotal folds) in the male and the labia (labial folds) in the
female. The parietal peritoneum will produce the processus vaginalis. Although present in both genders, this peritoneal diverticulum is more important
to the male fetus because it will permit the descent of the testicles. The embryologic entities between the skin and peritoneum permit the processus
vaginalis to penetrate them and form the inguinal canal. The downward journey of the testicles to the scrotum is thus allowed. Descent of the ovary
outside of the peritoneal cavity, however, is forbidden. The processus vaginalis finally closes to obstruct ovarian exodus but leaves the formation of
the inguinal canal in situ.
Ogilvie6 correctly stated that the descent of the testicles into the scrotum made a mess of the three-layered abdominal wall.
Lateral to the pubic tubercle are two openings: one is the fascia of Scarpa and is inferolateral to the pubic tubercle; the other (the superficial ring),
which is within the aponeurosis of the external oblique, is superolateral to the pubic tubercle. The two openings are about 4 cm apart in the adult...
The formation of the scrotum is a result of the fusion of the right and left labioscrotal folds. A scrotal septum separates the scrotum into two halves;
this separation is obvious externally by the raphe between the right and left scrotal halves. In the female the labioscrotal folds form the right and left
labia majora...
The formation of the femoral canal, mysterious and obscure, takes place after the formation of the three flat muscles of the anterior abdominal wall,
the formation of the transversalis fascia and its several thickenings, and the exodus of the several anatomic entities traveling downward from the
retroperitoneal space under the inguinal ligament to reach the lower extremities. Lytle7 is right in reporting that the flat muscles of the anterior
abdominal wall passing in front of the ligament of Cooper provide space for the spermatic cord and the great vessels of the lower extremity.
The embryologic and anatomic entities that produce the femoral canal and some that are merely good neighbors are:
Transversus abdominis aponeurosis
Transversalis fascia and its thickening
Ligament of Cooper (pectineal)
Ligament of Poupart (inguinal)
Ligament of Gimbernat (lacunar)
Femoral vein
Pectineus muscle and fascia
Lymphatics and lymph nodes
It is worth emphasizing Condon's8 repeated statements that the inguinal ligament and the lacunar ligament just happen to be close to the femoral
canal they do not have any role in defining the orifice of the normal femoral canal.
Neither the medial end of the inguinal ligament, as it approaches its attachment to the pubic tubercle, nor the lacunar ligament of Gimbernat as it
attaches to the pectineal ligament and fuses with the pectineal fascia helps to close this most medial space under the inguinal ligament, the femoral
canal. The manner of its formation still produces a lot of questions but permits us to know that the entrance to the femoral canal is located between
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canal. The manner of its formation still produces a lot of questions but permits us to know that the entrance to the femoral canal is located between
the posterior inguinal wall and the ligament of Cooper.
How strong embryologically and anatomically is this area of the posterior inguinal wall? Here the thickenings of the transversalis fascia and the
presence of transversus aponeurotic fibers start to play a great role. The femoral sheath is formed embryologically by the evagination of elements of
the abdominal wall by the outgrowth of the femoral vessels. The parietal fascial lining of the abdominal cavity which continues from the transversus
abdominis to the iliopsoas musculature is essentially drawn into the proximal thigh by the primitive vascular elements. It can be seen that the iliopubic
tract arches over the vessels to insert upon the pectineal ligament, thereby forming the medial extremity of the beginning of the funnel-shaped
femoral sheath. The intermediate portion of the tract, wherewith it is arching over the artery and vein, is carried out upon the femoral vessels,
together with transversalis fascia. This covering blends without interruption with the fascia of the iliopsoas musculature which lies just deep to the
vessels. The innermost lining of the sheath is provided by preperitoneal connective tissue.
Another anatomic entity that should be mentioned is the iliopsoas fascia, which might be considered continuous below with the fascia lata of the
thigh. On its journey toward the thigh, it has interconnections with the transversalis fascia to form septa between the external iliac artery and vein,
and between the external iliac vein and the femoral canal. As it continues into the thigh it provides a posterior wall for the femoral sheath. According
to Lytle,7 at the medial part of the inguinal ligament the fascia lata's journey is interrupted and it turns backward from the posterior border of the
inguinal ligament to form the lacunar ligament.
The iliopubic tract and the femoral sheath are very closely related to the femoral canal. Embryologically, both belong to the transversalis fascia and
transversus abdominis aponeurosis. However, in fresh cadavers one can observe in the floor of the femoral canal that the pectineal fascia fuses with
the overlying femoral sheath. It is our opinion that both iliopubic tract and femoral sheath are specializations chiefly of the transversus and
transversalis fascia. The fixation of the femoral sheath to the iliopubic tract anteriorly and medially tells us that the sheath is an independent
embryologic and anatomic entity, or perhaps it is just part of the iliopubic tract traveling into the thigh.
There is a variably large opening in the fascia lata, the saphenous hiatus, which permits the great saphenous vein to enter the femoral sheath and,
simultaneously, to join and empty into the femoral vein. It is at this opening in the fascia lata that some femoral hernias may protrude into the
superficial fascia of the thigh.
The femoral canal is the small opening between the insertion of the pectineal ligament and transversalis fascia onto the iliopubic tract and the
external iliac vein. This elliptical opening is typically occupied by lymphatic tissue, fat, and a small vessel or two - unless an aberrant obturator artery
or aberrant obturator vein also happens to cross the opening from its origin at the inferior epigastric artery and/or vein. With careful dissection, one
can open the femoral canal throughout its passage beneath the inguinal ligament and see the convergence and passage of fat-covered lymphatic
vessels through the wall of the canal and its delicate inner lining. What is the purpose of the femoral canal? It has two important roles: to permit the
passage of the efferent lymph vessels from the deep inguinal lymph nodes to the abdomen, and to permit expansion of the femoral vein when the
venous pressure of the lower extremity is elevated.9 As we emphasize later this expansion does not prevent femoral herniation.
The embryologic question is: Are the posterior and lateral walls of the femoral sheath formed from the pectineal and psoas fasciae and from the iliacus
fascia (laterally)? Our observations lead us to believe so. We will not muddy the water more; let's all remember simply that the femoral sheath is a
prolongation of the transversalis fascia into the thigh, possibly originating mostly from the iliopubic tract and from the transversalis fascia, or it may
be an independent formation.
McVay10 stated that the defect in a femoral hernia is a narrowing of the insertion of the transversus abdominis aponeurosis onto Cooper's ligament.
Mc Vay11 also said, "A femoral hernia is never congenital in origin in that there is never a preformed peritoneal sac, as with indirect inguinal hernia."
The chief argument against the congenital origin of femoral hernia has been its rarity in infants and children. We have been able to find only three
reports of femoral hernia in fetuses.12,13,14 All three fetuses were between two and three months of age. We have not seen any similar reports in the
recent literature.
Monro15 stated also that "a femoral hernia is never congenital" and hypothesized that "a congenital anomaly, consisting of a narrow insertion of the
iliopubic tract into the pectineal line of the pubis and causing a broad 'femoral dimple'" is an etiologic factor. Perhaps. Still embryologic, anatomic, and
etiologic factors overall are full of Delphian and Byzantine ambiguities. The question of whether femoral hernia can have a congenital origin is not easy
to answer. Several reports of femoral hernia in newborns have appeared in the literature, with their authors endorsing a congenital origin.
Weakness of structures around the femoral canal is not easily demonstrated in infants. Zimmerman and Anson16 have observed that the relative
weakening of this region begins at the age of twenty.
Various explanations have been put forward for the developmental formation of a femoral hernial sac.
1. Adherence of the developing femoral artery to the peritoneum pulls the latter into the femoral canal forming a peritoneal sac.
2. Abnormal attachment of the testicular gubernaculum exerts a pull on the abdominal wall to form a peritoneal dimple, the precursor of a hernial sac.
3. Traction upon the peritoneum results from the adhesion of adipose tissue in the femoral canal with peritoneal fat in this region.
However attractive these theories, they remain possibilities without observational confirmation. Although empty femoral hernial sacs are known in
adults, Tasche17 examined 64 newborns without finding one. While his sample was too small in view of the incidence of femoral hernia, the fact
remains that a congenital predisposing defect has yet to be demonstrated. However, Mitchell18 reported a small peritoneal femoral diverticulum.
That there is no proof of a developmental defect must not make us overlook the fact that femoral hernias do occur in children and that they can
become strangulated. It should be noted that in at least one case19 the hernia was diagnosed as inguinal and the scrotum was entered before the
true condition was realized.
The femoral canal remains predominantly open (Last 9 called this the "dead space"), but it is partially filled with some fat and lymphatics and has in its
exit the Cloquet or Rosenmller lymph node. All the preceding structures together form the crural septum - which of course will not stop the formation
of femoral herniation.
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Wilson20 stated that the conclusion of Hahn-Pedersen et al.21 that femoral herniation is prevented by periodic venous dilatation of the femoral vein
and occlusion of the canal is not sound; we agree.
Congenital Anomalies
Anomalies of the anterior body wall are listed in Table 9-2.
Table 9-2. Anomalies of the Anterior Body Wall
Anomaly
Prenatal Age at First

Onset
Appearance
Sex Chiefly
Affected
Relative
Frequency
Remarks
Deformities of the thorax
Late in fetal life
At birth or in
infancy
Male
Common
Familial tendency
Unilateral thoracic wall aplasia
Weeks 6-7
At birth
Male
Very rare
Simple defects
Week 7
At any age
Male
Rare
Ectopia cordis
Week 3
At birth
Male
Rare
Few affected persons reach maturity; common in

nonviable monsters
Amastia
Week 6
At birth
Female
Very rare
Familial tendency
Polymastia
Week 6
At any age
Equal?
Common
Familial tendency
Umbilical hernia
Week 10
At birth
Equal
Common
Usually disappears spontaneously
Omphalocele
Week 10
At birth
Equal
Uncommon
Failure of normal intestinal return
Gastroschisis
Weeks 6-7
At birth
Male
Uncommon
Herniation through defect in abdominal wall
Incomplete closure of the processus vaginalis Around birth
In infancy
Male
Common
Results in inguinal hernia or hydrocele
Epispadias
Week 4
At birth
Male
Uncommon
Exstrophy of the bladder
Week 6
At birth
Male
Uncommon
Untreated patients die eventually from

pyelonephritis
Exstrophy of the cloaca
Week 5
At birth
Equal
Very rare
All should be reared as females
Absence of abdominal musculature with

urinary tract defects
Week 7
In infancy
Male
Rare
Aplasia of abdominal musculature without

urinary tract defects
Week 7
In infancy
Male?
Very rare
Sternal defects:
Source: Skandalakis JE, Gray SW (Eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994, p. 546; with permission.
Kluth and Lambrecht 22 present a summary of current theories of normal and abnormal embryologic development of the anterior abdominal wall. Nielsen et
al.23 studied the effects of antenatal diagnosis of abdominal wall defects on the route of delivery and surgical outcome. While it is not within the scope of
this chapter to discuss these important issues, we advise the interested student to read these two presentations.
Congenital and acquired umbilical hernias are discussed later in this chapter under "Hernias of the Anterior Abdominal Wall."
SURGICAL ANATOMY
Anterior Abdominal Wall

The terminology "aponeurosis" and "fascia" can be confusing because both entities can present as sheets of connective tissue. An aponeurosis is dense,
regular, collagenous connective tissue that joins a muscle to its origin or insertion. Perhaps stated more clearly, an aponeurosis is a flattened tendon. This is
in contrast to the nature of the majority of tendons in the body, which are more cordlike in appearance.
Around each muscle the epimysium a connective tissue sheath or fascia that ranges from diffuse to dense continues over both surfaces of the
aponeurosis as the epitendineum. It may or may not be thick enough to be easily demonstrable on gross inspection. It does not have the strength of an
aponeurosis. A fascial sheet may become aponeurotic secondarily, providing for part of the origin or insertion of a muscle. In practice, the fascia covering a
particular muscle is usually named by the name of the muscle, such as psoas fascia.
The anterior abdominal wall can be considered to have two parts: anterolateral and middle (or midline). The anterolateral portion is composed of the external
oblique, the internal oblique, and the transversus abdominis muscles. The middle portion is composed of the rectus abdominis and pyramidal muscles (Table
9-3).
Table 9-3. Muscles of the Abdominal Wall
Name
Origin
Insertion
Action
Nerve
External
oblique
Inferior border of
lower 8 ribs
Aponeurosis to linea alba from xiphoid to

symphysis, iliac crest, anterior superior iliac
spine
Compresses
abdomen
Lower 6 thoracic
spinal nerves
Observations
Flexes and
laterally rotates
spine
Depresses ribs
Internal
oblique
Iliac fascia
Lower border of ribs 9-12
Anterior iliac crest
With aponeurosis to linea alba
Same as above
Lower 6 thoracic Related to lateral of inguinal ligament

spinal nerves
(approx.), but does not arise from
ligament
1st lumbar spinal
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Anterior iliac crest
Lumbar
aponeurosis
Transversus
abdominis
With aponeurosis to linea alba
1st lumbar spinal

nerve
Pecten pubis
Iliac crest
Through aponeurosis to linea alba
Lumbodorsal fascia
Pecten pubis
Compresses
abdomen
Same as above
Related to lateral of inguinal ligament

but does not arise from ligament
Depresses ribs
Cartilages of lower
ribs
Rectus
abdominis
Crest of pubis and

pubic symphysis
Cartilages of ribs 5-7

Xiphoid process
Compresses
abdomen
Intercostals 6-12
Lifts chest
Flexes spine
Quadratus
lumborum
Psoas
major
Iliolumbar ligament
12th rib
Posterior iliac crest
Tips of transverse processes of L1-4
Transversus
processes of L1-5
Lesser trochanter of femur
Sides of bodies and

fibrocartilages T12L5
Iliacus
Upper of iliac
fossa
Fixes last rib

Flexes spine at
the same side
Flexes thigh and
rotates it laterally
T12
L1-L3
L1-3
Flexes spine and

bends spine
laterally
Tendon of psoas major to lesser trochanter
Flexes and laterally Femoral (L2-3)

rotates thigh
Inner lip of iliac

crest
Anterior sacroiliac
ligament
Base of sacrum
Pyramidal
Pubis and anterior

pubic ligament
Linea alba
Tenses linea alba
T12
Cremaster
Internal oblique
muscle
Tubercle and crest of pubis
Draws up testis
Genital branch of
genitofemoral
nerve
Transversus
abdominis
aponeurosis
Modified from Pansky B, House EL. Review of Gross Anatomy: A Dynamic Approach. New York: Macmillan, 1964, p. 272; with permission.
Remember the dictum of McVay and Anson:24,25 There are no muscles that originate from or insert into the inguinal ligament. We agree. However, Gray's
Anatomy (38th ed.)26 states that there is some disagreement as to whether the fibers of the transversus abdominis arise directly from the inguinal ligament
(that is, from the lower edge of the aponeurosis of the external oblique) or from the adjacent iliac fascia.
Anterolateral Portion
The external and internal oblique muscles (Fig. 9-1) and the transversus abdominis muscle are arranged so that their fibers are roughly parallel as they
approach their insertion on the rectus sheath. A muscle-splitting incision here will not encounter widely-differing directions of muscle fibers. More laterally,
toward the flank, the fibers of the different muscles are more divergent. The choice between muscle splitting and some muscle transection is often
encountered during urological exposure through flank incisions.
Fig. 9-1.
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Transversus abdominis muscle and aponeurosis; external and internal oblique muscles and their aponeuroses have been removed. (Modified from Skandalakis JE,
Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Originally, it was thought that the aponeuroses of the three flat muscles of the anterior abdominal wall were composed of one lamina only, and that each of
the laminae unilaterally proceeded to contribute to the anterior and posterior laminae of the rectus sheath. However, our knowledge of the aponeurotic
structural wall is more complete because of the work of Askar27 and Rizk28 (Fig. 9-2). In several publications, both authors reported independent findings
that radically changed the traditional view of the formation of the anterior and posterior laminae of the rectus sheath and that of the linea
alba.27,28,29,30,31
Fig. 9-2.
A and B. Transverse sections through anterior abdominal wall, traditional view: A, immediately above umbilicus. B, below arcuate line. C-E, Schematic transverse
sections through ventral abdominal wall, showing bilaminar aponeuroses, external oblique, internal oblique, transversus abdominis, and sites of linear decussation
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sections through ventral abdominal wall, showing bilaminar aponeuroses, external oblique, internal oblique, transversus abdominis, and sites of linear decussation
that compacted from linea alba. (Modified from Williams PL (ed). Gray's Anatomy (37th ed). New York: Churchill Livingstone, 1989; with permission.)
EXTERNAL OBLIQUE MUSCLE

The external oblique muscle arises from the lower eight ribs, with the lowest attachment to the tip of the 12th rib. There, the fibers from the 11th and 12th
ribs pass nearly vertically to insert upon the anterior half of the outer margin of the iliac crest, thereby forming the free posterior border of the muscle.
Above, the slips of origin from the upper ribs interdigitate with fibers originating in the pectoralis major and the serratus anterior muscles. The external
oblique musculature is oriented so that the majority of its fibers pass inferiorly and medially, like "hands in the front pockets." The muscle becomes
aponeurotic along a line that passes vertically downward from the 9th costal cartilage, forming the linea semilunaris. Below the anterior superior iliac spine,
the external oblique muscle is wholly aponeurotic.
External Oblique Fascia (Innominate Fascia of Gallaudet)

The external oblique fascia is a thin, tissuelike membrane covering the external oblique muscle and aponeurosis. At the superficial ring, it forms the
intercrural fibers between the crura. On its way down to the scrotum, following the spermatic cord, the innominate fascia of Gallaudet forms the external
spermatic fascia. Remember: the external oblique aponeurosis does not usually extend down toward the scrotum as a covering of the spermatic cord.
External Oblique Aponeurosis

According to Rizk,28 the aponeurosis of the external oblique (Fig. 9-3) is formed by two layers: superficial and deep. These, together with the bilaminar
aponeuroses of the internal oblique and transversus abdominis, form (by linear decussation) both the rectus sheath and, finally, the linea alba. If Rizk is
correct, the following is true: The anterior lamina of the rectus sheath at the lower abdominal wall could be formed, theoretically, by six aponeurotic layers
(two from each flat muscle) fused together. The posterior lamina does not exist as a substantial structure, usually consisting of nearly transparent
aponeurotic bands and transversalis fascia.
Fig. 9-3.
External oblique muscle and aponeurosis (skin and layers of superficial fascia removed). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The "touchdown" (insertion, fusion) point of the bilaminar external oblique aponeurosis to the anterior lamina of the rectus sheath (Fig. 9-4) is never at the
linea alba or the lateral border of the rectus sheath. Instead, it is always somewhere between the linea alba and the lateral border. The aponeurosis of the
external oblique muscle tends to remain separate from those of the internal oblique and transversus abdominis. It thus contributes little to the actual
structure of the anterior lamina of the rectus sheath, acting only to cover it superficially.32
Fig. 9-4.
"Touchdown point" (triangle) of external oblique aponeurosis is always between linea alba and semilunar line, as shown here in diagram of relaxing incision. X,
Point of relaxing incision at anterior lamina of rectus sheath. (Modified from Skandalakis JE, Colborn GL, Gray SW, Skandalakis LJ, Pemberton LB. The surgical
anatomy of the inguinal area Part 1. Contemp Surg 1991;38:20-34; with permission.)
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anatomy of the inguinal area Part 1. Contemp Surg 1991;38:20-34; with permission.)
The inferior edge of the external oblique aponeurosis is convex. This is due to the following factors:
The attachment of the aponeurosis inferior to the iliacus fascia
The internal pressure of viscera pressing outward upon the aponeurosis and creating the convexity
The convexity is most apparent laterally. This convexity is less apparent medially where the aponeurosis arches over the exiting femoral artery and vein to
reach the pubic tubercle. This aponeurosis also forms the lacunar ligament (of Gimbernat) and the reflected inguinal ligament.
The lower border of the external oblique aponeurosis, suspended between the anterior superior iliac spine and the pubic tubercle, is termed the inguinal
ligament. The classic point of view holds that the inguinal ligament is, therefore, simply the inferior edge of the external oblique aponeurosis.
The superficial inguinal "ring" is the triangular opening of the external oblique aponeurosis 1 to 1.5 cm above and lateral to the pubic tubercle. This opening is
formed by the splitting of the external oblique aponeurosis. The opening allows passage of the spermatic cord or round ligament and makes the crura of the
subcutaneous ring.
The inferior crus (lateral crus) inserts into the tubercle and pubic pecten. The superior crus (medial crus) inserts into the anterior surface of the tubercle,
pubic bone, and symphysis. The insertion of the inferior crus is, in part, by way of the lacunar ligament. Fibers from the superior crus cross the midline to
insert on the opposite tubercle.
There are three important facts to remember regarding the external oblique aponeurosis.
In the inguinal area, there are three regional modifications of the external oblique aponeurosis: the inguinal ligament, the lacunar ligament, and the reflected
inguinal ligament.
Only fascial attachments (no muscles) enter or originate in the inguinal ligament.
Cooper's ligament is possibly, and only possibly, a lateral continuation of the lacunar ligament of Gimbernat. If this statement is correct, then the ligament of
Cooper belongs to the anterior lamina of the abdominal wall. To be more specific, the ligament of Cooper, along with the ligament of Gimbernat, is the product of the
aponeurosis of the external oblique muscle. We realize that this assumption would destroy the well accepted classification of anterior and posterior laminae. What is
Cooper's ligament? In all honesty, we do not know. Both ligaments Cooper's and Gimbernat's are good neighbors. It may be that the point of their union is
indeed the meeting point of the anterior and posterior laminae. On the other hand, Cooper's ligament may represent the tendinous origin of the pectineal ligament
which, secondarily, provides a significant site of insertion for the abdominal wall musculature inferomedially.
The inguinal ligament, lacunar ligament (Gimbernat's), and ligament of Cooper are considered later in this chapter under "Inguinofemoral Area."
INTERNAL OBLIQUE MUSCLE
The internal oblique muscle (Fig. 9-5) arises in part from the thoracolumbar fascia and the iliac crest. These fibers insert upon the inferior borders of the
lower three or four ribs. The uppermost bundle of these muscle bundles is essentially continuous with the internal intercostal muscle layer. Fibers arising from
the anterior two-thirds of the iliac crest pass upward and medially (like "hands in the back pockets"). The lower fibers of origin, arising from iliopsoas fascia,
pass nearly horizontally, or curve medially and downward. The lowest fibers arch over the spermatic cord or round ligament, forming its cremasteric layer.
Fig. 9-5.
Internal oblique muscle and its arch (external oblique aponeurosis removed, spermatic cord not retracted). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr.
Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
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Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
There is continuing disagreement over the relationship of the internal oblique muscle to other entities in the inguinal region. McVay11 regarded the origin of
the muscle to be the iliopsoas muscle fascia. We have observed this condition in fresh, slender cadavers. This arrangement can be seen when the internal
oblique muscle is easily separated from the inguinal ligament with a knife handle. According to McVay,24,25 as mentioned earlier, there are no muscles that
start from or insert into the inguinal ligament; there are only fascial attachments.
The medial termination of the internal oblique muscle is also subject to debate. Many surgeons and anatomists concur regarding its participation in the
anterior rectus lamina. However, there is disagreement within both groups about the formation of the conjoined tendon. This topic will be covered later.
The fibers of the internal oblique muscle do not add substantially to the lower portion of the posterior inguinal wall, because they do not have a broad
insertion into Cooper's ligament.33 The internal oblique aponeurosis is formed by two layers, anterior and posterior. These layers are fused and, together
with the two other bilaminar aponeuroses, contribute primarily to the anterior rectus sheath lamina. They decussate at the linea alba, there becoming
continuous with the contralateral aponeuroses.
TRANSVERSUS ABDOMINIS MUSCLE
The transversus abdominis muscle, the deepest of the three flat anterior abdominal muscles, arises from four locations:
Inner surface of the lower six costal cartilages
Thoracolumbar fascia
Iliac crest
Fascia of the iliopsoas
The uppermost fibers of the transversus abdominis muscle interdigitate with those of the respiratory diaphragm. From various sites of origin, the transversus
fibers pass medially. The uppermost fibers become aponeurotic rather near the midline and, thus, posterior to the rectus abdominis. At the level of the
umbilicus, the aponeurotic fibers begin somewhat lateral to the rectus. The lower fibers remain muscular almost to the lateral border of the superficial
inguinal ring.
In most cases, the arching lower border of the transversus musculature occurs at a level slightly above the deep inguinal ring and, therefore, does not
contribute to the muscular covering of the spermatic cord. In some cases, however, the transversus may contribute substantially to the cremasteric muscle
covering of the cord.
By their aponeurotic nature, the lower fibers of origin of the transversus abdominis contribute to the formation of the iliopubic tract. This
musculoaponeurotic band is given additional substance by the transversalis fascia. As seen laparoscopically, the iliopubic tract also appears to receive a
significant contribution from extraperitoneal connective tissue. This connective tissue seemingly enhances the bright reflectivity of the tract under
laparoscopic illumination.
The iliopubic tract usually becomes distinct several centimeters medial to the anterior superior iliac spine. Near its beginning, the fibers of the tract appear
to diverge from one another. This clearly muscular band of fibers arches medially, passing above the deep inguinal ring. Other fibers, aponeurotic in nature,
arise from the iliopsoas fascia and, as the iliopubic tract, pass deep to the deep inguinal ring. They insert upon the pectineal ligament of Cooper, forming the
medial border of the femoral ring.
It should be noted that a relatively thin part of the aponeurotic band may pass above the deep inguinal ring. In such cases, the margins of the deep inguinal
ring are formed both above and below by the iliopubic tract.
The inguinal ligament cannot be seen from within the abdominal cavity, because it is concealed by muscular and aponeurotic fibers of the more deeply
situated elements of the anterior abdominal wall. This is true, also, in the area of the femoral canal, which is the region of "touchdown," or insertion, of
aponeurotic and fascial elements upon the pectineal ligament medial to the external iliac vein and artery. Just distal to this point, these vessels, now
renamed the femoral vein and artery, pass into the lower limb within a tube of connective tissue called the femoral sheath.
The femoral canal is an ellipsoidal, funnel-shaped declivity just medial to the external iliac (femoral) vein, through which lymphatic vessels from the lower
part of the body enter the abdominal cavity. The medial border of the femoral ring, the entrance to the femoral canal, is clearly formed by aponeurotic fibers
of the iliopubic tract and transversalis fascia. Furthermore, this boundary is reinforced more deeply by the insertion of muscular fibers of the transversus
muscular arch, subsequent to its passage above the deep inguinal ring.
As the iliopubic tract passes beneath the deep inguinal ring and in front of the external iliac vessels, it contributes substantially to the anterior layer of the
femoral sheath. Posteriorly, this sheath is formed by the iliopsoas fascia, with deeper contributions from fascia of the pectineal muscle.
Debate regarding the origin of the internal oblique muscle in the inguinal area also applies to the transversus abdominis muscle. We again agree with
McVay11 that this muscle arises in the inguinal area from the iliopsoas fascia, and not from the inguinal ligament.
The transversus abdominis arch is useful for the repair of inguinal hernias. This anatomic entity is formed by the free aponeurotic and muscular lower margin
of the muscle. Medially, however, the arch is principally aponeurotic. Toward the internal ring, it is both muscular and aponeurotic. In the environment of the
internal ring, the internal oblique is muscular, and the transversus abdominis is aponeurotic. The transversus abdominis muscle inserts on Cooper's ligament.
In addition, medially in the inguinal area, all the aponeurotic layers of the three flat muscles pass anterior to the rectus muscle and form the anterior lamina
of the sheath.
The integrity of the transversus abdominis muscle prevents the formation of a hernia. We agree with Mc Vay11 that, in this sense, the transversus
abdominis is the most important layer of the abdominal wall. If we believe Askar27 and Rizk28 that the aponeurosis of this muscle is bilaminar, then both
laminae (anterior and posterior) fuse, or there is some attenuation of the posterior layer, as reported by Rizk. Rizk28 also described each abdominal
aponeurosis as bilaminar and each wall of the rectus sheath as trilaminar (like plywood).
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For a further discussion of the conjoined area (tendon) (Fig. 9-6), see "Conjoined Area (Tendon)" later in this chapter under "Surgical Anatomy of the
Inguinofemoral Area."
Fig. 9-6.
"Conjoined area." (Modified from Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Embryologic and anatomic basis of inguinal
herniorrhaphy. Surg Clin North Am 1993;73:799-836; with permission.)
Middle Portion
RECTUS ABDOMINIS AND PYRAMIDAL MUSCLES
The rectus muscle is the master muscle of the abdominal wall.Dr. Omar Askar (personal communication to JE Skandalakis, 1990)
The rectus abdominis muscle attaches to the 5th, 6th, and 7th costal cartilages and the xiphoid process above. Below, it attaches to the pubic crest, to
the ligamentous tissue at the symphysis pubis, and the superior ramus of the pubis. It is broader but thinner superiorly.
Each rectus muscle is traversed by three tendinous lines (the tendinous intersections or inscriptions) at the level of the xiphoid process, at the umbilicus,
and halfway between these points. One or two additional fibrous intersections may occur below the level of the navel. These irregular, curved, or zigzagging
tendinous bands are usually tightly affixed to the anterior lamina of the rectus sheath. They are occasionally attached to the posterior lamina as well,
although the tendinous fibers do not ordinarily pass more than halfway through the muscle. Studies by Milloy et al.34 demonstrate that three inscriptions are
the most common pattern (58%), and four inscriptions the next most common (35%).
Some have conjectured that the tendinous intersections represent the original embryonic segmentation of the muscle or myosepta delineating the myotomes
that form the muscle. Definitive proof of the nature of the bands remains elusive. It may be that the fibrous intersections serve a distinct function, rather
than being embryonic "leftovers." These fibrous bands attach the rectus muscles firmly to the anterior lamina of the rectus sheath and to the superior
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than being embryonic "leftovers." These fibrous bands attach the rectus muscles firmly to the anterior lamina of the rectus sheath and to the superior
attachment to the semirigid thoracic wall. Thus, as the supraumbilical portion of the rectus contracts, that portion of the rectus sheath becomes taut,
perhaps assisting in respiratory (or other) physiologic mechanisms.
The rectus muscle (Fig. 9-7) is enclosed within a stout sheath formed by the bilaminar aponeuroses of the three flat muscles that divide and pass anteriorly
and posteriorly around the muscle. As noted above, the space between the muscle and the sheath permits the muscle to contract freely with essentially
little restraint, save for the supraumbilical portion. From the rib margin to a point midway between the umbilicus and the pubis (linea semicircularis of
Douglas), the posterior sheath is made up of the posterior leaf of the internal oblique aponeurosis, the aponeurosis of the transversus abdominis muscle, and
the transversalis fascia. Below this level, the posterior wall is formed by transversalis fascia alone, with variable contributions of aponeurotic bands from the
transversus abdominis. The deep epigastric arteries and veins course along the posterior surface of the rectus muscle, so below the linea semicircularis they
are separated from the peritoneum by only transversalis fascia.
Fig. 9-7.
Rectus abdominis muscle and rectus sheath. (Modified from Schwartz SI (ed). Principles of Surgery (6th ed). New York: McGraw-Hill, 1990; with permission.)
The two recti are separated by the linea alba, a tendinous line wherein the three flat muscles both fuse with one another and decussate across the midline.
By means of the decussation of aponeurotic fibers, the contralateral flat muscles may be continuous with one another. For instance, the aponeurotic fibers
of the external oblique muscle of one side are continuous with the internal oblique of the opposite side.27,28 This arrangement is of obvious importance in
the contractile properties of the abdominal wall. The linea alba is considerably wider above the umbilicus than below it. Thus, a midline incision inferior to the
umbilicus will tend to pass through the laminae of the rectus sheath.
When the supine subject begins to raise the head, the rectus abdominis muscle begins to act before the trunk begins to move. Thus, the rectus abdominis
muscle fixes the thorax, so that the sternocleidomastoid muscles can be effective in flexing the neck. Although the rectus is very important in flexing the
trunk, it plays little or no role in rotating the trunk. The oblique muscles figure significantly in trunk flexion. The internal oblique is also quite active in
maintaining the posture of the upright torso, whereas the external oblique and rectus muscles are quiet.35
The internal oblique and transversus abdominis muscles extend superiorly only to the costal margin, whereas the rectus muscle passes ventral to the costal
margin in its superior insertion. In this region, therefore, the sternum and costal cartilages provide the posterior wall for the rectus sheath. No aponeurotic
lamina is present.
In the lower one-fourth of the abdominal wall, the aponeuroses pass anterior to the rectus muscle as the anterior rectus sheath lamina. The posterior lamina
here is formed essentially by transversalis fascia alone together with a highly variable quantity of aponeurotic transversus bundles. This allows passage of
the inferior epigastric vascular supply into the sheath.
The semicircular line of Douglas (linea semicircularis) marks the lower level of the aponeurotic posterior lamina. This concavity of the arcuate line is usually
directed downward or downward and laterally. If the change from aponeurosis to transversalis fascia is gradual, the line is poorly defined. If the change is
abrupt, the line is well marked.
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abrupt, the line is well marked.

