Triangle Of Pain

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Triangle Of Pain

What is in the triangle of pain?

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,

  1. Surgeons performing laparoscopic inguinal hernia repair should also be aware of the triangle of pain and doom.
  2. The triangle of doom is a triangle bound by the vas deferens, testicular vessels, and the peritoneal fold.
  3. 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.

Why is it called the triangle of 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,

It bears significance in laparoscopic repair of groin hernia, Surgical staples are avoided here. Similarly, the Triangle of Pain is an important landmark in laproscopic surgery. 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 is the triangle of pain and doom inguinal hernia?

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 triangle of pain margins?

10.5. Laparoscopic approach – The laparoscopic approach to hernia repair provides a posterior perspective to the peritoneal and preperitoneal spaces. The parietal peritoneum covers the deep layer of the abdominal wall above the inguinal ligament. On the midline suspends the residual cords of ourach or the median umbilical ligament which extends from the fundus of the bladder to the umbilicus.

Corda arteria umbilicalis or the medial umbilical ligament, which covers the distal portion of the umbilical artery, is located just lateral to the precedent. The lateral umbilical ligament is the fold of peritoneum around the epigastric vessels. These folds delineate three shallow fossae on either side of the midline: Supravesical, medial, and lateral fossae.

Very rarely, internal inguinal hernias may occur in the supravesical fossa. The medial fossa is the region where direct hernias are encountered. The lateral fossa which lies lateral to the inferior epigastric vessels corresponds to the deep inguinal ring, the location of indirect hernias.

Bogros’s preperitoneal space, which contains preperitoneal fat and areolar tissue, is situated between the peritoneum and the posterior lamina of the transversalis fascia. The medial aspect of this space which corresponds to the superior region of the bladder is known as the space of Retzius. The Cooper’s ligament is viewed roughly in a horizontal direction.

The bandelette of Thomson may be visualized in thin individuals after mobilization of the peritoneum. The vascular space is situated between the posterior and anterior laminae of the transversalis fascia, and it houses the inferior epigastric vessels.

The inferior epigastric artery supplies the rectus abdominis. It is derived from the external iliac artery, and it anastomoses with the superior epigastric, a continuation of the internal thoracic artery. The epigastric veins course parallel to the arteries within the rectus sheath, posterior to the rectus muscles.

Inspection of the internal inguinal ring will reveal the deep location of the inferior epigastric vessels. The nerves pass from under or through the bandelette of the Thomson lateral to the external inguinal fossa and the spermatic vessels. The nerves of interest in the inguinal region are the ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves.

The preperitoneal anatomy seen in laparoscopic hernia repair led to the characterization of important anatomic areas of interest, known as the “triangle of doom,” the “triangle of pain,” and the “circle of death.” The triangle of doom is bordered medially by the vas deferens and laterally by the vessels of the spermatic cord, the summit of the triangle corresponding to the deep inguinal ring.

The contents of the space include the external iliac vessels, the deep circumflex iliac vein, the femoral nerve, and the genital branch of the genitofemoral nerve. The triangle of pain is a region bordered by the iliopubic tract above and the gonadal vessels below.

What are the boundaries of the triangle of doom in females?

Triangle of “doom”

UPDATED : The ” triangle of doom ” is a name given to a roughly triangular area in the posterior aspect of the anterior wall of the lower abdominopelvic region. It is used by surgeons repairing an inguinofemoral hernia with a mesh and they want to avoid large vascular structures, namely the external iliac artery and vein. The “triangle of doom” will be highlighted when you hover your cursor over the image. The so-called “triangle of doom” is a misnomer perpetuated by the first laparoscopic surgeons who observed the anatomy of the inguinofemoral region from the posterior aspect. It is neither a triangle (as it only has two boundaries), nor is it an (no such person – that is why is should not use uppercase). It does indicate an area where it is extremely dangerous to place staples or sutures during laparoscopic surgery. The “triangle of doom” is an inverted “V” shaped area with its apex at the internal (deep) inguinal ring. The “triangle of doom” is bound laterally by the gonadal vessels, and medially by the vas deferens in the male, or the round ligament of the uterus in the female. Within the boundaries of this area you can find the external iliac and vein.
It should be pointed out that although the “triangle of doom” landmark does protect the surgeon from damaging the external iliac vessels, a portion of these vessels lie outside of this area. In fact, there are several other areas of concern for neurovascular damage when performing a laparoscopic, The image also depicts other structures of anatomical importance for laparoscopic : • • • (a)• Inferior (deep) epigastric artery (c) Image property of:, Artist:,
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Clinical anatomy of the inguinofemoral hernias, as well as abdominal and perineal hernias are some of the developed and delivered to the medical devices industry by : Triangle of “doom”

What is Hesselbach’s triangle?

