The tension-free hernioplasty

Since the first true herniorrhaphy was performed by Bassini over 100 years ago, all modifications and surgical techniques have shared a common disadvantage: suture line tension. The anatomic, physiologic, and pathologic characteristics of hernia recurrence are examined. The prime etiologic factor behind most herniorrhaphy failures is the suturing together, under tension, of structures that are not normally in apposition. With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity.

Hip and groin injuries in athletes

Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, they can result in extensive rehabilitation time. Thus, an accurate diagnosis and well-organized treatment plan are critical. Because loads of up to eight times body weight have been demonstrated in the hip joint during jogging, presumably even greater loads can occur during vigorous athletic competition. The available imaging modalities are effective diagnostic tools when selected on the basis of a thorough history and physical examination. Considerable controversy exists as to the cause and optimal treatment of groin pain in athletes, or the so-called "sports hernia." There has also been significant recent attention focused on intraarticular lesions that may be amenable to hip arthroscopy. This article briefly reviews several common hip and groin conditions affecting athletic patients and highlights some newer topics.

The athletic hernia: a systematic review

The athletic hernia is an obscure condition of uncertain etiology commonly seen in soccer and rugby players. The pain is often debilitating and may place an athletic career at risk. Treatment failures are frustrating to the athlete and the physician. The anatomy involved, diagnostic criteria, and treatment modalities are inconsistently described in the medical, surgical and orthopaedic literature. There is no evidence-based consensus available to guide decision-making. We performed an overview of the anatomy and pathoanatomy and a systematic review of the literature to gain insight into the disease and its treatment. Most studies are Level IV. The most common operative finding is a deficient posterior wall of the inguinal canal, although other abdominal wall abnormalities are frequently found. Open and laparoscopic repairs produce excellent results, but the latter allows earlier return to play. Magnetic resonance imaging appears to have excellent diagnostic potential for athletic hernia. A multidisciplinary approach to groin pain in the athlete is recommended.

Groin injuries and groin pain in athletes: part 1

Sports injuries to the hip and groin region have been noted in 5% to 9% of high school athletes. These injuries occur most commonly in athletes participating in sports involving side-to-side cutting, quick accelerations and decelerations, and sudden directional changes.Symptoms may range from intermittent episodes of mild discomfort to severe and chronic career-ending pain. Groin injuries may result from a variety of causes. Although this article deals mainly with athletic etiologies, the physician must keep in mind that many other medical conditions may also affect the groin. Because of these overlapping medical conditions and because the anatomy of the region is so complex, a team approach is optimal. In Part 1 of this two-part series, ligament/muscle strains, nerve entrapment syndromes, and posterior abdominal wall abnormalities are reviewed as common causes of groin pain.

Groin flap design and versatility

The groin flap is a reliable and well-established reconstructive option for pedicled or free-tissue transfer. Concern regarding its variable vascular origin and caliber has limited its use. To overcome this, a simplified guideline based on the transverse diameter of the patient's index and long fingers at the distal interphalangeal level has been developed. Thus "rule of two finger widths" positions the origin of the vascular pedicle from the femoral vessels two finger widths below the inguinal ligament, the upper flap border two finger widths above the inguinal ligament, the lower flap border two finger widths below the vascular origin, and both parallel to the flap axis, which lies along a line from the vascular origin to the anterosuperior iliac spine. This new groin flap design provides the necessary guidelines for vascular identification, accommodates pediatric and adult stature, and ensures primary donor-site closure if flap dimensions are within the prescribed boundaries. In addition, a new sartorius-cutaneous groin flap is presented. This combines the cutaneous groin flap with the proximal sartorius muscle (up to 15 cm), which is supplied by the deep vessels of the superficial circumflex iliac system. The sartorius-cutaneous groin flap further emphasizes the concept of single-pedicle compound or combined flaps and additionally enhances the extensive reconstructive versatility of previously described groin flaps. Over 200 pedicled and free groin flaps have been performed according to the "rule of two finger widths" over the past 5 years. There have been no complications related to flap design, such as difficulty with flap elevation, marginal necrosis, or donor-site closure.(ABSTRACT TRUNCATED AT 250 WORDS)

Sonography of Inguinal Region Hernias

OBJECTIVE

The purpose of this article is to describe the anatomy of the inguinal region in a way that is useful for sonographic diagnosis of inguinal region hernias, and to illustrate the sonographic appearance of this anatomy. We show sonographic techniques for evaluating inguinal, femoral, and spigelian hernias and include surgically proven examples.

