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Anatomy and Physiology – The anatomy of the inguinal canal can be quite complex and thorough knowledge of anatomy from the preperitoneal view is imperative to perform a good laparoscopic inguinal hernia repair. Several important landmarks include the inferior epigastric vessels (which help distinguish between a direct and indirect hernia), the pubic bone/Cooper’s ligament, the vas deferens/cord structures/round ligament, and the iliopubic tract,

Surgeons performing laparoscopic inguinal hernia repair should also be aware of the triangle of pain and doom. The triangle of doom is a triangle bound by the vas deferens, testicular vessels, and the peritoneal fold. The importance of this triangle is in this area you can find the external iliac artery and vein.

The triangle of pain is bound by the iliopubic tract, testicular vessels, and the peritoneal fold. This triangle holds the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve. Secondary to the important structures located in these two triangles it has been strongly recommended to avoid traumatic fixation of mesh in these areas as it could cause major vascular injuries or nerve injury that could result in chronic pain.

What is the triangle of doom and pain anatomy?

Important anatomic structures and landmarks – During laparoscopic inguinal hernia repair, it is important to recognize the following important structures in the abdominal cavity: the median umbilical fold, the medial umbilical fold, the lateral umbilical fold, Hesselbach’s triangle, the internal inguinal ring and the femoral ring. Bilateral inguinal area under laparoscopy. Important anatomic landmarks in the extraperitoneal space. The pubic symphysis is the first exposed anatomical landmark at separation of the space of Retzius and is the medial reference line when placing mesh. Cooper’s ligament (also known as the pectineal ligament) is easier to identify because it is white, shiny and tough tendinous tissue.

It is an extension of the lacunar ligament, running infero-laterally along the pectineal line and attaching to the pectineal line. Cooper’s ligament is a structure that can hold a mesh and tacks. One or a number of anastomotic vessels between the inferior epigastric or the external iliac vessels and the obturator arteries or veins, namely, the corona mortis, can be visualized at the site 5 cm away from the pubic symphysis, arching over Copper’s ligament ( Figure 10 ).

The corona mortis includes arteries and veins, most of which travel alone and leave the pelvic cavity via the obturator canal. During surgery, significant hemorrhage may occur, and hemostasis may be difficult to achieve if the corona mortis vessels are accidentally cut because they may retract into the obturator canal. The separation continues laterally along Cooper’s ligament and the dark blue external iliac vein; the white, elastic, pulsating external iliac artery can be seen after passing the corona mortis. The slightly thin inferior epigastric arteries and veins can be seen at the top of the external iliac vessels.

Most of the inferior epigastric arteries are branches of the external iliac arteries or veins. The inferior epigastric artery usually runs with two veins along the back of the rectus abdominis muscle toward the umbilicus. The identification of the inferior epigastric vessels is very important before accessing the space of Bogros.

Separating between the inferior epigastric vessels and the deep transverse abdominal fascia is the only approach to correctly gain access to the space of Bogros ( Figure 11 ). Otherwise, it is easy to accidentally damage the inferior epigastric vessels or pierce the peritoneum, which may cause difficulties while performing laparoscopic surgery or even require conversion to open surgery. Correct access to the space of Bogros. During a laparoscopic inguinal hernia repair, the dangerous triangle (the triangle of doom) refers to a triangular area bound by the vas deferens, the testicular vessels and the peritoneal fold. Within the boundaries of this area, you can find the external iliac artery and vein.

Separation in this area is risky in the setting of an external iliac vascular malformation or aneurysm. The triangle of pain is a triangular area located lateral to the dangerous triangle and bound by the iliopubic tract, the testicular vessels and the peritoneal fold. This area from lateral to medial includes the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve and the femoral nerve, which runs on the surface of the psoas muscle and the iliac muscle.

Most of these nerves pass through the deep surface of the iliopubic tract to innervate the corresponding area of the perineum and thigh ( Figure 12 ). The femoral nerve is 6 cm above the inguinal ligament and is not easily injured because it is covered by the psoas muscle.

• The lateral femoral cutaneous nerve runs just below the iliac fascia and enters the thigh in the 1- to 4-cm-wide region infero–medial to the anterior superior iliac spine under the iliopubic tract.
• During separation of the space of Bogros, avoiding piercing the iliac fascia and exposing the nerves is one of the most effective methods to reduce the incidence of postoperative chronic neuropathic pain.