The pyramidal muscle attaches to the pubic crest and symphyseal ligamentous tissues and inserts into the linea alba. The pyramidal muscle is absent on one
or both sides in 10 to 20 percent of subjects.36 When present, its insertion into the linea alba is a landmark for an accurate midline incision.
The superior and inferior epigastric arteries are responsible for the blood supply of the rectus muscle. The superior epigastric vessels are terminal branches
of the internal thoracic artery. The larger, inferior epigastric vessels arise from the external iliacs. The arteries snake behind the muscle within its sheath.
The superior and inferior epigastric vessels anastomose at approximately the middle one-third of the muscle.
The most characteristic phenomenon of the superior and inferior epigastric arteries occurs when the muscle contracts: the epigastric vessels glide within
their fascial coverings. This avoids injury, bleeding, and the formation of hematoma within the rectus sheath.
Two veins, the superior and inferior epigastric venae comitantes, accompany each epigastric artery.
LINEA ALBA
Rizk28 believes that the linea alba should be considered not so much an insertion for the abdominal muscles, but rather the common area of decussation of
their intermediate aponeuroses. According to Rizk, the incision most destructive to the abdominal wall is the vertical midline. The least destructive incision is
the subcostal.
Askar's research27 shows that the linea alba is formed by decussating aponeurotic fibers of the rectus sheath. According to Askar, there is a single
decussation of fibers of both the anterior and posterior rectus sheath laminae in 30% of cases. A single decussation of anterior rectus sheath laminae and a
triple decussation of posterior rectus sheath laminae is found in 10% of cases. A triple decussation of aponeurotic fibers of both anterior and posterior
rectus laminae occurs in 60% of cases. Subjects in the group with single fibrous crossings of both the anterior and posterior rectus sheath laminae may be
more susceptible to linea alba herniation.
The linea alba (Figs. 9-2, 9-3, 9-4) is well formed from the xiphoid process of the sternum to the umbilicus. However, below the umbilicus the formation is
very vague and in most cases indiscernible. Inferiorly, superficial fibers from the linea alba pass in front of the rectus muscle to find attachment to the
symphysis pubis. Deep fibers radiate laterally behind the rectus to attach to the posterior surface of the pubic crest, forming the so-called adminiculum
lineae albae.
The linea alba is one of the most common routes of approach in abdominal surgery and also the most common site of incisional hernias. Rath et al.37
undertook a study of its morphology and other factors. They found that morphologic results allowed definition of diastasis of the rectus muscles in terms of
subject age. In subjects less than 45 years of age, diastasis was considered as a separation in excess of 10 mm between the two rectus muscles above the
umbilicus, 27 mm at the umbilical ring, and 9 mm below the umbilicus. In subjects more than 45 years of age, the corresponding values were 15 mm, 27 mm,
and 14 mm respectively. To quote from their findings, "In the biomechanical study the subumbilical region exhibited a coefficient of elasticity greater than
that of the supra-umbilical portion, but no significant difference in resistance was found between the different parts studied."
UMBILICAL AREA
Most anatomy books describe the umbilicus in one or two sentences. We owe our knowledge of anatomy of the umbilicus to Orda and Nathan,38 who
described in detail the entities involved and their variations.
Embryologically, the umbilicus (Figs. 9-8, 9-9) is a midline fusion of the medial aponeurotic borders of both rectus abdominis aponeuroses around the
umbilical cord. This fusion may take place around the 10th week, after the herniated midgut returns to the peritoneal cavity. During the period of fetal
circulation, the following embryologic entities are found at the umbilicus:
Left umbilical vein
Vitellointestinal duct
Vitelline artery and vein
Urachus
Two umbilical arteries
Fig. 9-8.
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Structures in umbilical cord. V-I, vitellointestinal. (Modified from Basmajian JV, Slonecker CE. Grant's Method of Anatomy (11th ed). Baltimore: Williams & Wilkins,
1989; with permission.)
Fig. 9-9.
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A, Posterior surface of anterior abdominal wall of newborn infant, seen from inside abdomen; umbilical cord still attached. B, Diagrammatic sagittal section through
normal umbilicus showing relation of umbilical ring to linea alba, round ligament, median umbilical ligament (urachus), and umbilical and transversalis fasciae. Note
absence of subcutaneous fat over umbilical ring. C, Diagrammatic sagittal section through small umbilical hernia; hernial sac covered by skin only. (Modified from
Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of Surgery.
New York: Parthenon, 1996; with permission.)
The embryologic entities associated with the umbilical cord and umbilicus are shown in Table 9-4.
Table 9-4. Structures Associated with the Umbilical Cord and Umbilicus
In the Primitive Body Stalk
At the Umbilicus at Term
In the Neonatal Abdomen
Pathology
Yolk stalk (vitelline duct)
Absent or vestigial
Absent
Meckel's diverticulum or umbilical sinus or fistula
Extraembryonic coelom
Absent
None
Herniated intestine
Returned to abdomen
Returned to abdomen
Vitelline arteries
Absent
Celiac, superior, and inferior mesenteric arteries
Vitelline veins
Absent
Part of portal vein
Allantois
Absent or vestigial
Urachus (median umbilical ligament)
Patent urachus; undescended bladder
Umbilical arteries
Both present
Medial umbilical ligaments
Single umbilical artery (1%)
Umbilical veins
Only left vein present
Round ligament in falciform ligament
Failure of return: omphalocele
Undifferentiated mesenchyme Embryonic connective tissue at cord None

Source: Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of
Surgery. New York: Parthenon, 1996, p. 6; with permission.
Remember the following four anatomic entities, which pass through the umbilical ring in the newly born child:
Left umbilical vein (round ligament of the liver)
Urachus (median umbilical ligament)
Two umbilical arteries (medial umbilical ligaments)
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The umbilicus is located at the center of the umbilical region. For all practical purposes, the umbilicus is a scar. It is not the same in all individuals. Its
boundaries are the epigastric area above, the hypogastric area below, and the right and left lumbar areas laterally.
The umbilicus is essentially at the vertical midpoint of the linea alba. It marks the junction of the lower end of the well-formed upper linea alba and the
beginning of the poorly-defined lower linea alba.
Umbilical Ring
The medial umbilical ligaments (obliterated umbilical arteries) and the urachus (obliterated allantoic duct) participate in the formation of the fibrous umbilical
ring. The round ligament (obliterated umbilical vein) arises from the inferior margin of the ring and passes superiorly in the falciform ligament. According to
Orda and Nathan,38 the umbilical ring (Fig. 9-10) and its four essentially solid tubes (two obliterated umbilical arteries, the urachus, and the round ligament)
are related as follows:
Umbilical ligaments
In 74% of cases, the ligamentum teres of the liver crosses the umbilical ring, and attaches to its lower margin.
In 24%, the ligamentum teres splits and attaches to the upper margin of the ring, forming a triangle. The urachus also splits to form another triangle related to
the lower margin of the ring. It is possible that the structure and manner of formation of these triangles are involved in the genesis of supraumbilical or
infraumbilical hernias.
Umbilical fascia
In 36%, a localized thickening of the transversalis fascia in this area, named the umbilical fascia, covers the umbilical ring in toto. This fascial "buffer" can protect
against the genesis of an umbilical hernia.
In 38% of individuals, the umbilical fascia covers only the upper part of the umbilical ring.
In 6% of individuals, the umbilical fascia covers only the lower part of the umbilical ring.
In 4% of individuals, the umbilical fascia is located above the ring.
In 16% of individuals, the umbilical fascia is absent.
Fig. 9-10.
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Variations in umbilical ring and umbilical fascia seen from posterior (peritoneal) surface of body wall. A-C, Variations in disposition of umbilical ligaments. Arrows
indicate: A, Usual relations (74 percent) of umbilical ring (UR), round ligament (RL), urachus (U), and medial umbilical ligaments (MUL). Round ligament crosses
umbilical ring to insert on its inferior margin. B, Less-common configuration (24 percent). Round ligament splits and attaches to superior margin of umbilical ring. C,
Rare configuration (less than 1 percent). Round ligament branches before reaching umbilical ring. Each branch continues with the medial umbilical ligament without
attaching to umbilical ring. D-G, Variations in presence and form of insertion of umbilical fascia. D, Thickened transversalis fascia forms umbilical fascia covering
umbilical ring (36 percent). Arrows indicate: E, Umbilical fascia covers only superior portion of umbilical ring (38 percent). F, Umbilical fascia covers only inferior
portion of umbilical ring (6 percent). G, Though present, umbilical fascia does not underlie umbilical ring (4 percent). (No figure: Fascia is entirely absent in 16
percent.) (Modified from Orda R, Nathan H. Surgical anatomy of umbilical structures. Int Surg 1973;58:454-464; with permission.)
TRANSVERSALIS FASCIA
The name transversalis fascia, formerly applied to the deep fascia covering the internal surface of the transversus abdominis muscle, can be applied in a
general way to the entire connective tissue sheet lining the parietal musculature of the abdominal cavity. It covers muscles, aponeuroses, bones, and
ligaments. The transversalis fascia may be closely adherent, such as the portion covering the transversus abdominis aponeurosis. In other areas it may be
thick or thin and discrete.
Some anatomists consider the transversalis fascia to be a laminated layer of tissue located between the peritoneum and the posterior wall of the
transversus abdominis muscle anteriorly. Its upward continuation blends with the inferior diaphragmatic fascia. Downward it is continuous with the iliac and
pelvic fasciae and several other thickenings related to the inguinofemoral area, where it is said to split into anterior and posterior laminae. Its posterior
pathway toward the posterior lumbar wall fuses with the anterior lamina of the thoracolumbar fascia.
A deficient posterior wall, found in the inguinal canal of 23% to 25% of patients, lacks the support of the aponeurosis of the transversus abdominis
muscle.39 The transversalis fascia, therefore, is the only anatomic entity contributing to the continuity of the floor.39 Structural weakness may occur when
the arch is in a high position or when there is poor arch participation in the posterior walls and floor (Fig. 9-11). In a few patients, the transversalis fascia
crura may be difficult to locate, owing to their underdevelopment. Without statistical data, we can only propose that this is a congenital defect or variation.
Fig. 9-11.
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Cross section of a weak posterior canal wall. (Modified from Lampe EW. The transversalis fascia. In Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB
Lippincott, 1995, pp. 53-57; with permission.)
PERITONEUM
The peritoneum is the innermost layer of the abdominal wall anteriorly, laterally, and posteriorly. It is loosely connected with the transversalis fascia in most
areas, except at the internal ring, where the connection is stronger. It can also be fused rather tightly to the posterior lamina of the rectus sheath,
rendering their separation difficult. The processus vaginalis, a peritoneal diverticulum, is embryologically related to the deep inguinal ring (see the chapter on
the peritoneum for details).
Some comparisons between the structures of the upper three-fourths of the abdominal wall and those of the lower one-fourth are shown in Table 9-5.
Table 9-5
Upper Midline
Lower Midline
Linea alba well developed
Linea alba poorly developed
Right and left recti well separated
Right and left recti close together
Anterior and posterior layers of sheath present
Only anterior layer of sheath present
Aponeurosis of external oblique weak or absent Aponeurosis of external oblique strong and well developed
Source: Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of
Surgery. New York: Parthenon, 1996, p. 4; with permission.
Blood Supply of the Anterior Abdominal Wall

Where there have been no previous incisions, the blood supply to the abdominal wall creates no problem. Where scars are present, the surgeon should be
familiar with details of the blood supply to avoid necrosis from ischemia to specific areas. If possible, the surgeon should proceed through an existing scar.
With multiple operations the abdominal wall may develop weakness resulting in acute herniation and dehiscence or in the formation of ventral hernia; these
are secondary to bad technique or compromising the blood supply of the wall.
ARTERIES
The superficial tissues of the lower anterolateral abdominal wall are supplied by three branches of the femoral artery. These branches, from lateral to medial,
are the superficial circumflex iliac artery (Fig. 9-12), the superficial epigastric artery, and the superficial external pudendal artery. Branches of these arteries
travel toward the umbilicus in the subcutaneous connective tissues.
Fig. 9-12.
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Superficial arteries of inguinal region. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill,
The superficial epigastric artery anastomoses with the contralateral artery. All three arteries have anastomoses with the deep arteries. Following its origin
from the femoral artery, the superficial epigastric artery ascends across the inguinal region, halfway between the pubic tubercle and the anterior superior
iliac spine. It then passes toward the umbilicus.40
The deep arteries lie between the transversus abdominis and the internal oblique muscles. They are the posterior intercostal arteries 10 and 11, the anterior
branch of the subcostal artery, the anterior branches of the four lumbar arteries, and the deep circumflex iliac artery.
The deep circumflex iliac artery arises from the external iliac, several centimeters above the inguinal ligament. The vessel passes laterally in the iliac fossa,
supplying the ilium and the iliacus muscle. A large ascending branch of the deep circumflex iliac passes deep to the iliopubic tract. Then, adjacent to the
anterior superior iliac spine, it ascends vertically within the abdominal wall between the transversus abdominis and the internal oblique. This branch is,
apparently, the primary arterial source for the internal oblique muscle. Its existence allows this muscle to be used as a free flap or pedicle flap or, together
with a portion of the iliac crest, a combined muscular and osseous flap.41
The rectus sheath is supplied by two arteries. The superior epigastric artery arises from the internal thoracic artery. The inferior epigastric artery arises from
the external iliac artery, just above the inguinal ligament. The inferior epigastric artery is distinctly larger than the superior epigastric artery. The average
diameter of the former is 3.4 mm, while the diameter of the latter is 1.6 mm.
Generally, the inferior epigastric artery divides into two large branches below the level of the umbilicus. These vessels communicate with the superior
epigastric artery above the level of the umbilicus.42 These epigastric arteries anastomose with one another in about 40 percent of subjects,34 although the
anastomosing branches are generally less than 0.5 mm in diameter.42
The superior epigastric artery enters the upper end of the rectus sheath, deep to the rectus muscle. Musculocutaneous branches pierce the anterior rectus
sheath to supply the overlying skin.43 The perforating arteries (Fig. 9-13) are closer to the lateral border of the rectus than to the linea alba. The number
and size of perforating branches of the inferior epigastric vessels, in particular, become greatest at the level of the umbilicus and just inferolateral to it. Few
perforators are present in the lower fifth of the rectus region (Fig. 9-14).42
Fig. 9-13.
Vessels supplying anterior abdominal wall. EOP, External oblique perforators; SCI, Superficial circumflex iliac artery; SE, Superior epigastric artery; DCI, Deep
circumflex iliac artery; IE, Deep inferior epigastric artery; SIEA, Superficial inferior epigastric artery. (Modified from Hester TR Jr, Nahai F, Beegle PE, Bostwick J III.
Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast Reconstruct Surg 1984;74:657-666; with permission.)
Fig. 9-14.
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Primary territories of vessels supplying anterior abdominal wall. Above, left: Skin territory of superficial inferior epigastric artery (SIEA). Above, right: Skin territory of
external oblique perforators (EOP). Center: Skin territory of deep epigastric system. Below, left: Skin territory of superficial circumflex iliac system (SCI). Below, right:
Skin territory of deep circumflex iliac system (DCI). (Modified from Hester TR Jr, Nahai F, Beegle PE, Bostwick J III. Blood supply of the abdomen revisited, with
emphasis on the superficial inferior epigastric artery. Plast Reconstruct Surg 1984;74:657-666; with permission.)
Creating an incision too far laterally will result in bleeding from the several perforating arteries, and muscle paralysis from cutting the musculocutaneous
nerves. To avoid injury to major vessels in abdominal operative laparoscopic procedures, laterally situated trocars should be placed at least 8 cm from the
midline, and at least 5 cm above the pubic bone.44 Should vascular injury occur, thought should be given to enlarging the incision and directly securing the
injured vessel. The vessel should be occluded with electrocautery, ligature, or vascular clip to avoid the formation of a large hematoma or serious
postoperative bleeding. Injury can occur following movements of the trunk by the unconscious or conscious patient, which can lead to traction on and
reopening of the injured vessel.45
The inferior epigastric artery arises in the preperitoneal connective tissue. It enters the sheath at or below the level of the semicircular line of Douglas,
passing between the rectus muscle and the posterior layer of the sheath.
VEINS
The veins follow the arteries.
Further information about anterior abdominal circulation may be found later in this chapter under "Blood Supply of the Inguinal Area."
Lymphatics of the Anterior Abdominal Wall

The lymphatic drainage of the skin of the anterior abdominal wall is presented in Figure 9-15. The lymphatics can be divided into supraumbilical and
infraumbilical networks with further groupings for superficial and deep structures.
Fig. 9-15.
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Probable lymphatic drainage of anterior abdominal wall. Deep drainage shown on left. Superficial drainage shown on right. Arrows indicate course of drainage.
The superficial supraumbilical network drains to axillary, pectoral, and infraclavicular lymph nodes. The deep supraumbilical network drains to axillary and
internal mammary nodes, with some lymphatics to the lymph nodes at the area of the porta hepatis. The superficial infraumbilical network drains to
superficial inguinal lymph nodes. The deep infraumbilical network drains to aortic lymph nodes and deep femoral lymph nodes.
Read an Editorial Comment
Nerve Supply to the Anterior Abdominal Wall

Both the anterolateral portion of the abdominal wall and the rectus abdominis muscle are supplied by anterior rami of the 7th to 12th thoracic nerves and
the 1st lumbar nerve. A branch (the lateral cutaneous ramus) arises from each anterior ramus and pierces the outer two flat muscles. It innervates the
external oblique muscle and forms the lateral cutaneous nerve.
The anterior rami of the last six thoracic nerves enter the posterior layer of the rectus sheath, innervating the rectus muscle. They send perforating
branches through the anterior layer of the sheath to form the anterior cutaneous nerves. The first lumbar nerve forms an anterior cutaneous nerve without
passing through the rectus sheath. These relationships are shown diagrammatically in Figure 9-16.
Fig. 9-16.
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Course of anterior ramus of segmental nerves in anterior body wall. A, Seventh to twelfth thoracic nerves. B, First lumbar nerve. (Modified from Skandalakis JE, Gray
SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
According to Monkhouse et al.,32 variation in the arrangement of the segmental nerves to the anterior abdominal wall is considerably greater than that
suggested in most textbooks. For instance, one cannot predict with confidence that the umbilical region is supplied by the 10th thoracic spinal nerve.
Rectus muscle paralysis, with weakening of the abdominal wall, will result from section of more than one of these nerves. There is little if any crosscommunication between the segmental nerves to the rectus abdominis muscle. The anterior ramus must not be mistaken for the branch of the subcutaneous
nerve that runs in the same direction as, but is superficial to, the external oblique muscle. Injury of the motor supply to a segment of the rectus muscle will
result in fibrosis of that segment.
Lee and Dellon46 stated that groin pain of neural origin can be treated with positive outcomes by realizing that symptoms can be referred to regions other
than the groin. They related referred pain in the knee to the lateral femoral cutaneous nerve, in the pelvic viscera to the iliohypogastric nerve, and in the
testicle to the genitofemoral nerve. The fourth source of referred pain is the ilioinguinal nerve. Referred pain may be related to more than one of the nerves.
The lateral femoral cutaneous nerve was decompressed and the other nerves were resected.
Surgical Considerations of the Anterior Abdominal Wall

(NOTE: Further surgical considerations are included later in this chapter under "Incisions of the Anterior Abdominal Wall" and "Hernias of the Abdominal Wall.")
Rectus sheath hematoma (arterial or venous) takes place without trauma or disease in most cases (see Fig. 9-7). A palpable mass may or may not be present at
the right or left rectus area. When the patient tenses the rectus muscle, the tender mass may be palpable. This is Fothergill's sign.47 Occasionally, the hematoma
may be mistaken for a spigelian hernia or acute abdominal process. Use of ultrasonography, CT, or MRI for diagnosis avoids unnecessary surgical intervention. If
symptoms persist, incision and evacuation is the procedure of choice.
Desmoid tumors are benign tumors of aponeurotic origin. The home of desmoid tumors is the anterolateral abdominal wall formed by the three flat muscles. The
etiology of such tumors is unknown. The treatment of choice is wide excision.
Editorial Comment There is debate as to whether desmoid tumors should be classified as benign (aggressive fibromatosis) or as low grade fibrosarcomas (Grade
I). Desmoids virtually never metastasize, but they present and behave in a fashion identical to low grade soft tissue sarcomas. Desmoids of the abdominal wall can
usually be cured by wide excision; inadequate excision will lead to local recurrence. Deaths due to abdominal wall desmoids are infrequent, but desmoid tumors in
certain critical areas such as the abdomen, pelvis, or the neck may be initially unresectable or may lead to death from unresectable local recurrence. (Roger S.
Foster, Jr., MD)
The superficial fascia of the anterior abdominal wall includes the adipose layer of Camper and the membranous layer of Scarpa. Scarpa's fascia of the lower anterior
abdominal wall possesses regional peculiarities. It is attached to the crest of the ilium and to the symphysis pubis, but not to the superior border of the pubic crest.
More laterally, Scarpa's fascia is attached to the fascia lata of the thigh.
Extravasating fluid from the perineal region can pass superiorly deep to this fascial layer, but it cannot pass into the limb. By the same token, therefore, any
collection of fluid within the scrotum may be drained with ease by a small suprapubic incision and finger dissection.
Nicodemo 48 reported access to the pelvic extraperitoneal space by a suprapubic pathway. This was performed by puncture in a midline position 1 cm above the
pubis between the linea alba and the vesicoumbilical fascia.
Rectus abdominis muscle and omental flaps can be used to reconstruct huge chest wall defects, either as free flaps or based upon a vascular pedicle.
If the periumbilical fasciae do not fuse at the base of the umbilical cord, formation of an umbilical hernia will result (at the center of the umbilicus). In most cases,
the hernia will close spontaneously within a few years.
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Emergency surgery is advised for viscus incarceration.

When supraumbilical or infraumbilical hernias are diagnosed, surgery is advised.
Inguinofemoral Area
Inguinal Canal
ANATOMY OF THE INGUINAL CANAL IN INFANTS AND CHILDREN
There are readily apparent differences between the inguinal canals of infants and adults.49 In infants, the canal is short (1 to 1.5 cm), and the internal and
external rings are nearly superimposed upon one another. Scarpa's fascia is so well developed that the surgeon may mistake it for the aponeurosis of the
external oblique muscle, resulting in treating a superficial ectopic testicle as an inguinal cryptorchidism. There also may be a layer of fat between the fascia
and the aponeurosis. We remind surgeons of the statement of White50 that the external oblique fascia has not been reached as long as fat is encountered.
In a newborn with an indirect inguinal hernia, there is nothing wrong with the posterior wall of the inguinal canal. Removal of the sac, therefore, is the only
justifiable procedure. However, it is extremely difficult to estimate the weakness of the newborn's posterior inguinal wall by palpation. If a defect is
suspected, a few interrupted permanent sutures might be used to perform the repair.51
ADULT ANATOMY OF THE INGUINAL CANAL
The inguinal canal in the adult is an oblique rift in the lower part of the anterior abdominal wall. It measures approximately 4 cm in length. It is located 2 to 4
cm above the inguinal ligament, between the opening of the external (superficial) and internal (deep) inguinal rings.
The boundaries of the inguinal canal (Fig. 9-17) are as follows:
Anterior: The anterior boundary is the aponeurosis of the external oblique muscle and, more laterally, the internal oblique muscle. Remember, there are no external
oblique muscle fibers in the inguinal area, only aponeurotic fibers.
Posterior: In about of subjects, the posterior wall (floor) is formed laterally by the aponeurosis of the transversus abdominis muscle and the transversalis fascia;
in the remainder, the posterior wall is transversalis fascia only. Medially the posterior wall is reinforced by the internal oblique aponeurosis.
Superior: The roof of the canal is formed by the arched fibers of the lower edge (roof) of the internal oblique muscle and by the transversus abdominis muscle and
aponeurosis.
Inferior: The wall of the canal is formed by the inguinal ligament (Poupart's) and the lacunar ligament (Gimbernat's).
Fig. 9-17.
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Highly diagrammatic representation of the inguinal canal, presenting only the anterior and inferior formations and the internal and external rings. (Modified from
Skandalakis JE, Skandalakis LJ, Colborn GL, Androulakis J, McClusky DA III, Skandalakis PN. The surgical anatomy of the hernial rings. In: Baker RJ, Fischer JE (eds).
Mastery of Surgery (4th ed). Philadelphia: Lippincott Williams & Wilkins, 2001; with permission.)
The boundaries of the rings are as follows:

External ring (Fig. 9-18): There is a triangular opening of the aponeurosis of the external oblique, the base being part of the pubic crest with the margins formed by
two crura, superior (medial) and inferior (lateral). The superior crura is formed by the aponeurosis of the external oblique itself; the inferior crura is formed by the
inguinal ligament. To be more specific, the medial crus is attached to the lateral border of the rectus sheath and to the tendon of the rectus abdominis muscle in a
very peculiar pathway. The lateral crus is attached to the pubic tubercle.
Internal ring (Fig. 9-19): The boundaries of this ring, which is an inverted "V" -or "U"-shaped normal defect in the transversalis fascia, are not so simple. The arms of
the , anterior and posterior, are a special thickening of the transversalis fascia, forming a sling. The inferior border is formed by another thickening of the
transversalis fascia the iliopubic tract which is not always very aponeurotic.
Fig. 9-18.
Highly diagrammatic representation of the external inguinal ring. (Modified from Skandalakis JE, Skandalakis LJ, Colborn GL, Androulakis J, McClusky DA III,
Skandalakis PN. The surgical anatomy of the hernial rings. In: Baker RJ, Fischer JE (eds). Mastery of Surgery (4th ed). Philadelphia: Lippincott Williams & Wilkins,
Fig. 9-19.
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Surgical anatomy of the internal inguinal ring. (Modified from Skandalakis JE, Skandalakis LJ, Colborn GL, Androulakis J, McClusky DA III, Skandalakis PN. The surgical
anatomy of the hernial rings. In: Baker RJ, Fischer JE (eds). Mastery of Surgery (4th ed). Philadelphia: Lippincott Williams & Wilkins, 2001; with permission.)
The internal inguinal ring is an opening of the transversalis fascia corresponding to the middle of the inguinal ligament (see section on sphincteric action
under the physiology of the inguinal canal).
The inguinal canal contains, in males, the spermatic cord, or in females, the round ligament of the uterus.
The anterior wall of the inguinal canal (Fig. 9-20) is formed by the aponeurosis of the external oblique muscle and by participation of the internal oblique
muscle more laterally. As a point of reference, the internal oblique muscle in the inguinal area is muscular, not aponeurotic. The superior wall ("roof") of the
inguinal canal is formed by the arching lower borders of the internal oblique and transversus abdominis muscles and their aponeuroses. The inferior wall of
the inguinal canal is formed by the inguinal ligament and the lacunar ligament.
Fig. 9-20.
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Parasagittal section through right mid-inguinal region, illustrating separation of musculoaponeurotic lamina into anterior and posterior inguinal walls. (Modified from
Nyhus LM. The preperitoneal approach and iliopubic tract repair of femoral hernias. In: Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB Lippincott,
1995, p. 178-184; with permission.)
The posterior wall (Fig. 9-20, Fig. 9-21) is formed primarily by fusion of the aponeurosis of the transversus abdominis muscle and the transversalis fascia in
three-fourths of subjects and by only the transversalis fascia in the remaining one-fourth.52
Fig. 9-21.
A, Normal anatomy of posterior wall of inguinal canal. Inset: Femoral sheath and its contents. B, Direct inguinal hernia. Note iliopubic tract. (Modified from
Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am
1993;73:799-836; with permission.)
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From both anatomic and surgical standpoints, the posterior wall (floor) is the most important wall of the inguinal canal. Medially the posterior wall is
reinforced by the internal oblique aponeurosis.
According to Madden,53 the "piriform fossa" forms part of the posterior wall ("floor") of the inguinal canal. This region is a semi-ovoid space filled with
fibrofatty tissue, located at the medial part of the floor. The piriform fossa is bounded as follows53 (Fig. 9-22, Fig. 9-23A):
Superior: Iliopubic tract (which inserts into Cooper's ligament)
Inferior: Shelving edge of inguinal ligament
Lateral: Medial wall of femoral sheath
Medial: Ligament of Gimbernat
"Floor": Ligament of Gimbernat
Fig. 9-22.
Piriform fossa of Fruchaud, popularized by Madden. (Modified from Colborn GL, Skandalakis JE. Importance of the iliopubic, Cooper's and Gimbernat's ligaments.
Probl Gen Surg 1995;12:35-40; with permission.)
Fig. 9-23.
A, Posterior wall ("floor") and piriform fossa (arrow) of the inguinal canal. In this illustration the fascia of the posterior wall has been reconstructed by suturing the
superior segment to the inferior segment (iliopubic tract). B, Anterior view of Fruchaud's myopectineal orifice. (A Modified from Madden JL. Abdominal Wall Hernias.
Philadelphia: WB Saunders, 1989; with permission. B Modified from Wantz GE. Atlas of Hernia Surgery. New York: Raven Press, 1991; with permission.)
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Philadelphia: WB Saunders, 1989; with permission. B Modified from Wantz GE. Atlas of Hernia Surgery. New York: Raven Press, 1991; with permission.)
Wantz54 noted that Fruchaud55 did not characterize hernias by their clinical presentation; instead, Fruchaud believed that all hernias of the groin begin
within the groin, in an area he named the myopectineal orifice (Fig. 9-23B). This area in the groin is bounded as follows:
Superior: Arch of internal oblique muscle and transversus abdominis muscle
Lateral: Iliopsoas muscle
Medial: Lateral border of rectus muscle and its anterior lamina
Inferior: Pubic pecten
The inguinal ligament spans and divides this framework. The area is traversed by the spermatic cord and femoral vessels and is covered on its inner surface
solely by the transversalis fascia.54
SPERMATIC CORD
The spermatic cord is presented in depth in the chapter on the male genital system. We include here a brief review of the surgical anatomy of this important
entity in the inguinal canal.56
The spermatic cord consists of a matrix of connective tissue continuous proximally with extraperitoneal connective tissue. It contains the ductus
deferens, three arteries, three veins, the pampiniform plexus, and two nerves, concentrically invested by three layers of tissue. One other nerve, the
ilioingual nerve, usually lies just lateral to the major layers of the cord within the inguinal canal.
The elements of the spermatic cord relate to each other as follows: 1) anterior is the pampiniform plexus, and 2) posterior are the ductus deferens
and the remnant of the processus vaginalis or hernia sac. These anatomic entities, as well as other contained structures, are covered by the
spermatic fasciae. The spermatic cord, on the way to the scrotum, lies deep to the fasciae of Camper and Scarpa. The components of the cord are
noted in Table 9-6. The key to remember is "three": three layers of fasciae, three arteries, three veins, three nerves, as well as multiple lymphatics
and one duct.
Table 9-6. the Spermatic Cord and Its Covering
Three fasciae:
External spermatic (from external oblique fascia)
Cremasteric (from internal oblique muscle and fascia)
Internal spermatic (from transversalis fascia)
Three arteries:
Testicular artery
Cremasteric artery
Deferential artery
Three veins:
Pampiniform plexus and testicular vein
Cremasteric vein
Deferential vein
Three nerves:
Genital branch of genitofemoral nerve
Ilioinguinal nerve
Sympathetic nerves (testicular plexus)
Lymphatics
Source: Skandalakis JE, Colborn GL, Pemberton LB, Skandalakis LJ, Gray SW. The surgical anatomy of the inguinal area Part 2. Contemp Surg 38(2):28-38, 1991;
with permission.
Superficial Fascia
The superficial fascia (Figs. 9-24, 9-25) is divided into a superficial fatty part (Camper's fascia) and a deep membranous part (Scarpa's fascia). The adipose
layer continues downward and laterally into the thigh, gluteal region, and perineum and upward over the anterior abdominal wall and thoracic region. The
membranous layer of Scarpa is continuous upward with the fatty layer in the pectoral region, forming the anterior boundary of the retromammary space.
Inferiorly, it attaches to the fascia lata of the thigh below the inguinal crease. It is also attached superolaterally to the iliac crest. According to Brantigan,57
Scarpa's fascia does not adhere to the symphysis pubis (Fig. 9-26).
Fig. 9-24.
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Superficial fascia (dartos): composed of Scarpa's fascia (membranous) and muscle, and Camper's fascia, which is fatty. Gallaudet's fascia is a continuation of Buck's
fascia.
Fig. 9-25.
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Superficial and deep fascia of the penis. Note the continuity between the elements of the superficial fascia (which form the superficial fascia of the penis), and also
the continuity of the Gallaudet fascia of the abdominal wall with the deep (Buck's) fascia of the penis. The cleft between the superficial (Colles') fascia of the
perineum and the deep (Gallaudet) fascia of the perineum is also shown.
Fig. 9-26.
Scarpa's fascia. Symp, symphysis pubis. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
The adipose layer and the membranous layer combine in the pubic region, losing much of the fatty content. Together, they form the fundiform ligament, a
relatively loose fibrous structure that attaches to the base of the penis (or the clitoris). There, receiving input of smooth muscle fibers, the superficial fascia
continues as the dartos tunic of the penis and scrotum (or as the clitoris), where it serves as a superficial fascial layer.
In the perineum, the membranous layer is renamed Colles' fascia (Figs. 9-24, 9-25, 9-26). It attaches laterally to the ischiopubic rami and posteriorly to the
base of the urogenital diaphragm. In this way, a space called the superficial perineal cleft (Figs. 9-24, 9-25) is limited posteriorly and laterally. This cleft is
bounded deeply by the muscle fascia (of Gallaudet) of the superficial perineal pouch. Extravasation of fluid from this area occurs in an anterior direction,
passing anterosuperiorly around the genitalia to reach the anterior abdominal wall.
Deep Fascia
The deep muscular fascia of the anterior wall (known as the fascia innominata or Gallaudet's fascia) (Figs. 9-24, 9-25, 9-26) is continuous over the shaft of
the penis or clitoris, forming their deep fascial investment. There they are known as Buck's fascia. In the perineum, this tough fascial layer is continuous
over the superficial musculature, again referred to as fascia of Gallaudet or as inferior (external) perineal fascia.
Hollinshead58 considered Buck's fascia to be an independent layer. This fascial layer, together with tough connective tissue from the lowest extent of the
rectus sheath and the front of the pubic bone, forms the suspensory ligament of the penis or clitoris. It then proceeds more distally as the deep fascia of
those structures.
Inguinal Ligament
The lower edge of the external oblique aponeurosis extends from the anterior superior iliac spine to the pubic tubercle. This is the inguinal ligament (ligament
of Poupart). The ligament is related laterally to the iliopsoas muscle and its fascia. It is related medially to the femoral vessels. The ligament is also related
indirectly to the femoral ring, to the iliopubic tract, and to other thickenings of the transversalis fascia.
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indirectly to the femoral ring, to the iliopubic tract, and to other thickenings of the transversalis fascia.
Doyle59 drew attention to the probability that it was Fallopius, not Poupart, who first described this aponeurotic band as a ligament, noting that none of the
biographers of Poupart attributed this discovery to him. Doyle added that Poupart was far better known for his writings on ghostly apparitions, dragonflies,
and hermaphroditic insects.
Gimbernat's ligament and the reflected inguinal ligament are formed before the inguinal ligament reaches the pubic tubercle (see the section on the ligament
of Gimbernat (lacunar ligament) below).
Aponeurosis and Fascia of the External Oblique Muscle as Related to the Groin
The external oblique muscle is not present in the groin area. Only its aponeurosis (Fig. 9-27) extends downward and medially, to pass anterior to the rectus
muscle. Here, it also joins the aponeurosis of the internal oblique muscle and that of the transversus abdominis to form the anterior layer of the rectus
sheath. Between this attachment and an inferior attachment to the pubic bone lies a triangular hiatus (superficial inguinal ring) through which passes the
spermatic cord or the round ligament. The innominate fascial covering of the external oblique muscle travels further downward and forms the external
spermatic fascia of the spermatic cord.
Fig. 9-27.
Aponeurosis of external oblique has been incised and retracted upward and medially. Spermatic cord within inguinal canal has been mobilized and retracted.
(Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
Conjoined Area (Tendon)