CONCLUSION

Understanding healthy inguinal anatomy is essential for diagnosing inguinal region hernias. Sonography can diagnose and differentiate between various inguinal region hernias.

Surgical anatomy of the inguinal area

The anatomy of the inguinal region is enigmatic and confusing. Among the many structures involved in hernial repair are the iliopubic tract, the transversus abdominis aponeurosis and the transversalis fascia, the transversalis crura and sling, and the inguinal canal. There is still much disagreement among surgeons and anatomists about the existence, structure, and function of these anatomic entities.

The gymnasts' hip and groin: a magnetic resonance imaging study in asymptomatic elite athletes

OBJECTIVE

Specific patterns of developmental adaptation of the proximal femur have been recognized in some sports. Gymnastics are characterized by repetitive axial loading and hip rotations in combination with extreme hip positions. It is unknown how and if these forces can affect an immature skeleton in the long term. We sought to evaluate this, by means of magnetic resonance imaging of the hip and groin of such elite asymptomatic athletes.

MATERIALS AND METHODS

We performed a case-control comparative MR imaging study of both hips and groin of 12 (7 male, 5 female) skeletally mature young (mean age 18.6 years) asymptomatic international level gymnasts with a minimum of 10 years' training with age-matched non-athletes. At the time of recruitment, none of the athletes had a recorded musculoskeletal complaint or injury in the anatomical area around the hip.

RESULTS

The study showed that elite gymnasts share four common morphological characteristics on MRI that deviate from normal and are considered to be the result of adaptational changes to the specific sport: high centre-column-diaphysis angle (coxa valga140° on average), ligamentum teres hypertrophy, friction of the iliotibial band with oedema surrounding the greater trochanter, and a high incidence (62.5 %) of radiological appearances of ischiofemoral impingement.

CONCLUSION

Our study showed that elite gymnasts share four common morphological characteristics on MRI that deviate from normal. These findings were in asymptomatic subjects; hence, radiologists and sports physicians should be aware of them in order to avoid unnecessary treatment.

Anatomy of the proximal musculotendinous junction of the adductor longus muscle

Injuries to the adductor longus commonly occur in the proximal part of the muscle tendon unit, close to the insertion site on the pubic bone. Ultrasonography, magnetic resonance imaging (MRI) and surgery have been helpful in localising the lesions, but the exact anatomy of the musculotendinous junction (MTJ) and insertion of the muscle remain unclear. We studied the anatomical features of the MTJ and measured the dimensions of the tendinous insertion into the pubic bone on 37 cadavers: 18 men and 19 women. The medial boundaries were the longest part of the tendon bilaterally in women, while the lateral aspect of the left muscle was greater in men. Tendinous fibres were predominantly found on the anterior surface, while the posterior surface consisted mainly of muscle tissue. The MTJ was clearly demarcated. There were several types of anomalies present which partially explains the difficulty in localising the site of injury and highlights the importance of individualized treatment.

Antegrade puncture of the femoral artery: morphologic study

To determine the optimal site for antegrade puncture of the femoral artery, the authors evaluated three cadaver specimens and computed tomographic (CT) scans of 50 patients. The relationships among the common femoral artery, the femoral artery bifurcation, the center of the femoral head, and the inguinal ligament were evaluated. CT showed that the center of the femoral head was always located caudal to the level of the inguinal ligament but cranial to the bifurcation of the common femoral artery. Therefore, the femoral head seems to provide a reliable landmark for entering the common femoral artery.