Clinical data have shown that the lateral femoral cutaneous nerve and the femoral branch of the genitofemoral nerve are more commonly damaged. Minor damage can result in abnormal sensation in the area innervated by these nerves. Such symptoms can resolve spontaneously in 2–4 weeks.

However, these abovementioned nerves can suffer major damage or entrapment when performing separation or fixation or when controlling bleeding, which may cause abnormal sensation in the nerve-innervated area, especially chronic neuropathic pain, and may even cause motor disorders in the lower extremity.

It is extremely difficult to manage or improve these symptoms. Lateral femoral cutaneous nerve and genitofemoral nerve. The iliopubic tract is a thickened tendinous structure of the transverse abdominal fascia that connects the anterior superior iliac spine and the pubic tubercle and parallels the inguinal ligament ( Figure 13 ).

It arches medially across the front of the femoral vessels to insert via broad attachment onto the pubic tubercle and Cooper’s ligament. The iliopubic tract is the outer boundary of the triangle of pain. The lateral part of a mesh should be fixated at a spot just above the level of the iliopubic tract.

The white iliopubic tract can be seen at the lower edge of a direct hernia ring or below an internal inguinal ring. However, the degree of development of the iliopubic tract may vary individually; the iliopubic tract in other areas may not be easy to recognize under the laparoscope. Representation of the right Cooper’s ligament, the iliopubic tract and the inguinal ligament. The vas deferens/the round ligament of the uterus and testicular blood vessels can be completely exposed only when the internal spermatic fascia is incised and the hernia sac or the peritoneal fold is separated to the cephalad direction.

What is the boundary of the triangle of pain?

The superior boundary of the triangle of pain was formed by the iliopubic tract and the inferior boundary by peritoneal reflection. The femoral nerve, along with the lateral femoral cutaneous nerve of the thigh, formed the contents of the triangle of pain (Figures 3 and 4).

What is the triangle of doom boundaries in females?

Opinion Review Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. World J Gastrointest Surg. Jul 27, 2020; 12(7): 307-325 Published online Jul 27, 2020. doi: 10.4240/wjgs.v12.i7.307 Figure 8 Triangle of doom and triangle of pain. Triangle of doom and triangle of pain should be adequately recognized by the surgeon. Triangle of doom is an inverted V-shaped area bound laterally by the gonadal vessels and medially by the vas deferens in male patients, or the round ligament in female patients.

The EIA, external iliac vein, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and femoral nerve are involved in this area. Area of the triangle of pain involves the femoral branch of the genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, and the anterior cutaneous branch of the femoral nerve.

Even a subtle injury to the nerves located within the triangle of pain is a risk factor for intractable pain. ARM: Abdominal rectal muscle; EIA: External iliac artery; EIV: External iliac vein; Gb-GFN: Genital branch of the genitofemoral nerve; IPT: Iliopubic tract; LFCN: Lateral femoral cutaneous nerve; VD: Vas deferens.

Citation: Yasukawa D, Aisu Y, Hori T. Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World J Gastrointest Surg 2020; 12(7): 307-325 URL: https://www.wjgnet.com/1948-9366/full/v12/i7/307.htm DOI: https://dx.doi.org/10.4240/wjgs.v12.i7.307

What is the triangle of doom boundaries face?

The danger triangle of the face consists of the area from the corners of the mouth to the bridge of the nose, including the nose and maxilla.

Why is it called the triangle of doom and pain?

Deep and superficial dissection of the lumbar plexus. The Triangle of Doom is an anatomical triangle defined by the vas deferens medially, spermatic vessels laterally and peritoneal fold inferiorly. This triangle contains external iliac artery and vein, the deep circumflex iliac vein, the genital branch of genitofemoral nerve and hidden by fascia, the femoral nerve,

1. It bears significance in laparoscopic repair of groin hernia,
2. Surgical staples are avoided here.
3. Similarly, the Triangle of Pain is an important landmark in laproscopic surgery.
4. The boundaries are: the gonadal vessels ( testicular artery and vein ) medially, the iliopubic tract superiorly and the peritoneal reflection below.

Contents of this triangle include the femoral branch of the genitofemoral nerve, and the lLateral cutaneous nerve of the thigh. After placing the mesh, the surgeon must avoid putting tacks to secure the mesh below the iliopubic tract, or it can injure the nerves.

What are the three parts of pain?