Buried among the names of structures real or imaginary in the inguinal region is the term conjoined tendon. If one consults a medical dictionary, one finds
that anatomists decided in 189560 that it should be called the falx inguinalis. At the time of this decision, inguinal anatomy was still developing.
About 1900, the term conjoined tendon entered the literature.61 The earliest use has not been found. The term appears in the 1902 edition of Gerrish's
Textbook of Anatomy by American Authors.62 In 1950,63 1960,64 and again in 1985,65Nomina Anatomica's authors admitted that usage favored conjoined
tendon rather than falx inguinalis. They agreed that tendo conjunctivus would be considered an "official alternative."
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The conjoined tendon is, by definition, the fusion of lower fibers of the internal oblique aponeurosis with similar fibers from the aponeurosis of the
transversus abdominis where they insert on the pubic tubercle and superior ramus of the pubis.
This description is simple and straightforward. The trouble is that the anatomic configuration thus described is extremely rare. Hollinshead58 considered it to
be present in only 5% of cases; Condon66 allowed 3%; McVay61 believed it to be only an artifact of dissection.
In spite of this, we surgeons and anatomists continue to behave as if the conjoined tendon were usually present. Skandalakis et al.52 looked at 100 reports
of herniorrhaphy (including seven cases of their own) where it had been soberly stated that "the conjoined tendon was sutured to the shelving edge of the
inguinal ligament," or "to the ligament of Cooper."
What is used in the operating room for the repair of an inguinal hernia is the transversus abdominis aponeurosis, the transversalis fascia, and the lateral
edge of the rectus sheath. Occasionally, the internal oblique muscle, the internal oblique aponeurosis, the falx inguinalis (in the original sense), the
ligamentum interfoveolare, or the reflected inguinal ligament is used. None of these are "conjoined," but there is a tendency among surgeons to use the term
for any mass of fascia or aponeurosis from the internal oblique or the transversus abdominis muscles.
Since several structures are juxtaposed in this area and the term "conjoined" is widely used, Gray and Skandalakis67 proposed that the concept of the area
of the conjoined tendon should be renamed the "conjoined area" (see Fig. 9-6). The area can be identified easily by the inexperienced surgeon who
understands that it is occasionally tendinous. In other words, this is the area in which there would be a conjoined tendon if there were a conjoined tendon.
We believe our suggestion will accommodate both the myth and the facts.
We have tried to avoid this controversy, but many years of teaching anatomy and practicing surgery require us to take a position based on the following
points:
"The conjoined tendon does not exist." (McVay)61
"The distinction between falx inguinalis and conjoined tendon is one of anatomic nicety and admittedly of little practical significance in the operating room provided
that the distinction is understood." (Condon)66
The term conjoined area can be applied correctly to that region that contains the ligament of Henle, the transversus abdominis aponeurosis, the inferomedial fibers
of the internal oblique muscle or aponeurosis, the reflected inguinal ligament, and the lateral border of the rectus sheath.
Ligament of Gimbernat (Lacunar Ligament)

The ligament of Gimbernat (Fig. 9-28) is a triangular extension of the inguinal ligament before its insertion upon the pubic tubercle. It is inserted at the
pecten pubis, and its lateral end meets the proximal end of the ligament of Cooper. Condon68 asserted "... it [the ligament of Gimbernat] never forms the
medial border of the normal femoral canal." Similarly, Doyle59 stated emphatically that the lacunar ligament is situated 4-15 mm medial to the femoral ring,
and thus has no part in forming its medial border. The results of hundreds of dissections that the senior author of this chapter has done, whether on fixed or
unfixed material, leave no doubt in his mind as to the validity of this point of view. Other investigators, however, hold the view that the lacunar ligament
forms the medial border of the canal.
Fig. 9-28.
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Inguinal ligament, lacunar ligament (Gimbernat's), pectineal ligament (Cooper's), neuromuscular compartment, vascular compartment, compartment of femoral
canal. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and
Anatomical Basis of Surgery. New York: Parthenon, 1996; with permission.)
The lacunar ligament was first described by Antonio de Gimbernat in 1793.69 According to Madden,53 the ligament can be demonstrated only when "the
piriform fossa is completely exposed," since it practically forms the floor of the fossa.
Doyle59 argued strongly that the term "lacunar ligament" should be dropped, since this is not an independent entity or ligament, but simply that part of the
external oblique aponeurosis that inserts upon the pectineus fascia at an angle to the pectineal line. He noted further that this structure was absent in
newborn infants.
Cooper's Ligament (Pectineal Ligament)

Almost 200 years ago, Sir Astley Cooper70 described this "ligament." One of the authors of this chapter (JES) has stated repeatedly that the anatomy of the
ligament of Cooper continues to be terra incognita. Every time he dissects a fresh cadaver, his ideas change regarding the anatomy of this ligament.
However, we present here the most likely findings, without supporting them very strongly.
According to Nyhus and Bombeck,71 "Periosteum of the pelvis ...is intimately fused with another condensation of the transversalis fascia and iliopubic tract
to form Cooper's ligament."
According to Hollinshead,58 "...it [Cooper's ligament] is sometimes described simply as a lateral continuation of the lacunar ligament."
Condon66 states that Cooper's ligament is the periosteum of the superior ramus of the pubis, strongly reinforced by endoabdominal fascia (transversalis
fascia), with more reinforcement by the transversus abdominis aponeurosis and the iliopubic tract medially.
According to McVay,61 the ligament is the periosteum of the superior ramus of the pubis lateral to the pubic tubercle, where the inferior aponeurosis of the
transversus abdominis is inserted.
F. Wood Jones72 stated that a lateral extension of dense tendinous fibers from the base of the lacunar ligament, passing along the pectineal line, forms the
pectineal ligament (ligament of Astley Cooper).
Harold Ellis73 described the pectineal ligament (of Cooper) as the thickened periosteum along the pectineal border of the superior pubic ramus, which
continues medially with the pectineal part of the inguinal ligament (Gimbernat's or lacunar).
Neidhardt 74 stated that the pectineal ligament is formed by three layers:
The deep layer, which is in continuity with the periosteum of the superior pubic ramus.
The middle, muscular layer, which is formed by the pectineus muscle.
The superficial aponeurotic layer, which is formed by the overlapping of the vertical fibers of the pectineal aponeurosis and transverse fibers running along the
arcuate line of the pelvis.
Gardner et al.75 defined Cooper's ligament as a "...lateral periosteal extension of the lacunar ligament along the pectineal line, covering the pectineal line and
the upper part of the pectineal fascia."
Lockhart 76 stated, "A lateral extension along the pectineal line from the lacunar ligament is termed the pectineal ligament (Astley Cooper)."
Last 9 reported that the pectineal line of the horizontal ramus of the pubic bone, covered by an expansion from the conjoined tendon that fuses with the
periosteum, is called the pectineal ligament (or ligament of Astley Cooper).
Basmajian and Slonecker77 stated that the pectineal ligament is a strong fibrocartilaginous band of periosteum.
Decker and du Plessis78 stated that the lateral sharp edge of the lacunar ligament gives a fascial extension backwards for 12 mm along the iliopectineal line
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(brim of pelvis). Here it blends with the periosteum and is called Cooper's ligament. They added that it is currently (1986) thought that aponeurotic fibers of
the transversus abdominis or the transversalis fascia itself insert into the pectineal ligament 4-8 mm lateral to the lacunar ligament.
Lindner79 considers the pectineal (Cooper's) ligament to be a lateral extension of the inferior fibers of the lacunar ligament for about 3 cm along the
pectineal line of the os pubis. It is reinforced by the posteriorly-reflected fibers of the iliopubic band of the transversalis fascia.
Madden53 describes the ligament of Cooper as a conjoined line of insertion for the iliopubic tract above and the fascial part of the ligament of Gimbernat
below, as well as the origin of the pectineal muscle and its fascia.
Our experience has proven that the ligament of Cooper includes elements of the following anatomic entities:
Periosteum
Lateral part of the lacunar ligament (fused to the periosteum)
Fibers originating from the upper part of the pectineal fascia in such a way that the fascia is located under the periosteum and the lacunar ligament. Perhaps one
can say that this is an area of origin of muscle (pectineus), as well as insertion.
Aponeurotic fibers from the insertion of the transversus abdominis and the iliopubic tract
Insertion of the transversalis fascia
(Occasionally) fibers from the insertion of the rectus tendon
(Occasionally) fibers from the insertion of the internal oblique muscle
Fusion of the outer lamina of extraperitoneal connective tissue
For all practical purposes, Cooper's ligament consists of:

Periosteum of the pectineal line
Insertion of the iliopubic tract from above to the periosteum
Insertion of the lacunar ligament from below to the periosteum
Origin of the pectineus tendon from below (Figs. 9-29, 9-30, 9-31.)
Fig. 9-29.
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Some anatomic entities participating in formation of pectineal ligament (Cooper's) (highly diagrammatic). (Modified from Colborn GL, Skandalakis JE. Importance of
the iliopubic, Cooper's and Gimbernat's ligaments. Probl Gen Surg 1995; 12:35-40; with permission.)
Fig. 9-30.
Insertion of iliopubic tract into ligament of Cooper and possible origin of pectineal aponeurosis (highly diagrammatic). (Modified from Colborn GL, Skandalakis JE.
Importance of the iliopubic, Cooper's and Gimbernat's ligaments. Probl Gen Surg 1995;12:35-40; with permission.)
Fig. 9-31.
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Lacunar ligament (Gimbernat's) partially covers pectineal aponeurosis (highly diagrammatic). (Modified from Colborn GL, Skandalakis JE. Importance of the iliopubic,
Cooper's and Gimbernat's ligaments. Probl Gen Surg 1995;12: 35-40; with permission.)
Dare we anatomists and surgeons ask for greater precision than can reasonably be determined? Is the word "ligament" the correct one? If the ligament is
the periosteum, then this "ligament" is the reinforcement by thick fibrous tissue of several anatomic entities. What about the concept that the Cooper's
ligament belongs to the external oblique aponeurosis complex? Do modern beliefs about the anterior and posterior laminae of the abdominal wall and inguinal
canal and, therefore, the repair of inguinal hernias, need to change (see Fig. 9-21)? We doubt it.
One thing is certain, though: Cooper's ligament is always there to be used if the surgeon decides to use it, regardless of whether or not it is a "ligament."
Remember
The iliopubic tract is inserted into the ligament of Cooper from above (superiorly).
The ligament of Gimbernat is inserted partially upon the ligament of Cooper from below (inferiorly).
The pectineus tendon originates from the ligament of Cooper from below (inferiorly). Its medial part is covered by the ligament of Gimbernat.
Arch of the Transversus Abdominis

The arch of the transversus abdominis muscle becomes less muscular and more aponeurotic (transversus aponeurosis) as it approaches the rectus sheath
(see Fig. 9-1). Close to the internal ring, it is covered by the much more muscular arch of the internal oblique muscle (see Fig. 9-5), but it is rarely covered
in the lower medial portion of the inguinal region. Remember that in the inguinal canal region the internal oblique is muscular. The transversus abdominis is
aponeurotic.
Ligament of Henle (Falx Inguinalis)

The ligament of Henle was originally termed falx inguinalis. We prefer the former term because the falx has become confused with the conjoined tendon
(previously described in this chapter). The ligament of Henle is the lateral vertical expansion of the rectus sheath that inserts on the pecten of the pubis.
Since this ligament is present in one-third to one-half of patients and is fused with the transversus aponeurosis and fascia, it may be seen occasionally in
the surgical field, and the surgeon's needle may penetrate it once or twice in the course of hernia repair.
Interfoveolar Ligament (Hesselbach's Ligament)

The interfoveolar ligament is a thickening of the transversalis fascia at the medial side of the internal inguinal ring. It lies in front of the inferior epigastric
vessels like a spider web. It is not a true ligament, and when well-developed, one has the impression that it is only a lateral condensation of the ligament of
Henle.
Reflected Inguinal Ligament (Colles' Ligament)

The reflected inguinal ligament consists of aponeurotic fibers from the inferior crus of the external inguinal ring that extend to the linea alba. This is the
posterior crus of French anatomists.
Iliopubic Tract
Alexander Thomson described the iliopubic tract in 1836.80 Some historians believe that Hesselbach81 provided a description in 1814. The tract is known by
several names: ligament of Thomson, deep crural arch, deep femoral arch, anterior femoral sheath, and (in French) bandelette iliopubienne.
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several names: ligament of Thomson, deep crural arch, deep femoral arch, anterior femoral sheath, and (in French) bandelette iliopubienne.
The iliopubic tract is an aponeurotic band that begins near the anterior superior iliac spine. It extends medially to attach to Cooper's ligament. It forms the
inferior margin of the deep musculoaponeurotic layer made up of the transversus abdominis muscle and aponeurosis and the transversalis fascia (see Fig. 921A & B).
Laterally, the tract is attached to the iliacus and psoas fasciae. It continues more laterally to the anterior superior spine of the ilium. It passes medially to
form the lower border of the internal inguinal ring. Together with the transversalis fascia, the tract crosses the femoral vessels to form the anterior margin
of the femoral sheath. The tract curves around the medial surface of the femoral sheath to attach to the pectineal ligament. It provides the medial border
of the femoral ring and femoral canal. Its lower margin is attached to the inferior edge of the inguinal ligament along a variably dense line of fusion in the
region of the inguinal canal.
Condon66 found the iliopubic tract present in 98 percent of dissections. He pointed out that it has been confused frequently with the inguinal ligament,
which, although nearby, belongs to the superficial musculoaponeurotic layer. The iliopubic tract is part of the deep layer.
The shelving edge of the inguinal ligament is located anterior to the iliopubic arch. Therefore, the iliopubic arch can be seen by a special anterior dissection.
With the spermatic cord elevated, one can see that the shelving edge of the external oblique and the iliopubic tract are attached to one another or in some
degree continuous with one another.
As noted earlier, Madden53 agreed that the iliopubic tract is the inferior segment of the posterior wall of the inguinal canal. He wrote that the key to
understanding the iliopubic tract in this area is the piriform fossa, boundaries of which have been previously described under the heading "Adult Anatomy of
the Inguinal Canal."
The iliopubic tract, therefore, is related to a direct inguinal hernia inferiorly, but it is not related to a classic external supravesical hernia.
The surgeon approaching this area must be familiar with the topographic anatomy, aware of the surgical physiology, and assured of the technique for
approximation of the crura.
Transversalis Fascia Crura

The transversalis fascia crura is a thickening of the transversalis fascia. It forms an incomplete ring in the shape of an inverted "V" or "U" at the deep
inguinal ring (see Fig. 9-19). There are two crura. The anterior (superior) long crus is attached to the transversus abdominis muscle or its aponeurosis. The
posterior (inferior) short crus is attached to the iliopubic tract.
REMEMBER:
The cremaster vessels (Figs. 9-32, 9-33) and the genital branch of the genitofemoral nerve are located very close to the iliopubic tract at the posterior wall
of the inguinal canal.
Fig. 9-32.
Iliopubic tract and its relations to genital branch of genitofemoral nerve. (Modified from Colborn GL, Skandalakis JE. Importance of the iliopubic, Cooper's and
Gimbernat's ligaments. Probl Gen Surg 1995;12:35-40; with permission.)
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Fig. 9-33.
Pathway of genital branch of genitofemoral nerve from deep inguinal ring to medial side of spermatic cord (highly diagrammatic). FA, Femoral artery; FV, Femoral
vein. (Modified from Colborn GL, Skandalakis JE. Importance of the iliopubic, Cooper's and Gimbernat's ligaments. Probl Gen Surg 1995;12:35-40; with permission.)
According to Condon,82 the iliopubic tract is visible along the inferior margin of the deep inguinal ring, but it is partially covered by the inguinal ligament.
When demonstrating the iliopubic tract to our students, we point out the following areas (Fig. 9-32):
Proximal: At the inferior margin of the deep inguinal ring, the inguinal ligament is elevated, the tissue under and behind is cleaned, and the silver-colored area is
grasped with a hemostat. This is the surgical beginning of the iliopubic tract.
Distal: After cleaning the piriform fossa, the tissues above are grasped with another hemostat. This is the surgical end of the iliopubic tract. Movement of one
hemostat will produce movement of the other.
Medial: Careful separation and elevation of the fusion between the inguinal ligament and tissues located below and posteriorly will reveal a thickening of the
transversalis fascia. This is the iliopubic tract.
Iliopectineal Arch
The iliopectineal arch is a band of fascia and aponeurotic fibers marking the attachment of the external oblique aponeurosis to the fasciae of the iliacus and
psoas muscles. It attaches laterally to the anterior superior iliac spine and medially to the iliopubic (iliopectineal) eminence.
The iliopectineal arch (Fig. 9-34) divides the space beneath the inguinal ligament into two separate spaces: the lacuna musculorum of the iliopsoas muscle
laterally, and the lacuna vasculorum of the external iliac vessels medially. In the region of the iliopubic eminence, this fascial band is further strengthened by
profuse contributions from the fascia of the pectineus muscle and other entities and forms a fascial complex called the iliopectineal fascia. The surgeon
never directly uses this fascia, but it is important as a common junction of several structures of the lateral groin. These structures are:
The insertion of fibers of the external oblique aponeurosis
The insertion of fibers of the inguinal ligament
The origin of part of the internal oblique muscle
The origin of part of the transversus abdominis muscle
Part of the lateral attachment of the iliopubic tract. It contributes also to the lateral wall of the femoral sheath.
Fig. 9-34.
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Iliopectineal arch. (Modified from Nyhus LM. An anatomical reappraisal of the posterior inguinal wall. Surg Clin North Am 1964;44:1305; with permission.)
Transversalis Fascia as Related to the Inguinal Area

Sir Astley Cooper70 described the transversalis fascia as follows:
"When the lower portions of the internal oblique and transversalis muscles are raised from their subjacent attachments, a layer of fascia is found to
be interposed between them and the peritoneum, through which the spermatic vessels emerge from the abdomen. This fascia, which I have ventured
to name fascia transversalis, varies in density, being strong and unyielding towards the ilium, but weak and more cellular towards the pubes."
The inguinal canal is similar to a cleft between two major musculoaponeurotic layers. The anterior layer is formed by the external oblique aponeurosis and
the innominate (Gallaudet's) fascia. The posterior layer is formed by the internal oblique aponeurosis, the transversus abdominis aponeurosis, and the
transversalis fascia (see Figs. 9-19, 9-35). This latter layer is of primary importance to the surgeon repairing the floor of the inguinal canal.
Fig. 9-35.
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A, Transversalis fascia and femoral sheath (old concept). B, Transversalis fascia and femoral sheath (new concept), emphasizing bilaminar nature of transversalis
fascia in inguinal area (highly diagrammatic). (Modified from Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Embryologic and anatomic
basis of inguinal herniorrhaphy. Surg Clin North Am 1993;73:799-836; with permission.)
The term "transversalis fascia" was applied in the past to the deep fascia covering the internal surface of the transversus abdominis muscle. Now, it applies
to the entire connective tissue sheet lining the musculature of the abdominal cavity. In some areas, this fascial layer is given a specific name, such as
"iliacus" or "psoas" fascia, where it covers those specific muscles.
The transversalis fascia varies in nature. It is thin and closely adherent in the portion covering the transversus abdominis aponeurosis, but in other areas it
is thick and discrete.70 By itself, however, the transversalis fascia is a weak layer, useless for hernia repair. Yet, when fused with the transversus abdominis
aponeurosis, it forms "good stuff" for repair.
Cooper's Posterior Lamina of Transversalis Fascia

One of the authors of this chapter, Dr. John E. Skandalakis, admits that in spite of familiarity with the publications of Cooper,70,83 he and his colleagues
never thought about the possibility of a bilaminar formation of the transversalis fascia at the inguinal area (Fig. 9-35) until their exposure to the work of
Read.84
In their52 innumerable dissections (both fresh and old cadavers), and work in the operating room, they found a thin membrane that covered the
preperitoneal fat. They paid little attention to this, because the presence of more adipose preperitoneal fat led them to think this was simply a tissuepaperlike membrane covering the fat. They never thought of this tissue as the posterior cooperian lamina of the transversalis fascia.
They observed "the transversalis fascia" (ostensibly, the anterior lamina), but they considered this lamina alone as representing the entirety of the
transversalis fascia. As to the covering of the preperitoneal fat, they never investigated the beginning and the end of this preperitoneal covering. They also
noted the presence of the inferior epigastric vessels under the "transversalis fascia." Again, they did not pay any attention to their fixation anteriorly or their
deeper occurrence in relation to the preperitoneal fat.
It may be that the fascial layer which is now being called the "posterior layer" of the transversalis fascia is simply an extraperitoneal layer of connective
tissue. This appears to be the same layer of tissue that provides the perirenal fascial envelope. Whether or not the "posterior layer" of the transversalis
fascia is truly attributable to the transversus abdominis, or whether it is more simply a lamina of extraperitoneal connective tissue is still subject, perhaps, to
debate. Certainly, further study is needed.
Layers of the Abdominal Wall in the Inguinal Region

In accordance with Read's84 approach in 1992 to the nature of the transversalis fascia, the following are the layers of the abdominal wall in the inguinal
region (Fig. 9-36):
1. Skin
2. Subcutaneous fasciae (Camper and Scarpa) containing fat (superficial fascia)
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2. Subcutaneous fasciae (Camper and Scarpa) containing fat (superficial fascia)

3. Innominate fascia (Gallaudet). This fascia may not always be recognized as a distinct entity. Its absence or presence is of no surgical importance. It is responsible
for the formation of the external spermatic fascia.
4. External oblique aponeurosis, including the inguinal, lacunar, and reflected inguinal ligaments (see Figs. 9-3, 9-5, 9-27)
5. Spermatic cord
6. Transversus abdominis muscle and aponeurosis, internal oblique muscle, falx inguinalis (Henle), and the conjoined tendon (when present).85 We agree with
McVay61 that the inguinal part of the transversus abdominis muscle originates from the iliopsoas fascia and not from the inguinal ligament. The muscle inserts into
the pectineal (Cooper's) ligament (see Fig. 9-1).
7. Anterior lamina of transversalis fascia
8. Posterior lamina of transversalis fascia
9. Preperitoneal connective tissue with fat
10. Peritoneum
Fig. 9-36.
Layers of the abdominal wall in the inguinal region are shown in B and D. Path of indirect inguinal hernia also shown. Dashed lines indicate sites of incision. A and
B, Incarceration at external ring. C and D, Incarceration at internal ring. E, Rare lateral inguinal hernia. Herniation may occur through the fibers of the internal
oblique muscle, superior and lateral to the internal inguinal ring. (Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of hernial rings. Surg Clin
North Am 1974;54:1227-1246; with permission.)
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Condon66 pointed out that there are two groups of structures, one a mirror-image of the other: skin to aponeurosis (1 to 4 above) and aponeurosis to
peritoneum (6 to 10 above).
Spaces and Fossae

SPACE OF BOGROS
Fat and other connective tissue, either thick or thin, lies within a space between the peritoneum and the posterior lamina of the transversalis fascia that is
called the space of Bogros (Fig. 9-37). Fibrous bands are present, and lipomata similar to those in the spermatic cord occasionally are found. The
preperitoneal space is exposed by the reflection of parietal peritoneum toward the iliac fossa before it reaches the pubic bone.11
Fig. 9-37.
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Highly diagrammatic representation of the layers of the abdominal wall and inguinal area. 1, External oblique fascia (fascia of Gallaudet); 2, External oblique
aponeurosis; 3, Internal oblique muscle; 4, Transversus abdominis muscle and its aponeurosis; 5, Transversalis fascia anterior lamina (third layer); 6, External
spermatic fascia; 7, Cooper's ligament; 8, Pubic bone; 9, Pectineus muscle; 10, Possible union of transversalis fascia laminae; 11, Transversalis fascia posterior
lamina (second layer); 12, Vessels (second space); 13, Peritoneum (first layer); 14, Space of Bogros (first space); 15, Preperitoneal fat; 16, Transversus abdominis
aponeurosis and anterior lamina of transversalis fascia; 17, Femoral artery; 18, Femoral vein. (Modified from Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis
LJ, Pemberton LB. Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am 1993;73:799-836. Drawn with R.C. Read; with permission.)
According to Stoppa (personal communication, Ren Stoppa to John E. Skandalakis, 1992), Bogros was a French anatomist and surgeon who wrote a thesis
in 1823 about the surgical anatomy of the iliac region. Bogros described a triangular space with the following boundaries:
Lateral: Iliac fascia
Anterior: Transversalis fascia
Medial: Parietal peritoneum
Stoppa wisely stated that this cleavable interparietoperitoneal space is considered to be the lower prolongation of the great posterior para-urinary space.
Hureau et al.86,87 after radiologic and anatomic studies of this area, considered the composition of the posterior para-urinary area to be the following:
Anterior: Gerota's fat contained within the fascia
Posterior: A cellular space that most likely incorporates the space of Bogros in the internal iliac fossa
According to Bendavid,88 the space of Bogros is a lateral extension of the retropubic space of Retzius. It may be explored by incising the transversalis fascia
from the internal ring to the pubic crest. Bendavid also reported that a venous network is most likely located at the lower and anterior part of the space of
Bogros, with fixation of the network to the anterior wall. The Bendavid "venous circle," located at the subinguinal space of Bogros, is a variable circular
venous network composed of the deep inferior epigastric vein, the iliopubic vein, the rectusial vein, the retropubic vein, and the communicating
rectusioepigastric vein (Figs. 9-38, 9-39). Bendavid advised familiarity with this venous circle, particularly for those surgeons using prosthetic material.
Fig. 9-38.
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Deep inguinal vasculature within space of Bogros. (Modified from Bendavid R. The space of Bogros and the deep inguinal venous circulation. Surg Gynecol Obstet
Fig. 9-39.
A-D, Variations in vasculature of deep inguinal venous system. (Modified from Bendavid R. The space of Bogros and the deep inguinal venous circulation. Surg
Gynecol Obstet 1992;174:355-358; with permission.)
We quote from Colborn and Skandalakis:89

The fascinating and instructive essay by Bogros on the surgical anatomy of the inguinal region contains much food for thought, in addition to
observations which we believe to be understandable misinterpretations of regional anatomy. Among the informative descriptions provided by Bogros is
one detailing the origin, course, and branching pattern of the deep circumflex iliac artery (called the anterior iliac in the thesis), a vessel which is
frequently overlooked in conventional descriptions of the anatomy of the inguinal region pertaining to inguinal herniorrhaphy. Much of the artery lies
deep to the iliopubic tract, and is crossed there by several nerves of significance.
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deep to the iliopubic tract, and is crossed there by several nerves of significance.
Bogros speaks of the extraperitoneal space inferiorly within the abdominal cavity where the peritoneum reflects from the anterior abdominal wall to
the iliac fossa. There, at a space some 12-14 mm wide, he notes the external iliac and inferior epigastric vessels are devoid of serosal covering, and
are accessible to ligation without division of the peritoneum.
It is our assumption that the extraperitoneal space described by Bogros, in which the inferior epigastric and external iliac vessels can be secured and
ligated, is the space or is coextensive with the space now being referred to as the "space of Bogros." As noted by Dr. Bendavid, the preperitoneal
space of Bogros is continuous with the retropubic space of Retzius and is entered in "external" herniorrhaphies when the posterior lamina of the
transversalis fascia is divided and the inferior epigastric vessels are exposed, surrounded by adipose tissue.
Bogros stated that there is a "layer of cellular tissue" between the transversalis fascia and the epigastric vessels and, further, that there is,
posteriorly, a thicker layer of similar tissue which separates the vessels from the peritoneum. The more anterior layer of extraperitoneal fascia has
been noted by others, recently also by Read. We have observed that the extraperitoneal layer of connective tissue often splits quite distinctly lateral
to the inferior epigastric vessels, with one lamina passing anterior to the inferior epigastric artery and vein and the other lamina passing posterior to
those vessels. Perhaps Bogros was familiar with the work of Cooper about the bilaminar transversalis fascia in this area.
As we see it, the more anterior lamina of the extraperitoneal connective tissue varies considerably in its density, and in the amount of adipose tissue
with which it may be associated. When one divides this layer of tissue, one can then enter the retropubic space of Retzius. The deeper lamina is more
complex. Just medial to the inferior epigastric vessels, it appears to form the lateral edge of the vesicoumbilical fascia, which contains the umbilical
artery, and the urachus. This lamina also seems to more or less clearly form a mesentery-like structure for the round ligament or ductus deferens. The
inguinal representation of the extraperitoneal layers of connective tissue is but one expression of the complex regional specializations of this matrix,
illustrated also by the renal fasciae. Fused with the aponeurotic origin of the transversus abdominis from the fascia iliaca, the extraperitoneal
connective tissue contributes heavily also to the characteristic appearance of the iliopubic tract.
Bogros describes the course of the inferior epigastric artery clearly, observing that it courses first inferiorly, and then curves back sharply upward to
reach, and ascend upon, the anterior abdominal wall. In that the inferior epigastric artery can arise from the external iliac artery 0-5 cm proximal to
the origin of the deep circumflex iliac and the passage of the main artery beneath the inguinal ligament, according to Bogros, does the point of origin
of the inferior epigastric from the external iliac affect the length of the above-noted space, wherein the artery is devoid of peritoneal covering?
Bogros sheds no light on this interesting and pertinent question.
Most likely Bogros was aware of the work of Francois Poupart (1616-1708), who published his work about the inguinal ligament in 1705. The authors
do not understand if Bogros intended to state that part of the external iliac artery lies between the fascia iliaca and the intrinsic muscle fascia or the
iliacus muscle.
The description of the branches and distribution of the inferior epigastric vessels, as detailed by Bogros, is intriguing in its details. He observes that
the first branch passes medially to supply the tissues within the femoral canal, notably lymphatic in nature, and then continues to anastomose with,
or replace, the obturator artery. These important observations and the fact that such vessels can easily suffer injury in herniorrhaphies have been
mentioned often in recent literature. Bogros notes that the second branch of the inferior epigastric, the retropubic artery, can likewise be the source
of an aberrant obturator artery. In herniorrhaphy, some authors recommend division of the ligament of Gimbernat (the lacunar ligament); but such an
action can injure the aberrant obturator artery ("the enemy below") and result in herniation or extensive blood loss.
When thinking of the so-called "ligament of Gimbernat," one generally assumes that reference is being made to the lacunar portion of the inguinal
ligament, which, after its insertion at the pubic tubercle, inserts along the pectineal ligament of Cooper. It is interesting to note that Bogros refers to
the transversalis fascia and transversus aponeurosis (the medial end of the iliopubic tract?) as the ligament of Gimbernat, apparently in keeping with
accepted terminology of the period.
The description of the origin, course, and relations of the common and external iliac vessels is clear and interesting in its manner of presentation.
Bogros observes that one can draw a line beginning a centimeter or so below the navel in the midline to the midpoint of the inguinal ligament, thereby
defining the underlying position of the iliac artery and its availability for palpation. He also observes that the femoral nerve emerges from the trough
between the psoas and iliacus lateral to the external iliac artery some distance cranial to the inguinal ligament. This is an important consideration at
the present time because of the frequent practice of placement of staples lateral to the internal inguinal ring in laparoscopic herniorrhaphy.
Some explanations of the fascial arrangements as presented by Bogros, particularly those concerned with the inguinofemoral region, would be
unacceptable by many present workers. Among other things, he perceived that the fascia lata of the thigh provides the origin for the fascia lining the
abdominal cavity and covering the walls of the abdomen externally, a concept which seems comparable to saying that the hand and fingers are
extensions of, and derivatives of the thumb.
Of course, the primary objective of the thesis is that of elaborating a safe and well-defined course of approach for the surgical exposure of the
inferior epigastric and external iliac arteries without injury to them and without invasion of the peritoneal cavity. His lucid description of the approach
and its rationale is most enjoyable reading, and striking, especially for the time at which he wrote.
Three paragraphs in the thesis of Bogros give particulars of a space that has been wisely named the "space of Bogros," and perhaps to honor him for
his excellent anatomic work. The descriptive information implicitly supports the opinions of Hureau et al., Bendavid, and ourselves that Bogros
adequately defined the space named for him which exists between the peritoneum and the transversalis fascia. First, Bogros states, "The peritoneum,
as it reflects from the iliac region of the anterior abdominal wall to the iliac fossa leaves in front a space 12-14 mm wide, where the external iliac
artery ends and where the inferior epigastric artery begins." Second, "The external iliac artery and the first portion of the epigastric artery course
along the iliac area of the abdominal wall. These vessels are so placed that they are only separated from the lower abdominal cavity by the
peritoneum and a more or less thick cellular layer." Third, Bogros' thesis notes, "A loose layer of cellular tissue separates it (the inferior epigastric
artery) from the transversalis fascia anteriorly. Posteriorly, a thicker layer of the same tissue separates it from the peritoneum, shortly beyond its
origin."
We disagree with several of Bogros' statements, but it is not the purpose of this chapter to present our disagreement with nonessential matters. But,
together with Hureau, Stoppa, Bendavid, et al., we want to place Bogros' name in the anatomic annals together with the names of so many other
scientists from France. We are sure that Bogros never thought that the space he described would be the home of prosthetic materials for the modern
treatment of hernia of the abdominal wall; but Stoppa, with his excellent work, keeps the prostheses imprisoned in the space of Bogros.
SUPERFICIAL PERINEAL CLEFT
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SUPERFICIAL PERINEAL CLEFT