Tack entrapment of the ilioinguinal nerve during laparoscopic hernia repair

Nerve injury has a reported incidence of 2% during laparoscopic hernia repair. These injuries usually involve the femoral branch of the genitofemoral nerve and the lateral cutaneous nerve of the thigh. Recently, in an effort to decrease the size of the port sites, surgeons have been using 5-mm tacking devices. These devices penetrate tissue more deeply and in so doing may injure nerves not classically at risk, such as the ilioinguinal and the iliohypogastric. We report the first documented injury to the ilioinguinal nerve during laparoscopic hernia repair. In addition, we review the anatomy and technique in an effort to help avoid this complication in the future.

Relationship of the inguinal ligament to pelvic radiographic landmarks: anatomic correlation and its role in femoral arteriography

PURPOSE

Because of the known risks of suprainguinal catheterization, an anatomic study of the inguinal ligament was performed in 10 cadavers.

MATERIALS AND METHODS

The position of the inguinal ligament as estimated by means of palpation and use of anatomic landmarks was compared with the actual ligament position as determined by means of groin dissection. Infrainguinal contrast material injections were also performed to assess competence of the inguinal ligament against spread of hematomas.

RESULTS

The radiographically determined position was an average of 15.2 mm superior to the actual ligament position (range, 3 mm below to 24 mm above). The palpated position of the ligament was an average of 7.8 mm superior to its actual position (range, 7 mm below to 23 mm above). Contrast material injections demonstrated the inability of the inguinal ligament to contain blood or fluid, with formation of retroperitoneal hematomas.

CONCLUSION

Puncture of the femoral vessels should be positioned in the midportion of the femoral head, as determined with fluoroscopy for maximum safety during catheterizations.

The iliac bone or osteocutaneous transplant pedicled to the deep circumflex iliac artery. I. Anatomical and technical considerations

The technique of microsurgical vessel anastomosis has brought about many new ideas in reconstructive surgery. Many bone sites have been examined for their suitability as donor areas. For reconstructive purposes in the maxillo-facial region, the iliac bone has proven to be the best because of its shape and bulk. A large part of this bone is nourished by the deep circumflex iliac artery (DCIA). Branches of this vessel surround the iliac crest, perforate the flat abdominal muscles, and supply blood to the overlying skin. The anatomical properties of this region present the possibility of raising a large osteomyocutaneous flap.

Reassessment of groin anatomy during the evolution of preperitoneal hernia repair

BACKGROUND

Need to define accurately groin anatomy as visualized by the preperitoneal approach.

METHODS

Dissections of the right groin in 135 fresh male cadavers carried out during autopsy examination. Documentation by photographs and notes.

RESULTS

Classic descriptions of groin anatomy confirmed for the most part. Errors concerning the lacunar ligament and conjoined tendon identified. Accurate descriptions, applicable to groin hernia repair, provided of the iliopubic tract, transversus abdominis arch and aponeurosis, femoral canal, and related structures.

CONCLUSIONS

Improved communication and understanding by and among surgeons regarding groin anatomy is needed.

Surgical anatomy of the inguinal region: implications during inguinal laparoscopic herniorrhaphy

INTRODUCTION

In laparoscopic inguinal hernia repair the inguinal region is approached and hernia repair performed from the interior side instead of the classical open external access. Exploration and placement of staplers in the internal inguinal region during laparoscopic hernia repair may sever different anatomical structures, or induce specific complications such as nerve entrapment, neuralgia, hematomas or osteitis. The incidence of these complications may be reduced by careful dissection of the preperitoneal tissues and by placing a prosthetic mesh without the use of stapling. As laparoscopic techniques evolved, different sizes of meshes have been used. An exact determination of mesh size was hitherto not investigated.

AIM

Cadaver studies of the topography of blood vessels and nerves in the preperitoneal tissue in this region were carried out in order to assess a safe position and adequate size of the prosthetic mesh.

METHODS

Dissection in 6 preserved human female cadavers was performed to define the actual surface of the internal inguinal region. A physical model was developed to formulate the ideal size of the prosthesis. Specific measurements were used to define the maximal size of the meshes, so as to place them without stapling, and without inducing neurovascular complications.