Transduction – Three types of stimuli can activate pain receptors in peripheral tissues: mechanical (pressure, pinch), heat, and chemical. Mechanical and heat stimuli are usually brief, whereas chemical stimuli are usually long lasting. Nothing is known about how these stimuli activate nociceptors.

The nociceptive nerve endings are so small and scattered that they are difficult to find, let alone study. Nonetheless, there have been some studies of the effects of chemicals on the firing frequency of identified primary afferent nociceptors. A variety of pain-producing chemicals activate or sensitize primary afferent nociceptors (Bisgaard and Kristensen, 1985; Juan and Lembeck, 1974; Keele, 1966).

Some of them, such as potassium, histamine, and serotonin, may be released by damaged tissue cells or by the circulating blood cells that migrate out of blood vessels into the area of tissue damage. Other chemicals, such as bradykinin, prostaglandins, and leukotrienes, are synthesized by enzymes activated by tissue damage (Armstrong, 1970; Ferreira, 1972; Moncada et al., 1985; Vane, 1971).

1. All of these pain-producing chemicals are found in increased concentrations in regions of inflammation as well as pain.
2. Obviously, the process of transduction involves a host of chemical processes that probably act together to activate the primary afferent nociceptor.
3. In theory, any of these substances could be measured to give an estimate of the peripheral stimulus for pain.

In practice, such assays are not available to clinicians. It should be pointed out that most of our knowledge of primary afferent nociceptors is derived from studies of cutaneous nerves. Although this work is of general importance, the bulk of clinically significant pain is generated by processes in deep musculoskeletal or visceral tissues.

Scientists are beginning to study the stimuli that activate nociceptors in these deep tissues (Cervero, 1982, 1985; Coggeshall et al., 1983; National Academy of Sciences, 1985). In muscle, there are primary afferent nociceptors that respond to pressure, muscle contraction, and irritating chemicals (Kumazawa and Mizumura, 1977; Mense and Meyer, 1985; Mense and Stahnke, 1983).

Muscle contraction under conditions of ischemia is an especially potent stimulus for some of these nociceptors. Despite progress in our understanding of the physiology of musculoskeletal nociceptors, we still know very little about the mechanisms underlying common clinical problems such as low back pain.

What is the difference between TEP and Tapp?

Background – An inguinal hernia is a defect in the endo‐abdominal fascia of sufficient size to allow escape of intraperitoneal or pre‐peritoneal contents into the groin. Inguinal hernias usually present as a lump, with or without some discomfort, which may limit daily activities and the ability to work.

• They can occasionally be life‐threatening if the bowel strangulates or becomes obstructed.
• Hernia repairs are responsible for approximately 80,000 finished consultant episodes, 100,000 bed days and 33,000 day cases per year in England and Wales alone ( HES 2003 ).
• Open surgical techniques using a mesh prosthesis instead of sutures to repair the defect are most commonly used to repair inguinal hernia ( O’Riordan 1996 ).

However, there is a continuing increase in the number of laparoscopic procedures performed since their introduction using mesh in the late 1991( Corbitt 1991, Schultz 1991 ). Exact figures on the types of repair used in current surgical practice are not easy to obtain ( Wellwood 1998 ).

1. In 2000, an audit of the NHS in Scotland between 1 April 1998 and 31 March 1999 found that 229 (4%) of inguinal hernia repairs were carried out using laparoscopic surgery, 4612 (84%) were open mesh surgery, 65 (1%) open preperitoneal surgery, and 600 (11%) were open non‐mesh surgery ( Hair 2000 ).
2. Most repairs were performed using general anaesthetic on an inpatient basis and there was a significant trend to perform a laparoscopic repair or an open preperitoneal repair for patients with bilateral and recurrent hernias.

The most commonly used laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. TAPP requires access to the peritoneal cavity with placement of a mesh through a peritoneal incision.

This mesh is placed in the preperitoneal space covering all potential hernia sites in the inguinal region. The peritoneum is then closed above the mesh leaving it between the preperitoneal tissues and the abdominal wall where it becomes incorporated by fibrous tissue. TEP repair was first reported in 1993 ( Ferzli 1993 ).

TEP is different in that the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum. This approach is considered to be more difficult than TAPP but may lessen the risks of damage to the internal organs and of adhesion formation leading to intestinal obstruction, which has been linked to TAPP.