This potential space lies between Colles' membranous fascia of the perineum and the muscle fascia of the superficial perineal pouch. The superficial pouch
contains the ischiocavernosus and bulbospongiosus muscles and erectile bodies, etc. The superficial pouch covers the more deeply situated urogenital
diaphragm.
For all practical purposes, the superficial perineal cleft is present in the scrotum or the labia majora and is continuous with the potential space deep to the
fascia of Scarpa of the anterior abdominal wall. The testes move freely, with only the skin and dartos being fixed within the eight layers of the scrotum.51
The tunica vaginalis is a serous membrane of the peritoneum.
The external (superficial and deep) and internal pudendal arteries as well as twigs from the testicular and cremasteric arteries are primarily responsible for
the blood supply to the scrotum and the labia majora. The terminal branches of vessels to the skin of the scrotum lie transversely. Therefore, scrotal
exploration should be done through a transverse incision to minimize bleeding.
Lymphatic drainage from the scrotum, labia majora, and skin of the inguinal area is via the superficial inguinal lymph nodes. Lymph drainage from the testis
passes cranially with the gonadal vessels to reach nodes at the level of the kidney.
HESSELBACH'S TRIANGLE
Hesselbach's triangle (Fig. 9-40) is defined as having the inferior (deep) epigastric vessels as its superior or lateral border, the lateral edge of the rectus
abdominis muscle as its medial border, and the inguinal ligament as its inferolateral border.
Fig. 9-40.
Hesselbach triangle as originally described (left) and as accepted today (right). Note that part of supravesical fossa lies within triangle. (Modified from Skandalakis
PN, Skandalakis LJ, Gray SW, Skandalakis JE. Supravesical hernia. In Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB Lippincott, 1995, pp. 400-411;
with permission.)
Most direct inguinal hernias and external supravesical inguinal hernias occur in this area. The rectus sheath, however, is the only suitable naturally-occurring
structure for hernia repair. Of course, the epigastric vessels above the triangle cannot be used. The iliopubic tract or the pectineal ligament can be used
rather than the inguinal ligament. Presently, tension-free mesh prostheses are being more and more widely used in repairs of hernias of the abdominal wall.
The prostheses provide dependable, relatively inexpensive and lasting support for the defective region.
FOSSAE OF THE LOWER ANTERIOR ABDOMINAL WALL
The posterior surface of the anterior abdominal wall above the inguinal ligament is divided into three shallow fossae (Fig. 9-41). Located on either side of the
midline, these fossae are marked by the obliterated embryonic urachus, extending from the dome of the bladder to the umbilicus (median umbilical ligament).
Laterally, the fossae are separated by the medial umbilical ligaments (obliterated umbilical arteries) and the lateral umbilical ligaments (inferior or deep
epigastric arteries).
Fig. 9-41.
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Fossae of anterior abdominal wall and their relation to sites of groin hernias. A, Umbilicus. B, Median umbilical ligament (obliterated urachus). C, Medial umbilical
ligament (obliterated umbilical arteries). D, Lateral umbilical ligament containing inferior (deep) epigastric arteries. E, Falciform ligament. Sites of possible hernias: 1,
Lateral fossa (indirect inguinal hernia); 2, Medial fossa (direct inguinal hernia); 3, Supravesical fossa (supravesical hernia); 4, Femoral ring (femoral hernia). (From
Rowe JS Jr, Skandalakis JE, Gray SW. Multiple bilateral inguinal hernias. Am Surg 1973;39:269-270; with permission.)
The fossae are as follows:

The lateral inguinal fossae (Fig. 9-41), lateral to the inferior epigastric arteries, contain the internal inguinal rings. They are the site of indirect inguinal hernias.
The medial inguinal fossae, between the inferior epigastric arteries and the medial umbilical ligaments, are the site of direct inguinal hernias.
The supravesical fossae, between the medial and median umbilical ligaments, are the site of external supravesical hernias.
The supravesical fossa partially overlies Hesselbach's triangle, so that the medial umbilical ligament lies within it. Therefore, a hernia through either the
medial or the supravesical fossa is a direct inguinal hernia. Depending upon location, a direct hernia may be inguinal (in the medial fossa) or supravesical (in
the supravesical fossa).
The termination of the aponeurosis of the internal oblique muscle and the transversus abdominis muscle meet to form the "conjoined tendon" in only a very
small percentage of subjects, if in any. Because the presence of this entity is very rare, we prefer the lateral border of the rectus sheath as the landmark
for a supravesical hernia.51
SPACES BETWEEN THE INGUINAL LIGAMENT AND THE ILIOPECTINEAL LINE
Between the inguinal ligament and the superior pubic ramus is a space organized into three compartments: neuromuscular, vascular, and femoral canal (see
Fig. 9-28). The most lateral of these is the neuromuscular. This area contains the iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous
nerve.
The locations and variations of the femoral nerve have been described by Leggett and Lintz,90 Oertel,91 Ferner,92 and Gisel.93 The femoral nerve may pierce
the iliacus muscle. It may be found between the femoral artery and vein. Part of the nerve may be a fellow traveler with the superior gluteal nerve to supply
the rectus femoris and vastus lateralis. Or the femoral nerve may be found deep in the iliacus muscle. In bilateral dissection of 68 cadavers, Spratt et al.94
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the rectus femoris and vastus lateralis. Or the femoral nerve may be found deep in the iliacus muscle. In bilateral dissection of 68 cadavers, Spratt et al.94
report finding three cases of the femoral nerve being split by variant slips of iliacus and psoas major muscle.
Medial to the area containing the iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve is the vascular compartment which contains
the femoral artery and vein.
Femoral Canal and Femoral Sheath

Still more medial to the vascular compartment containing the femoral artery and vein is the compartment of the femoral canal. The femoral sheath, an
extension of the transversalis fascia of the abdomen, envelops the femoral artery, the femoral vein, and the femoral canal.
The femoral canal is the most medial of the three compartments of the sheath. It is where a femoral hernia may pass. This canal is conical, approximately
1.25 to 2.0 cm in length (Fig. 9-42). The fossa ovalis, the opening in the fascia lata for the great saphenous vein, is at its apex. Thus, a femoral hernia may
present as a bulge of the skin over the fossa ovalis.
Fig. 9-42.
Boundaries of femoral ring and femoral orifice. (Courtesy Parviz K. Amid, Alex G. Shulman, Irving L. Lichtenstein, modified.)
Berliner95 gave an anatomic explanation about the genesis of femoral hernia. He stated that if the transversus abdominis fibers insert on the superior pubic
ramus as a narrow band, then a conelike defect will develop that is primarily responsible for femoral herniation.
The femoral ring is inflexible. The transverse diameter ranges from 8 to 27 mm, and the anteroposterior diameter ranges from 9 to 19 mm. However, in 70%
of patients, these diameters are 10 to 14 mm and 12 to 16 mm, respectively.61 The boundaries are as follows:
Lateral: A connective tissue septum which interconnects the anterior and posterior sheath laminae and the femoral vein
Posterior: The iliacus fascia and the pectineal ligament of Cooper
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Posterior: The iliacus fascia and the pectineal ligament of Cooper

Anterior: The iliopubic tract (most internally) and the inguinal ligament (more externally)
Medial: The transversalis fascia, the aponeurotic insertion of the transversus abdominis muscle, and the lacunar ligament (more medially). An evagination of
preperitoneal connective tissue forms a delicate inner lining for the femoral canal.
McVay61 located the lacunar ligament at the medial margin of the femoral ring in only 8 of 362 subjects. He suggested that the aponeurosis of the
transversus abdominis is the usual boundary. Condon68 stated that either the aponeurosis or the "recurving fibers" of the iliopubic tract may form the medial
boundary.
The canal usually contains areolar connective tissue, lymph nodes, and lymphatic channels. A large node is often present at the upper end of the canal.96
This node is known as Cloquet's node to the French and Rosenmueller's node to the Germans. The distal end of the canal is closed by a tenuous fatty
tissue, the septum femorale.
Where is the site of obstruction in an incarcerated or strangulated femoral hernia: the femoral ring, or a point 1.5 cm below the ring? Lytle97 believed the
latter. He advised partial transection of the ligament of Gimbernat. We prefer partial transection of the inguinal ligament to avoid injury to an aberrant
obturator artery passing medial to the hernial sac (Fig. 9-43).
Fig. 9-43.
Femoral hernia. A, An aberrant obturator artery passes medial to hernial sac (dangerous to incise lacunar ligament). B, Aberrant obturator artery passes lateral to
hernial sac (safe to incise lacunar ligament). (Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of hernial rings. Surg Clin North Am
1974;54:1227-1246; with permission.)
Bony Elements Related to the Inguinal Area

Those parts of the pelvis and the pelvic brim related to the soft parts of the inguinofemoral area are:
Iliopectineal line
Pubic tubercle
Symphysis pubis
The iliopectineal line and the arcuate line form the terminal line (linea terminalis) of the pelvis. The iliopectineal line of the pubic bone and the pubic crest
creates the anterior part; the arcuate line of the ileum makes up the posterior part. The terminal line extends from the promontory of the sacrum to the
pubic symphysis (Fig. 9-44).
Fig. 9-44.
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Some bony elements and ligamental parts of inguinal femoral area. ASIS, Anterior superior iliac spine. PT, Pubic tubercle. (Modified from Skandalakis JE, Colborn GL,
Gray SW, Skandalakis LJ, Pemberton LB. The surgical anatomy of the inguinal area Part 1. Contemp Surg 1991;38:20-34; with permission.)
The iliopectineal line is of greater concern than the arcuate line in the anatomy of hernias for the following reasons:
Tendinous fibers of the pectineus muscle are attached to the iliopectineal line in toto
The pectineal ligament of Cooper is attached to the medial part of the iliopectineal line
The iliopubic tract inserts upon it.
At the medial end of the iliopectineal line lies the pubic tubercle. The medial portions of the lacunar ligament and the "conjoined tendon," when present,
attach to the pubic tubercle.
Blood Supply of the Inguinal Area

ARTERIES
The blood supply to the inguinal area is very rich. We do not attempt to fully describe it here, but rather to present only some aspects of it. For descriptive
purposes, it may be divided into a superficial part for the subcutaneous fat and a deeper part for the musculoaponeurotic components.
Three superficial branches of the femoral artery help supply the abdominal wall below the umbilicus, giving off rami that pass upward in the subcutaneous
connective tissue. From lateral to medial they are:
Superficial circumflex iliac artery (close to the iliac crest)
Superficial epigastric artery (at the midgroin area, with an upward vertical orientation)
Superficial external pudendal artery (inferior to the inguinal ligament at the fossa ovalis)
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Superficial external pudendal artery (inferior to the inguinal ligament at the fossa ovalis)
The superficial epigastric artery anastomoses with the contralateral artery, and all have anastomoses with the deep arteries.
Deep arteries lie between the internal oblique and transversus abdominis muscles. They are:
10th and 11th posterior intercostal arteries
Anterior branch of the subcostal artery
Anterior branches of the four lumbar arteries
Ascending branch of the deep circumflex iliac artery
The blood supply to the rectus sheath is from the superior and inferior epigastric arteries, which frequently anastomose. The inferior epigastric artery enters
the rectus sheath at or about the semicircular line of Douglas (arcuate line), between the rectus muscle and the posterior lamina of the sheath. The deep
arterial network of the abdominal wall is composed of the inferior epigastric artery and the deep circumflex iliac artery. Both originate from the distal part of
the external iliac artery.
The inferior epigastric artery gives off two branches:
External spermatic (cremasteric), which becomes part of the spermatic cord
Pubic, which crosses the ligament of Cooper and anastomoses with the obturator artery to occasionally become the aberrant obturator artery
The deep circumflex iliac artery is located outside the preperitoneal space, deep to the iliopsoas fascia, close to the iliopectineal arch. From its origin, the
deep circumflex iliac artery passes laterally, at first deep to the fascia iliaca and then beneath the iliopubic tract. Its ascending branch passes upward
vertically, just medial to the anterior superior iliac spine and between the transversus and internal oblique muscles. In laparoscopic herniorrhaphy, the deep
circumflex iliac artery is subject to injury by staples or suture placement in anchoring mesh prostheses, and results occasionally in the formation of a
hematoma.
VEINS
The veins follow the arteries. The inferior epigastric veins and the deep circumflex iliac veins, two for each artery, empty into the external iliac vein.
Beware: remember the venous circle of Bendavid88 referred to previously in the presentation on the space of Bogros.
Lymphatics of the Inguinal Area

Inguinal lymph nodes may be divided into:
Superficial nodes between the superficial fascia and the fascia lata
Deep inguinal nodes beneath the fascia lata
Aberrant inguinal nodes within the inguinal canal
SUPERFICIAL INGUINAL NODES

Superficial inguinal nodes have been divided for more than 100 years into five arbitrary zones.96,98 These zones, centered on the termination of the great
saphenous vein, are shown in Figure 9-45. They cover an area defined in Figure 9-46.
Fig. 9-45.
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Lymph node distribution around great saphenous vein and its tributaries. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General
Surgery. New York: McGraw-Hill, 1983; with permission.)
Fig. 9-46.
Boundaries of area to be included in a radical excision of inguinal lymph glands. Measurements are approximate. (Data from Daseler EH, Anson BJ, Reimann AF.
Radical excision of the inguinal and iliac lymph glands. Surg Gynecol Obstet 1948;87:679.) (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
In 450 dissections, Daseler et al.98 reported that the number of lymph nodes varied from 0-8 in zone 1, from 0-7 in zone 2, from 0-3 in zone 3, from 0-9 in
zone 4, and from 0-3 in zone 5.
Although the number of nodes is small (Daseler and colleagues98 found an average of only 8.25 nodes per leg dissected), these nodes are perhaps the
largest single group of lymph nodes in the body. The number of nodes varies from 4 to 25, and is inversely proportional to the size of the individual nodes.
Within the zones, the nodes lie along the blood vessels (see Fig. 9-45). The superolateral nodes (zone 1) extend along the superficial circumflex iliac vessels
inferior to the inguinal ligament. Haagensen and associates96 found a few above the ligament on the aponeurosis of the external oblique muscle. The
superomedial nodes (zone 2) are associated with the superficial epigastric and the external pudendal vessels as far as 1 cm above the inguinal ligament.
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superomedial nodes (zone 2) are associated with the superficial epigastric and the external pudendal vessels as far as 1 cm above the inguinal ligament.
Inframedial nodes (zone 3) were absent in 20 percent of dissected anatomic specimens examined by Daseler and colleagues;98 in 37 percent, only a single
node was present. In the inferolateral quarter (zone 4), a chain of nodes lies lateral to the great saphenous vein. A node at the junction of the great and
accessory saphenous veins is relatively constant. The central zone (zone 5) had no nodes in 84 percent of dissected anatomic specimens, and only a single
node in another 15 percent.
The area that must be included in a radical inguinal lymphadenectomy is shown in Figure 9-46. Superficial nodes from all five zones will be included in the
area outlined.
DEEP INGUINAL NODES
Two or three small nodes lie beneath the fascia lata along the femoral vein. The largest (the node of Cloquet), at the femoral ring between the vein and the
lacunar ligament, is almost always present. Metastasis to Cloquet's node, like metastasis to apical nodes of the axilla, makes the prognosis poor. All of these
nodes lie within the boundaries of the area of radical excision (Fig. 9-46).
ABERRANT NODES
Aberrant nodes include some small nodes in the inguinal canal, over the symphysis pubis, and at the base of the penis.
PATHWAYS OF LYMPH
The superficial inguinal nodes receive lymph from the entire lower limb, the infraumbilical abdominal wall, buttock, perineum, anal canal, penis, and the
scrotum or the labia and the vagina external to the hymen. Drainage from the glans penis or glans clitoridis is usually said to be to the deep inguinal nodes.
Remember
The lymphatic drainage from the testes passes superiorly with the testicular vessels and ends in the renal and preaortic nodes. It does not drain to the
inguinal nodes.
Efferent lymphatics from the superficial nodes, especially the lower nodes, pass to the deep nodes. Those from the inferior groups (zones 3, 4, and 5) pass
to superior nodes (zones 1 and 2) and then upward to the lowest iliac nodes along the external iliac vessels.
There may be significant quantities of lymphatic tissue between the lymph nodes at the femoral ring and intrapelvic lymphatic tissue near the obturator
canal. Such nodes and tissue can readily hide a large aberrant obturator artery and/or vein. Injury to such aberrant vessels can lead to profuse loss of
blood, especially if there is a "circle of death"99 formed by anastomoses between the aberrant artery and a normal obturator artery.
Nerve Supply of the Inguinal Area

We quote from Skandalakis et al:56
The ilioinguinal and genitofemoral nerves are prone to injury in laparoscopic procedures (Fig. 9-47).
Fig. 9-47.
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Nerves of inguinal region. (Modified from Gray SW, Skandalakis JE. Atlas of Surgical Anatomy for General Surgeons. Baltimore: Williams & Wilkins,
After leaving the superficial inguinal ring, the ilioinguinal nerve subdivides into: 1) large anterior scrotal or labial branches; 2) a small pubic branch to
the lower pubic area and the base of the penis or clitoris; and 3) crural branches to the upper inner thigh and inguinal crease.100
The ilioinguinal nerve was present in 97.5 per cent of 200 bodies studied by Zaluska.101 It originated from the lumbar plexus independently in 72.5 per
cent, was combined together with the iliohypogastric in 25 per cent, and was absent in 2.5 per cent. The ilioinguinal nerve was formed by one root
(usually L1; rarely, L2) in 92.5 per cent and by two roots in 5 per cent. According to Bardeen,102 the ilioinguinal nerve is composed of fibers from L1
in 89.8 per cent, arising from L1 alone in 51.5 per cent and from T12 and L1 in 38.3 per cent. In 6.6 per cent, the ilioinguinal nerve was replaced by
the genital branch of the genitofemoral nerve. Bardeen102 observed that the ilioinguinal and iliohypogastric were combined in about 15 per cent of
cases.
According to most anatomy texts (e.g., Gray's Anatomy103), the ilioinguinal nerve passes within the abdominal wall, above the iliac crest, deep to the
internal oblique to a point just medial to the anterior superior iliac spine, at which point it becomes visible between the external and internal obliques
and then passes into the inguinal canal. In our investigation, the ilioinguinal nerve crossed the iliac fossa in 25.5 per cent of cases.
The genitofemoral nerve typically divides into a femoral (lumboinguinal) branch and a genital (external spermatic) branch. The femoral branch passes
in the femoral sheath beneath the inguinal ligament, ventral or lateral to the femoral artery, and supplies the skin of the thigh in the vicinity of
Scarpa's (femoral) triangle. We have observed that the femoral branch may communicate with, or be replaced by, an intermediate femoral cutaneous
nerve arising in the iliac fossa. The genital branch exits the abdomen in the inferomedial angle of the deep ring, in company with the cremasteric
branches of the inferior epigastric vessels. Lying deep to the cremaster, it supplies that muscle and some of the skin of the scrotum. The genital
branch was frequently combined with the ilioinguinal nerve (7.7%) in the present study.
Within the deep inguinal ring the genital branch is deep medially, with the cremasteric vessels; i.e., medial in such a way that the suturing of the
crura of the internal ring is above and superficial to the position of the nerve. Therefore, entrapment of the genital branch of the genitofemoral nerve
at the deep ring should occur very rarely - perhaps just in those unusual cases in which the genital branch and the ilioinguinal nerves are combined
and therefore located more superficially. Leaving the deep inguinal ring, the genital branch is located at the lower margin of the iliopubic tract,
together with the cremasteric vessels. Entrapment and injury of the nerve can take place only with deep suturing of the iliopubic tract (see Figs. 932, 9-33).
The surgeon should also be careful not to injure the following three nerves: lateral femoral cutaneous, femoral, and anterior femoral cutaneous (a
frequent variation).
Src et al.104 reported their findings about the course of the lateral femoral cutaneous nerve. The nerve was examined bilaterally in 22 cadavers (44
nerves). Twenty-three passed as a single trunk under the inguinal ligament. Fourteen passed through the ligament with a point of passage 1.52 0.84 cm
from the anterior superior iliac spine.
Three pathways of the genital branch of the genitofemoral nerves in the inguinal canal, as reported by Akita et al.,105 are shown in Fig. 9-48.
Fig. 9-48.
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Three pathways of the genital branch of the genitofemoral nerves in the inguinal canal. A, Type I: The branches run on the superior surface of the inguinal ligament
at the deep inguinal ring. B, Type II: The genitofemoral nerve runs on the inferior surface of the inguinal ligament and a recurrent branch of the nerve pierces the
ligament to enter the canal. C, Type III: A branch of the genital branch pierces the transversus abdominis muscle, runs on the inner surface of the internal oblique
muscle, and at a lower level pierces the internal oblique muscle to enter the canal. CR, Cremaster; Fa, Femoral artery; fb, Femoral branch of the genitofemoral
nerve; gb, Genital branch of the genitofemoral nerve; gf, Genital branch of the femoral nerve; IEa, Inferior epigastric artery; IL, Inguinal ligament; OE, Obliquus
externus; OI, Obliquus internus; PB, Pubis; SC, Spermatic cord; TA, Transversus abdominis. (Modified from Akita K, Niga S, Yamato Y, Muneta T, Sato T. Anatomic
basis of chronic groin pain with special reference to sports hernia. Surg Radiol Anat 1999;21:1-5; with permission.)
Summary of the Inguinofemoral Area

There can be little question that one of the greatest students of inguinal anatomy was Dr. Chester McVay. His collective review of the subject,61 as well as
his other publications, made him the authority. Rather than paraphrase his dogma, we have chosen to reprint his summary of inguinal anatomy in his own
words.
The three musculoaponeurotic laminae of the inguinal region are covered on each of their two flat surfaces by fascial sheets. The innermost of these
six fascial plates is called the transversalis fascia and the outermost the innominate fascia; the four remaining fascial laminae have never been named.
The medial three-fourths of the inguinal ligament is a free edge when divested of its fasciae; it is not a strong cordlike structure and is only slightly
thicker than the external oblique aponeurosis. It is anchored in position by fascia from which it can be readily displaced. The lacunar ligament is not a
special triangular plaque between the inguinal ligament and the pubic pecten but merely part of the pubic insertion of mutually parallel external oblique
aponeurotic fibers. It does not form the medial boundary of the femoral ring and cannot be seen from the abdominal side of the intact inguinal region.
The external oblique aponeurosis, like the external oblique muscle, is covered on either surface by a sheet of fascia, the external one of which is the
thickest and called the innominate fascia by Gallaudet. The intercrural fibers usually lie within the substance of the fascial plane on the external
aspect of the external oblique aponeurosis, but in a few instances, some of these fibers pass between the aponeurotic fibers and continue their
course within the fascial plane on the internal aspect of the aponeurosis. The subcutaneous inguinal ring is a triangular defect with the base on the
pubic crest and the apex directed superolaterally. None of the aponeurotic fibers contribute to the external spermatic fascia; the latter is composed
entirely of the fasciae that invest the aponeurosis and fuse in the defect left by the diverging aponeurotic fibers. Intercrural fibers may be
incorporated in the external spermatic fascia.
The inguinal portion of the internal oblique muscle, including the cremaster muscle, originates from the iliopsoas fascia deep to the inguinal ligament,
not from the inguinal ligament; and the lowest fibers of the internal oblique muscle insert onto the pecten of the pubis. The muscle fibers of the
cremaster muscle usually descend well grouped together on the posterolateral aspect of the cord and lose themselves on the testicle; rarely, a few
muscle fibers can be found ascending on the medial aspect of the cord to a pubic insertion.
The inguinal portion of the transversus abdominis muscle originates from the iliopsoas fascia deep to the inguinal ligament in common with the
corresponding portion of the internal oblique and not from the inguinal ligament. The pubic insertion of the lowermost portion of the transversus
abdominis muscle is primarily onto that portion of the iliopectineal line known as the pecten. The transversus muscle and aponeurosis formed a
complete inguinal stratum in 93 percent of the 362 inguinal regions studied. The fasciae on either surface of the transversus abdominis aponeurosis
are carried out on the spermatic cord as the internal spermatic fascia and prolonged inferiorly on the femoral vessels as the anterior component of the
femoral sheath. When muscle fibers from the transversus abdominis layer are carried down on the cord, they lie within the confines of the internal
spermatic fascia and do not contribute to the cremaster layer.
Beneath the linea semicircularis, the medial continuation of the transversalis fascia splits to invest the rectus muscle. Illustrations which show the
fascia transversalis passing entirely posterior to the rectus muscle, inferior to the fold of Douglas, are not correct. In 1 percent of the specimens,
that portion of the transversus aponeurosis inferior to the linea semicircularis does not contribute to the rectus sheath but inserts directly into the
lateral aspect of the rectus muscle with an interdigitation of fibers.
The femoral sheath is a prolongation of the parietal abdominal fasciae into the thigh around the femoral vessels. It is a perfect tube, with the anterior
component a direct continuation of the fascial investments of the transversus and internal oblique muscles, although principally composed of the
transversalis fascia, and the posterior component is a slip from the iliopsoas fascia, not the iliopsoas fascia proper. Within the femoral sheath proper is
a visceral sheath continuous with the preperitoneal connective tissue.
The medial boundary of the femoral ring is the lateral edge of the aponeurosis of insertion of the transversus abdominis muscle onto the pecten of the
pubis, not the lacunar ligament.
The falx inguinalis is the lateral expansion of the rectus abdominis tendon of insertion onto the pecten of the pubis. The conjoined tendon does not
exist after careful dissection, and its falciform margin is usually an artifact of dissection. The ligamentum interfoveolare is a thickening in the
transversalis fascia at the medial side of the abdominal inguinal ring due to the reduplication of this fascial layer by the evaginated internal spermatic
fascia.
In repair of a direct inguinal hernia, the aponeurosis of the transversus and internal oblique muscles should be sutured to the fibrous ridge covering
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the pecten of the pubis, Cooper's ligament, superior pubic ligament, as far laterally as the femoral vein and not to the inguinal ligament. This will give
a firm, nonyielding repair and, in addition, obviate the occurrence of a femoral hernia. Aponeurosis, not fascia, should be the principal constituent in
the repair of any hernia.
Our respected friend Rn Stoppa and his colleagues have recently presented new information about inguinofemoral anatomy. We present two excerpts
verbatim from their works, with accompanying illustrations.
The authors have intraoperatively observed that the retroparietal components of the spermatic cord are contained within a spermatic sheath, the
patency and morphology of which have been established. Anatomical dissections have identified its relations with the inter-parieto-peritoneal fibrous
structures and the external iliac vessels. Careful preservation of this "spermatic sheath" during the mobilization of the cord is recommended to avoid
pervascular sclerosis due to contact with the large mesh prostheses used in groin hernia repairs. This is important to preserve as much sheath as
possible and may be potentially useful if a reoperation is required for vascular surgery, organ transplant, or lymph node dissection (Figs. 9-49, 9-50,
9-51).106
Fig. 9-49.
Intraoperative schematic view looking from the left towards the right side of the patient during the surgical repair of an inguinal hernia through a
midline preperitoneal approach. The intraoperative aspect of the right spermatic sheath after its separation from the peritoneum can be seen. The
sheath is triangular in shape with its contents, the vas deferens (d) at its medial border and the spermatic vessels (s) laterally. Note that the
external iliac vessels (a,v) are immediately beneath it and will be protected by the sheath after its "parietalization." (Modified from Stoppa R, Diarra
B, Mertl P. The retroparietal spermatic sheath: an anatomical structure of surgical interest. Hernia 1997;1:55-59; with permission.)
Fig. 9-50.
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Schematic anatomic aspect of the retroparietal segment of the spermatic sheath, surrounding the ductus deferens (d) and the spermatic vessels
(s). The superior layer of the sheath is thicker than its inferior layer. Note the relations between the spermatic sheath and the external iliac vessels
(a,v). (Modified from Stoppa R, Diarra B, Mertl P. The retroparietal spermatic sheath: an anatomical structure of surgical interest. Hernia 1997;1:5559; with permission.)
Fig. 9-51.
Two schematic aspects of the retroparietal segment of the spermatic sheath. Left, Narrow sheath (rare). Right, Usual lateral extension of sheath.
(Modified from Stoppa R, Diarra B, Mertl P. The retroparietal spermatic sheath: an anatomical structure of surgical interest. Hernia 1997;1:55-59;
with permission.)
A second paper includes this information:
Following an anatomic study of the spermatic sheath and in the light of anatomic dissections and frozen cadaver transverse sections, the authors
define the inferior and lateral extensions of the fascia visceralis described by Couinaud and Mathis, especially into the Bogros (spermatic sheath),
Retzius (umbilical-prevesical fascial) and retrorectal (retrorectal fascial) spaces. These points are important in hernia surgery when a large
retroparietal prosthesis is used, in urologic surgery, and in carcinologic colorectal surgery (Figs. 9-52, 9-53, 9-54).107
Fig. 9-52.
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Anterior left lateral view of right spaces of Retzius and Bogros on a cadaver dissection (left) and tracing (right), showing the pelvic part of the
urogenital fascia, its lateral expansion, its continuity in the spermatic sheath and the umbilico-prevesical fascia. 1, peritoneal sac; 2, umbilicoprevesical fascia; 3, umbilical a.; 4, vas deferens; 5, external iliac vessels; 6, large lateral expansion of the urogenital fascia; 7, spermatic vessels;
8, abdominal wall; 9, right anterior-superior iliac spine; 10, pubic region. (Modified from Stoppa R, Diarra B, Mertl P. The retroparietal spermatic
sheath: an anatomical structure of surgical interest. Hernia 1:55-59, 1997; with permission.)
Fig. 9-53.
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Anterior view of the right Bogros space and iliac fossa on a cadaver dissection (left) and photo-tracing (right). The urogenital fascia is retracted
medially to show its relations with the peritoneum and the external iliac vessels. The urogenital fascia, surrounding the right kidney, is prolonged
downward into the spermatic sheath and the umbilico-prevesical fascia. 1, peritoneal sac; 2, umbilico-prevesical fascia; 3, umbilical a.; 4, urogenital
fascia, retracted medially; 5, spermatic vessels; 6, external iliac vessels; 7, iliopsoas m.; 8, lateral femoro-cutaneous n.; 9, right kidney in its
sheath; 10, right anterior-superior iliac spine; 11, abdominal wall; 12, pubic region. (Modified from Stoppa R, Diarra B, Mertl P. The retroparietal
spermatic sheath: an anatomical structure of surgical interest. Hernia 1:55-59, 1997; with permission.)
Fig. 9-54.
Schematic posterior aspect of the anterolateral abdominal wall and spermatic sheath in the inguinal region. (Modified from Diarra B, Stoppa R,
Verhaeghe P, Mertl P. About prolongations of the urogenital fascia into the pelvis: An anatomic study and general remarks on the interparietalperitoneal fascia. Hernia 1997;1:191-196; with permission.)
Histology of the Inguinofemoral Area

Waugh and Read108 in 1972 were the first, or among the first, to study the relationship of collagen synthesis and inguinal hernia. In two later reports,
Peacock109,110 discussed the local surgical biology of patients with hernia, emphasizing metabolic connective tissue abnormalities. He stated that hernia is
the result of an imbalance between normal collagen synthesis and normal collagen degradation.
Berliner111 performed biopsies from the transversalis fascia close to the internal ring at the site of direct hernias and from normal transversus abdominis
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Berliner111 performed biopsies from the transversalis fascia close to the internal ring at the site of direct hernias and from normal transversus abdominis
aponeurosis superior to the bulge of a direct hernia. He concluded that wound healing requires a fibroblastic response and an adequate supply of oxygen to
initiate an ongoing balance of collagen synthesis and enzymatic lysis. An incision into the posterior wall of the inguinal canal that is closed and without
tension is necessary to stimulate fibroplasia where it will be useful. Sutures under tension stimulate an inadequate fibroblast response.
Physiology of the Inguinofemoral Area

The integrity of the normal inguinal canal depends upon the following:
Sphincteric action of the transversus abdominis and internal oblique muscles at the internal ring
Shutter action of the transversus abdominis aponeurosis, which forms the transversus abdominis arch.
SPHINCTERIC ACTION
The transversalis fascia (Fig. 9-55) forms an incomplete ring, like a sling, around the internal ring. It consists of a thickening forming two crura: a long
anterior crus and a short posterior crus. The anterior crus is fixed superiorly to the transversus abdominis muscle or aponeurosis and medially to the internal
ring. The posterior crus is connected to the iliopubic tract. The resulting configuration is an inverted U-shaped sling. The sling closes the internal ring under
the muscular edge of the internal oblique muscle by contraction of the transversus abdominis muscle.
Fig. 9-55.
Transversalis fascia in lateral and lower parts of abdominal cavity. (Modified from Lampe EW. The transversalis fascia. In: Nyhus LM, Condon RE (eds). Hernia (4th
ed). Philadelphia: JB Lippincott, 1995, pp. 53-57; with permission.)
SHUTTER ACTION
As the transversus abdominis and the internal oblique muscles contract concurrently, the arch formed by the aponeurosis of the transversus abdominis
muscle (Fig. 9-56) moves laterally toward the iliopubic tract and the inguinal ligament. This action reinforces the posterior wall of the canal. When the arch
fails to reach the inguinal ligament area, the patient is a candidate for herniation in any part of the inguinal or femoral area.
Fig. 9-56.
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Cross section of a strong posterior canal wall. (Modified from Lampe EW. The transversalis fascia. In: Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB
Lippincott, 1995, pp. 53-57; with permission.)
Surgical Considerations of the Inguinofemoral Area

In 1890, Bassini112 expressed the opinion, "Considering all that is written about the radical treatment of the inguinal hernia up until now, it can be somewhat
risky to try to publish more about this subject." One hundred years later, Bendavid113 could count 81 inguinal and 79 femoral operative repair techniques.
The most popular procedures for primary repair of inguinal hernias are:114
Open methods
Lotheissen-McVay or Cooper's ligament procedure: Arch is sutured to Cooper's ligament
Shouldice procedure: Imbrication of several layers of inguinal area
Nyhus procedure: Preperitoneal approach and iliopubic tract repair with or without prosthetic mesh
Lichtenstein procedure: Prosthesis placed anteriorly to avoid tension
Plug technique of Gilbert
Laparoscopic methods
Transabdominal preperitoneal (TAPP)
Intraperitoneal onlay mesh (IPOM)
Totally extraperitoneal (EXTRA)
The surgeon should employ the techniques he/she knows best.

