Urogenital fascia anatomy study in the inguinal region of 10 formalin-fixed cadavers: new understanding for laparoscopic inguinal hernia repair

Purpose To investigate the urogenital fascia (UGF) anatomy in the inguinal region, to provide anatomical guidance for laparoscopic inguinal hernia repair (LIHR). Methods The anatomy was performed on 10 formalin-fixed cadavers. The peritoneum and its deeper fascial tissues were carefully dissected. Results The UGF’s bilateral superficial layer extended and ended in front of the abdominal aorta. At the posterior axillary line, the superficial layer medially reversed, with extension represented the UGF's deep layer. The UGF's bilateral deep layer medially extended beside the vertebral body and then continued with the transversalis fascia. The ureters, genital vessels, and superior hypogastric plexus moved between both layers. The vas deferens and spermatic vessels, ensheathed by both layers, moved through the deep inguinal ring. From the deep inguinal ring to the midline, the superficial layer extended to the urinary bladder’s posterior wall, whereas the deep layer extended to its anterior wall. Both layers ensheathed the urinary bladder and extended along the medial umbilical ligament to the umbilicus and in the sacral promontory, extended along the sacrum, forming the presacral fascia. The superficial layer formed the rectosacral fascia at S4 sacral vertebra, and the deep layer extended to the pelvic diaphragm, terminating at the levator ani muscle. Conclusion The UGF ensheaths the kidneys, ureters, vas deferens, genital vessels, superior hypogastric plexus, seminal vesicles, prostate, and urinary bladder. This knowledge of the UGF’s anatomy in the inguinal region will help find correct LIHR targets and reduce bleeding and other complications.

Clinical Evaluation of Abdominal Wall Hernias

Hernia is defined as protrusion of a viscus or part of a viscus through a weakening or defect in the wall of its containing cavity. Areas of potential anatomical weakness includes inguinal canal, femoral canal, linea alba, umbilical scar, as well as acquired surgical trauma. The weakening/defect may be acquired (like surgical scar) or congenital (like deep inguinal ring). Raised intraabdominal pressure is the most important factor that leads to the development of hernia through the weak areas. Clinically, the hernia usually presents with an abdominal swelling that progresses gradually over time. The sites of hernia are characteristic and usually points towards the diagnosis. While evaluating a hernia clinically, it is important to identify the content of the hernia sac and whether it suffers any complication, as well as the cause of the hernia development. Failing to identify these prior to surgery, will likely result in morbidity as well as recurrence. This chapter will focus on the clinical art of history taking and examination of different abdominal hernias.

INTRAOPERATIVE ASSESSMENT OF TOPOGRAPHIC-ANATOMICAL PARAMETERS OF THE INGUINAL CANAL IN HERNIA AND ITS VALUE IN CHOOSING HERNIOPLASTY METHOD

Purpose. To give a comparative description of the topographic and anatomical parameters of the inguinal canal in hernias and to evaluate its importance in choosing a method of hernioplasty. Material and methods. In 120 patients with types II, IIIa, IIIb inguinal hernias, the height of the inguinal space (h-IS), the total thickness of the internal oblique and transverse abdominal muscles forming the upper wall of the inguinal canal (TMT) and the diameter of the deep inguinal ring (DDIR) were measured intraoperatively. Results. Pairwise comparisons of the IS height revealed statistically significant differences in this parameter between hernias types II and IIIa, as well as between types II and IIIb (p = 0.0432) in all age groups. In the studied age groups, there were statistically significant differences in the diameter of the deep inguinal ring between patients with hernias types II and IIIa, as well as types II and IIIb (p <0.001). The TMT of the upper wall of the IC in all age groups did not depend on the type of inguinal hernia and was associated with the patient's age. Conclusion. Intraoperative morphometry is an objective method for assessing the topographic and anatomical parameters of the inguinal canal and should underlie the choice of the method of tension or tension-free inguinal hernioplasty during open surgical interventions.