Laparoscopic repair is technically more difficult than open repair and there is evidence of a ‘learning curve’ in its performance ( Wright 1998 ). It is likely that some of the higher rates of potentially serious complications reported for laparoscopic repair are associated with learning effects, particularly for the more complex TEP repair.

Indirect comparisons between TAPP and TEP have raised questions about whether the two procedures do perform differently for some outcomes such as recurrence. Very large randomised controlled trials such as those conducted by the MRC Laparoscopic Groin Hernia Group and Neumayer and colleagues, both of which a compared a predominatly TEP arm with open repair, suggested that TEP has a higher risk of recurrence than open mesh repair.

However, a systematic review comparing laparoscopic with open mesh repair found no evidence of a difference in recurrence rates between TAPP and open mesh repair ( McCormack 2003 ; McCormack NICE 2004 ). While any conclusions drawn on such indirect comparisons should be treated with caution they do raise questions that can only be satisfactory addressed by well designed studies and systematic reviews of such studies that directly compare TAPP with TEP.

There is a scarcity of data directly comparing laparoscopic TAPP and laparoscopic TEP and questions remain about their relative merits and risks. In light of this, the review aims to compare TAPP and TEP directly in order to determine which method is associated with better outcomes, in particular, serious adverse events and subsequent potential consequences such as persisting pain.

What is the theory of area of triangle?

What is the Area of a Triangle? – The area of a triangle is defined as the total region that is enclosed by the three sides of any particular triangle. Basically, it is equal to half of the base times height, i.e. A = 1/2 × b × h. Hence, to find the area of a tri-sided polygon, we have to know the base (b) and height (h) of it,

• Example: What is the area of a triangle with base b = 3 cm and height h = 4 cm?
• Using the formula,
• Area of a Triangle, A = 1/2 × b × h
• = 1/2 × 4 (cm) × 3 (cm)
• = 2 (cm) × 3 (cm)
• = 6 cm 2

Apart from the above formula, we have Heron’s formula to calculate the triangle’s area when we know the length of its three sides. Also, trigonometric functions are used to find the area when we know two sides and the angle formed between them in a triangle. We will calculate the area for all the conditions given here.

What is the law of triangle area?

The area of a triangle is defined as the total space occupied by the three sides of a triangle in a 2-dimensional plane. The basic formula for the area of a triangle is equal to half the product of its base and height, i.e., A = 1/2 × b × h. This formula is applicable to all types of triangles, whether it is a scalene triangle, an isosceles triangle, or an equilateral triangle.

1.	What is the Area of a Triangle?
2.	Area of Triangle Formula
3.	Area of Triangle Using Heron’s Formula
4.	Area of Triangle With 2 Sides and Included Angle
5.	How to Find the Area of a Triangle?
6.	FAQs on Area of Triangle

What are toxic boundaries?

Unhealthy relationship boundaries Image created by the Author via Jasper Art and Canva It’s normal to set boundaries in relationships. After all, we need to protect ourselves from getting hurt. However, some people take it too far and end up with unhealthy boundaries that can damage their relationships.

Here are four of the most common toxic boundaries and how to fix them. Before we cover four specific boundaries, we must know the meaning of toxic boundaries. Unhealthy boundaries are any expectations or behaviors that are harmful to yourself or others in your relationships. They usually manifest as control, manipulation, or exploitation.

“No partner in a love relationship should feel that he has to give up an essential part of himself to make it viable.” — May Sarton General unhealthy boundary behaviors include (We’ll look at four specific boundaries in a moment):

Physical abuse. This can involve any type of physical force against another person, including hitting, kicking, choking, and hair pulling. Emotional abuse. This can involve any type of verbal or nonverbal behavior that is intended to hurt another person emotionally, such as name-calling, put-downs, constant criticism, or gaslighting. Mental abuse. This can involve any type of behavior that is intended to control or manipulate another person, such as threats, blackmail, or mind games. Spiritual abuse. This can involve any type of behavior that is intended to control or exploit another person’s spiritual beliefs or practices, such as forcing them to participate in religious activities against their will.

Ok, now that we have a baseline of common understanding, let’s explore four specific toxic boundaries that creep into relationships. When one partner constantly exerts control over the other by limiting their ability to do things on their

What is Inguinodynia?

Definition. Inguinodynia is pain or discomfort lasting greater than 3 months after surgery.

What is the trapezoid of disaster?