The entities we consider to comprise the "good stuff" useful for the repair of inguinofemoral herniation are
Inguinal ligament
Lacunar ligament (Gimbernat's)
Pectineal ligament (Cooper's)
Transversalis fascia and transversus abdominis aponeurosis
Iliopubic tract
Anterior femoral sheath
Transversalis fascia crura
Conjoined area
Arch of internal oblique and transversus abdominis muscle
Laparoscopic Anatomy of the Inguinal Area

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The laparoscopic anatomy of the inguinal area from the peritoneum to the posterior surface of the myopectineal orifice of Fruchaud was detailed by Brick
and colleagues.115 Their findings of laparoscopic and open dissection of several cadavers are excerpted below (Figs. 9-57, 9-58).
Fig. 9-57.
Inguinofemoral anatomy (preperitoneal approach). Aberrant anterior femoral cutaneous nerve (A) traced through iliopubic tract, artifactually revealing inguinal
ligament (IL). D, Ductus deferens; EIA, External iliac artery; EIV, External iliac vein; F, Femoral nerve; FR, Medial border of the femoral ring, formed by the
"touchdown" of the transversus abdominis; G, Gonadal vessels; IE, Inferior epigastric vessels; IP, Iliopubic tract; L, Lateral femoral cutaneous nerve; O, Aberrant
obtuator artery; TA, Transversus abdominis muscular arch. (From Brick WG, Colborn GL, Gadacz TR, Skandalakis JE. Crucial anatomic lessons for laparoscopic
herniorrhaphy. Am Surg 1995;61:172-177; with permission.)
Fig. 9-58.
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Inguinofemoral structures seen laparoscopically in transperitoneal approach. Arrow indicates lumen of an aberrant obturator vein, avulsed at its junction with
external iliac vein. Because it was compressed by insufflation pressure, the aberrant vessel was not seen until its injury. Genital branch of genitofemoral nerve can
be seen lying on external iliac artery between gonadal vessels and ductus deferens. D, Ductus deferens; G, Gonadal vessels; IE, Inferior epigastric vessels; IP,
Iliopubic tract; PL, Pectineal ligament; TA, Transversus abdominis muscular arch. (From Brick WG, Colborn GL, Gadacz TR, Skandalakis JE. Crucial anatomic lessons for
laparoscopic herniorrhaphy. Am Surg 1995;61:172-177; with permission.)
In the majority of our laparoscopic dissections, we found it necessary to use the transperitoneal approach, at least initially, because the peritoneum
and transversalis fascia were frequently fused posterior to the rectus and were inseparable, even with the Hassan cannula or balloon inflation. This
fusion of tissue is attributable in part to the advanced age (average 74 years) and associated previous operations in such a population pool. Except
when the cadaver possessed much extraperitoneal fat, it was usually very easy to see the color and arrangement of fibers to guide us to the
identification of the transversus abdominis muscular arch and the iliopubic tract. Preperitoneal fatty tissue and membranous tissue can be reflected or
removed from these entities to expose the internal ring, gonadal vessels (male), and ductus deferens or round ligament.
In reflecting the peritoneum from the inguinal triangle, we have seen some specimens in which the medial umbilical fold was near to, or even overlaid
the lateral umbilical fold, making it somewhat more difficult to identify and clearly expose the inferior epigastric vessels. In such cases, the lateral
surface of the bladder was often nearer the internal inguinal ring than expected. This problem was worse in specimens with much extraperitoneal fat,
in which cases the bladder could not be seen immediately. In some bodies the bladder was quite dilated, extending a considerable distance above the
pubis, even though empty. It should be remembered that the lateral edge of the bladder can lie just medial to the medial umbilical ligament, near
which point the patent part of the umbilical artery supplies superior vesical branches to the bladder. If the medial umbilical ligament appears to be
more lateral than anticipated, one should guard against an unexpected encounter with, and injury to, the urinary bladder.
In most cases, it is possible to identify and protect the genital branch of the genitofemoral nerve because it lies upon, and runs parallel with, the
external iliac artery; it is often seen rather early, following the reflection of the peritoneum and fatty tissue away from the external iliac and testicular
vessels. In one case, wherein the genital branch of the genitofemoral appeared to be more than 2 mm in diameter, it proved to be a combined
ilioinguinal and genital branch which, after traversing the spermatic cord, exited the inguinal canal at the external inguinal ring, thereafter following
the normal course of distribution of the ilioinguinal nerve.
In every specimen we have dissected thus far, one or more additional nerves of varying size were found superficial to, or between, the fascial laminae
over the iliacus muscle, between the femoral branch of genitofemoral and the usual position of the lateral femoral cutaneous nerve, just medial to the
anterior superior iliac spine (Fig. 9-59). These are described briefly here to emphasize the unpredictability of the nerves which pass through the
region.
Fig. 9-59.
Anatomic features exposed in preperitoneal laparoscopic herniorrhaphy on left side, including atypical femoral cutaneous nerve and aberrant
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Anatomic features exposed in preperitoneal laparoscopic herniorrhaphy on left side, including atypical femoral cutaneous nerve and aberrant
obturator artery. Aberrant artery can be seen giving off a small branch to tissues within femoral ring before descending across pectineal ligament.
Iliopubic tract partially dissected to expose deep circumflex iliac vessels. (Modified from Brick WG, Colborn GL, Gadacz TR, Skandalakis JE. Crucial
anatomic lessons for laparoscopic herniorrhaphy. Am Surg 1995;61:172-177; with permission.)
According to texts and atlases of anatomy or surgery, the only nerve typically described just lateral to the internal inguinal ring is the femoral branch
of the genitofemoral nerve. The exposed nerve was in several cases larger than that anticipated for the femoral branch of genitofemoral nerve, which
is usually a relatively small cutaneous nerve that supplies only the skin over the region of the femoral triangle of the thigh. When the nerve was
dissected out in two cadavers, it proved to be an anterior femoral cutaneous nerve. In four cadavers, the nerve was a combination of the femoral
branch of genitofemoral and the lateral femoral cutaneous nerve. In these instances, at the point where the lateral femoral cutaneous nerve began
passage beneath the iliopubic tract, the nerve was at least two centimeters medial to the anterior superior iliac spine.
Frequently a small or medium sized, unnamed nerve (0.5-2.5 mm) was seen piercing the tract one centimeter or more lateral to the internal inguinal
ring, thereafter providing twigs to the lower part of the anterior abdominal wall musculature; in other specimens, however, nerves seen in this position
provided cutaneous supply to the anterior aspect of the thigh; in two cases, the nerve proved to be the source of an aberrant ilioinguinal nerve or
lateral femoral cutaneous nerve. In two cases, a nerve which was seen initially lying deep to the position of the femoral branch of the genitofemoral
nerve proved to be an early rising nerve to the pectineus muscle of the thigh. With two types of exceptions, the nerves identified lateral to the
external iliac artery passed through the iliopubic tract, lateral to the internal inguinal ring. The exceptions were the normal and the aberrant lateral
femoral cutaneous nerve and the early rising motor nerve to the pectineus.
Just lateral to the external iliac artery, halfway between the anterior superior iliac spine and the pubic tubercle, the femoral nerve lies in the groove
between the psoas major and the iliacus (Fig. 9-59). It is not seen unless the iliacus fascia covering is removed, even though it appears from beneath
the psoas major approximately 6 cm superior (craniad) to the iliopubic tract. The femoral nerve, like the lateral femoral cutaneous nerve, leaves the
abdomen by passing deep to the deep circumflex iliac vessels, the iliopubic tract, and the inguinal ligament. An early rising anterior femoral cutaneous
nerve lies ventral to the femoral nerve; it can course either through, or deep to, the iliopubic tract. In two cases, we have seen the nerve to the
pectineus lying just superficial to the femoral nerve. After passing beneath the inguinal ligament, this nerve coursed deep to the femoral vessels to
reach the pectineus muscle.
The deep circumflex iliac artery and vein leave the lateral aspect of the external iliac vessels just deep to, or slightly cranial to, the inferior edge of
the iliopubic tract (Fig. 9-59). In some cases, therefore, the deep circumflex iliac vessels lie deep to the inferior (posterior) one-third of the iliopubic
tract. These vessels take origin from the external iliacs at the same level, or up to several centimeters distal to the origin of the inferior epigastric
artery and vein. Because the inferior epigastrics initially curve sharply inferiorly from their origin, before ascending the anterior abdominal wall, it is
easy not to note how proximally they arise, in comparison with the deep circumflex iliac vessels.
Medial to the inferior epigastric vessels, one can usually identify without difficulty the pectineal ligament and then the medial border of the femoral
ring (Fig. 9-59). As the fatty and membranous connective tissue are cleared from this area, we always encountered iliopubic veins of varying caliber,
and in half the bodies, we noted the presence of an aberrant obturator artery that crossed the femoral ring before crossing the pectineal ligament.
The aberrant obturator artery typically provides one or more branches to the tissues within the femoral canal. The presence of such vessels, both
normal and aberrant, was usually not suspected, for it takes little connective tissue to conceal them from sight. In one case, we found a large
suprapubic tributary to the external iliac vein only after we saw the large, gaping opening where the tributary had ended before it was avulsed.
Large external iliac lymph nodes may conceal the presence of nerves just lateral to the external iliac vessels. Lymph vessels and nodes medial to the
external iliac vein can disguise the presence of suprapubic or aberrant obturator vessels. These lymphatic elements are continuous with those within
the femoral canal and, at the abdominal opening of the canal, often totally obscure an aberrant obturator artery, aberrant obturator vein, or both, of
rather large diameter.
TOPOGRAPHY
The topographic laparoscopic anatomy of the inguinal area (surgical layers, spaces, fossae, and the other anatomic entities between) is listed below.
Layers
The order of the surgical layers:
1. Peritoneum
2. Posterior lamina of the transversalis fascia
3. Anterior lamina of the transversalis fascia and the transversus abdominis aponeurosis
Spaces
The order of the surgical spaces:
1. Space of Bogros (space between the peritoneum and the posterior lamina of transversalis fascia)
2. Vascular space (space between the posterior and anterior laminae of the transversalis fascia). This includes the aponeurosis of the transversus abdominis muscle.
Fossae
The order of the fossae, from midline to periphery:
1. Supravesical
2. Medial
3. Lateral
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Each of these fossae is the potential home of a hernia.

The myopectineal orifice of Fruchaud is present at the fusion of the anterior lamina of the transversalis fascia with the transversus abdominis aponeurosis. It
is the potential site for one or a combination of inguinofemoral herniations.
O'Malley et al.116 studied the anatomy of the peritoneal aspect of the deep inguinal ring from a laparoscopic standpoint (Figs. 9-60, 9-61). They summarized
their findings as follows:
There are a number of important structures to be avoided in suturing or stapling during laparoscopic inguinal herniorrhaphy, not all of which are easily
identifiable at laparoscopy. This is particularly so of the ductus deferens. Measurements were taken of the angle made by the ductus deferens with
testicular vessels, and of the thickness of tissue in the vicinity of the internal ring into which sutures or staples are likely to be inserted. The angle
(mean SD) made by the ductus with testicular vessels was 38.6 4.4 on the right, and 48.6 7.2 on the left (P <0.05) (measurements for right
and left sides taken from different cadavers). Thickness of tissue around the ring (peritoneum, transversalis fascia and intervening connective tissue)
varies at different sites, being greatest lateral to the testicular vessels (2.2 0.4 mm) and least over the ductus (0.2 0.1 mm). The angle
measured constitutes the apex of the "triangle of doom,"117 and with its use the position of the ductus deferens may be predicted and the underlying
external iliac vessels avoided when stapling during herniorrhaphy.
Fig. 9-60.
Intraabdominal aspect of right deep inguinal ring and associated structures in lean male. CT, Tissue over conjoined area; DD, Ductus deferens (position marked by
broken white line); IEV, Tissue over inferior epigastric vessels; MUL, Medial umbilical ligament (obliterated umbilical artery); TV, Testicular vessels (position marked
by broken white line); *, Angle of Doom between ductus deferens and testicular vessels; White arrow, Apex of triangle; Sup, Superior; Inf, Inferior; Med, Medial; Lat,
Lateral. (From O'Malley KJ, Monkhouse WS, Qureshi MA, Bouchier-Hayes DJ. Anatomy of the peritoneal aspect of the deep inguinal ring: implications for laparoscopic
inguinal herniorrhaphy. Clin Anat 1997;10:313-317; with permission.)
Fig. 9-61.
Intraabdominal aspect of right deep inguinal ring and associated structures in obese male with indirect inguinal hernia. Iliopubic tract is obvious in this specimen at
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mouth of hernial sac. H, opening of large indirect inguinal hernia; DD, Ductus deferens; IPT, Iliopubic tract (position marked by broken white line); TV, Testicular
vessels (position marked by broken white line); *, Angle of Doom between ductus deferens and testicular vessels; Black arrow, Apex of triangle; Sup, Superior; Inf,
Inferior; Med, Medial; Lat, Lateral. (From O'Malley KJ, Monkhouse WS, Qureshi MA, Bouchier-Hayes DJ. Anatomy of the peritoneal aspect of the deep inguinal ring:
implications for laparoscopic inguinal herniorrhaphy. Clin Anat 1997;10:313-317; with permission.)
SUMMARY OF LAPAROSCOPIC ANATOMY

A study of the laparoscopic cadaveric anatomy of the inguinal area by Skandalakis et al.118 is excerpted here.
Figures 9-37, 9-62, and 9-63 will be the basis of orientation for the study of anatomic entities, folds, and spaces with which the laparoscopist should
be familiar.
Fig. 9-62.
Laparoscopic anatomy of inguinal area demonstrating layers, fossae, and spaces (highly diagrammatic). TF, Transversalis fascia; Tr Abd Apon,
Transversus abdominis aponeurosis; Ing Fem, Inguinofemoral; Post, Posterior; Ant, Anterior. (From Colborn GL, Skandalakis JE. Laparoscopic
cadaveric anatomy of the inguinal area. Probl Gen Surg 1995;12:13-20; with permission.)
Fig. 9-63.
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Laparoscopic topographic anatomy of inguinal region. In men, spermatic vessels join vas deferens to form spermatic cord. Unlike direct hernia,
indirect hernia presents fascial defect lateral or medial to inferior epigastric vessels. (Modified from Peters JH, Ortega AE. Laparoscopic inguinal
hernia repair. In: Hunter JG, Sackier JM, eds. Minimally Invasive Surgery. New York: McGraw-Hill, 1993; with permission.)
In the peritoneum, three fossae are formed. They are separated by folds or ligaments; these are formed by anatomic entities that elevate the
peritoneum. The fossae from the midline to the periphery are the:
Supravesical fossa (A in Fig. 9-64), between the median umbilical ligament or fold (the urachus, obliterated or not) and the medial umbilical ligament
or fold (the obliterated segment of the umbilical artery). This is the home of the external supravesical hernia.
Medial fossa ( B in Fig. 9-64), between the medial umbilical ligament or fold and the lateral umbilical ligament or fold (inferior or deep epigastric
artery and vein). This is the area in which the direct hernia is developed.
Lateral fossa (C in Fig. 9-64), lateral to the lateral umbilical ligament. Within the fossa is the deep inguinal ring, through which the indirect hernia
develops. In many cases, with the peritoneum in place, the laparoscopist also will observe two underlying anatomic entities in the male: the gonadal
vessels (bluish cordlike structures) and the ductus deferens (like a silver cord).
Fig. 9-64.
Bladder and anterior abdominal wall (posterior view). Possible pathways of external supravesical hernias shown on left; pathways of internal
supravesical hernias shown on right. A, Supravesical fossa with mouth of supravesical hernia. B, Medial fossa. C, Lateral fossa. D, Inguinal ligament.
E, Umbilicus. F, Middle umbilical ligament (obliterated urachus). G, Lateral umbilical ligament (obliterated umbilical artery). H, Inferior (deep)
epigastric artery. (Modified from Skandalakis PN, Skandalakis LJ, Gray SW, Skandalakis JE. Supravesical hernia. In: Nyhus LM, Condon RE (eds).
Hernia (4th ed). Philadelphia: JB Lippincott, 1995, pp. 400-411; with permission.)
Under the peritoneum and between the peritoneum and the posterior lamina of the transversalis fascia is the space of Bogros, which is filled with
variable quantities of preperitoneal fat. This is the area in which the laparoscopist will insert the prosthesis (see Fig. 9-37).
Another space is the area formed between the anterior and posterior laminae of the transversalis fascia; the inferior epigastric vessels are located
within this area. Occasionally, the posterior lamina is very thin and unrecognizable. Then the space of Bogros extends to the anterior lamina of the
transversalis fascia, which is the well-known "transversalis fascia." Within the lower part of the space of Bogros is the inguinal venous circle, which
has been described recently by Bendavid88 and which forms a venous network for several tributaries (see Figs. 9-35, 9-37, 9-38, 9-39).
Remember
With gas insufflation into the inguinal area, the veins collapse. The laparoscopist should, therefore, be very gentle.
After the removal of fibrofatty tissues, the laparoscopist will see the most superficial anatomic entity, the inferior epigastric vessels. With further
cleaning, the transversus abdominis muscular arch and the iliopubic tract will be seen. Both are closely related to the internal ring: the arch forms the
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cleaning, the transversus abdominis muscular arch and the iliopubic tract will be seen. Both are closely related to the internal ring: the arch forms the
superior boundary, and the iliopubic tract forms the inferior boundary of the ring (Fig. 9-65). Neither the inguinal ligament (Poupart's) nor the lacunar
ligament (Gimbernat's) can be seen from a laparoscopic standpoint. Cooper's ligament, however, will be seen at the pubic brim as a shiny white
cordlike formation.
Fig. 9-65.
After incising and retracting peritoneum, inferior epigastric vessels (the most superficial anatomic entities) are visible. Transversus abdominis
muscular arch and iliopubic tract may or may not be visible. (From Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area.
Probl Gen Surg 1995;12:13-20; with permission.)
The external iliac artery and vein are located in a deeper plane within the triangle formed by the spermatic vessels and the ductus deferens. Distally,
at the internal ring, these vessels lie to the right and left of the apex of the triangle, but, proximally in our dissections they were always within it. The
origins of the inferior epigastric and deep circumflex iliac vessels are also within this area.
Another important triangle is the myopectineal orifice of Fruchaud (see Fig. 9-23B). Its boundaries are as follows.
Superior: Arch of the internal oblique muscle and the transversus abdominis muscle
Lateral: Iliopsoas muscle
Medial: Lateral edge of rectus abdominis muscle
Inferior: Pubic pecten
The iliopubic tract divides Fruchaud's orifice into two visible parts.
Above: the spermatic cord
Below: the external iliac vessels, covered by the anterior lamina of the femoral sheath (Figs. 9-66, 9-67).
Fig. 9-66.
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After more cleaning, transversus abdominis muscular arch, iliopubic tract, and ligament of Cooper become visible. (Modified from Colborn GL,
Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Probl Gen Surg 1995;12:13-20; with permission.)
Fig. 9-67.
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After still more cleaning, spermatic cord and iliac vessels become visible. (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy
of the inguinal area. Probl Gen Surg 1995;12:13-20; with permission.)
The anterior lamina of the transversalis fascia is fused with the transversus abdominis aponeurosis forming the floor or posterior wall of the inguinal
canal. The overall anatomy of this area may be appreciated from Fig. 9-68.
Fig. 9-68.
Panoramic laparoscopic view of anatomic entities of inguinal area. (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the
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inguinal area. Probl Gen Surg 1995;12:13-20; with permission.)
Characteristically, the nerves in this area (Fig. 9-69) are located lateral to the deep inguinal ring. The vessels are located below and medial to the
ring.
Fig. 9-69.
Vessels and nerves related to iliopubic tract (highly diagrammatic). (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of
the inguinal area. Probl Gen Surg 1995;12:13-20; with permission.)
The most lateral nerve is the lateral femoral cutaneous nerve. In most cases, it leaves the iliac fossa just medial to the anterior superior iliac spine.
Superficial to the external iliac artery is the genital branch of the genitofemoral nerve. Lateral to the external iliac artery is the femoral branch of the
genitofemoral nerve. Further, but not far enough away to avoid injury, is the femoral nerve (see Fig. 9-59), which lies in the trough between the
psoas and iliacus muscles.
Several important vessels are medial to the deep inguinal ring:
Venous circle (venous network of the deep inferior epigastric vein, the iliopubic vein, the rectusial vein, the retropubic vein, and the communicating
rectusioepigastric vein)88
Inferior epigastric artery and vein
Internal and external iliac artery and vein
Rectus vessels
Suprapubic and retropubic vessels
Aberrant obturator artery and/or vein (present in 30-40% of cases)
Remember the nerves lateral to the deep ring:
Lateral femoral cutaneous nerve
Genital branch of the genitofemoral nerve

Femoral branch of the genitofemoral nerve
Femoral nerve
Remember the vessels medial to and below the deep ring:
Venous circle
Inferior epigastric artery and vein
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Muscular (rectus) vessels

Suprapubic vessels
Retropubic vessels
Aberrant obturator artery and/or vein (in 30-40% of cases)
Three danger areas are the Triangle of Doom,117 the Triangle of Pain,119 and the Circle of Death. (The originator of the term Circle of Death is
unknown to the authors, and therefore, not cited.) A discussion of these three danger areas follows.
The Triangle of Doom (Fig. 9-70) is formed by the gonadal vessels laterally and the ductus deferens medially. These anatomic entities meet at the
deep inguinal ring. Within this triangle are: external iliac vessels, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and the femoral
nerve (deep).
The Triangle of Pain (Fig. 9-71) is formed by the iliopubic tract inferolaterally and the gonadal vessels superomedially. The contents of this
imaginary triangle include several nerves, such as lateral femoral cutaneous, anterior femoral cutaneous, femoral branch of genitofemoral, and femoral
nerve.
The arterial network of the Circle of Death (Fig. 9-72) is formed by the common iliac artery, internal and external iliac arteries, obturator artery,
aberrant obturator artery, and inferior epigastric artery. The venous counterparts are similar in name, course, and position.
Fig. 9-70.
Triangle of Doom. (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Probl Gen Surg 1995; 12:13-20;
with permission.)
Fig. 9-71.
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Triangle of Pain. (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Probl Gen Surg 1995;12:13-20;
with permission.)
Fig. 9-72.
Circle of Death. (Modified from Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Probl Gen Surg 1995; 12:13-20;
with permission.)
To avoid anatomic complications to the nerves, remember that most of the nerves are located lateral to the deep inguinal ring. Avoid stapling or
suturing laterally below the level of the ring.
The lateral femoral cutaneous nerve is located lateral and deep to the iliopubic tract. The femoral branch of the genitofemoral nerve is lateral to and
parallel with the external iliac artery. To avoid injury to the femoral nerve, do not dissect the iliacus fascia lateral to the spermatic vessels and
external iliac artery.
To avoid complication to the vessels, use the inferior epigastric vessels to guide you to the great vessels, which are located below and medial to the
deep ring. Carefully avoid the great vessels, since injury could cause fatal bleeding. To avoid ischemic orchitis, be sure not to injure the gonadal
vessels, which travel toward the deep inguinal ring. The deep circumflex vessels are located parallel, but deep, to the iliopubic tract.
To avoid complications to the organs, you can protect the urinary bladder by identifying it. To locate it, find and follow the medial umbilical ligament.
Avoid dissection medial to the ligament. Avoid injury to the ductus deferens in its course toward the internal ring. This is of utmost importance in
bilateral herniorrhaphy repair, because sterility can result.
Remember
In approximately 30% of cases, the laparoscopic anatomy of one side will not be a mirror image of the other side.
Posterior (Lumbar) Wall

Anatomy and Topographic Relations
Anatomically speaking, the posterior abdominal wall is formed by one muscle, the quadratus lumborum muscle. In the realm of treatment of retroperitoneal
pathology and repair of lumbar hernias (Fig. 9-73A,C), one may also speak of a "surgical" posterior lumbar wall. From inside to outside (from peritoneum to
skin) (Fig. 9-73B), the surgical posterior lumbar wall comprises the following anatomic entities:
1. Peritoneum
2. Extraperitoneal membranous connective tissue and fat
3. Transversalis fascia
4. Deep muscular layer (quadratus lumborum muscle and psoas muscle)
5. Middle muscular layer (sacrospinalis, internal oblique, and serratus posterior inferior)
6. Thoracolumbar fascia (posterior, middle, and anterior)
7. Superficial layer (composed posterolaterally by the latissimus dorsi muscle and anterolaterally by the external oblique muscle)
8. Superficial fascia (formed by two layers of fibrous tissue with thin or thick adipose tissue between them)
9. Tough skin
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9. Tough skin
Fig. 9-73.
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A: Left, Inferior hernia through Petit's triangle; base of triangle formed by iliac crest; right, superior hernia through Grynfeltt's triangle; base of inverted triangle
formed by 12th rib. B, Diagrammatic cross section through posterior body wall in lumbar region. Pathway of superior lumbar hernia indicated by arrow. C-1, Hernia
through inferior lumbar triangle. C-2, Normal relations of descending colon and left posterior abdominal wall in cross section. C-3, Herniation of descending colon
through inferior lumbar triangle. 1, External oblique muscle; 2, Internal oblique muscle; 3, Transversus abdominis muscle; 4, Psoas muscle; 5, Quadratus lumoborum
muscle; 6, Latissimus dorsi muscle; 7, Sacrospinalis muscle; 8, Posterior layer of thoracolumbar fascia; 9, Anterior layer of thoracolumbar fascia; 10, Transversus
abdominis aponeurosis. (A, B Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The
Embryological and Anatomical Basis of Surgery. New York: Parthenon, 1996; with permission. C Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical
anatomy of hernial rings. Surg Clin North Am 1974;54:1227-1246; with permission.)
Remember
The posterior and middle layers envelop the sacrospinalis muscle. The middle and anterior layers envelop the quadratus lumborum.
The middle layer continues laterally to the aponeurosis of the transversus abdominis muscle by fusion of all 3 layers.
Is the transversus abdominis aponeurosis part of the thoracolumbar fascia? Most likely.
SUPERIOR LUMBAR TRIANGLE (GRYNFELTT)

The larger superior triangle is inverted (apex pointing downward) and is more constant. The superior triangle is related to the 12th thoracic and first lumbar
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The larger superior triangle is inverted (apex pointing downward) and is more constant. The superior triangle is related to the 12th thoracic and first lumbar
nerves. For all practical purposes, it is avascular. The boundaries of the superior triangle are:
Anterior (abdominal): posterior border of the internal oblique muscle
Posterior (lumbar): anterior border of the sacrospinalis muscle
Base: 12th rib and the serratus posterior inferior muscle
Roof: external oblique and the latissimus dorsi muscles
Floor: aponeurosis of the transversus abdominis, formed by the union of the layers of the thoracolumbar aponeurosis
INFERIOR LUMBAR TRIANGLE (PETIT)

The smaller inferior triangle is upright (apex pointing upward). It is less constant and more vascular. Its boundaries are:
Anterior (abdominal): posterior border of the external oblique muscle
Posterior (lumbar): anterior (lateral) border of the latissimus dorsi muscle
Base: iliac crest
Roof: superficial fascia
Floor: internal oblique muscle, with contributions from the transversus abdominis muscle and the posterior lamina of the thoracolumbar fascia and the internal
oblique muscle
The two triangles may be compared as follows:

Superior Triangle
Inferior Triangle
Inverted triangle (apex down)
Upright triangle (apex up)
Larger
Smaller
More constant
Less constant
More common site of lumbar hernia
Less common site of lumbar hernia
Related to 12th thoracic nerve and first lumbar nerve
No nerves
Avascular
Vascular
Covered by latissimus dorsi muscle
Covered by superficial fascia and skin
Floor: union of the layers of the thoracolumbar fascia to form the aponeurosis of the
transversus abdominis
Floor: thoracolumbar fascia, internal oblique muscle, and partially by

transversus abdominis
Surgical Considerations of the Posterior Wall

Differential diagnosis between lipoma and lumbar hernias must be made.
PHYSIOLOGY OF THE ABDOMINAL WALL

The four flat, paired muscles of the abdominal wall are involved in many physiologic actions. The more obvious functions include flexion, extension, and
rotation of the trunk and pelvis. These muscles also participate in respiration, defecation, micturition, parturition, and the mechanisms of the inguinal canal.
In 1535, Andrs de Laguna1 observed, "This part of the body has eight (sic) muscles by means of which it can attract, retain, concoct, expel and perform
many other natural functions."
INCISIONS OF THE ABDOMINAL WALL
Principles
Maingot 120 stated three requirements for a proper abdominal incision:
accessibility
extensibility
security
Improved anesthesia resulting in increased relaxation, development of stronger suture materials, and improved operating room technique have greatly
enabled the surgeon to achieve these requirements with less trauma to the patient.
Before an incision is made, it must be planned. Some general considerations are:
probable accuracy of the diagnosis
necessity for speed
habitus of the patient
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We recognize that the personal preference of the surgeon and, more importantly, how he or she was trained, are powerful factors in deciding the type of
incision to be undertaken. Also remember Keeney's121 dictum, "Pray before surgery, but remember: God will not alter a faulty incision."
Keeping these considerations in mind when selecting an incision, there are a number of other factors to take into account. The following rules should be
observed where they apply:
The incision should be adequate: long enough for good exposure and for room to work, but short enough to avoid unnecessary complications.
Skin incisions should follow Langer's lines where possible.
Incisions parallel with existing scars should be avoided. The existing scar should be excised before proceeding.
Muscles should be split in the direction of their fibers rather than transected. An exception is the rectus muscle, which may be transected because it has a
segmental nerve supply. There is no risk of denervation.
The openings formed through the different layers of the abdominal wall should not be superimposed.
Cutting of nerves should be avoided wherever possible.
Muscles and abdominal organs should be retracted toward, not away from, their neurovascular supply.
Drainage tubes (Penrose or other) should be inserted in separate small incisions, not in the main incision. They may weaken the wound.
Cosmetic considerations must be given close attention, but Maingot's 120 principles must not be sacrificed.
The varieties of abdominal incisions are legion (Fig. 9-74). Some have descriptive names; others are eponymous. Few surgeons can deny a secret wish to
have an incision, an instrument, or a procedure named for them.
Fig. 9-74.
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Varieties of abdominal incisions. A, Midline (linea alba) incision. B, Paramedian (rectus) incision with muscle retraction. C, Subcostal incision. D, McBurney incision. E,
Transverse abdominal incision. F and G, Two types of thoracoabdominal incisions. H, Paramedian (rectus) incision with muscle splitting. I, Pararectus incision. J,
"Hockey stick" (thoracoabdominal) incision. (A-I Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission. J Modified from Skandalakis JE, Skandalakis PN, Skandalakis LJ. Surgical Anatomy and Technique: A Pocket Manual (2nd ed.)
New York: Springer-Verlag, 2000; with permission.)
We like the statement by W. Robert Rout 122 in his chapter on abdominal incisions. He states that some descriptions of incisions have "been omitted here
either because of ignorance, because they are obsolete or little used, or because they are modifications of those described." Among those that we have
omitted are the so-called alphabetical incisions, which have a distorted resemblance to certain alphabetical characters. The only incision of this type that is
commonly used is the T incision.
Incisions of the Anterior Abdominal Wall

Careful excision of the scar is important in approaching the peritoneal cavity through a previous surgical incision. The excision of unsightly scars with
subsequent meticulous closure of the skin by subcutaneous sutures ensures a better cosmetic appearance of the scar. Consideration should be given to
making the new incision away from the scar of the previous operation when there is reason to suspect the presence of underlying attached intestine.
However, reopening a previous incision may be appropriate if it is placed to ensure adequate exposure for the management of the anticipated diagnosis, or if
it is weakened by a postoperative hernia, which should be repaired.Robert M. Zollinger123
Vertical Incisions
UPPER MIDLINE INCISION AND EXTENSIONS
Upper midline incisions of the linea alba and the transversalis fascia (Fig. 9-75) may reveal abundant and well-vascularized fat in the upper midline. We
suggest that incisions of the peritoneum be made slightly to the left of the midline to avoid the ligamentum teres in the edge of the falciform ligament. If the
ligamentum teres is encountered, it may be ligated and divided.
Fig. 9-75.
Vertical incisions. A, Incision through linea alba. B, Incision through rectus muscle (paramedian), splitting muscle. C, Incision lateral to rectus sheath (pararectus).
Segmental nerves to rectus muscle (dashed line) will be cut. 1, Skin; 2, Three flat muscles and their aponeuroses; 3, Transversalis fascia; 4, Peritoneum; 5, Rectus
abdominis muscle; 6, Linea alba. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983;
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with permission.)
As soon as the linea alba is incised, mark the opposite sides of the incision with 0 nonabsorbable suture. This ensures accurate realignment during closure.
Close the linea alba from above downward, or perhaps from caudal to cranial. Be sure to suture the linea alba rather than the fascia of the external oblique
(Gallaudet). This avoids an iatrogenic hernia.
Feasible extensions include the following:
An upper midline incision can be enlarged upward by removal of the xiphoid process and upward extension of the peritoneal opening. This widens the operative
field from about 6 cm to 10 cm or more 124 (Fig. 9-76). A similar extension with removal of the xiphoid process and extrapleural splitting of the sternum was used by
Wangensteen 125 to provide access to the upper margin of the liver, vena cava, and hepatic veins, as well as the gastroesophageal junction (see Fig. 9-74G).
The midline incision can be continued laterally through the lower costal cartilages. The cartilages can then be scraped and resected. The pleura is not entered.
A thoracic extension of a midline abdominal incision can be made through the 8th intercostal space as far as the scapula.126 In this procedure, the midline incision
is exploratory. The need for the thoracic extension depends on the pathology revealed by exploration.
Sternal splitting can be used to continue the midline incision upward. The anesthesiologist must be prepared for an intentional or unintentional opening of the
pleural cavity.
A lateral extension to one or even both sides can be L- or T-shaped. It involves transection of the rectus muscle. As in thoracic extensions, this procedure is
required when unsuspected, laterally-placed lesions are found. Had the lesions been anticipated, the transverse incision alone would have been sufficient.
A downward continuation of an upper midline incision is always an available option.
Fig. 9-76.
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Increased abdominal exposure by excision of xiphoid process. Left, Upper midline abdominal incision. Right, Usual exposure of about 6 cm (broken lines), and 10-11
cm exposure obtained after excision of xiphoid process (solid lines). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General
Surgery. New York: Mc Graw-Hill, 1983; with permission.)
LOWER MIDLINE INCISION AND EXTENSIONS