The Hesselbach triangle, also called the inguinal triangle, is a region of the lower, anterior abdominal wall, or groin, that was first described by Frank Hesselbach, a German surgeon and anatomist, in 1806. It describes a potential area of weakness in the abdominal wall, through which a hernia can protrude.

Why is Hesselbach’s triangle weak?

Hesselbach’s triangle IMPORTANCE A direct hernia passes through the Hesselbach’s triangle while an indirect one passes lateral to it. This area is the weakest because the abdominal here consists only of the transversalis fascia covered by the external oblique aponeurosis.

BOUNDARIES HOW TO DO THE TEST? First published on : 4 May 2010

As shown by the figure below: Inferiorly : Inguinal ligament Laterally : Inferior epigastric artery Medially : Lateral border of rectus abdominis. To confirm this we can do a ring occlusion test whereby the deep inguinal ring is occluded at 1.25cm above the midpoint of the inguinal ligament after reducing the hernia. Now we can ask the patient to cough or stand up. If the hernia is seen even though the deep ring is occluded it means that the hernia is of the direct type. Last reviewed on : 2 May 2020 DEFINITION Hypokalemia is defined as a serum potassium level of less than 3.5 mmol/L. Normal level= 3.5-5.5 mmol/L. It is encountered in >20% of patients. Patients are usually asymptomatic but severe arrhythmias and rhabdomyolysis can occur. Non-specific complaints include easy fatiguability and skeletal muscle weakness. The preferred method of replacement is via the oral route but at times this is not possible. The article below will give you an idea about how to calculate the amount of KCl to be given I.V.1) Potassium deficit in mmol is calculated as given below: K deficit (mmol) = (K normal lower limit – K measured ) x kg body weight x 0.4 2) Daily potassium requirement is around 1 mmol/Kg body weight.3) 13.4 mmol of potassium found in 1 g KCl, ( molecular weight KCl = 39.1 + 35.5 = 74.6) Suppose we get an asymptomatic patient of 70 Kg with a serum potassium level of 3.0 mmol/L and he is on nil by mouth but having an adequate diuresis, w The plantar response is an important test to identify an upper motor neuron lesion. PROCEDURE To elicit it, the muscles of the lower limbs must be relaxed. The outer edge of the sole of the foot is stimulated by firmly scratching a blunt object like a key or a stick along it from the heel towards the little toe. This is what Joseph Babinski did in the year 1896. He described the ‘great toe sign’ that year and then in 1903 the ‘toe abduction or fan sign’. Nowadays, a final medial movement across the sole of the metatarsus is also done.i.e. we start at the heel to the little toe and finally arcing to the big toe. The final arcing movement is absent in the original Babinski plantar response test. Babinski sign refers to a combination of ‘the great toe sign’ and the ‘fan sign’. SIGNIFICANCE The normal response is plantar flexion of the toes (down going) and they are drawn together. More precisely, there is flexion of the big toe and addu Hyperemia and congestion both indicate a local increased volume of blood in a particular tissue. Hyperemia is an active process that result from augmented blood flow due to arteriolar dilation (e.g. at sites of inflammation or in skeletal muscle during exercise). The affected tissue is redder than normal because of engorgement with oxygenated blood. Congestion, on the other hand, is a passive process resulting from impaired venous return out of a tissue. It may occur due to systemic causes like cardiac failure or a local cause like isolated venous obstruction. The tissue is cyanosed because the worsening congestion leads to accumulation of deoxygenated hemoglobin in the affected tissues. INTRODUCTION The Apgar score was devised in 1952 by Dr Virginia Apgar (anesthesiologist) as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after birth. This helps to identify those requiring resuscitation and can also be used to predict survival in the neonatal period. MNEMONIC A mnemonic for learning purposes includes: A – Appearance (skin colour) P – Pulse (heart rate) G – Grimace (reflex irritability) A – Activity (muscle tone) R – Respiration Another mnemonic is also useful: How – Heart rate Ready – Respiration Is – Irritability This – Tone Child – Colour Apgar scoring is divided into 1 and 5-min scores.1-MIN SCORE Sixty seconds after complete birth, the five parameters specified in the table above must be evaluated and scored. A total score of 10 indicates that the baby is in the best possible condition. A score between 0-3 me DEFINITION Edema is an abnormal presence of excessive fluid in the interstitial space. PATHOPHYSIOLOGY The movement of water and low molecular weight solutes such as salts between the intravascular and interstitial spaces is controlled primarily by the opposing effect of vascular hydrostatic pressure and plasma colloid osmotic pressure. Normally the outflow of fluid from the arteriolar end of the microcirculation into the interstitium is nearly balanced by inflow at the venular end. A small residual amount of fluid may be left in the interstitium and is drained by the lymphatic vessels, ultimately returning to the bloodstream via the thoracic duct. Either increased capillary pressure, diminished colloid osmotic pressure or inadequate lymphatic drainage can result in an abnormally increased interstitial fluid i.e. edema. An abnormal increase in interstitial fluid within tissues is called edema, while fluid collections in the different body cavities are variously : Hesselbach’s triangle

What is the triangle of pain surgery?