The authors introduced the term ‘Trapezoid of Disaster,’ describing also that nerves located lateral to the testicular vessels within the ‘Triangle of Pain’ were also at risk. The most comprehensive analysis of the posterior inguinal anatomy was given by Annibali et al.

What is the space of Bogros?

Space of Bogros As stated by Bogros, the space is bound laterally by the iliac fascia, anteriorly by the trans- versalis fascia, and medially by the parietal peritoneum. In the original concept, the space of Bogros lies between the peritoneum and the anterior lamina of the transver- salis fascia.

What is iliopubic tract?

Abstract – A band of fascial thickening, termed the iliopubic tract, lies on the posterior aspect of the inguinal region and has been described in the surgical literature as playing an important role during herniorraphy. This study was undertaken to examine the gross and microscopic anatomy of the iliopubic tract in 12 cadavers.

The results confirmed that the iliopubic tract can be readily identified as a thickening of the transversalis fascia running deep and parallel to the inguinal ligament. It attaches to the superomedial part of the pubic bone medially, but laterally its fibres fan out within the fascia transversalis and fascia iliaca without bony attachment to the iliac spines.

In contrast to the inguinal ligament, the histological analysis of the iliopubic tract shows a high elastin to collagen ratio. The functional signficance of this structure merits further study, but there is no doubt that it is important in many approaches to inguinal herniorraphy.

Where did the hand of doom come from?

Artifact Stats – Artifact: Hellboy’s Right Hand of Doom Appears: Hellboy (2004) Origins: Originally owned by the great spirit Anum that watched over earth’s birth, the indestructible Right Hand of Doom was grafted onto Hellboy when he was just a child by his father Azzael. About the author Adrienne Clark Adrienne is a writer and editor from Seattle and is MoPOP’s Content Wizard (patent pending).

What is the wheel of doom?

Murr and the wheel The Wheel of Doom is a wheel that the Jokers will sometimes use to choose tasks that the others have to do for challenges. The challenge they must do is determined by which space they land on when spinning the wheel. There was a similar but unrelated Wheel of Doom in Joke & Dagger,

What is the circle of death in inguinal hernia?

Laparoscopic Anatomy of Inguinal Hernia Laparoscopic Anatomy of Inguinal Hernia In the lower abdomen, there are five peritoneal folds or ligaments which are seen through the laparoscope in the umbilicus. These ligaments are generally overlooked at the time of open surgery. Diagrammatic representation of ligaments Two Medial Umbilical Ligament One on Either Side The paired medial umbilical ligament is an obliterated umbilical artery except where the superior vesical arteries are found in the pelvic portion. The medial umbilical ligaments are the most prominent fold of the peritoneum. Important landmarks in laparoscopic hernia repair: (1) Medial umbilical ligament; (2) Inferior epigastric vessels; (3) Spermatic vessels; (4) Vas deferens; (5) External iliac vessels in “Triangle of doom”; (6) Indirect defect

• Two Lateral Umbilical Ligaments
• Three dangerous areas where stapling and electrosurgery should be avoided:
• Triangle of Doom

Lateral to the medial umbilical ligament, the less prominent paired lateral umbilical fold contains the inferior epigastric vessels. The inferior epigastric artery is a lateral border of Hesselbach’s triangle and hence is a useful landmark for differentiating between direct and indirect hernia.

Any defect lateral to the lateral umbilical ligament is an indirect hernia and medial to it is a direct inguinal hernia. The femoral hernia is below and slightly medial to the lateral inguinal fossa, separated from it by the medial end of the iliopubic tract internally and the inguinal ligament externally.

Important landmarks for extraperitoneal hernia dissection include the musculoaponeurotic layers of the abdominal wall, the bladder, Cooper’s ligament, and the iliopubic tract. The inferior epigastric artery and vein, the gonadal vessels and vas deferens should also be recognized.

The space of Retzius lies between the vesicoumbilical fascia posteriorly and the posterior rectus sheath and pubic bone, anteriorly. This is the space first entered in the extraperitoneal repair of a hernia. The triangle of doom is defined by vas deferens medially, spermatic vessels laterally, and external iliac vessels inferiorly.