RESULTS

The designed physical formula defines the size of the mesh as a function of the maximum intra-abdominal pressure, the size of the abdominal wall defect and the abdominal wall tension.

CONCLUSION

On mathematical and physical grounds our study points out that the size of the currently used prosthetic mesh (10 x 15 cm) is large enough to be placed without stapling so that with proper placement no recurrences should occur.

Anatomical landmarks for femoral nerve block: a comparison of four needle insertion sites

The site for needle insertion in femoral nerve block varies significantly among various descriptions of the technique. To determine the site with the highest likelihood of needle-femoral nerve contact, femoral nerve block was simulated in a human cadaver model (17 femoral triangles from 9 adult cadavers). Four 20-gauge 50-mm-long styletted catheters were inserted at four frequently suggested insertion sites for femoral nerve block. At the levels of inguinal ligament and the inguinal crease, the catheters were inserted adjacent to the lateral border of the femoral artery and 2 cm lateral to the femoral artery. During anatomical dissection, we studied the number of catheter-nerve contacts for each of the four insertion sites, and relationships between the femoral nerve and other anatomical structures of relevance to femoral nerve block. Insertion of the needle at the level of the inguinal crease, next to the lateral border of the femoral artery resulted in the highest frequency of needle-femoral nerve contacts (71%). Of note, the femoral nerve was significantly wider (14.0 vs 9.8 mm) and closer to the fascia lata (6.8 vs 26.4 mm) at the inguinal crease than at the inguinal ligament level. We conclude that needle insertion at the inguinal crease level immediately adjacent to the femoral artery produced the highest rate of needle-femoral nerve contacts. The main factors influencing this result include the greater width of the femoral nerve and the more predictable femoral artery-femoral nerve relationship at the inguinal crease level, compared with the inguinal ligament level.

IMPLICATIONS

Insertion of a needle at the inguinal crease level and immediately adjacent to the lateral border of the femoral artery results in a high rate of needle-femoral nerve contact.

Abdominal musculature and the transversalis fascia: an anatomical viewpoint

This anatomical study investigated the connection of the muscles of the abdominal wall to the transversalis fascia in the groin. In six unfixed male corpses we prepared the single levels of the inguinal abdominal wall and examined their interrelationships. Of special interest were the direction of the force vectors determined by the direction of the muscular fibers in relation to the transversalis fascia. We found no confirmation of a direct connection between the muscles of the abdominal wall and the transversalis fascia in the inguinal region. No force vector of the different muscular layers points away from the triangle of Hesselbach. By contraction each muscle thus relaxes the transversalis fascia of the Hesselbach triangle.

Significance of inguinal folds for diagnosis of congenital dislocation of the hip in infants aged three to four months

We evaluated the usefulness of the appearance of asymmetrical inguinal folds in the frog leg position as a screening indicator for congenital dislocation of the hip (CDH) in the hope that we might be able to decrease the frequency of radiographic examinations of 3-4-month-old infants. Abnormal inguinal folds were observed in 499 (23.8%) of the 2,111 patients examined at the Asahikawa Health Center, and these 499 included all patients with complete dislocation or subluxation. Abnormal inguinal folds were also present in all 29 previously untreated patients with complete dislocation and in 11 with subluxation seen in our department. Because limited passive hip abduction is less sensitive than abnormal inguinal folds, we recommend inguinal fold assessment as a useful adjunct to other screening methods for CDH in 3-4-month-old infants.

Groin hernia: anatomical and surgical history

The history of surgical repair of groin hernia is a lengthy record of assorted techniques in search of a cure for an ailment that comes in many sizes and shapes and that has plagued humanity for thousands of years. Although improvements are still being sought and found, for several decades surgeons have had the means to relieve most hernia sufferers. A remaining issue is whether the wide array of surgical procedures can or should be whittled down to a few "standard" operations that are safe, effective, and cost-efficient. The history of the anatomy of groin hernia shows how much there was to learn and how much remains to be learned. It also shows how important it is for the surgeon to know and understand both the anatomy of the area and the formation of groin hernia.