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.

  1. Any defect lateral to the lateral umbilical ligament is an indirect hernia and medial to it is a direct inguinal hernia.
  2. 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.

  1. 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.
  2. 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.

  1. In laparoscopic bilateral repair with three ports technique, there is simultaneous access to both sides without any additional trocar placement.
  2. 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.

Bilateral inguinal hernias require 2 incisions, doubling the pain; or 2 operations. • Recurrent inguinal hernias are very difficult to operate open and more liable to complications. • The size of the mesh used in open methods is limited by the natural fusion of muscles. • 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.

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

  1. Many surgeons agree that for bilateral or recurrent inguinal hernias, laparoscopic repair is unquestionably the method of choice.
  2. Laparoscopic surgery is not recommended for big irreducible and incarcerated hernia.
  3. 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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What is the hernia triangle called?

The Inguinal (Hesselbach’s) Triangle The inguinal triangle ( Hesselbach’s triangle) is a region in the anterior abdominal wall. It is alternatively known as the medial inguinal fossa. It was first described by Frank Hesselbach, a German surgeon and anatomist, in 1806. In this article, we shall look at the anatomy of the inguinal triangle – its borders, contents and clinical relevance.

What is the pain pattern of a hernia?

Inguinal hernia – Inguinal hernias occur when part of the membrane lining the abdominal cavity (omentum) or intestine protrudes through a weak spot in the abdomen — often along the inguinal canal, which carries the spermatic cord in men. An inguinal hernia isn’t necessarily dangerous.

A bulge in the area on either side of your pubic bone, which becomes more obvious when you’re upright, especially if you cough or strain A burning or aching sensation at the bulge Pain or discomfort in your groin, especially when bending over, coughing or lifting A heavy or dragging sensation in your groin Weakness or pressure in your groin Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

What is a Richter hernia?

Discussion – In 1558, Fabricius Hildanus reported the first case of Richter hernia; however, it was not until 1778 that German surgeon August Gottlieb Richter gave his scientific description of this rare entity that would later adopt his name.1 A Richter hernia occurs when the anti-mesenteric wall of the intestine protrudes, causing strangulation without obstruction.2 They are most commonly diagnosed in patients 60 to 80 years of age and comprise up to 10 percent of all strangulated hernias.2 These hernias can occur in prior incisions, but they are more commonly seen in small hernia rings large enough to trap a small portion of the bowel wall.3, 4 The most common locations of presentation are femoral hernias (72 to 88 percent), followed by inguinal canal hernias (12 to 24 percent), and abdominal wall incisional hernias (4 to 25 percent).5 Because patients infrequently have obstructive symptoms, they tend to progress more rapidly to gangrene than is typically seen in other types of strangulated hernias.

Repair is typically approached in the pre-peritoneal fashion, with a mandatory laparotomy and resection of bowel if gangrenous or perforated. The silent nature of this hernia’s presentation, and the fact that the patient continues to pass flatus and bowel movements, makes it particularly dangerous. By the time of presentation, there is typically ischemia of the affected bowel.

Due to this ischemia, intestinal resection is mandatory. Not only is there morbidity and mortality due to the hernia, but there is also morbidity and mortality due to the bowel resection. The necrotic bowel is not the only worrisome aspect of these hernias.

Where is a spigelian hernia located?

Diagnosis and management of Spigelian hernia: A review of literature and our experience Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Find articles by Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Find articles by Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Find articles by Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Find articles by Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi – 110 060, India Find articles by Received 2008 Sep 3; Accepted 2008 Nov 10.

  • © Journal of Minimal Access Surgery This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
  • Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line.

Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique.

  • Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically.
  • It has been estimated that it constitutes 0.12% of abdominal wall hernias.
  • The spigelian hernia has been repaired by both conventional and laparoscopic approach.
  • Laparoscopic management of spigelian hernia is well established.

Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach.

  • We retrospectively reviewed our experience of ten patients between 1997 and 2007.
  • Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic.
  • In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP).