This triangle contains external iliac artery and vessels, the deep circumflex iliac vein, the genital branch of the genitofemoral nerve and hidden by fascia, the femoral nerve. The staple should not be applied in this triangle otherwise; chances of mortality are there if these great vessels are injured. Triangle of Doom

1. Triangle of Pain
2. Circle of Death
3. Indications of Laparoscopic Repair of Hernia
4. Contraindications of Laparoscopic Repair of Hernia
5. Advantages of Laparoscopic Approach
6. Disadvantages of Open Method
7. Types of Laparoscopic Hernia Repair
8. Patient Selection

Triangle of pain is defined as spermatic vessel medially, the iliopubic tract laterally and inferiorly the inferior edge of a skin incision. This triangle contains a lateral femoral cutaneous nerve and anterior femoral cutaneous nerve of the thigh. The staple in this area should be less because nerve entrapment can cause neuralgia.

This is also called as corona Mortis and refers to vascular ring form by the anastomosis of an aberrant obturator artery with the normal obturator artery arising from a branch of the internal iliac artery. At the time of laparoscopic hernia, if this vessel is torn, both ends of the vessel can bleed profusely, because both arise from a major artery.

The surgeon should remember these anatomic landmarks and the point of mesh fixation should be selected superiorly, laterally, and medially. The indications for performing a laparoscopic hernia repair are essentially the same as repairing the hernia conventionally.

There are, however, certain situations where laparoscopic hernia repair may offer definite benefits over conventional surgery to the patients. These include: • Bilateral inguinal hernias • Recurrent inguinal hernias. In recurrent hernia, the surgery failure rate is as high as 25 to 30 percent, if again repaired by open surgery.

The distorted anatomy after repeated surgery makes it more prone to recurrence and other complications like ischemic orchitis. In recurrent hernia, the laparoscopic approach offers repair through the inner healthy tissues with clear anatomical planes and thus, a lower failure rate.

In laparoscopic bilateral repair with three ports technique, there is simultaneous access to both sides without any additional trocar placement. Even in patients with clinically unilateral defects after entering inside the abdominal cavity, there is 20 to 50 percent incidence of a contralateral asymptomatic hernia being found which can be repaired, simultaneously, without any additional morbidity of the patient.

• Nonreducible incarcerated inguinal hernia • Prior laparoscopic herniorrhaphy • Massive scrotal hernia • Prior pelvic lymph node resection • Prior groin irradiation. • Tension-free repair that reinforces the entire myo-pectineal orifice • Less tissue dissection and disruption of tissue planes • Three ports are adequate for all type of hernias • Less pain postoperatively • Low intraoperatively and postoperative complications • Early return to work.

Requires 4 to 6 inches of incision at the groin • Generally very painful, because of muscle spasm • Considerable postoperative swelling of tissues in the groin, around the wound. • Requires cutting through the skin, fat, and good muscles in order to gain access for repair, which in itself causes damage.

• Frequent complications of wound hematomas, wound infection, scrotal hematomas, and neuroma. • Usually takes 6 to 8 weeks for recovery. • Sometimes long-term disability may follow, e.g. neuralgia, neuroma, and testicular ischemia. • Whether a flat mesh or a plug is used from the front, they do not hold themselves in place; what holds them in place are stitched, so the strength of the repair still depends on the stitches, not so much on the mesh or plug.

1. Bilateral inguinal hernias require 2 incisions, doubling the pain; or 2 operations.
2. Recurrent inguinal hernias are very difficult to operate open and more liable to complications.
3. The size of the mesh used in open methods is limited by the natural fusion of muscles.
4. All meshes and plugs shrink with time, and this works against all open methods.

Any method of repair must achieve 2 fundamental goals, removal of the sac from the defect and durable closure of the defect. In addition, the ideal method should achieve these with the least invasion, pain, or disturbance of normal anatomy. Laparoscopic repair in expert hands is now quite safe and effective and is an excellent alternative for patients with an inguinal hernia.

It is the confusion that laparoscopic repair is more complex and is not widely available. The public needs to be educated as to its advantages. All surgeons agree that for bilateral or recurrent inguinal hernias, laparoscopic repair is unquestionably the method of choice. The argument against its use for unilateral or primary inguinal hernias is unfounded if it is the best for bilateral or recurrent hernias.

Many techniques were used to repair hernia like: • Simple closure of the internal rings • Plug and patch repair • Intraperitoneal Onlay mesh repair • Transabdominal preperitoneal mesh repair (TAPP) • Total extraperitoneal repair (TEP). The technique of transabdominal preperitoneal repair was first described by Arregui in 1991.