Techniques for a lower midline incision are a little different from those of an upper midline incision. The surgeon will find some anatomic differences between
the midline above and below the umbilicus. The linea alba is narrow and more difficult to identify below. Remember that the bladder must always be
decompressed by catheterization prior to surgery. Marking stitches should be placed to preserve proper alignment during closure.
Feasible extensions include the following:
An upward extension of a lower midline incision is always available to the surgeon. The incision should go around the umbilicus to the left to avoid the ligamentum
teres.
Lateral extensions are the same as the upper midline extensions previously described.
Downward extension of the incision is not possible.
Occasionally, the anatomy of the umbilicus permits a transumbilical extension. The surgeon must be sure the umbilical folds are clean.
RECTUS (PARAMEDIAN) INCISION AND EXTENSIONS
The rectus (paramedian) incision (Fig. 9-75B) is preferred by the surgeon who wishes to close the abdominal wall in layers. It does not destroy muscle tissue
or nerves. The rectus muscle should be retracted laterally to prevent tension on vessels and nerves (Fig. 9-77). Tendinous inscriptions may be encountered,
especially in the upper abdomen, and must be incised. Drains must be placed in a separate incision.
Fig. 9-77.
Incision through the rectus sheath without muscle splitting. A, Lateral retraction of rectus muscle following incision of anterior layer of sheath. B, Release of traction
allows intact muscle to bridge incision through sheath (compare with Fig. 9-75B). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in
General Surgery. New York: McGraw-Hill, 1983; with permission.)
NOTE: Among 70 instances of wound dehiscence reported by Haddad and Macon,127 16 percent could be attributed to the presence of drains in the main
incision.
Feasible extensions are similar to those previously described for midline incisions.
PARARECTUS INCISION (KAMMERER-BATTLE)
The pararectus incision (Kammerer-Battle) (Fig. 9-75C) is made along the lateral border of the rectus sheath. It is undesirable because it cuts across the
nerve supply to the rectus muscle. The blood supply from the inferior epigastric artery also may be compromised.
There are no feasible extensions of the pararectus incision, because further injury to nerve and blood supply would result.
MIDRECTUS (TRANSRECTUS) INCISION
The right or left midrectus (transrectus) is a vertical incision that splits the rectus muscle. It is not recommended because innervation and blood supply are
compromised.
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compromised.
COMPARISON OF VERTICAL INCISIONS

Guillou and associates128 compared the complications of three types of vertical incisions: in the midline, through the rectus abdominis muscle (medial
paramedian), and lateral to the muscle (lateral paramedian). The lateral paramedian incision took longer to perform and had more infections, but it resulted in
fewer incisional hernias than the other two incisions. Guillou et al.128 concluded from their study of 207 operations that the lateral paramedian incision is the
best of the vertical incisions.
Transverse Incisions
In transverse incision, both the rectus sheath and muscle are incised.
UPPER ABDOMINAL TRANSVERSE INCISION
The rectus muscle is transected during an upper abdominal transverse incision. If the incision involves only a short portion of the oblique muscles, they can
be split. If the incision extends farther laterally, the flat muscles may be incised along the line of the skin incision. There will be no weakness of the
abdomen.
LOWER ABDOMINAL TRANSVERSE INCISION
Both rectus abdominis muscles are incised, and perhaps also right or left flat muscles. The lower abdominal transverse incision is not recommended because
exposure of the peritoneal cavity is poor, and postoperative incisional herniation is possible.
ROCKEY-DAVIS INCISION
The Rockey-Davis incision is a transverse incision from the anterior superior iliac spine to the lateral border of the right rectus muscle. It is very frequently
used.
PFANNENSTIEL INCISION
The Pfannenstiel transverse abdominal incision (Fig. 9-78) is made horizontally just above the pubis. The anterior rectus sheaths and the linea alba are
transected and reflected upward 8 to 10 cm. The rectus muscles are retracted laterally, and the transversalis fascia and the peritoneum may be cut in the
midline. The iliohypogastric nerve must be identified and protected.129
Fig. 9-78.
Pfannenstiel transverse abdominal incision showing iliohypogastric nerve between internal oblique muscle and external oblique aponeurosis just lateral to border of
rectus muscle. (Modified from Grosz CR. Iliohypogastric nerve injury. Am J Surg 1981;142:628; with permission.)
The limited exposure of the pelvic and lower peritoneal cavities provided by the excellent Pfannenstiel incision makes repair very difficult for injuries of the
ureters, urinary bladder, and small and large bowel; however, these complications are rare.
Salgado et al.130 report that the Pfannenstiel incision makes possible a complete and successful harvest of the rectus abdominis muscle for tissue
reconstruction purposes.
MODIFICATIONS
There are several modifications such as lateral upper abdominal transverse incision (Singleton), transverse midabdominal incision, and left transverse incision
for abdominoperineal procedure (Coller).
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FEASIBLE EXTENSIONS
All the transverse incisions may be extended in the midline. The lower abdominal incision may be extended laterally by dividing the tendinous attachment of
the rectus muscle to the pubis. Lateral extension also may be attained by leaving the rectus muscle attached but retracting it medially and splitting the
muscles of the anterolateral wall. This usually requires ligation of the inferior epigastric vessels. Extension too far laterally may jeopardize the nerves (Fig. 979). Transverse incisions carried too far laterally may cut the iliohypogastric nerve. Inguinal incisions may injure the ilioinguinal nerve directly, or it may
inadvertently be included in a suture during closure of the incision.
Fig. 9-79.
Courses of the iliohypogastric and ilioinguinal nerves. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission.)
Oblique Incisions
SUBCOSTAL INCISION AND EXTENSIONS
During a subcostal incision the rectus sheath is incised transversely. The rectus muscle is cut, and the external oblique muscle is split and retracted. The
incision should extend laterally no farther than necessary in order to avoid cutting intercostal nerves. The operator usually sees the small 8th and the larger
9th nerves. The latter should be retracted and preserved.
The external oblique, internal oblique, and transversus abdominis muscles usually can be split. Occasionally, the external oblique fibers must be cut laterally
and downward.
Lipton and colleagues131 discussed the advantages of a costal incision "two finger breadths above and parallel to the right costal margin" from the midline to
the right axillary line. They reported a better exposure for biliary tract procedures with no postoperative wound dehiscence or incisional hernia in 181
patients followed for 2 years. However, a subcostal incision two fingerbreadths below and parallel to the right costal margin is the incision most frequently
used.
An oblique incision can be extended laterally to the contralateral side of the body or to the same side by following the costal arch and avoiding the nerves.
It can be extended upward or downward on the linea alba. It can be extended obliquely upward through the costal arch if it is necessary to convert it to a
thoracoabdominal incision.
MCBURNEY (GRIDIRON) INCISION AND EXTENSIONS
The McBurney (gridiron) incision requires incising the skin for a distance of about 8 cm, starting 4 cm medial to the right anterosuperior spine and extending
downward on a line from the spine to the umbilicus. The aponeurosis of the external oblique muscle and the internal oblique and transversus abdominis
muscles are split in the direction of their fibers. The iliohypogastric nerve, deep to the internal oblique muscle, must be identified and preserved.
A McBurney incision can be extended upward and laterally for several centimeters without cutting muscles. Medial extension requires transecting the rectus
sheath and muscle. In some instances, it is easier to close the incision and make a new one.
RIGHT OR LEFT LATERAL OBLIQUE (KOCHER)
This is an oblique incision from the tip of the right or left 10th rib to the pubic crest.
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This is an oblique incision from the tip of the right or left 10th rib to the pubic crest.
Incisions of the Inguinofemoral Area

INCISIONS ABOVE THE INGUINAL LIGAMENT
Incisions above the inguinal ligament include the oblique inguinal, 2-3 cm above and parallel to the ligament, and the transverse inguinal, gently curved
(following the lines of Langer, if possible) approximately 3 cm above the inguinal ligament.
INCISIONS BELOW THE INGUINAL LIGAMENT
Transverse and vertical incisions below the inguinal ligament are made just above the femoral swelling.
OTHER INCISIONS
Several other incisions are used. These include a lower midline incision without entering the peritoneal cavity, a low inguinal groove for indirect inguinal
hernia in girls,132 and several modifications of vertical or transverse incisions.
Incisions of the Posterior (Lumbar) Abdominal Wall

There are several varieties of incisions for exploration of the posterior (lumbar) abdominal wall, as well as various modifications. There is also confusion in the
literature regarding the terminology and topographic anatomy of lumbar incisions. The surgeon must be familiar with topographic local anatomy, must choose
an incision with which he or she is familiar, and must tailor the incision to the underlying pathology.
Lumbar incisions should be extraperitoneal, extrapleural, and subdiaphragmatic. They should have sufficient length and be as high as possible. Rolnick133
presented sound advice: "Small incisions are inadequate and dangerous. Yet, on the other hand, it is an error to make a very large incision which almost
'quarters' the patient."
Several incisions described in the literature:
Oblique incision of Bergman-Israel
Vertical incision of Simon-Czerny
Transverse incision of Pean
Trapdoor incision of Bardenheuer
Rib removal incision
Israel-Mayo incision
Presman interspace incision
Negamatsu incision
It is not within the scope of this chapter to present all the above incisions in detail, but a few will be described briefly.
Oblique Incision
The oblique incision (Figs. 9-80B, 9-81) is the one most frequently used by urologists. It proceeds from the kidney angle (lateral border of sacrospinalis
muscle and 11th rib) to the anterior superior spine. The following anatomic entities are incised: skin, subcutaneous fat and fascia, latissimus dorsi muscle,
serratus posterior inferior, external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, and preperitoneal fat.
Fig. 9-80.
Posterior approaches to kidney. A, Vertical incision. B, Oblique incision. (Modified from Decker GAG, du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical
Anatomy. Bristol: Wright, 1986; with permission.)
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Fig. 9-81.
Danger of opening pleura by oblique kidney incision when 12th rib does not project beyond outer border of sacrospinalis.
Vertical Incision
The vertical incision (Figs. 9-80A, 9-82, 9-83, 9-84, 9-85) proceeds along the lateral border of the sacrospinalis from the 12th rib to the iliac crest in a
perpendicular orientation. The following anatomic entities are incised: skin, subcutaneous fat and fascia, latissimus dorsi, serratus posterior inferior,
thoracolumbar fascia (3 layers), fascia transversalis, and preperitoneal fat.
Fig. 9-82.
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Anatomic structures encountered in exposing kidney by vertical incision along outer border of sacrospinalis (kidney capsules not shown). (Modified from Decker GAG,
du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy. Bristol: Wright, 1986; with permission.)
Fig. 9-83.
First layer of muscles to divide in lumbar approach to kidney. Incision shown in blue. (Modified from Rolnick HC. Genito-urinary surgery. In: Thorek M (ed). Surgical
Errors and Safeguards (5th ed). Philadelphia: JB Lippincott, 1960; with permission.)
Fig. 9-84.
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Second layer, showing relation of incision (blue) in lumbar approach to kidney and to division of internal oblique muscle. (Modified from Rolnick HC. Genito-urinary
surgery. In: Thorek M (ed). Surgical Errors and Safeguards (5th ed). Philadelphia: JB Lippincott, 1960; with permission.)
Fig. 9-85.
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Third layer, showing relation of incision (blue) for lumbar approach to kidney and to transversalis fascia and muscle. (Modified from Rolnick HC. Genito-urinary
surgery. In: Thorek M (ed). Surgical Errors and Safeguards (5th ed). Philadelphia: JB Lippincott, 1960; with permission.)
Thoracoabdominal Incisions
The thoracoabdominal incision has had many proponents and critics since its inception approximately 100 years ago.134-138 Detractors have noted as
possible problems the occurrence of chest wall instability and increased pain following transection of the costal arch.
Today, many surgeons struggle unnecessarily to do difficult procedures transabdominally that could more easily be performed through a thoracoabdominal
incision. This procedure is probably underutilized. Moreover, the thoracodabdominal incision is often misused in operations on the esophageal hiatus or
fundus. These are better approached transthoracically without abdominal extension. However, when proper indications exist, the thoracoabdominal incision
offers superb exposure of the upper abdomen through the widely-opened diaphragm and allows for retraction of the costal cage. Depending upon the side
chosen, this approach can also be used to perform right liver lobe resections, resections of the distal esophagus and proximal stomach, and procedures of
the descending aorta.
In the more commonly used left thoracoabdominal approach, the incision extends from a point on the posterior axillary line near the inferior angle of the
scapula and runs in the seventh or eighth intercostal space (Fig. 9-86). It then crosses the costal margin and rectus muscle obliquely in a line toward the
umbilicus. The incision then continues down the linea alba toward the pubis. If further posterosuperior exposure is necessary, the incision may traverse the
serratus anterior and latissimus dorsi muscles for even greater exposure. The thoracic and abdominal portions of the incision can be tailored to suit a
particular procedure.
Fig. 9-86.
Seventh or eighth intercostal space incision crosses costal margin obliquely and extends down midline to the pubis. (Modified from Lumsden AB, Colborn GL,
Sreeram S, Skandalakis LJ. The surgical anatomy and technique of the thoracoabdominal incision. Surg Clin North Am 1993;73:633-644; with permission.)
Closure begins with reapproximation of the diaphragm, employing interrupted nonabsorbable sutures. Care is required to include all three layers (pleura,
diaphragm, and peritoneum). Pericostal figure-of-eight sutures are placed around the ribs at their superior margins, but are left untied. After inserting a
chest tube, the pericostal sutures are tied, and the costal arch is sutured. The viscera are returned to their appropriate positions, and the abdomen is
closed.
ANATOMIC COMPLICATIONS OF ABDOMINAL INCISIONS
Anatomic Complications of Anterior Abdominal Incisions

Hemorrhage, hematoma formation, ischemia, seroma, infection, herniation, and other complications are possible with any surgical incisions. Additionally, in
the abdomen incisions may lead to dehiscence and evisceration or incisional hernia, as shown in Table 9-7.
Table 9-7. Summary of Anatomic Complications of Abdominal Incisions
Procedure
Vascular Injury
Nerve Injury
Organ Injury by
Perforation
Inadequate Procedure
All abdominal
incisions
Hemorrhage
Muscle paralysis
Abdominal viscus
Evisceration
Hematoma
Neuroma formation
Dehiscence
Ischemia
Upper midline incision None
Incisional hernia
None
Abdominal viscus
Too short an incision may be extended upward and
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Upper midline incision None
None
Lower midline
incision
None
Rectus incision

Abdominal viscus

downward
None
Bladder
Too short an incision may be extended upward
None, with lateral retraction
None, with lateral retraction
Abdominal viscus

downward
Pararectus incision
Ischemia of medial portion of

rectus
Injury to nerve supply to rectus

muscle
Abdominal viscus
Too short an incision may be extended
Upper transverse
incision
Superior epigastric artery
Injury to more than one nerve
Abdominal viscus
Too short an incision may be extended
Lower transverse
incision
Inferior epigastric artery
Iliohypogastric nerve
Bladder
Limited lateral extension possible
Subcostal incision
Hemorrhage
8th and 9th intercostal nerves
Abdominal viscus
May be extended in abdominal midline or chest wall
McBurney incision
Hemorrhage
Iliohypogastric nerve
Abdominal viscus
May be too small
Thoracoabdominal
incision
Hemorrhage
Intercostal nerves
Abdominal viscus
Ilioinguinal nerve
Ischemia of skin flap with T

incisions
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983, p. 301; with permission.
There are repeated reports of herniation through a small abdominal wall incision for insertion of a Penrose drain, laparoscope, or trocar. Munk and Kjer139
reported omental herniation after laparoscopy. Sinus formation secondary to suture granuloma is less important; as soon as the suture is removed, the sinus
will heal spontaneously.
Nerve Injury
Specific incisions may result in nerve injury with muscle paralysis or painful neuroma formation. McGuire140 reported that pain is greatest in vertical midline
and paramedian incisions. This is due to traction from both sides of the oblique muscles. Pain was reported to be less with transverse or oblique incisions.
However, if pain continues, nerve entrapment and neuroma is the most probable cause.
A rare phenomenon is muscular atrophy secondary to injury of the nerves that innervate the three flat muscles and the rectus abdominis muscle.
Stulz and Pfeiffer141 observed that two nerves of the lower abdominal wall, the iliohypogastric and the ilioinguinal (see Fig. 9-79), were especially subject to
incisional injury. These nerves and their injuries are discussed below.
The iliohypogastric nerve gives off a cutaneous branch. This emerges from the internal oblique muscle and passes medially under the aponeurosis of the
external oblique muscle above the internal inguinal ring. It supplies the skin of the groin and the pubic symphysis. This nerve may be injured during
appendectomy or a Pfannenstiel incision by retraction of the edges of the split internal oblique and transversus abdominis muscles.129
The ilioinguinal nerve lies parallel with and below the iliohypogastric nerve and parallel with and above the inguinal ligament. It frequently penetrates the
internal oblique entities (muscle, fascia or aponeurosis) just medial to the anterior superior iliac spine. Thereafter, it passes between the internal oblique
muscle and the external oblique aponeurosis to reach the superficial inguinal ring. Cutaneous branches supply a narrow band of skin of the inguinal region,
the anterior scrotum or labium, the root of the penis, and a small area of the anteromedial skin of the upper thigh. Injury to the ilioinguinal nerve can result
from splitting and retracting the external oblique aponeurosis or from sutures placed through the aponeurosis during closure of the incision.
Dehiscence
Haddad and Macon127 reviewed records of over 18,000 abdominal procedures and found 70 cases of postoperative wound dehiscence (0.4 percent). The
greatest single predisposing factor was obesity of the patient (40 percent). Prolonged ileus or bowel obstruction (35 percent) and wound infection (33
percent) were other important factors.
The relationship between the technique of wound closure and wound dehiscence was examined by Sanders and DiClementi.142 They concluded that the
cause of dehiscence is not poor quality of the tissue but the improper use of sutures. Dehiscence can be caused by selecting sutures with too small a bite
or by placing them too far apart or tying them too tightly. We agree with these authors in principle, but the condition of the tissues is also important.
Hypoproteinemia does not encourage wound healing. In patients whose protein intake is at all questionable, hyperalimentation is recommended.
In contaminated cases, secondary closure of the skin 4 to 5 days later is a mature surgical decision. The sutures at the initial closure may be placed but not
tied until later.
Greenall and associates143 in Great Britain reported that although transverse incisions are more time-consuming and cause more bleeding, there was no
dehiscence and only two incisional hernias among 281 such operations. In a comparable group of 276 midline incisions, there were 2 cases of dehiscence and
9 incisional hernias.
Studying the mechanical stress on the rectus muscle, Nilsson and colleagues144 found that 8 weeks after operation, the muscle had regained its normal
preoperative strength. They concluded that if incisional rupture occurs, it will occur soon after the operation.
According to McGuire,140 dehiscence and evisceration of major laparotomy incisions occur at a rate of 0.5%. He recommended multilayered transverse and
paramedian incisions instead of midline incisions. Although statistics may point to a higher occurrence of evisceration with midline incisions, there is no
concrete evidence that this type of incision will lead to dehiscence or evisceration in an adult.
The authors of this chapter believe that predisposing factors such as obesity, chronic cachexia, or postoperative abdominal distention are more likely to be
implicated in this tragic phenomenon than faulty technique during closure of the abdominal wall.145,146
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To avoid dehiscence and evisceration, we advise the following:

Use nonabsorbable sutures.
Use good technique. Anatomic approximation of the fasciae should be carried out without tension.
In our experience, a combination of interrupted and continuous sutures is the best approach.
Use retention sutures to avoid evisceration.
With intact fascia, use packing.
The patient should be taken to the operating room immediately when repair is indicated.
Use nasogastric suction.
Avoid tying the suture too tightly; local ischemia can result from overly tight sutures.
In differential diagnosis for incisional hernia, consider both bona fide herniation and bulging which occurs secondary to partial muscular paralysis. The
surgeon should avoid cutting the nerve supply of the muscle involved. It is important to be as certain as possible that nerves are not incorporated within
the line of suturing. To avoid painful neuroma, any nerves that must be divided should be buried far from the site of future formation of the scar.
Incisional hernias should be repaired as soon as possible after the initial "normal" inflammatory process is over. Any delay in surgery means dangerous
widening of the incisional hernia and ring. The surgeon should avoid suturing the scar of the hernia ring. All scar tissue, suture material (if any), or
granulation tissue should be debrided. Closure should be done by using fresh tissue, not scar tissue. Prosthetic mesh should be used as necessary.
The following is a summary of the most important aspects of incisional hernias presented by Dr. George Wantz152 at a symposium on the subject.
. . .Major incisional hernias of the abdominal wall are hernias with a repairable parietal defect greater than 10 cm. Major incisional hernias are often
associated with obesity, hytertension, and diabetes, and usually are formidable and intimidating surgical problems. As the hernia enlarges there
occurs: respiratory insufficiency, atrophy and ischemic infected ulcerations of the skin overlying the hernia sac, retraction and atrophy of the lateral
abdominal muscles which thereby enlarge the parietal defect, and loss of the right of visceral domain within the abdominal cavity. Preoperative
pneumoperitoneum may be very beneficial. It stretches the abdomen and intraabdominal adhesions, strengthens the diaphragm, and allows reduction
of the contents of the hernia sac without causing the often fatal abdominal compartment syndrome.
The objectives of incisional hernioplasty are to close the parietal defect and to reattach in the midline the tendons of the retracted lateral abdominal
muscles. Two techniques that acccomplish these objectives have been developed in France. They produce superb, long lasting results, and are
deserving of widespread use. The most popular technique implants a large piece of mesh behind the muscles of the abdomen. The preferred mesh is
Mersilene (Dacron) because it is soft, flexible, rapidly integrated, and conforms to the curvatures of the abdomen and pelvis. The soft and elastic
Dacron requires traction-fixation with absorbable sutures that work superbly for stretching the lateral muscles and flattening the peritoneum. Staples
are not a suitable substitute for traction-fixation sutures. Polypropylene mesh can be substituted for polyester mesh when the size of the mesh is
relatively small and the abdominal surface level. Often it need not be fixed. Large pieces of the semirigid polypropylene meshes will impair flexibility of
the abdominal wall. To prevent abdominal viscera from contact with the permanent mesh omentum and/or absorbable mesh is interposed. Gibson and
Clotteau-Prmont relaxing incisions are used to facilitate midline aponeurotic closure.
In premuscular prosthetic repair the mesh should be polypropylene because polyester mesh in this position is not strong enough to resist tearing.
Fibrin glue is used to affix the mesh to the abdominal wall, and enhances the results. In the premuscular repair the midline needs closing by Gibson
relaxing incisions and a suture overlap of the two medial segments of the rectus sheath.
Closed suction drainage is essential to prevent hematomas and seromas in the space containing mesh.
Chrysos and colleagues153 reported that tension-free incisional ventral hernia repair with ePTFE (expanded polytetrafluoroethylene) patch is a safe and easy
process without major complications or recurrence.
Matapurkar et al.154 presented the potential to eliminate the possible cause of late recurrence in incisional hernia with the Marlex peritoneal sandwich repair
in which regeneration of the abdominal wall aponeurosis took place in experiments on 7 mongrel dogs. Carlson et al.155 urged tissue expansion to restore
abdominal domain and allow soft-tissue closure in complicated ventral hernia defects.
The "components separation" method of abdominal wall repair uses the medial advancement of an innervated composite of muscle and fascial tissues to
reconstruct massive midline full-thickness defects and abdominal wounds.156 Shestak et al.,157 who mention that "components separation" avoids additional
donor-site morbidity, point out that it can be used only if there is an intact and innervated rectus abdominis muscle.
Sanders et al.158 reported that the laparoscopic approach to incisional hernia repair is a safe alternative to the open method.
According to Szymanski et al.,159 laparoscopic mesh repair has a low early recurrence rate and can be performed safely on an outpatient basis.
Heniford et al.160 reported a 98.1% completion rate in their laparoscopic ventral and incisional hernia mesh repair patients, with acceptable complication and
recurrence rates.
Larson161 points out that the follow-up period for laparoscopic hernia repair is only 2 or 3 years, but that the procedure may decrease the hernia recurrence
rate to 10-15 percent. He emphasizes the need for safe access and trocar placement.
Factors contributing to good healing without wound dehiscence, postoperative incisional hernia, or disfiguring scar include:
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Factors contributing to good healing without wound dehiscence, postoperative incisional hernia, or disfiguring scar include:
Absence of tension, pressure, and dead spaces
Presence of good hemostasis
Debridement
Irrigation
Good approximation of the skin
Hodgson and colleagues,162 who admit that the ideal suture for closing abdominal fascia has yet to be determined, recommend nonabsorbable suture
material and a continuous technique for a lower rate of incisional hernia.
Anthony et al.163 reported the following factors affecting recurrence rates for repair of incisional hernia:
1. Incisional hernias repaired with prosthetic material have fewer recurrences than those repaired by reapproximation of autogenous tissue.
2. Obesity is associated with significantly increased incidence of recurrence.
3. Most recurrent incisional hernias occur within the first three postoperative years.
They also reported an overall recurrence rate for the initial repair of incisional hernia at 45%, and at 29% for those patients repaired with prosthetic
material.
Echoing the findings of Anthony et al.163 is the assertion of Luijendijk and colleagues164: "Among patients with midline abdominal incisional hernias, mesh
repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia."
Anatomic Complications of Posterior (Lumbar) Abdominal Incisions

Oblique Incision
Violation of the pleura allows contamination by the underlying infection or by upward travel of malignant cells. To protect the pleura, the surgeon should
remember that the inner half of the 12th rib is crossed by the pleura. Occasionally, the 12th rib is very short. If so, use the 11th, but remember that the
pleura is in real danger during this part of the operation.
Protection of the nerves is imperative with any incision, especially the oblique. The following nerves should be protected:
Intercostals
Iliohypogastric
Ilioinguinal
If it is absolutely necessary to incise one of the above nerves, cut the iliohypogastric nerve only.
Vertical Incision
Violation of the peritoneal cavity by an unwanted opening of the peritoneum allows spread of infection or malignancy from the retroperitoneal space to the
peritoneal cavity.
Dehiscence may occur. This may happen with oblique incisions and in the anterior abdominal wall as well. The incision should be anatomically closed to avoid
posterior operative herniation, occasionally difficult to repair.
Lumbar incisions very close to the midline will not divide nerves, since nerves are located laterally.
If a procedure is tailored to treat pathology outside the transversalis fascia, remember the locations and relations of the adrenals, kidneys, and upper ureters. For
more details, study the kidney chapter.
Thoracoabdominal Incisions
Since thoracoabdominal incisions affect combinations of thoracic and abdominal entities, the reader will find further information in the chapters on the thorax
and the abdomen.
Remember
Injury to the neurovascular network at the intercostal spaces should be avoided. The neurovascular network is located at the lower borders of the ribs.
A rib should be resected if necessary.
Merendino 165 advised that injury to the phrenic nerve can be avoided by using either circumferential incisions in the periphery of the diaphragm or incisions
through the central tendon as far medially as the entrance of the phrenic nerve. He also advised avoidance of lateral and transverse incisions.
The diaphragmatic attachment to the chest wall should be left in place to facilitate diaphragmatic closure.
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Gentle mobilization will avoid injuries to the spleen, liver, kidneys, ureters, stomach, and colon.
The diaphragm should be closed with interrupted nonabsorbable sutures. The pleura, the diaphragm, and the peritoneum should be included.
Bleeding should be avoided by protecting the first lumbar vein (located just behind the left renal vein) during left kidney mobilization.
HERNIAS OF THE ABDOMINAL WALL AND SURGICAL TREATMENT

In this section we consider many hernias of the anterior and posterior abdominal wall. Presentation of internal abdominal hernias is in the chapter on the
peritoneum and omenta.
The hernias of the anterior abdominal wall to be covered:
Epigastric (ventral) hernia
Umbilical hernia
Congenital and acquired hernias
Infantile umbilical hernia
Acquired umbilical hernia in adults
Omphalocele (exomphalos)
Gastroschisis
Ileal prolapse at the umbilicus
Lateral ventral (spigelian) hernia
Inguinofemoral (groin) hernias
Indirect inguinal hernia
Indirect sliding inguinal hernia
Direct inguinal hernias
Supravesical hernias
Multiple groin hernias
Interparietal hernias
Femoral hernias
Pediatric hernias
The hernias of the posterior abdominal wall to be considered are those of the superior lumbar triangle (Grynfeltt) and the inferior lumbar triangle (Petit).
These follow the presentation of the hernias of the anterior abdominal wall.
Hernias of the Anterior Abdominal Wall

Epigastric (Ventral) Hernia
The ring of the epigastric hernia (Fig. 9-87) is located at the linea alba from the xiphoid process to 1-2 cm above the umbilicus. It is composed entirely of
fibers of the linea alba. Unlike the ring of an umbilical hernia, the ring of a ventral hernia is entirely fibrous. Perforation of the intestine is the only danger.
Fig. 9-87.
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Epigastric hernia. A, Transverse section through normal linea alba. B, Transverse section through hernia of linea alba. (Modified from Skandalakis JE, Gray SW, Akin
JT Jr. The surgical anatomy of hernial rings. Surg Clin North Am 1974;54:1227-1246; with permission.)
Umbilical Hernias
CONGENITAL AND ACQUIRED
Umbilical hernias are classified as upper, middle and lower (see Fig. 9-10A through 9-10G ).
The upper hernial defect is triangular. It is located within the bifurcated round ligament just above the upper border of the umbilical ring (Fig. 9-10B).
The middle hernial defect is a fibrous ring at the medial aponeurotic borders of both rectus abdomini. This defect permits the entrance of the umbilical cord.
It is located at the middle of the upper and lower linea albae. The ring is associated with the four tubes (two obliterated umbilical arteries, the urachus, and
the round ligament) and the umbilical fascia (see Figs. 9-9, 9-10B).
The lower hernial defect is the triangular area of the bifurcated urachus just below the lower border of the ring (Fig. 9-10C).
Infantile Umbilical Hernia

In the infantile form of umbilical hernia, the abdomen bulges between the recti at the umbilicus. The umbilical ring is slightly larger than normal. Incarceration
is rare. The defect usually cures itself without surgery.
Acquired Umbilical Hernia in Adults

The herniation of acquired umbilical hernia of an adult (Fig. 9-88) is usually through the linea alba at the upper margin of the ring. The ring itself is formed by
the fusion of all the layers of the abdominal wall. The incarcerated loop of intestine may be freed by a circular incision around and not over the sac.
Fig. 9-88.
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Umbilical hernia. A, Section through normal umbilicus. B, Section through umbilical hernia. C, Lateral view of hernia. Dashed line, line of incision. (Modified from
Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of hernial rings. Surg Clin North Am 1974;54:1227-1246; with permission.)
Perforation of the incarcerated loop is the obvious danger. The falciform ligament should be ligated to avoid bleeding.
Be sure to differentiate between herniation and an umbilical nodule. A paraumbilical nodule is a direct extension of metastatic disease secondary to direct
extension from pancreatic adenocarcinoma via a lymphatic or vascular network. This nodule is the so-called sign of Sister Mary Joseph,166 who was surgical
assistant to Dr. William Mayo of the Mayo Clinic.
Omphalocele (Exomphalos)
An omphalocele (Fig. 9-89) is the herniation of intraperitoneal structures through the umbilical ring into the base of the umbilical cord. There is no skin
overlying the defect, but a double covering layer of amnion outside and peritoneum inside.
Fig. 9-89.
Sagittal section through a small omphalocele. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia
Repair: The Embryological and Anatomical Basis of Surgery. New York: Parthenon, 1996; with permission.)
Omphalocele is a primary failure of the developing intestines to return to the abdominal cavity in the tenth week. At birth, the umbilical ring is very large and
the herniated viscera are contained in a thin avascular sac. A normal umbilical cord inserts into the apex of the sac or its remnants.
As in gastroschisis, the abdominal cavity is usually too small to contain the intestinal mass. Even if the intestines can be placed in the abdomen, the
pressure against the diaphragm may cause inadequate ventilation and death.
Rough handling of the intestines may produce volvulus, ischemia, necrosis, and perforation. Malrotation and incomplete fixation of the colon to the abdominal
wall are usual. Obstruction must be avoided when replacing the viscera. For treatment of exomphalos major, Wakhlu and Wakhlu167 reported success with
delayed ventral hernia repair by double breasting of the fibrous tissue sheath underlying the skin.
Dunn and Fonkalsrud168 stated that despite many improvements, the mortality of surgical repair of omphalocele is more than 10 percent. But they found
that long-term quality of life of these children is good.
Gastroschisis
Gastroschisis is a cleft or defect of the umbilicus with herniation of peritoneal contents (Fig. 9-90). It occurs on the right in most cases. There is a defect in
the development of the musculature of the abdominal wall. The normal return of the intestines to the abdomen ruptures the body wall and permits the
escape of the intestines through the defect. There is no hernial sac, and the abdominal cavity is underdeveloped.169
Fig. 9-90.
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Gastroschisis. The herniation is lateral to umbilicus through a congenital muscular defect. A gelatinous matrix, but no sac, surrounds herniated intestines. Although
gastroschisis occurs on the right in most cases, it is shown here on the patient's left. (Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of
hernial rings. Surg Clin North Am 1974;54:1227-1246; with permission.)
At birth, the hernia is lateral to the normal umbilicus. The herniated intestine is usually embedded in a gelatinous matrix. Occasionally the stomach and
sigmoid colon are herniated.
To the best of our knowledge, no case of gastrochisis has been reported with hepatic herniation per se. Grosfeld and Weber170 reported that a portion of
the hepatic edge may protrude through the defect. They also cited evisceration of the small bowel and the colon, stomach, gallbladder, uterus and fallopian
tubes, urinary bladder, and undescended testes.
Kluth and Lambrecht 22 wrote that abdominal wall defects are the result of disturbed development of the embryonic umbilicus. It is their belief that
gastrochisis "is more likely a ruptured small omphalocele than a developmental entity of its own."
When treating gastrochisis, the loops of intestines must be separated and inspected for possible perforations or atresias.
Ileal Prolapse at the Umbilicus

In ileal prolapse at the umbilicus, the umbilical ring is normal, but a patent Meckel's diverticulum is present. In infancy or early childhood, the ileum may
prolapse through the umbilicus. It will be everted, with the mucosal surface to the outside.171 There is, of course, no hernial sac. This must not be mistaken
for an umbilical polyp.160
Lateral Ventral (Spigelian) Hernia

