Anatomy of the peritoneal aspect of the deep inguinal ring: implications for laparoscopic inguinal herniorrhaphy

Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia

PURPOSE

Chronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy.

METHODS

We dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images.

RESULTS

The courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine.

CONCLUSION

Nerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior triple neurectomy can be considered.

Anatomical variations of medial umbilical ligament: clinical significance in laparoscopic exploration of children

BACKGROUND

The anatomy and clinical significance of obliterated umbilical artery called as medial umbilical ligament (MUL) have not been documented well in literature. In this study, we investigated anatomical variations of MUL determined by laparoscopic exploration of abdomen in children and anatomy dissection on cadaver.

PATIENTS AND METHODS

The anatomy of MUL was investigated in a total of 126 patients including 41 retrospective cases. All 126 patients had laparoscopic exploration for a lower abdominal pathology. In retrospective group, videos demonstrating clearly both MULs and the region during laparoscopic exploration were selected. A dissection on an adult male cadaver was also performed. A preliminary grading scale of anatomical appearance of MUL was obtained.

RESULTS

In grade 0, patients had no visible ligament (n = 14); in grade 1, MUL was a fibrous cord without a web formation (n = 63); in grade 2, MUL was a fibrous cord with a web (n = 49). MULs on both sides of the lower abdominal wall were symmetrical in all cases except one having a cloacal anomaly. This case had a solitary MUL on the right side.

CONCLUSIONS

A MUL with a fibrous cord and significant web may cause technical difficulties and narrow the working space in laparoscopic exploration of children. It may also affect the surgeon's preference on trocar locations. In all grades of anatomical variation of MUL, formation of the ligament on both sides of the lower abdominal wall is similar. If there is a single umbilical artery, it becomes a solitary MUL after birth, and the possibility of associated malformations, especially urogenital abnormalities increases in such cases.

The assessment of quality of life in a trial on lightweight mesh fixation with fibrin sealant in transabdominal preperitoneal hernia repair

BACKGROUND

Chronic pain is a major concern in open and laparoscopic hernia repair. Study groups have adopted a variety of tools to assess postoperative (postOP) pain and quality of life (QoL). Unfortunately, modifications of existing tests and self-designed questionnaires are common, yielding unvalidated results and making comparison of data difficult. The aim of this study was to assess the QoL in transabdominal preperitoneal mesh repair (TAPP) with fibrin sealant (FS) for lightweight mesh fixation, applying the standardised Short Form 36 (SF36) questionnaire in its unmodified design. The SF36 has already been validated and implemented in a large number of studies. In this trial the physical-health-component summary measure (PHM), summarising the physical health-related scales, served as the primary outcome parameter.

MATERIALS AND METHODS

After informed written consent was obtained, TAPP with fibrin mesh sealing was performed in 11 non-selected consecutive patients by a single surgeon. A direct control group (e.g. TAPP with staples) was not enrolled, because a favourable change in the QoL in patients subjected to the mesh sealing approach was the tested hypothesis and not the comparison of techniques. The macroporous mesh (TI-Mesh, GfE, Germany) was fixed with 1 ml of FS (FS, Tisseel, Tissucol, Baxter Biosciences, Austria), and the QoL and pain were assessed preoperatively and 1 year postOP using the SF36 survey and the visual analogue score (VAS).

RESULTS

After 12 months, recurrences or complications were observed. The analysis of the unmodifed SF36 revealed a highly significant improvement in the PHM, based on significant changes of all physical-health-related scales. The scale 'social functioning' (SOCIAL), which belongs to the mental-health-related scale, had also significantly improved. The VAS was significantly reduced after 1 year.

CONCLUSIONS

Despite a small number of patients (n = 11), a strikingly significant improvement in physical health and reduction of pain was detected with the unmodified SF36 and the VAS 1 year after TAPP repair with fibrin-sealed lightweight meshes. We suggest the use of the unmodified SF36 for QoL in hernia repair in order to assess all aspects of recovery (physical and mental) and to facilitate comparison of data.

Inguinal hernia: measurement of the biomechanics of the lower abdominal wall and the inguinal canal

BACKGROUND

The stability of the lower abdominal wall may play a considerable role in the development of inguinal hernia. Therefore, the strength of the individual wall layers needs to be quantified. Despite numerous advances in hernia repair, comparatively few systematic biomechanic and morphometric analyses have been performed. Our aim was to establish and apply a standardised procedure for testing the abdominal wall layers' stability.

METHODS

After dissecting the abdominal walls of 16 cadavers into separate layers, we used a spherical punch and a force transducer to investigate the forces necessary to foraminate the layer. In addition, maximum tensile-strength and suction tests and histologic morphometry were performed.

RESULTS

The transversalis fascia was torn up on an average of 10.5 N, the peritoneum including pre- and subperitoneal tissue on 46.6 N, the aponeurosis of obliquus internus abdominis muscle on 51.7 N, and the aponeurosis of obliquus externus abdominis muscle on 92.6 N. Tensile tests of tissue strips obtained from defined areas showed comparable results. In contrast, surgical mesh revealed values between 60 and 150 N in punching tests. Left-right comparisons, as well as comparisons of the individual areas, revealed considerable intra- and inter-individual differences.

CONCLUSIONS

Biological hernia repair should focus on a reinforcement of the tissue layers with the highest biomechanic stability. Reinforcement of the transversal fascia must be questioned according to our results of poor mechanical resistance.