In the transabdominal preperitoneal (TAPP) repair, the peritoneal cavity is entered, the peritoneum is dissected from the myopectineal orifice, mesh prosthesis is secured, and the peritoneal defect is closed. This technique has been criticized for exposing intraabdominal organs to potential complications, including small bowel injury and obstruction.

The totally extraperitoneal (TEP) repair maintains peritoneal integrity, theoretically eliminating these risks while allowing direct visualization of the groin anatomy, which is critical for a successful repair. The TEP hernioplasty follows the basic principles of the open preperitoneal giant mesh repair, as first described by Stoppa in 1975 for the repair of bilateral hernias.

The general anesthesia and the pneumoperitoneum required as part of the laparoscopic procedure do increase the risk in certain groups of patients. Most surgeons would not recommend laparoscopic hernia repair in those with pre-existing disease conditions. Patients with cardiac diseases and COPD should not be considered a good candidate for laparoscopy.

The laparoscopic hernia repair may also be more difficult in patients who have had previous lower abdominal surgery. The elderly may also be at increased risk for complications with general anesthesia combined with pneumoperitoneum. If the patient is young or the hernia small, it does not matter how the hernia is repaired.

Many surgeons agree that for bilateral or recurrent inguinal hernias, laparoscopic repair is unquestionably the method of choice. Laparoscopic surgery is not recommended for big irreducible and incarcerated hernia. Hernia repair like many other laparoscopic procedures should not be performed under local anesthesia.

A small direct hernia can be performed under spinal anesthesia if TEP is planned but best anesthesia for laparoscopic hernia repair is GA.

• The Minimal Access surgery course was created in a manner that after this program surgeon & gynecologist will be able to do all the taught surgery their own on their patients.

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Which body part is most sensitive to pain?

The forehead and fingertips are the most sensitive parts to pain, according to the first map created by scientists of how the ability to feel pain varies across the human body. It is hoped that the study, in which volunteers had pain inflicted without touching them, could help the estimated 10 million people in the UK who suffer from chronic pain by allowing physicians to use lasers to monitor nerve damage across the body.

1. This would offer a quantitative way to monitor the progression or regression of a condition.
2. Lead author Dr Flavia Mancini, of the UCL Institute of Cognitive Neuroscience, said: “Acuity for touch has been known for more than a century, and tested daily in neurology to assess the state of sensory nerves on the body.

It is striking that until now nobody had done the same for pain.” In the study, a pair of lasers were used to cause brief sensation of pinprick pain to 26 blindfolded healthy volunteers on various parts of their body without any touch, in order to define our ability to identify where it hurts, known as “spatial acuity”.

Sometimes only one laser would be activated, and sometimes both. The participants were asked whether they felt one sting or two, at varying distances between the two beams and researchers recorded the minimum distance between the beams at which people were able to accurately say whether it was one sting or two.

“This measure tells us how precisely people can locate the source of pain on different parts of their body,” said senior author Dr Giandomenico Iannetti, of the UCL department of neuroscience, physiology and pharmacology, “Touch and pain are mediated by different sensory systems.” The researchers, whose work is published in the journal Annals of Neurology and was funded by the Wellcome Trust, found that with the exception of the hairless skin on the hands, spatial acuity improves towards the centre of the body whereas the acuity for touch is best at the extremities.

1. The spatial pattern was highly consistent across all participants.
2. The experiment was also conducted on a patient who lacked a sense of touch and the results were consistent with those of the healthy volunteers, demonstrating that acuity for pain does not require a functioning sense of touch.
3. Dr Roman Cregg, from the UCL Centre for Anaesthesia, who is a clinical expert who treats patients with chronic pain, said the research had important implications for the assessment of chronic pain, which currently tends to rely on asking patients to subjectively describe their discomfort on a scale of one to 10.

“This method offers an exciting, non-invasive way to test the state of pain networks across the body,” said Cregg. “Chronic pain is often caused by damaged nerves, but this is incredibly difficult to monitor and to treat. The laser method may enable us to monitor nerve damage across the body, offering a quantitative way to see if a condition is getting better or worse.” Work-related back pain is alone estimated to account for 4.9 million days of employee absenteeism, according to the TUC,

What are the triangles in human anatomy?

Anterior Triangle of the Neck – The anterior cervical triangle is bounded by the midline of the neck, the anterior border of the sternocleidomastoid muscle (SCM), and the inferior border of the mandible, This triangle is typically subdivided into three paired and one unpaired triangle.