Femoral pseudo-hernias

Before surgical intervention in the femoral area, doctors should be mindful of two situations in which surgery is not indicated and, in fact, may cause harm.

Classic groin hernia repair…lest we forget

Currently, operative repair of inguinal hernia is most often performed using one of the open mesh procedures or laparoscopic techniques. These newer approaches minimize anatomical dissection critical to the time-honored traditional hernia surgery described by Bassini, Halsted, McVay, Laroque, Shouldice, and other early pioneers. The familiarity with groin anatomy and the technical skill gained in performing these operations is currently missing from present-day surgical residency training. This article reviews 5 classic hernia operations described by the surgeons whose name they bear, with a view toward better understanding the authors' techniques and philosophies. Each of these operations, though considered by some as of historical interest only, offers today's surgeon reliable alternatives when the simple application of mesh by open or laparoscopic technique is inappropriate. (Curr Surg 62:249-252. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery.).

The preperitoneal approach to the groin and the inferior epigastric vessels

Preperitoneal, a word coined by Nyhus in the 1960s, has been applied not only to posterior approaches that he, Stoppa, and Wantz popularized but to anterior exposures of the groin, which divide the transversalis fascia. This assumes that all give similar views of the easily cleaved space of Bogros. However, accumulated anatomical observations reveal the transversalis fascia as having not one but two layers. The inferior epigastric vessels run between rather than in the preperitoneal space, which is avascular and has its own fascia lining the peritoneum. Historical evidence shows that both the midline Cheatle-Henry and lateral Ugahary-Kugel approaches, which transect the abdominal wall, provide excellent exposure of the avascular preperitoneal space. However, neither the unilateral posterior McEvedy approach nor the anterior approach does, as only part of the musculature and fasciae are retracted. The inferior epigastric vasculature and posterior lamina transversalis fascia, which remain in situ, block the view. Unless they are disrupted or circumvented, neither of the latter approaches or subsequent repairs should be labeled preperitoneal.

Anatomical pitfalls in the technique for total extra peritoneal laparoscopic repair for inguinal hernias

PURPOSE

The totally extraperitoneal laparoscopic approach for the treatment of inguinal hernia is a well-recognized technique with proven efficacy, low failure rate, and reduced post-operative pain. This laparoscopic technique is reputed to be a more difficult procedure to learn and practice than a laparoscopic trans-abdomino-pre-peritoneal procedure: we hope this is because many surgeons don't well know extra-peritoneal anatomy of groin. So we proposed a "step by step" anatomical analysis, with pitfalls to avoid, of a totally extraperitoneal laparoscopic approach for treatment of inguinal hernia.

METHODS

Our experience with totally extraperitoneal laparoscopic inguinal hernia repair with regard to the morphology of the inguinal-femoral region concerns 23 cadaver dissection and more than 400 surgical procedures, now permits clarification of a surgical technique that has hitherto not been well known.

CONCLUSION

Photographic representations of surgical views are displayed, and detailed descriptions applicable to anatomical structures are presented.

Pubomyoaponeurotic foramen and posterior groin plait for groin hernia

Sir Astley Paston Cooper stated in 1804 that a sound knowledge of proper anatomy of hernia is vital. But even in the succeeding two centuries, the confusion has only multiplied by varied and overly enthusiastic descriptions, some speculative and others real, by different workers. An attempt has been made to highlight the size of the controversies surrounding the anatomical structures forming the inguinal canal and groin. The inguinal and femoral hernias should be viewed collectively as one entity and together be called groin hernias. Therefore, the passage for their superficial emergence through the anterior abdominal wall is redefined and is called pubomyoaponeurotic foramen. It is uniformly accepted that the strong posterior wall of the groin area is the only preventive factor towards the emergence of hernia; it has been renamed as posterior groin plait. Therefore, proper understanding of its structure towards effective repair and reinforcement is the only safe method, whether the procedure is carried out by anterior or posterior route or laparoscopically. Hence, an attempt has been made to elucidate its true structure. In spite of so many descriptions, the exact anatomy of hernia is yet to be resolved.