Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

1 Clinical Anatomy

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The preperitoneal plane lies between the peritoneum and the posterior lamina of the transversalis fascia. There are two spaces that are of particular interest in the laparoscopic repair of inguinal hernias: the space of Retzius, the most medial of which lies superior to the bladder, and the space of Bogros, which is a lateral extension of the space of Retzius that extends to the level of the anterior superior iliac spine. Dissection of these planes gives the surgeon access to the myopectineal orifice of Fruchaud, an area of inherent weakness from which all inguinal hernias occur. This space is bound superiorly by the aponeurotic arch of the internal oblique and the transversus abdominis muscle, inferiorly by the Cooper ligament, medially by the lateral border of the rectus muscle, and laterally by the iliopsoas muscle. The inguinal ligament and iliopubic tract pass obliquely through the space ( Fig. 23.1 ).
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Three potential sites of hernia formation are associated with the myopectineal orifice: the indirect space, the direct space, and the femoral space. The direct and indirect spaces are located medial and lateral to the inferior epigastric vessels, respectively, and both are above the iliopubic tract. The femoral canal lies in the area bounded anterosuperiorly by the inguinal ligament, posteriorly by the pectineal ligament lying anterior to the superior pubic ramus, medially by the lacunar ligament, and laterally by the femoral vein ( Fig. 23.2 ).

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The inferior epigastric vessels are found in the same plane as the iliac vessels. The external iliac artery and vein course deep to the iliopubic tract in an area bounded medially by the vas deferens and laterally by the spermatic vessels, which has been dubbed the “triangle of doom.”
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The corona mortis represents a connection between the inferior epigastric vessels and the obturator vessels. This structure is overlying the Cooper ligament ( Fig. 23.3 ).

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The spermatic cord consists of three arteries, three veins, and two nerves as well as the vas deferens posteriorly and the pampiniform venous plexus anteriorly. The structures of the spermatic cord come together shortly before the cord enters through the internal inguinal ring (see Fig. 23.3 ).

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The femoral branch of the genitofemoral nerve is found lateral to the genital branch and is seen leaving the retroperitoneum underneath the iliopubic tract. Also found laterally and sometimes in association with the femoral branch of the genitofemoral nerve is the lateral cutaneous nerve of the thigh. The femoral nerve is not routinely seen during laparoscopic intervention (see Fig. 23.3 ).

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Bordered medially by the vas deferens and laterally by the vessels of the spermatic cord, with its base opposite to the deep ring, the contents of this space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve (see Fig. 23.3 ).

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This area is bounded by the gonadal vessels medially, the reflected peritoneum laterally, and the iliopubic tract superiorly. The femoral nerve, the genitofemoral nerve, the anterior femoral cutaneous nerve, and the lateral femoral cutaneous nerve are found in this region (see Fig. 23.3 ).

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