Lateral ventral hernia (Fig. 9-91) is a defect at the spigelian (fascial) zone at any point along its length. This zone is bounded laterally by the muscular
fibers of the internal oblique and medially by the lateral margin of the anterior lamina of the rectus sheath. A peritoneal sac is present, containing
preperitoneal fat or a viscus.
Fig. 9-91.
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Spigelian hernia. A, Sites of spigelian hernia. Sections through normal body wall above and below umbilicus shows semilunar zone of Spieghel. B, Relation of a
spigelian hernia to inguinal structures. C, Section through spigelian hernia. (Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of hernial rings.
Surg Clin North Am 1974;54:1227-1246; with permission.)
From inside to outside, the layers covered by the sac are:

Transversalis fascia
Aponeurosis of external oblique muscle
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Subcutaneous fat
Skin
The line of transition between muscle fibers and the aponeurosis of the transversus abdominis muscle and the lateral border of the rectus sheath defines the
semilunar, or spigelian, zone. A lateral ventral hernia may occur anywhere through the semilunar zone from above the level of the umbilicus to the pubic
symphysis173 (Fig. 9-91A). Many such hernias occur at the junction of the semilunar line of Spieghel and the semicircular line of Douglas (see Fig. 9-7). At
this point, the hernial ring is formed by the aponeurosis of the internal oblique muscle and the aponeurosis of the transversus abdominis muscle (Fig. 9-91B).
If the hernia is above the level of the umbilicus, the defect is formed by a tear in the transversus abdominis muscle and a defect of the aponeurosis of the
internal oblique muscle. The neck of the hernia may be tough and rigid. The sac is often covered by subcutaneous fat.
The aponeurosis of the external oblique muscle should be carefully incised. The sac is under the aponeurosis. Perforation of the intestinal loop is the chief
hazard.
Inguinofemoral (Groin) Hernias

The deep inguinal ring is a normal V-shaped defect at the transversalis fascia, bounded by the posterior and anterior crura. Direct and external supravesical
hernias do not have rings. However, the posterior wall of the inguinal canal may be totally or partially attenuated without any ability to protect normality in
this area. The femoral ring is below the inguinal ligament, and it is the entrance to the femoral canal.
INDIRECT INGUINAL HERNIA
Indirect inguinal hernia is rare in females, but by far the most common hernia in males. When the word "hernia" is used without a modifier, the reference is
usually to an indirect inguinal hernia (see Fig. 9-36C and D).
An indirect hernia enters the body wall through the internal inguinal ring, a V-shaped defect in the transversalis fascia. The existence at birth of the hernial
sac determines the type. If the hernial sac is the unclosed funicular portion of the processus vaginalis, the hernia is said to be "congenital" (Fig. 9-92A),
even though it occurs in later life. If the sac is not part of the tunica vaginalis and lies separate and parallel to a normally closed processus, the hernia is
termed "acquired" (Fig. 9-92B). In both types, the hernia passes through the internal inguinal ring and the neck of the hernial sac. The sac lies lateral to the
inferior epigastric artery.
Fig. 9-92.
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Defects of closure of processus vaginalis. Note: Drawings A, B, and F illustrate two views; view on right half of each diagram is a cross section of area indicated by
connecting diagonal line. X, Processus vaginalis. A, Completely unclosed processus; intestinal loop or omentum may follow testis into scrotum (congenital indirect
hernia). B, Cranial (funicular) portion of processus remains unclosed; herniation may occur later in life (acquired indirect hernia). C, All but cranial portion unclosed;
serous fluid accumulates to form infantile hydrocele. D, Midportion of the processus unclosed, forming cyst (cystic hydrocele). E, Normally closed processus; fluid may
accumulate in tunica vaginalis (adult hydrocele). F, Sliding indirect inguinal hernia. Descending viscus, usually colon, remains retroperitoneal; sac (processus
vaginalis) remains unclosed or becomes closed. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission.)
The indirect inguinal hernia passes downward through the inguinal canal, anterior and lateral to the spermatic cord, to emerge through the external inguinal
ring and enter the scrotum. If the hernia reaches the scrotum, it lies in the cavity of the tunica vaginalis ("congenital") or beside it ("acquired"). Figure 9-92
shows the different types of defects possible with incomplete closure of the processus vaginalis.
Indirect Sliding Inguinal Hernia

The indirect sliding inguinal hernia (Fig. 9-92F) differs from the indirect inguinal hernia because the wall of the contained viscus is in whole or part the
posterior wall of the sac. On the right side, the cecum is most likely involved. On the left side, the sigmoid colon is most likely involved. Other anatomic
entities involved are the ovaries and the tubes.
DIRECT INGUINAL HERNIA
A direct inguinal hernia (Fig. 9-93) passes through the inguinal canal but not through the spermatic cord. It does not come through the internal inguinal ring
and so is not covered by the spermatic sheath. It proceeds "directly" toward the external ring. There is no sac. The hernia pushes the transversalis fascia
ahead of it. The inferior epigastric artery lies lateral to a direct hernia and medial to an indirect hernia. The ring is little more than peritoneum and
preperitoneal connective tissue; hence strangulation is rare.
Fig. 9-93.
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Indirect hernia with interparietal diverticulum, direct hernia, and external supravesical hernia all present in one patient. Different sites of origin of each hernia and
relations shown. (Modified from Skandalakis JE, Burns WB, Sangmalee U, Sorg JL. Internal and external supravesical hernia. Am Surg 1976; 42:142-146; with
permission.)
Direct inguinal hernias usually originate in the median fossa. They also may originate in the supravesical fossa medial to the lateral umbilical ligament,118
creating external supravesical hernias.
SUPRAVESICAL HERNIA
Some groin hernias (Fig. 9-93) are closely related to pelvic organs at the brim of the pelvis. The posterior surface of the anterior abdominal wall presents
three shallow, paired fossae on either side of the midline (see Fig. 9-41). Supravesical hernias arise from the floor of the medial pair of these fossae, which
are separated from each other by the middle umbilical ligament, the remnant of the embryonic urachus (see "Fossae of the Lower Anterior Abdominal Wall").
Variations in their point of origin and their course make supravesical hernias a confusing group. We have proposed the following classification of these
hernias174:
External supravesical hernia
Internal supravesical hernia
Anterior
Retropubic
Invaginating
Right or left lateral (paravesical)
Posterior (retrovesical)
From its beginning in the supravesical fossa, a hernia may appear externally as a direct inguinal or a femoral hernia forming a palpable mass in the groin (Fig.
9-93). Almost half of direct inguinal hernias originate in the supravesical fossae.175 In older studies, direct hernias accounted for about 7.5 percent of all
hernias.176 Current estimates more than double that frequency.
External supravesical hernias exhibit no special symptoms or diagnostic problems. These hernias are always palpable and should be treated like other inguinal
hernias. Complications are the same as those of inguinal hernia.
MULTIPLE GROIN HERNIAS
Bilateral inguinal hernias are common, often with three different hernias on one side reported in the same patient. Rowe et al.177 reported the case of a
patient with eight separate hernias: a direct inguinal, indirect inguinal, femoral, and external supravesical hernia were present on each side at the same time
(Fig. 9-94). Combined indirect and direct inguinal hernia on the same side produces a "pantaloon" hernia.
Fig. 9-94.
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Four types of groin hernia and their landmarks. A, Indirect inguinal hernia. B, Direct inguinal hernia. C, Femoral hernia. D, External supravesical hernia emerging
from beneath rectus abdominis muscle. 1, Inguinal ligament; 2, External iliac artery; 3, Inferior epigastric artery; 4, Medial umbilical ligament; 5, Testis. (Modified
from Rowe JS Jr, Skandalakis JE, Gray SW. Multiple bilateral inguinal hernias. Am Surg 1973;39:269-270; with permission.)
Keynes178 suggested that the presence of an inguinal or femoral hernia may deepen the prevesical cul-de-sac and precipitate an external supravesical
hernia.
INTERPARIETAL HERNIA
In interparietal hernia (Fig. 9-95), the hernial sac enters the internal inguinal ring in a manner similar to an indirect inguinal hernia. Instead of passing
downward to emerge through the external ring into the scrotum (or in addition to such a course), a sac passes anteriorly between any two layers of the
abdominal wall. There may be multiple sacs.
Fig. 9-95.
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Interparietal hernia. Sac enters at internal ring. Sac may pass into any one or more spaces between layers of abdominal wall. An indirect hernia also may be
present. 1, Preperitoneal; 2 and 3, Interstitial; 4, Superficial. (Modified from Skandalakis JE, Gray SW, Akin JT Jr. The surgical anatomy of hernial rings. Surg Clin
North Am 1974;54:1227-1246; with permission.)
The constriction is at the interior ring in interparietal hernia. Repair is the same as that for complications of indirect inguinal hernia. The surgeon should
remember that the sac may be multilocular. Proceed slowly to avoid injury to the intestine.
FEMORAL HERNIA
Femoral hernias (Fig. 9-42, 9-43, 9-94) can be considered to be "acquired" because there is no preformed hernial sac. King179 presented the case of a
strangulated sliding femoral hernia containing fallopian tube and ovary in a six-month-old girl. He termed this a "developmental abnormality rather than
acquired." A similar case in a 2-year-old was reported by Oh et al.,180 who used positive-contrast peritoneography to diagnose bilateral indirect inguinal
hernia and femoral hernia in four individuals. They stated that these hernias were congenital. Gray and Skandalakis181 reported the case of a 40-day-old
female infant with a femoral hernia containing small bowel, ovary, and tube.
A femoral hernia passes from the femoral ring beneath the inguinal ligament (Fig. 9-43) and through the femoral canal to emerge at the saphenous opening
(fossa ovalis). Here, the diagnosis of femoral hernia can be confused with the presence of an inguinal hernia, a psoas abscess, an enlarged lymph node
(node of Cloquet), a varix of the saphenous vein, or a lipoma.182
For purposes of differentiation, remember that a femoral hernia passes below the inguinal ligament, while an inguinal hernia passes above it (Fig. 9-94).
Obesity in the patient or the orientation of the herniation can make the distinction less obvious, however.
Pediatric Hernias
There is nothing as interesting as an inguinal hernia.Robert Gross183
Myers184 gave pithy advice in his editorial on pediatric hernias:
. . .[I]t is important to reflect on the inguinal hernia itself which is not the mundane condition sometimes referred to by medical students and junior
resident medical staff as "just a hernia," but the cornerstone of a busy paediatric surgical practice. And why? one may ask.
The answers can be listed as follows:
Operative difficulties specifically those connected with the thin, transparent sac in many premature babies;
The association with undescended testis and the different opinions on timing of the operation when the two conditions co-exist;
Diagnostic difficulties: swelling in the inguinal region is described by the parent but the surgeon is unable to confirm its presence;
Timing of the operation once the diagnosis is definite. A good rule for inguinal hernia repair in babies -at least those under 12 months- is that the
operation is urgent and should be performed "yesterday."
Should contralateral exploration be performed? And if so, should the decision be based on site, age, or sex?
Handling of the total situation in the phenotypic female-karyotypic male, when the hernial sac contains gonads that are testes;
The parasurgical problems associated with surgery in the ex-premature baby with particular reference to blood sugar levels and temperature
control. In this context, post-conceptual age is of great importance in relation to the decision as to whether the operation should be performed as a
"day case." All day centers need to have firm rules to cover this aspect. At the Royal Children's Hospital, Melbourne, Australia, the current policy is
not to admit babies as "day cases" unless their postconceptual age is at least 44 weeks.
The role of spinal anesthesia, particularly in premature and ex-premature babies.
. . .I commend the need to maintain accurate personal records on all patients, regardless of the frequency of the condition they exhibit.
Wright wrote a series of articles on the treatment of childhood hernias. We reprint some of his conclusions below.
Direct inguinal hernia:185 "Repair of the transversalis fascia seems to be effective surgical treatment, with no known recurrence in this series."
Recurrent inguinal hernia:186 "When operating for indirect inguinal hernia, it is essential to consider and search for a direct weakness if the indirect sac is too small
to account for the clinical features."
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to account for the clinical features."

Femoral hernia:187 ". . .[T]he femoral approach with repair by suture of the inguinal ligament to the pectineal ligament and pectineus fascia is not followed by
recurrence and there is no need for a high approach or complex methods of repair. In unilateral hernias there is no need to explore the opposite side."
Spigelian hernia:188 "Repair follows general principles with layered or plicated closure of the defect with non-absorbable sutures. Recurrence is unlikely."
Redman189 stated that if the pediatric hernia sac is narrow, dissection from the spermatic cord can be simple. However, when the sac is wide and
practically wraps itself around the spermatic cord, dissection becomes complex. We agree.
Laparoscopic Herniorrhaphy
Laparoscopic repair of inguinofemoral herniorrhaphy has developed over the past 10 years. It is not within the scope of this chapter to present details about
technique; rather, we present only the pathway of three laparoscopic herniorrhaphies, which are the approaches to the preperitoneal space from the
peritoneum to the myopectineal orifice of Fruchaud.
Laparoscopic herniorrhaphy is usually performed using one of the following techniques:
TAPP (transabdominal preperitoneal)
IPOM (intraperitoneal only mesh)
Modification of TAPP (infraumbilical preperitoneal elevation of both inguinal areas without entering the peritoneal cavity)
In an editorial remarking on a study by Ferzli et al.190 concluding that it is not necessary to use staples in laparoscopic preperitoneal inguinal hernioplasty,
Wantz191 stated, "Avoiding staples and tacks to fix preperitoneal polypropylene mesh in place is a step forward in the evolution of laparoscopic
hernioplasty." Rosenberger et al.192 caution that dissection and the placement of staples either cranial to the iliopubic tract or lateral to the anterior
superior iliac spine can result in an injury to the nerves.
A study by Balzer et al.193 included the following recommendation regarding the placement of trocars. "While recognizing that the choice of incision sites for
laparoscopic surgery may be influenced by a multitude of factors, to minimise the danger of lesions of the large abdominal vessels we suggest the following
trocar sites (Fig. 9-96): 1. in the ventral midline; 2. in a zone of 5 cm width lateral to the lateral border of the rectus sheath."
Fig. 9-96.
To minimize the danger of lesions in the large abdominal vessels, locate trocars in the ventral midline or in a zone of 5 cm width lateral to the lateral border of the
rectus sheath. (Modified from Balzer KM, Witte H, Recknagel S, Kozianka J, Waleczek H. Anatomic guidelines for the prevention of abdominal wall hematoma induced
by trocar placement. Surg Radiol Anat 1999;21:87-89; with permission.)
Chandler et al.194 studied a wide spectrum of laparoscopic surgeries for collective data on entry access injuries. We quote from their study:
The distance from the abdominal skin surface immediately below the umbilicus to the ventral plane of the aorta over the fourth lumbar vertebra can
be less than 5 cm in a thin woman, and the abdomen of a very thin individual will not accommodate a large CO2 bubble. The umbilicus is at or
cephalad to the aortic bifurcation in 50% of supine, nonobese women and is consistently cephalad to the midline crossover of the left common iliac
vein.
They discuss the use of certain entry devices to control entry axial force.
Hernias of the Posterior (Lumbar) Abdominal Wall

Within the area of the posterior (lumbar) abdominal wall, two triangles are located: the superior lumbar triangle of Grynfeltt and the inferior lumbar triangle of
Petit. (For the boundaries of the triangles see "Anatomy and Topographic Relations" of the posterior [lumbar] wall in the section on Surgical Anatomy.)
Herniation may take place in either one of these triangles (see Fig. 9-73C).
Congenital lumbar hernia is a rare anomaly. Wakhlu and Wakhlu195 recommend early operation and repair with local tissues.
Posttraumatic lumbar hernias may occur through one of the triangles, or if the violent forces are great enough the defects may not necessarily be confined
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Posttraumatic lumbar hernias may occur through one of the triangles, or if the violent forces are great enough the defects may not necessarily be confined
to defined anatomic boundaries. Barden and Maull196 described a case of lumbar hernia in a patient who had been crushed between two train cars and who
required extensive reconstruction.
Arca et al.197 advised that the laparoscopic procedure for repair of lumbar hernias is safe and effective.
ANATOMIC COMPLICATIONS OF HERNIA REPAIR
Anatomic Complications of Hernia of Anterior Abdominal Wall

Epigastric Hernia
The surgeon must be careful to avoid perforating the intestine.
Umbilical Hernias
Just as with epigastric hernia, perforation of the intestine is a concern. To avoid bleeding from the falciform ligament, the ligament should be ligated. If the
urachus is patent, it should be ligated as a precaution.
Omphalocele
Rough handling of the intestines may produce volvulus, ischemia, necrosis, and perforation. Malrotation and incomplete fixation of the colon to the abdominal
wall are usual. Obstruction must be avoided when replacing the viscera.
Gastroschisis
The loops of intestine must be separated and inspected for possible perforations or atresias. There is no hernial sac, and the abdominal cavity is
underdeveloped.
Ileal Prolapse at the Umbilicus

The surgeon must be careful not to mistake ileal prolapse at the umbilicus for an umbilical polyp.
Lateral Ventral (Spigelian) Hernia

The aponeurosis of the external oblique should be carefully incised because the sac and its contents are under the aponeurosis. Perforation of the intestinal
loop is the chief hazard.
Anatomic Complications of Groin Hernia Repair

Inguinal Hernias
Hemorrhages or ecchymoses may form in the repair site, scrotum, or abdominal wall. In a series of 765 operations for groin hernias, Slattery et al.198 found
hematomas in 8 (1.05 percent). This was second only to wound infection (1.57 percent) among immediate complications.
The vessels usually responsible are the inferior epigastric vessels, external iliac vessels, or vessels of the spermatic cord. Other vessels less frequently
injured are the superficial epigastric artery and vein, deep and superficial circumflex iliac vessels, and aberrant obturator artery or vein.
Remember, a deep suture may penetrate the femoral vein. If the suture is tied, it will lacerate the vein. Also, the vein can be injured even though its wall is
not penetrated completely, resulting in the possible generation of thromboembolism. If the vessel is pierced and bleeds, the suture should be withdrawn and
finger pressure applied, without tying. This will stop bleeding. If laceration occurs, the vein should be repaired with a fine vascular suture.
Ischemia is not a major problem in inguinal hernia repair. Practically all the vessels in the inguinal area (except the external iliac artery) can be ligated with
impunity. These vessels include the:
Deep epigastric artery with its cremasteric and pubic branches
Ascending branch of the deep circumflex iliac artery between the internal oblique and transversus muscles, lateral to the position of the deep inguinal ring
Superficial epigastric artery toward the umbilicus
Superficial circumflex iliac artery inferior to the lateral half of the inguinal ligament
External pudendal artery in front of the spermatic cord
Callesen et al.199 concluded that choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.

Injury to the iliohypogastric, ilioinguinal, or genitofemoral nerves can be produced by cicatricial constriction and, in very rare instances, result in neuroma.
The goal is to avoid injury. If, in spite of careful attention, injury does occur and the patient continues to have pain, resection of the compromised nerve
and distant mobilization of the proximal segment is the procedure of choice.
In patients with postoperative pain after inguinal herniorrhaphy with mesh, Heise and Starling200 recommended removing mesh and performing neurectomy.
We quote from Skandalakis et al.56:
Injury to one or more of the following vessels is believed to be the cause of testicular atrophy and ischemic orchitis: testicular artery, deferential
artery, cremasteric artery, and posterior and anterior scrotal arteries.
The arteries of the testis and epididymis are shown in Fig. 9-97A and 97B . The internal spermatic, or testicular, artery arises from the aorta at about
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The arteries of the testis and epididymis are shown in Fig. 9-97A and 97B . The internal spermatic, or testicular, artery arises from the aorta at about
L2. The artery of the ductus deferens (deferential artery) arises from the inferior vesicular artery. The external spermatic, or cremasteric, artery
takes origin from the inferior epigastric artery.
Fig. 9-97.
Arteries of the testis and epididymis. A, The testicular artery (1) is the chief source of blood to the testis, but four other arteries anastomose with
the testicular artery and each other to form a collateral circulation. 2, Deferential artery; 3, Cremasteric artery; 4, Posterior scrotal artery; 5,
Anterior scrotal artery. B, The principal blood supply of the testicle is from the testicular artery, which arises from the aorta or the renal artery. The
testicle also receives blood from the artery of the vas deferens, which arises from the internal iliac artery, and from the cremasteric artery, which
originates from the external iliac artery. The cremasteric artery supplies blood to the cremaster muscle and to the tunica of the testicle. A rich
collateral circulation exists between the testicle and the arteries to adjacent structures, such as the prostate, scrotum, etc. (A, Modified from
Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission. B, Courtesy of GE
Wantz [modified].)
A good anastomosis exists between the gonadal and deferential arteries in all patients.201 There are also anastomoses between these and the
cremasteric arteries in approximately two-thirds of patients. Upon division of the cord, collateral circulation is sufficient to prevent gangrene in 98 per
cent of patients. Atrophy of the testis will occur in 80 per cent if the cord is divided. We strongly recommend that this procedure never be performed.
If the cord must be divided, it is advisable to keep the testicle in the scrotum and not bring it into the surgical field. Collateral circulation will probably
be served better with this action.
The testicular artery bifurcates between the upper one-third and the middle one-third of the testicle into the main testicular and epididymal
branches. Dissection of the epididymis during epididymectomy should start at the lower pole of the testicle and proceed upward (approximately 2.5
cm). From there, the surgeon will find the bifurcation and should ligate only the epididymal branch.
The pampiniform venous plexus is formed in the spermatic cord by 10-12 veins that segregate into anterior and posterior groups. Each group is
drained by three or four veins that join to form two veins proximal to the internal inguinal ring. These veins run in the extraperitoneal space on either
side of the testicular artery. The right testicular vein opens into the inferior vena cava; the left testicular vein enters the left renal vein. The
cremasteric vein flows into the inferior epigastric veins; the deferential vein drains into the pampiniform plexus and the vesical plexus, which is drained
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cremasteric vein flows into the inferior epigastric veins; the deferential vein drains into the pampiniform plexus and the vesical plexus, which is drained
by the prostatic venous plexus to the internal iliac vein.
Wantz202 argues convincingly that testicular atrophy is due not to division or compression of any of the cited arteries; rather, ischemic orchitis is
attributable to thrombosis of the delicate pampiniform veins, resulting from stretching or other trauma to the vessels. Testicular atrophy results more
commonly from classical herniorrhaphy than from laparoscopic procedures, Wantz202 observed, because of the necessary manipulation of the cord
elements in the open procedure. Such atrophy can be a sequela to dissection of the complete indirect sac from the spermatic cord (Fig. 9-98). The
collateral arterial supply to the testis is so rich that the cord can be severed without testicular atrophy.203
Fig. 9-98.
After opening and slitting the indirect hernial sac, it can be left in situ on the spermatic cord. (Modified from Wantz GE. Atlas of Hernia Surgery. New
York: Raven Press, 1991; with permission.)
Injury to the ductus deferens (vas) must be repaired by end-to-end anastomosis with fine nonabsorbable sutures.
Injury to the spermatic cord is usually by constriction secondary to overenthusiastic closure of the internal or external rings. Constriction produces vascular
stasis and painful testicular swelling with eventual atrophy. The ring should not be tightly closed; it should admit the surgeon's little finger.
Wantz204 wrote that most testicular atrophy follows dissection of a complete indirect inguinal hernial sac from the spermatic cord. He advocated leaving the
distal part of the sac in place.
In a series of 6,454 inguinal herniorrhaphies, Fong and Wantz205 emphasized the possibility of complications of ischemic orchitis and testicular atrophy. They
advised limited dissection of the distal spermatic cord as well as the use of a prosthesis for repair of recurrent hernias.
Nahabedian and Dellon206 analyzed 13 patients with pain from nerve injuries in the ilioinguinal area. The causes of the injuries included appendectomy,
inguinal herniorrhaphy, inguinal lymph node dissection, orchiectomy, total abdominal hysterectomy, abdominoplasty, iliac crest bone graft, and femoral
catheter placement. Patient satisfaction was high postoperatively, and all returned to their normal activity level.
Organs that may be injured (especially in sliding hernia) are the large intestine, small intestine, or urinary bladder. The following rules are useful:
The sac should be opened high and anteriorly.
An adhesion should not be cut before the surgeon verifies that the "adhesion" is not the mesentery of the intestine.
The sac should be closed under direct vision.
The sac of a direct inguinal hernia should not be opened, because the bladder might be injured.
In a sliding hernia, the colon is posterior, and the bladder is medial and anterior.
With any strangulated hernia, the viability of the intestine is the primary question. The best indications of viability are return of color, peristalsis, and good
vascular pulsation. If there is doubt, resection is in order. The surgeon must make sure that the incarcerated loop does not slip back into the abdomen and
become lost after its release from the hernial ring. Should this happen, an exploratory laparotomy must be performed immediately. Lavonius and Ovaska207
point out that at laparoscopy, the judgment of the viability of the contents of the incarcerated groin hernia is similar to that at laparotomy. They therefore
recommend the early use of laparoscopy to prevent many unnecessary laparotomies.
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recommend the early use of laparoscopy to prevent many unnecessary laparotomies.

Tension on the transversus abdominis aponeurosis when it is attached to the pectineal ligament (Cooper) can be relieved by a relaxing incision of the rectus
sheath. The incision is usually 5 to 7 cm long, just above the pubic crest and just lateral to the linea alba. The sheath should be elevated. The underlying
rectus abdominis should be gently pushed medial to separate the sheath and the muscle.
In rare cases, the anterior rectus sheath is poorly developed, and the transversus abdominis inserts into its lateral border. In such patients, the relaxing
incision does not provide relaxation of the tissue. If fibers of transversus abdominis pass behind the pyramidal muscle, they must be cut.
Femoral Hernia
The complications of femoral hernia are almost the same as those of inguinal hernia. The surgeon must remember to avoid injuring the femoral vein. In cases
of hernial strangulation, the lacunar ligament (Gimbernat) should not be cut. This cut might injure an aberrant obturator artery (see Fig. 9-43). It is safer to
make the cut ventral to the incarcerated hernia, cutting partially through the inguinal ligament (iliopubic tract). Hernandez-Richter et al.208 found
laparoscopic repair to be highly effective in nonemergency femoral hernia surgery, while cautioning that current surgical techniques need to be perfected to
avoid complications such as bladder lesion, port site infection, hematoma, ileus, and nerve irritation syndrome.
While femoral hernias are rare in infants and children, they do occur and account for about 4 percent of cases. Most occur on the right side. The majority
are in females.169
Interparietal Hernia
The complications of interparietal hernia are the same as those of inguinal hernia. The surgeon must remember the multilocularity of the hernial sac. Careful
dissection will avoid perforation of the small intestine.
External Supravesical Hernia

The complications are the same as in inguinal hernia.
Anatomic Complications of Laparoscopic Inguinal Hernia Repair

Laparoscopic herniorrhaphy is a procedure which was added to the surgical armamentarium in the relatively recent past. For all practical purposes, the
anatomic complications of laparoscopic inguinal herniorrhaphy are the same as those of open procedures.
The relationships of structures near the internal ring are not generally known, which predisposes to injury, as attested to in published and anecdotal
experience. It is potentially hazardous to place staples or sutures in this region, because there is considerable variability in nerves that pass through, or
deep to, the iliopubic tract lateral to the internal inguinal ring. In the medial portion, the surgeon must take the appropriate precautions to avoid unexpected
sources of hemorrhage. This includes remaining alert to the possible presence of an aberrant obturator artery or vein, and unexpected iliopubic vessels.
Excessive traction on an aberrant obtuator vein while cleaning the area of the Cooper ligament can tear a significant hole in the external iliac vein with
disastrous results.
With better knowledge of topographic anatomy of the involved anatomic entities and an acceptable learning curve, the anatomic complications of
laparoscopic herniorrhaphy will be fewer and fewer.
Reviewing the available literature from 1993 to 1996, we found anatomic complications of laparoscopic herniorrhaphy pertaining to the abdominal cavity,
abdominal walls, scrotum, genitourinary and gastrointestinal systems (with or without their corresponding vessels and nerves), and other entities.
Abdominal Cavity, Its Walls, and Scrotum

The reported complications include:
Intraperitoneal bleeding
Massive subcutaneous emphysema secondary to CO 2 insufficiency
Trocar site bleeding
Trocar site herniation involving the:
Peritoneum
Intestinal loop
Richter's hernia
Petechiae
Ecchymoses
Seromas
Hematomas
Subcutaneous lymph collection
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Omental adhesions
In order to reduce port-site herniation, Irving et al.209 advise use of one umbilical 12 mm port site and a 5 mm laparoscope.
Genitourinary System
GENITAL SYSTEM
The following complications of the genital system have been reported: spermatic cord hematoma, testicular atrophy and "asymmetry," orchitis, epididymitis,
and injury to the ductus.
Athanasakis et al.210 consider the tension-free hernioplasty an acceptable operative technique for hernia repair with very low recurrence and morbidity
rates. "Nevertheless," they write, "the surgeon must be meticulous in dissection, sparing the vessels and nerves of the cord and using the prosthetic mesh
appropriately."
Injury to the ductus can be avoided by following its pathway carefully toward the internal ring, especially when performing bilateral herniorrhaphy.
URINARY SYSTEM
Urinary bladder perforation, dysuria secondary to fixation of the mass to the bladder wall, and urinary retention are reported complications of the urinary
system.
To protect the urinary bladder, the medial umbilical ligament should be found and followed, avoiding any dissection medial to the ligament. Care must be
taken to avoid fixation of the mass to the wall of the urinary bladder.
Kobayashi et al.211 reported a case of urinary bladder injury during inguinal herniorrhaphy in a renal transplant patient whose protuberant bladder on the
grafted side was mistakenly identified as an internal inguinal hernia.
Neurovascular System
In previous pages we reported the research of Brick et al.115 on the anatomy of laparoscopic herniorrhaphy, emphasizing the importance of the location of
nerves and vessels. Of particular note are the Triangle of Doom, the Triangle of Pain, and the Circle of Death.
VESSELS
The vessel most commonly mentioned in the literature pertaining to the inguinofemoral region is the inferior epigastric artery. Most of the following vulnerable
vascular networks are located medial to and below the deep ring: the inferior epigastric artery and vein, the internal and external iliac artery and vein, the
aberrant obturator artery and/or vein, and several other veins, such as the "venous circle" of Bendavid,88 described earlier.
NERVES
The nerve most commonly mentioned in the literature regarding laparoscopic nerve injury is the lateral femoral cutaneous nerve. Complications include thigh
paresthesias and meralgia paresthetica. Davis212 reported injury of the lateral femoral cutaneous nerve, but no injury of the ilioinguinal nerve.
The following nerves are located lateral to the deep ring and are responsible for postoperative pain: the lateral femoral cutaneous nerve, the genital branch
of the genitofemoral nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve.
The most lateral nerve is the lateral femoral cutaneous nerve. The genital branch of the genitofemoral nerve is superficial to the external iliac artery. The
femoral branch of the genitofemoral nerve is lateral to the external iliac artery. The femoral nerve is very close to the genitofemoral. Staple placement
through the iliopubic tract lateral to the deep inguinal ring can injure any of the previously listed nerves because all are subject to unpredictable variations in
position and in composition.
In our studies, the ilioinguinal nerve was frequently formed in various combinations with the genitofemoral or, even more frequently, with the lateral femoral
cutaneous. The lateral femoral cutaneous nerve was seen to be occasionally formed by as many as three separate nerve bundles that pierced the iliopubic
tract separately between the anterior superior iliac spine and the external iliac artery.
Gastrointestinal System
Complications include obstruction, perforation, and adhesions of the small bowel.
Other
Other complications include pubic osteitis and thoracic pain. Umbilical endometriosis has been reported after laparoscopic-assisted subtotal hysterectomy
through the umbilical incision. Koninckx et al.213 suggest that implantation and potential development of menstrual endometrium increase after surgery, and
procedures that expose menstrual endometrial cells to nonepithelialized areas could be associated with an increased risk of endometriosis.
Anatomic Complications of Lumbar Hernia Repair