What are the triangles of the body anatomy?

Structure and Function – Anatomic Boundaries Anterior Triangle The anterior triangles refer to bilateral anatomic subdivisions of the neck comprising the anterior surface of the neck, deep to the superficial cervical fascia and platysma muscle. Laterally, the anterior triangle is bounded by the anterior border of the sternocleidomastoid muscle.

1. Its superior border is the inferior border of the mandible.
2. Medially, the boundary is the midline of the neck.
3. The anterior triangle can further subdivide into four sub-triangles.
4. The submandibular and submental triangles are the superior divisions, while the muscular and carotid triangles compose the inferior divisions of this anterior neck compartment.

The submandibular triangle is delineated by the inferior border of the mandible and the anterior and posterior bellies of the digastric muscle. The submental triangle is demarcated by the hyoid bone, the anterior belly of the digastric muscle, and the midline of the neck.

1. The muscular triangle is outlined by the anterior aspect of the sternocleidomastoid and superior belly of the omohyoid, the midline of the neck, and the hyoid bone.
2. The outline of the carotid triangle is the anterior aspect of the sternocleidomastoid, the superior belly of the omohyoid, and the posterior belly of the digastric and stylohyoid muscles.

The investing layer of the deep cervical fascia encases all of the infrahyoid muscles and forms the superficial boundary of the entire anterior triangle. The deep boundary of the carotid and muscular triangles is composed of the pretracheal layer of the deep cervical fascia, while the mylohyoid muscle forms the deep boundary of the submandibular and submental triangles.

• The submandibular gland, a major salivary gland, emerges from the lateral aspect of the mylohyoid muscle and occupies most of the submandibular triangle.
• Posterior Triangle The posterior triangle of the neck is posterior to the anterior triangle.
• The boundary of this triangle is the posterior surface of the sternocleidomastoid, the anterior surface of the trapezius, and the middle third of the clavicle.

The sternocleidomastoid and trapezius muscles join at the superior nuchal line, which forms the apex of the triangle. The investing layer of deep cervical fascia makes up the superficial border of the posterior triangle, while the prevertebral fascia makes up the floor.

The inferior belly of the omohyoid muscle passes deep to the sternocleidomastoid and crosses through the posterior triangle, further dividing it into the occipital and subclavian sub-triangles. Function of the Neck Triangles The anterior and posterior triangles of the neck provide a natural framework to organize the numerous contents of the neck into well-defined anatomic subdivisions.

The muscles, bones, and fascia of the cervical region form natural boundaries that enclose various other structures, including muscles, nerves, vasculature, and lymphatics. The following sections will further define the anterior and posterior triangles, clarify the contents of each, and discuss their clinical and surgical relevance.

What is the triangle in the upper limb anatomy?

There are 5 areas covered in the upper limb: The axilla, cubital fossa, extensor tendon compartments, carpal tunnel and anatomical snuffbox. The axilla is a pyramidal shaped anatomical area which gives passage for neurovascular structures, such as the brachial plexus and axillary vein, to enter and leave the upper limb.

1. It lies just beneath the glenohumeral joint, at the junction of the upper limb and thorax.
2. The cubital fossa is a triangular shaped area which can be found as a depression on the anterior surface of the elbow joint.
3. It contains the radial and median nerves, as well as the biceps tendon and brachial artery.

The carpal tunnel is an area in the anterior wrist which gives passage to the tendons of the flexor digitorum and flexor pollicis longus muscles from the anterior forearm and also the median nerve. Its floor is formed by the deep carpal arch and its roof by the superficial flexor retinaculum.

• The anatomical snuffbox is another area of the upper limb which can be seen as a triangular depression on the lateral aspect of the back of the hand.
• It contains the radial artery, cephalic vein and a branch of the radial nerve.
• The extensor tendon compartment of the wrist is a series of 6 tunnels which allow passage of the long extensor tendons of the forearm through the wrist into the hand.

Located on the posterior aspect of the wrist, these tunnels are lined by synovium and kept separate from one another by a fibrous septum. In this section, learn more about the anatomical areas of the upper limb

What is the anatomy of a triangle?

Triangles are made up of three line segments joined in three places. Each of these joints is called a vertex. In a triangle there are three angles, one at each vertex. These three angles must always total 180°.