Nigam’s inverted curtain hernioplasty: a modified lichtenstein tension free hernioplasty for inguinal hernia

Background: It is an open tension-free hernioplasty for primary inguinal hernias using minimal dissection and only 3 sutures to fix the mesh.Methods: A description of operative technique and patient’s demographics are presented.Results: 362 repairs were done with this technique over a period 18 years (March 2000 to March 2018). All were primary uncomplicated inguinal hernias.Conclusions: NICH tackles the both known aetiological factors for recurrence i.e., weakness in inguinal floor and tension at the suture line. It involves minimal tissue dissection and least number of sutures. Two sutures are used to fix the mesh with inguinal ligament. Third suture is used to make an artificial deep inguinal ring in the mesh as well as used to narrow the natural deep inguinal ring to further avoid recurrence. No suture is applied in main body of mesh which remains free like an inverted curtain covering the whole hernia susceptible region of groin. Prolene mesh is used which completely covers the potentially weak area on the floor of inguinal region irrespective of the size of the area in small or big frame persons. Semi double breasting of external oblique aponeurosis avoids displacement of mesh. NICH is associated with least recurrence, less post-operative pain, less post-operative complications and short learning curve.

To the Question about the Peculiarities of the Structure of Transverse Abdominal Fascia at the Persons of Different Sex, Age and with Different Form of the Inguinal Period

The study was aimed at finding new structural features of the rear wall of the inguinal canal, the use of which allow to improving the prevention of inguinal hernias. The study involved 123 corpses of different sex and age. Anatomical and physiological nature of the valve mechanism inguinal canal, the peculiarities of the structure of the back wall in individuals of different sex and age were revealed; the various forms of inguinal gap were studied. Using cluster analysis of transverse fascia thickness abdominal length and height of the deep inguinal ring was one of three variants of the structure back wall of the inguinal canal: a strong, transient and weak. The technique of determining the location of the deep inguinal ring relative to the edge of the internal oblique abdominal muscles is offered. The use of this technique objectively reflects the anatomical and physiological characteristics of the inguinal canal as a whole. In interpreting the results of a valve mechanism of deep inguinal ring should be considered ineffective in the medial or medial edge of the boundary location of the deep inguinal ring relative to the internal oblique abdominal muscles. Functional and anatomical factors that contribute to the formation of inguinal hernias were identified. It is proved that the triangular shape of the inguinal gap causes a high risk of inguinal hernias. In both sexes the transverse abdominal fascia becomes thinner with age, and the deep inguinal ring increases in size. The obtained data will improve the effectiveness of preventive measures.

A novel method for assessing valvular mechanism of deep inguinal ring considering the objective topographic anatomical criteria

Aim. To develop a method to assess the valvular mechanism of deep inguinal ring based on objective topographic anatomical criteria. Methods. The research was performed on 123 native corpses of persons without pathology of the anterior abdominal wall. Morphometric examination of the inguinal canal was carried out. The shape of the inguinal gap was determined, inguinal gap and inguinal canal length was measured, as well as deep inguinal ring length and height and deep inguinal ring height. Oval fissured inguinal gap was revealed in 49 (39.8%) persons, intermediate oval - in 51 (41.5%), triangular - in 23 (18.7%). Results. The dependence of the length of the inguinal canal, inguinal gap length, deep inguinal ring size and its standing height on the inguinal gap shape was examined. The method for an objective assessment of the deep inguinal ring valvular mechanism was proposed. The method is based on determining the deep inguinal ring location in reference to the internal oblique abdominal muscles by estimating the integral rate of the inguinal canal length and the inguinal gap length and deep inguinal ring height. Three options for the deep inguinal ring location: upper lateral, lower medial and boundary location are described. Deep inguinal ring positions were determined by cluster analysis. In cases of upper lateral position, which was observed in 28 (22.8%) of cases, the valvular mechanism of deep inguinal ring was stable. In cases of deep inguinal ring lower medial position (41 cases, 33.3%), the opposite results were gained. In cases of deep inguinal ring boundary location (54 cases, 43.9%), the valvular mechanism is stable, but may become insolvent if destructive changes of the lateral abdominal muscles and deep inguinal ring expansion were present. Conclusion. An objective method of assessing the deep inguinal ring valvular mechanism, based on determining the deep inguinal ring location in reference to the oblique abdominal muscles was developed.