Organ injury (most likely to the colon) during lumbar hernia repair is possible if the hernia is incarcerated or sliding. Injury occurs when opening the sac or
while taking deep bites of the protruding fat. During hernia repair through the superior lumbar triangle, there is danger of injury to the T12 and L1 nerves.
Recurrence is rare.
REFERENCES
1. de Laguna A. Anatomical Procedure, Or a Survey of the Dissection of the Human Body. Paris: Jacob Keruer, 1535.
2. Wolff E. La Science des Monstres. Paris: Gallimard, 1948.
3. Duhamel B. Embryology of exomphalos and allied malformations. Arch Dis Child 1963;38:142.
106/113
5/24/2014
4. Klippel CH Jr. The embryo considered as a vector field. In: El Shafie M, Klippel CH Jr (eds). Associated Congenital Anomalies. Baltimore: Williams & Wilkins,
1981, pp. 157-163.
5. Skandalakis JE, Colborn GL, Skandalakis LJ. The embryology of the inguinofemoral area: an overview. Hernia 1997;1:45-54.
6. Ogilvie H. Hernia. London: Edward Arnold, 1959.
7. Lytle WJ. Inguinal anatomy. J Anat 1979;128:581-594. [PubMed: 468709]
8. Condon RE. Reassessment of groin anatomy during the evolution of preperitoneal hernia repair. Am J Surg 1996;172:5-8. [PubMed: 8686802]
9. Last RJ. Anatomy: Regional and Applied (5th ed). Baltimore: Williams & Wilkins, Baltimore, 1972, p. 213.
10. McVay CB. Groin hernioplasty: Cooper's ligament repair. In: Nyhus LM, Condon RE (eds). Hernia (2nd ed). Philadelphia: JB Lippincott, 1978, p. 187.
11. McVay CB. Anson & McVay's Surgical Anatomy (6th ed). Philadelphia: WB Saunders, 1984, p. 545.
12. Depaul L. Hernie crurale chez un foetus. Soc Anat (Paris) 1842;17:208.
13. Pigne JG. Soc Anat (Paris) 1845;20:109.
14. Temple JL. Strangulated femoral hernia in a young boy. Lancet 1952;1:594. [PubMed: 14909478]
15. Monro AK. Femoral hernia. In: Maingot R (ed). Abdominal Operations (6th ed). New York: Appleton-Century-Crofts, 1969, p 1512.
16. Zimmerman LJ, Anson BJ. Anatomy and Surgery of Hernia. Baltimore: Williams & Wilkins, 1955.
17. Tasche LW. Etiology of femoral hernia. Arch Surg 1932;25:749-782.
18. Mitchell GAG. The condition of the peritoneal vaginal processes at birth. J Anat 1939;93:658-661.
19. Underhill BML. Strangulated femoral hernia in an infant: age five weeks. Br J Surg 1954;42:332. [PubMed: 13219323]
20. Wilson NM. Functional closure of the femoral canal. [letter] Br J Surg 1990;77:593. [PubMed: 2354348]
21. Hahn-Pedersen J, Bojsen-Moller F, Rosenklint A. Functional closure of the femoral canal revealed by computed tomographic scanning. Br J Surg
1989;76:1195-1197. [PubMed: 2597979]
22. Kluth D, Lambrecht W. The pathogenesis of omphalocele and gastroschisis: an unsolved problem. Pediatr Surg Int 1996;11:62-66.
23. Nielsen OH, Kvist N, Brocks V. Abdominal wall defects in the era of prenatal diagnosis. Pediatr Surg Int 1995;11:4-7.
24. McVay CB, Anson BJ. Aponeurotic and fascial continuities in the abdomen, pelvis and thigh. Anat Rec 1940;76:213.
25. McVay CB, Anson BJ. Composition of the rectus sheath. Anat Rec 1940;77:213.
26. Salmons S. Muscle. In: Williams PL (ed). Gray's Anatomy (38th ed). New York: Churchill Livingstone, 1995; p. 825.
27. Askar OM. Aponeurosis hernias: recent observations upon paraumbilical and epigastric hernias. Surg Clin North Am 1984;64: 315. [PubMed: 6233735]
28. Rizk NN. A new description of the anterior abdominal wall in man and mammals. J Anat 1980;131:373-385. [PubMed: 6452433]
29. Askar OM: A new concept of the aetiology and surgical repair of paraumbilical and epigastric hernias. Ann R Coll Surg Engl 1978;60:42. [PubMed:
147044]
30. Askar OM: Surgical anatomy of the aponeurotic expansions of the anterior abdominal wall. Ann R Coll Surg Engl 1977;59:313. [PubMed: 141898]
31. Rizk NN. A new description of the anterior abdominal wall. Anat Rec 1976;184:515.
32. Monkhouse WS, Khalique A. Variations in the composition of the human rectus sheath: a study of the anterior abdominal wall. J Anat 1986;145:61-66.
[PubMed: 2962970]
33. Martins T. Mechanism of descent of testicle under action of sex hormones. In: Essays in Biology in Honor of Herbert M. Evans. Berkeley: University of
California Press, 1943; p. 387-397.
34. Milloy FJ, Anson BJ, McAffee DK. The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 1960;110:293-302. [PubMed: 14422638]
35. Machado de Sousa O, Furlani J. Electromyographic study of some muscles of the anterolateral abdominal wall. Acta Anat 1981; 111:231-239.
36. Beaton LE, Anson BJ. The pyramidalis muscle: its occurrence and size in American whites and Negroes. Am J Phys Anthropol 1939;25:261.
37. Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevrel JP. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat
1996;18:281-288. [PubMed: 8983107]
107/113
5/24/2014
38. Orda R, Nathan H. Surgical anatomy of umbilical structures. Int Surg 1973;58:454-464.
39. McVay CB. The normal and pathologic anatomy of the transversus abdominis muscle in inguinal and femoral hernia. Surg Clin North Am 1971;51:1251.
[PubMed: 4256964]
40. Hester TR, Nahai F, Beegle PE, Bostwick J. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast
Reconstruct Surg 1984;74:657-666. [PubMed: 6238337]
41. Ramasastry SS, Futrell JW. Surgical anatomy of the internal oblique muscle: a practical approach. Am Surg 1987;53:278-281. [PubMed: 2953288]
42. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstruct Surg
1984;73:1-14. [PubMed: 6197716]
43. Nahai F, Brown RG, Vasconez LO. Blood supply to the abdominal wall as related to planning abdominal incisions. Am Surg 1976;42:691. [PubMed: 133628]
44. Hurd WW, Bude RO, DeLancey JOL, Newman JS. The location of abdominal wall vessels in relationship to abdominal landmarks apparent at laparoscopy.
Am J Obstet Gynecol 1994;171:642-646. [PubMed: 8092209]
45. Hurd WW, Pearl ML, DeLancey JOL, Quint EH, Garnett B, Bude RO. Laparoscopic injury of abdominal wall blood vessels: a report of three cases. Obstet
Gynecol 1993;82:673-676. [PubMed: 8378008]
46. Lee CH, Dellon AL. Surgical management of groin pain of neural origin. J Am Coll Surg 2000;191:137-142. [PubMed: 10945356]
47. Adams JT. Abdominal wall, omentum, mesentery, and retroperitoneum. In: Schwartz SI (ed). Principles of Surgery (6th ed). New York: McGraw-Hill,
1994; pp. 1485-1516.
48. Nicodemo P. Extraperitoneal endoscopic access to the pelvic regions via a suprapubic route. Surg Laparosc Endosc 1994;4:364. [PubMed: 8000636]
49. Sinaiko ES. A method to facilitate hernial repair in children. Surg Gynecol Obstet 1970;130:353. [PubMed: 5411285]
50. White RR. Atlas of Pediatric Surgery (2nd ed). New York: McGraw-Hill, 1978.
51. Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983.
52. Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Embryologic and anatomic basis of inguinal herniorrhaphy. Surg Clin North Am
73(4):799-836, 1993.
53. Madden JL. Abdominal Wall Hernias. Philadelphia: WB Saunders, 1989.
54. Wantz GE. Atlas of Hernia Surgery. New York: Raven Press, 1991.
55. Fruchaud H. Anatomie Chirurgicale des Hernies de l'Aine. Paris: C. Doin, 1956.
56. Skandalakis JE, Skandalakis LJ, Colborn GL. Testicular atrophy and neuropathy in herniorrhaphy. Am Surg 1996;62:775-782. [PubMed: 8751775]
57. Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963.
58. Hollinshead WH. Anatomy for Surgeons. New York: Paul B. Hoeber, 1958.
59. Doyle JF. The superficial inguinal arch: a reassessment of what has been called the inguinal ligament. J Anat 1971;108:297-304. [PubMed: 4251278]
60. Eycleshymer AC. Anatomical Names Especially the Basle Nomina Anatomica ("BNA"). New York: William Wood, 1917.
61. McVay CB. The anatomic basis for inguinal and femoral hernioplasty. Surg Gynecol Obstet 1974;139:931. [PubMed: 4278445]
62. Gerrish FH. A Textbook of Anatomy by American Authors (2nd ed). Philadelphia: Lea Brothers, 1902.
63. Nomina Anatomica. Baltimore: Williams & Wilkins, 1950, p. 1456.
64. Nomina Anatomica. New York: Excerpta Medica, 1980, p. 1963.
65. Basmajian JV. Nomina Anatomica (6th ed). New York: Churchill Livingstone, 1985, p. A33.
66. Condon RE. The anatomy of the inguinal region and its relation to groin hernia. In: Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: JB
Lippincott, 1995; pp. 16-52.
67. Gray SW, Skandalakis JE. Atlas of Surgical Anatomy for General Surgeons. Baltimore: Williams & Wilkins, 1985.
68. Condon RE. Surgical anatomy of the transversus abdominis and transversalis fascia. Ann Surg 1971;173:1. [PubMed: 4250833]
69. Gimbernat DA. Nuevo Mtodo de Operar en la Hernia Crural. Madrid: Ibarra, 1793.
70. Cooper A. The Anatomy and Surgical Treatment of Abdominal Hernia. Philadelphia: Lea & Blanchard, 1804.
108/113
5/24/2014
70. Cooper A. The Anatomy and Surgical Treatment of Abdominal Hernia. Philadelphia: Lea & Blanchard, 1804.
71. Nyhus LM, Bombeck CT. Hernias. In: Sabiston DC (ed). Textbook of Surgery (13th ed). Philadelphia: WB Saunders, 1986, pp. 1321-1352.
72. Jones FW (ed). Buchanan's Manual of Anatomy (8th ed). Baltimore: Williams & Wilkins, 1950.
73. Ellis H. Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students (6th ed). Oxford: Blackwell Scientific, 1977.
74. Neidhardt JPH. Surgical anatomy of the anterolateral and posterior abdominal walls and points of weakness. In: Chevrel JP (ed). Surgery of the
Abdominal Wall. Berlin: Springer-Verlag, 1987.
75. Gardner E, Gray DJ, O'Rahilly R. Anatomy: A Regional Study of Human Structure. Philadelphia: Saunders, 1986.
76. Lockhart RD. Myology. In: Romanes GJ (ed). Cunningham's Textbook of Anatomy (10th ed). London: Oxford University Press, 1964.
77. Basmajian JV, Slonecker CE. Grant's Method of Anatomy (11th ed). Baltimore: Williams & Wilkins, 1989.
78. Decker GAG, du Plessis DJ (eds). Lee McGregor's Synopsis of Surgical Anatomy. Bristol: Wright, 1986.
79. Lindner HH. Clinical Anatomy. Norwalk CT: Appleton and Lange, 1989.
80. Nyhus LM. An anatomical reappraisal of the posterior inguinal wall. Surg Clin North Am 1964;44:1305.
81. Hesselbach FC. Neueste anatomisch-pathologgische Untersuchungen uber den Ursprung und das Fortschreiten der Leisten und Schenkelbruche.
Wurzburg: Baumgartner, 1814.
82. Condon RE. The anterior iliopubic tract repair. In: Nyhus LM, Condon RE (eds). Hernia (4th ed). Philadelphia: Lippincott, 1995; pp. 136-152.
83. Cooper AP. The Anatomy and Surgical Treatment of Crural and Umbilical Hernia. London: Longman, 1807.
84. Read RC. Cooper's posterior lamina of transversalis fascia. Surg Gynecol Obstet 1992;174:426. [PubMed: 1570623]
85. Sorg J, Skandalakis JE, Gray SW. The emperor's new clothes or the myth of the conjoined tendon. Am Surg 1979;45:588-589. [PubMed: 507566]
86. Hureau J, Agossou-Voyeme AK, Germain M, Pradel J. Les espaces interparieto-peritoneaux posterieurs ou espaces retroperitoneaux: anatomie
topographique normale. J Radiol 1991;72: 101. [PubMed: 2056472]
87. Hureau J, Pradel J, Agossou-Voyeme AK, Germain M. Les espaces interparieto-peritoneaux posterieurs ou espaces retroperitoneaux: anatomie
tomodensitometrique pathologique. J Radiol 1991;72: 205. [PubMed: 2072340]
88. Bendavid R. The space of Bogros and the deep inguinal venous circulation. Surg Gynecol Obstet 1992;174:355-358. [PubMed: 1570610]
89. Colborn GL, Skandalakis JE. Anatomical commentaries on the space of Bogros. Postgrad General Surg 1995;6:21-22.
90. Leggett TH Jr, Lintz J. Eine Variett eines Teiles des N. femoralis. Anat Anz 1913;43:232-233.
91. Oertel O. Abnormer Verlauf des Nervus femoralis. Anat Anz 1923;56:550-553.
92. Ferner H. Ein abnormer Verlauf des Nervus femoralis. Anat Anz 1940;90:124-127.
93. Gisel A. Ein Nervus femoralis accessorius. Anat Anz 1948;96: 371-376.
94. Spratt JD, Logan BM, Abrahams PH. Variant slips of psoas and iliacus muscles, with splitting of the femoral nerve. Clin Anat 1996; 9:401-404.
95. Berliner SD. The femoral cone and its clinical implications. Surg Gynecol Obstet 1990;171:111-114. [PubMed: 2382186]
96. Haagensen CD, Feind CR, Herter FP, Slanetz CA, Weinberg JA. The Lymphatics in Cancer. Philadelphia: Saunders, 1972.
97. Lytle WJ. Femoral hernia. Ann R Coll Surg Engl 1957;21:244. [PubMed: 13470744]
98. Daseler EH, Anson BJ, Reimann AF. Radical excision of the inguinal and iliac lymph glands. Surg Gynecol Obstet 1948;87: 679.
99. Colborn GL, Skandalakis JE. Laparoscopic cadaveric anatomy of the inguinal area. Prob Gen Surg 1995;12:13.
100. Moosman DA, Oelrich TM. Prevention of accidental trauma to the ilioinguinal nerve during inguinal herniorrhaphy. Am J Surg 1977;133:146-148.
[PubMed: 835786]
101. Zaluska S. External structure of the ilioinguinal nerve in postfetal life in man. Folia Morphol 1975;34:419-424.
102. Bardeen CR. A statistical study of the abdominal and border-nerves in man. Am J Anat 1902;1:203.
103. Williams PL. Gray's Anatomy (38th ed). New York: Churchill Livingstone, 1995, pp. 1278-1280.
104. Src HS, Tanyeli E, Sargon MF, Karahan ST. An anatomic study of the lateral femoral cutaneous nerve. Surg Radiol Anat 1997;19:307-310. [PubMed:
16453390]
109/113
5/24/2014
16453390]
105. Akita K, Niga S, Yamato Y, Muneta T, Sato T. Anatomic basis of chronic groin pain with special reference to sports hernia. Surg Radiol Anat 21:1-5,
1999. [PubMed: 10370986]
106. Stoppa R, Diarra B, Mertl P. The retroparietal spermatic sheath: an anatomical structure of surgical interest. Hernia 1997;1:55-59.
107. Diarra B, Stoppa R, Verhaeghe P, Mertl P. About prolongations of the urogenital fascia into the pelvis: An anatomic study and general remarks on the
interparietal-peritoneal fascia. Hernia 1997;1:191-196.
108. Waugh PV, Read RC. Defective collagen synthesis in inguinal herniation. Am J Surg 1972;124:189.
109. Peacock EE Jr, Madden JW. Studies in the biology and treatment of recurrent inguinal hernia; II: Morphological changes. Ann Surg 1974;179:567.
[PubMed: 4274685]
110. Peacock EE Jr. Biology of hernia. In: Nyhus LM, Condon RE (eds). Hernia (2nd ed). Philadelphia: JB Lippincott, 1978; p. 79-97.
111. Berliner SD. Adult inguinal hernia: Pathophysiology and repair. Surg Annu 1983;15:307. [PubMed: 6353636]
112. Bassini E. Ueber die Behandlung des Leistenbruches. Arch Klin Chir 1890;40:429.
113. Bendavid R. New techniques in hernia repair. World J Surg 1989; 13:522-531.
114. Fitzgibbons RJ Jr, Camps J, Cornet DA, Nguyen NX, Litke BS, Annabali R, Salerno GM. Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial.
Ann Surg 1995;22:3-13.
115. Brick WG, Colborn GL, Gadacz TR, Skandalakis JE. Crucial anatomic lessons for laparoscopic herniorrhaphy. Am Surg 1995;61:172-177. [PubMed:
7856981]
116. O'Malley KJ, Monkhouse WS, Qureshi MA, Bouchier-Hayes DJ. Anatomy of the peritoneal aspect of the deep inguinal ring: implications for laparoscopic
inguinal herniorrhaphy. Clin Anat 1997;10:313-317. [PubMed: 16453390]
117. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg 1991;1:269-277. [PubMed: 1834279]
118. Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis
of Surgery. New York: Parthenon, 1996.
119. Annibali R, Quinn T, Fitzgibbons RJ Jr. Anatomy of the inguinal region from the laparoscopic perspective: critical areas for laparoscopic hernia repair.
Abstract presented at Hernia '93: Advances or Controversies. Indianapolis, Indiana. May 23-27, 1993.
120. Maingot R. Abdominal Operations (5th ed). New York: Appleton-Century-Crofts, 1969.
121. Keeney AH. In: Strauss MB. Familiar Medical Quotations. Boston: Little, Brown and Co, 1968, p. 598.
122. Rout WR. Abdominal incisions. In: Zuidema GD (ed). Shackelford's Surgery of the Alimentary Tract (4th ed). Philadelphia: WB Saunders, 1996, p. 327.
123. Zollinger RM. Some principles of reoperative surgery. In: Tompkins RK. Reoperative Surgery. Philadelphia: JB Lippincott, 1988, p. 4.
124. Saint JJ, Braslow LE. Removal of the xiphoid process as a aid in operations of the upper abdomen. Surgery 1953;33:361. [PubMed: 13038620]
125. Wangensteen O. Cancer of the Esophagus and the Stomach. New York: American Cancer Society, 1951.
126. Garlock J. Combined abdomino-thoracic approach for carcinoma of the cardia and lower esophagus. Surg Gynecol Obstet 83:737, 1946.
127. Haddad V, Macon WL. Abdominal wound dehiscence and evisceration: contributing factors and improved mortality. Am Surg 1980;46:508. [PubMed:
7416632]
128. Guillou PJ, Hall TJ, Donaldson DR, Broughton AC, Brennan TG. Vertical abdominal incisions - A choice? Br J Surg 1980;67: 395. [PubMed: 6992914]
129. Groscz CR. Iliohypogastric nerve injury. Am J Surg 1981;142: 628.
130. Salgado CJ, Orlando GS, Herceg S, Serletti JM. Pfannenstiel incision as an alternative approach for harvesting the rectus abdominis muscle for freetissue transfer. Plast Reconstr Surg 2000; 105:1330-1333.
131. Lipton S, Estrin J, Bloom N. A study of the costal incision for biliary tract surgery. Am Surg 1980;46:576. [PubMed: 6448555]
132. Gkora IH. Low inguinal groove incision for indirect inguinal hernias in girls: a preliminary report on an incisional proposal. J Am Coll Surg 1996;183:384386. [PubMed: 16453309]
133. Rolnick HC. Genito-urinary surgery. In: Thorek M (ed). Surgical Errors and Safeguards (5th ed). Philadelphia: JB Lippincott, 1960; pp. 590-620.
134. Chassin JL. Operative Strategy in General Surgery: An Expositive Atlas, vol 1. New York: Springer-Verlag, 1980.
110/113
5/24/2014
135. Crawford ES, Crawford JL. Diseases of the Aorta Including an Atlas of Angiographic Pathology and Surgical Technique. Baltimore: Williams & Wilkins,
1984.
136. Effler DB (ed). Blades Surgical Diseases of the Chest, 4th ed. St. Louis: CV Mosby, 1978.
137. Petrovosky BV (ed). Atlas of Thoracic Surgery, vol 2. St. Louis: CV Mosby, 1978.
138. Thorek P. Atlas of Surgical Techniques. Philadelphia: JB Lippincott, 1970.
139. Munk T, Kjer JJ. Herniation of the omentum after laparoscopy. Eur J Obstet Gynecol Reprod Biol 1994;56:69. [PubMed: 7982521]
140. McGuire HH Jr. Complications of abdominal wall surgery. In: Greenfield LJ (ed). Complications in Surgery and Trauma (1st ed). Philadelphia: JB
Lippincott, 1984; p. 466-474.
141. Stulz P, Pfeiffer KM. Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch Surg 1982;117:324327. [PubMed: 7065874]
142. Sanders RJ, DiClementi D. Principles of abdominal wound closure. II: Prevention of wound dehiscence. Arch Surg 1977;112: 1188. [PubMed: 334112]
143. Greenall MJ, Evans M, Pollock AV. Midline or transverse laparotomy? A random controlled clinical trial: I. Influence on healing. Br J Surg 1980;67:188.
[PubMed: 6988033]
144. Nilsson T, Milbech S, Jansen E, Serafimovski N. An indirect method to examine forces affecting Courvoisier's oblique gall-bladder incision. Acta Chir
Scand 1979;145:35. [PubMed: 155383]
145. Edlich RF, Rodeheaver G, Thacker JG, Edgerton MT. Technical factors in wound management. In: Hunt TK, Dunphy JE (eds). Fundamentals of Wound
Management. New York: Appleton-Century-Crofts, 1979, p. 364-454.
146. Hunt TK (ed). Wound Healing and Wound Infection. New York: Appleton-Century-Crofts, 1980.
147. Jones TE, Newell ET, Brubaker RE. The use of alloy steel wire in the closure of abdominal wounds. Surg Gynecol Obstet 1941; 72:1056-1059.
148. Hoerr SO, Allen R, Allen K. The closure of the abdominal incison; a comparison of mass closure with wire and layer closure with silk. Surgery
1951;30:166-173. [PubMed: 14846003]
149. Hermann RE. Abdominal wound closure using a new polypropylene monofilament suture. Surg Gynecol Obstet 1974;138:84-86. [PubMed: 4271821]
150. Dudley HAF. Layered and mass closure of the abdominal wall: a theoretical and experimental analysis. Br J Surg 1970;57:664-667. [PubMed: 4248581]
151. Sanders RJ, DiClementi D, Ireland K. Principles of abdominal wound closure I: Animal studies. Arch Surg 1977;112:1184-1187. [PubMed: 334111]
152. Wantz GE, Chevrel JP, Flament JB, Kingsnorth A, Schumpelick V, Verhaeghe P. Incisional hernia: the problem and the cure. J Am Coll Surg 188(4):429447, 1999.
153. Chrysos E, Athanasakis E, Saridaki Z, Kafetzakis A, Dimitriadou D, Koutsoumpas V, Chalkiadakis G, Xynos E, Zoras O. Surgical repair of incisional ventral
hernias using prosthetic materials (expanded polytetrafluoroethylene Gore-Tex dual mesh). Am Surg 2000;66:679-682. [PubMed: 10917481]
154. Matapurkar BG, Bhargave A, Dawson L, Sonal B. Regeneration of abdominal wall aponeurosis: new dimension in Marlex peritoneal sandwich repair of
incisional hernia. World J Surg 23: 446-451, 1999. [PubMed: 10085391]
155. Carlson GW, Elwood E, Losken A, Galloway JR. The role of tissue expansion in abdominal wall reconstruction. Ann Plast Surg 2000;44:147-153.
[PubMed: 10696040]
156. Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal wall defects: an anatomic and clinical study. Plast Reconstr
Surg 1990;86;519-526
157. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for reconstruction of massive midline abdominal wall defects:
anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000; 105:731-739.
158. Sanders LM, Flint LM, Ferrara JJ. Initial experience with laparoscopic repair of incisional hernias. Am J Surg 177:227-231, 1999. [PubMed: 10219859]
159. Szymanski J, Voitik A, Joffe J, Alvarez C, Rosenthal G. Technique and early results of outpatient laparoscopic mesh onlay repair of ventral hernias. Surg
Endosc 2000;14:582-584. [PubMed: 10890970]
160. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190:645-650.
[PubMed: 10872998]
161. Larson GM. Ventral hernia repair by the laparoscopic approach. Surg Clin North Am 2000;80:1329-1240. [PubMed: 10987039]
162. Hodgson NC, Malthaner RA, stbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000;231:436-442.
[PubMed: 10714638]
163. Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege RV, Turnage RH. Factors affecting recurrence following incisional herniorrhaphy. World J
111/113
5/24/2014
163. Anthony T, Bergen PC, Kim LT, Henderson M, Fahey T, Rege RV, Turnage RH. Factors affecting recurrence following incisional herniorrhaphy. World J
Surg 2000;24:95-101. [PubMed: 10594211]
164. Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, Ijzermans JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM,
Jeekel J. A comparison of suture repair with mesh repair for incisional hernia. New Engl J Med 2000;343:392-398. [PubMed: 10933738]
165. Merendino KA. The intradiaphragmatic distribution of the phrenic nerve. Surg Clin North Am 1964;44:1217-1226.
166. Foster MA, Gering SA, Bradley YC. Sister Mary Joseph's sign from metastatic disease of the pancreas. J Am Coll Surg 192(1): 130, 2001.
167. Wakhlu A, Wakhlu AK. The management of exomphalos. J Ped Surg 2000;35:73-76. [PubMed: 10646778]
168. Dunn JCY, Fonkalsrud EW. Improved survival of infants with omphalocele. Am J Surg 173:284-287, 1997. [PubMed: 9136781]
169. Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.
170. Grosfeld JL, Weber TR. Congenital abdominal wall defects: gastroschisis and omphalocele. Curr Prob Surg 1982;19:158.
171. Anthony JE Jr, Brawley WG. An unusual complication associated with omphalocele. J Med Assoc Ga 1963;52:363. [PubMed: 14013318]
172. Arnheim EE. Surgical complications of congenital anomalies of the umbilical region. Surg Gynecol Obstet 1950;91:71. [PubMed: 15442826]
173. Singer JA, Mansberger AR Jr. Spigelian hernia. Arch Surg 1973;107:515. [PubMed: 4269619]
174. Skandalakis JE, Burns WB, Sangmalee U, Sorg JL. Internal and external supravesical hernia. Am Surg 1976;42:142-146. [PubMed: 1247255]
175. Chandler SB. Studies on the inguinal region: II. The anatomy of the inguinal (Hesselbach) triangle. Ann Surg 1946;124:156.
176. Watson LF. Hernia (3rd ed). St. Louis: Mosby, 1948.
177. Rowe JS Jr, Skandalakis JE, Gray SW. Multiple bilateral inguinal hernias. Am Surg 1973;39:269. [PubMed: 4700657]
178. Keynes WM. Supravesical hernia. In: Nyhus LM, Harkins HN (eds). Hernia. Philadelphia: JB Lippincott, 1964.
179. King R. Congenital, strangulated hernia in an infant aged six months containing the ovary and fallopian tube. Br J Clin Pract 1978;32:209-210. [PubMed:
678420]
180. Oh KS, Condon VR, Dorst JP, Grajo G. Peritoneographic demonstration of femoral hernia. Radiology 1978;127:209-211. [PubMed: 635184]
181. Gray SW, Skandalakis JE. Strangulated femoral hernia in children. J Med Assn Ga 1962;51:386-387. [PubMed: 13901327]
182. Nyhus LM. The preperitoneal approach and iliopubic tract repair of femoral hernias. In: Nyhus LM, Condon RE (eds). Hernia (4th ed). 1995, Philadelphia:
JB Lippincott, p. 178-184.
183. Quoted in Myers NA. Herniae in paedriatric practice. Editorial Comments. Pediatr Surg Int 1994;9:159-160.
184. Myers NA. Herniae in paedriatric practice. Editorial Comments. Pediatr Surg Int 1994;9:159-160.
185. Wright JE. Direct inguinal hernia in infancy and childhood. Pediatr Surg Int 1994;9:161-163.
186. Wright JE. Recurrent inguinal hernia in infancy and childhood. Pediatr Surg Int 1994;9:164-166.
187. Wright JE. Femoral hernia in childhood. Pediatr Surg Int 1994;9: 167-169.
188. Wright JE. Spigelian hernia in childhood. Pediatr Surg Int 1994; 9:170-171.
189. Redman JF. An atraumatic anatomic technique for separation of the pediatric hernia sac from the spermatic cord. Urology 56(3):496-498, 2000.
190. Ferzli GS, Frezza EE, Pecoraro AM Jr, Ahern KD. Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal
hernia repair. J Am Coll Surg 188:461-465, 1999. [PubMed: 10235572]
191. Wantz GE. Laparoscopic hernioplasty without staples. [Editorial]. J Am Coll Surg 188:531, 1999. [PubMed: 10235582]
192. Rosenberger RJ, Loeweneck H, Meyer G. The cutaneous nerves encountered during laparoscopic repair of inguinal hernia. Surg Endosc 2000;14:731735. [PubMed: 10954819]
193. Balzer KM, Witte H, Recknagel S, Kozianka J, Waleczek H. Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar
placement. Surg Radiol Anat 21:87-89, 1999. [PubMed: 10399206]
194. Chandler JG, Corson SL, Way LW. Three spectra of laparoscopic entry access injuries. J Am Coll Surg 20001;192:478-491.
195. Wakhlu A, Wakhlu AK. Congenital lumbar hernia. Pediatr Surg Int 2000;16:146-148. [PubMed: 10663870]
196. Barden BE, Maull KI. Traumatic lumbar hernia. South Med J 93(11):1067-1069, 2000.
112/113
5/24/2014
196. Barden BE, Maull KI. Traumatic lumbar hernia. South Med J 93(11):1067-1069, 2000.
197. Arca MJ, Heniford BT, Pokorny R, Wilson MA, Mayes J, Gagner M. Laparoscopic repair of lumbar hernias. J Am Coll Surg 187:147-152, 1998. [PubMed:
9704960]
198. Slattery LR, Robson W, Grier N. Immediate complications of the surgery of hernia. Surg Clin North Am 1964;44:461. [PubMed: 14180333]
199. Callesen T, Bech K, Andersen J, Nielsen R, Roikjaer O, Kehlet H. Pain after primary inguinal herniorrhaphy: influence of surgical technique. J Am Coll Surg
188:355-359, 1999. [PubMed: 10195718]
200. Heise CP, Starling JR. Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy? J Am Coll Surg 187:514-518, 1998. [PubMed: 9809568]
201. Jordan WP Jr. Hydroceles and varicoceles. Surg Clin North Am 1965;45:1535. [PubMed: 5321945]
202. Wantz GE. Testicular atrophy and chronic residual neuralgia as risks of inguinal hernioplasty. Surg Clin North Am 1993;73:571-582. [PubMed: 8497804]
203. Heifetz CJ. Resection of the spermatic cord in selected inguinal hernias. Twenty years of experience. Arch Surg 1971;102:36-39. [PubMed: 4923036]
204. Wantz GE. Testicular atrophy as a risk of inguinal hernioplasty. Surg Gynecol Obstet 1982;154:570. [PubMed: 7064092]
205. Fong Y, Wantz GE. Prevention of ischemic orchitis during inguinal hernioplasty. Surg Gynecol Obstet 1992;174:399. [PubMed: 1570618]
206. Nahabedian MY, Dellon AL. Outcome of the operative management of nerve injuries in the ilioinguinal region. J Am Coll Surg 1997;184:265-268.
[PubMed: 9060923]
207. Lavonius MI, Ovaska J. Laparoscopy in the evaluation of the incarcerated mass in groin hernia. Surg Endosc 2000;14:488-489. [PubMed: 10858478]
208. Hernandez-Richter T, Schardey HM, Rau HG, Schildberg FW, Meyer G. The femoral hernia: an ideal approach for the transabdominal preperitoneal
technique (TAPP). Surg Endosc 2000;14:736-740. [PubMed: 10954820]
209. Irving SO, Deans GT, Royston CSM, Brough WA. Laparoscopic hernia repair (TAPP): A new method to reduce port-site-herniation. Surg Laparosc
Endosc 1997;7:49-50. [PubMed: 9116948]
210. Athanasakis E, Saridaki Z, Kafetzakis A, Chrysos E, Prokopakis G, Vrahasotakis N, Xynos E, Chalkiadakis G, Zoras O. Surgical repair of inguinal hernia:
tension free technique with prosthetic materials (Gore-Tex mycro mesh expanded polytetrafluoroethylene). Am Surg 66(8):728-731, 2000.
211. Kobayashi S, Monma T, Adachi W, Nakata S, Yamaura K, Amano J, Iizuka K, Nishizawa O, Kaneko G. Urinary bladder injury during inguinal herniorrhaphy
in a renal transplant patient: report of a case. Surg Today 2000;30:101-103. [PubMed: 10648096]
212. Davis AB. Laparoscopic hernia repair in the community hospital setting. Surg Laparosc Endos 1996;6:448-452. [PubMed: 8948037]
213. Koninckx PR, Donders G, Vandecruys H. Umbilical endometriosis after unprotected removal of uterine pieces through the umbilicus. J Am Assn Gynecol
Laparoscopists 2000;7:227-232. [PubMed: 10806267]
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Print: Chapter 9. Abdominal Wall and Hernias

"The founder of anatomy." Ligated vessels for hemostasis.

"The father of physiology." Performed hernia operations in Alexandria, Egypt.

Used cautery to drain hydrocele fluid

Provided a more complete classification of hernias

Recommended orchiectomy for treatment of hydrocele

Sutured sac, ligated cord and sac

Believed hydrocele to be a systemic disease originating in abdomen and extending to scrotum

Successfully resected bowel of patient with strangulated hernia

Stated that dilated spermatic vessels were cause of hydrocele

1778- Described partial strangulation of intestinal wall within hernial sac

Attributed hydrocele to rupture of hydatid cysts

Print: Chapter 9. Abdominal Wall and Hernias

Accurately described types and causes of hydrocele

Introduced subcutaneous ligature of sac for hernia repair

Found microfilariae in hydrocele fluid

Found live worms in hydrocele of spermatic cord

Proposed concept of injection treatment

Incorporated cord into imbrication of external oblique aponeurosis

Used extrapleural osteochondral flap approach during resection

Used Cooper's ligament for repair of inguinal hernia

Treated hydrocele with excision and eversion of tunica vaginalis

Resected stenosis through costal margin release procedure

Employed two-incision technique (esophagostomy and gastrostomy)

First to suggest one-incision approach. Only employed two-incision technique.

1931, By anatomic study, discovered cause of hydrocele

Revitalized preperitoneal procedure

First successful esophagogastrotomy in Europe

Devised procedure for reinforcing peritoneum using large unslit prosthesis

Studied iliopubic tract anatomically and used it for repair

Modified mesh-plug repair

History table compiled by David A. McClusky III and John E. Skandalakis.

Print: Chapter 9. Abdominal Wall and Hernias

Print: Chapter 9. Abdominal Wall and Hernias

Print: Chapter 9. Abdominal Wall and Hernias

Prenatal Age at First

Deformities of the thorax

Late in fetal life

Unilateral thoracic wall aplasia

Few affected persons reach maturity; common in

Usually disappears spontaneously

Failure of normal intestinal return

Herniation through defect in abdominal wall

Incomplete closure of the processus vaginalis Around birth

Results in inguinal hernia or hydrocele

Exstrophy of the bladder

Untreated patients die eventually from

Exstrophy of the cloaca

All should be reared as females

Absence of abdominal musculature with

Aplasia of abdominal musculature without

Anterior Abdominal Wall

Aponeurosis to linea alba from xiphoid to

Lower border of ribs 9-12

Anterior iliac crest

With aponeurosis to linea alba

Lower 6 thoracic Related to lateral of inguinal ligament

Print: Chapter 9. Abdominal Wall and Hernias

With aponeurosis to linea alba

1st lumbar spinal

Through aponeurosis to linea alba

Related to lateral of inguinal ligament

Crest of pubis and