There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years). Keywords: Extraperitoneal space, laparoscopy, spigelian hernia, total extraperitoneal approach, transperitoneal approach Spigelian hernias occurs through slit like defects in the anterior abdominal wall adjacent to the semilunar line which extends from the tip of the ninth costal cartilage to the pubic spine at the lateral edge of the rectus muscle inferiorly.

  • Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient.
  • It is also called “spontaneous lateral ventral hernia” or “hernia of semilunar line”.
  • The hernia ring is a well-defined defect in the transversus aponeurosis.
  • The diagnosis of spigelian hernia is difficult.
  • The hernia may be interparietal with no obvious mass on inspection or palpation.

The spigelian hernia has been repaired by both conventional and laparoscopic approaches. Most of the time when laparoscopy has been used as a treatment modality for spigelian hernia it has been done by transabdominal approach. Total extraperitoneal repair (TEP) of spigelian hernia has also been reported in literature.

  • The advantage of TEP approach is that it eliminates the complications related to violation of peritoneal layer to reach the preperitoneal space.
  • Symptoms can vary from abdominal pain, lump in the anterior abdominal wall or patient may have history of incarceration with or without intestinal obstruction.

Pain varies in type, severity, and location and depends upon contents of hernia. Pain often can be provoked or aggravated by maneuvers that increase the intra abdominal pressure and is relieved by rest. If patient has a palpable lump along the spigelian aponeurosis, the diagnosis is apparent.

The same applies if the hernia appears when the patient is upright and disappears spontaneously on lying down. The clinical diagnosis of hernia is complicated by that the defect continues to expand laterally and caudally between two oblique muscles. Some patients present with abdominal pain but no lump.

For these patients radiological investigations are required for diagnosis. If after radiological investigation the diagnosis is uncertain, diagnostic laparoscopy may be performed. We retrospectively reviewed our experience of ten patients with spigelian hernia between 1997 and 2007.

Eight patients (8/10) had abdominal pain and two (2/10) were asymptomatic. Out of eight patients with abdominal pain, six patients with spigelian hernia were diagnosed on clinical examination and two patients were diagnosed on radiological examination (Ultrasound, CT Scan). Two patients (2/10) presented with occult hernias which were asymptomatic.

One patient presented with a concomitant primary umbilical hernia and the other patient with bilateral inguinal hernia. A transverse incision is sited over the protrusion. External oblique aponeurosis is incised in the direction of its fibers to expose the peritoneal sac.

The most common sac content is omentum but intestine, appendix, gall bladder, stomach or ovary have been reported. Most surgeons simply invert the sac alone. The hernial orifice can be closed with sutures or prosthetic patch placed either in pre-peritoneal space or above the fascia. Intraperitoneal onlay mesh repair (IPOM): Intraperitoneal access is performed using Veress needle or open technique.

Once abdominal access is obtained, site of hernial orifice is readily identified and ports are placed at least 10 cm away from the hernial defect in the form of an arc of a circle whose center is the hernial defect. Contents are reduced from the sac and adhesiolysis is performed if required to obtain an overlap of 5 cm around the defect for a synthetic mesh.

The mesh is fixed using a combination of transabdominal sutures and tacks (Autosuture, Tyco health care, US surgicals, CT, USA). Once the hernia sac contents are reduced, a peritoneal flap is raised as in trans abdominal pre peritoneal (TAPP) approach and attempt is made to completely reduce the hernial sac.

After dissecting the peritoneal flap for about 5 cm around the hernial defect, Prolene mesh (Ethicon, Inc., Somerville, NJ, USA) is placed in the dissected extraperitoneal space and is fixed using tacks (Autosuture, Tyco health care, US surgicals, CT, USA).

  1. The peritoneal flap is closed either with tacks or with a continuous suture.
  2. Endoscopic TEP repair is performed using 3 midline ports.
  3. Extraperitoneal space is created by open access and a balloon.
  4. The spigelian hernial sac is identified around arcuate line and reduced completely,
  5. The peritoneum is dissected above the arcuate line to have a 5 cm margin around the hernial defect for mesh overlap.

A Prolene mesh (Ethicon, Inc., Somerville, NJ, USA) is used to cover the hernial defect. Mesh is fixed to anterior abdominal wall with spiral tacks (Autosuture, Tyco health care, US surgicals, CT, USA). We retrospectively reviewed our experience of ten patients with spigelian hernia between 1997 and 2007.

  • In six patients (6/10) we performed IPOM repair, in two patients (2/10) TAPP repair and in two (2/10) TEP repair.
  • Two patients with occult spigelian hernias had concomitant IPOM repair for primary umbilical hernia and TEP repair for bilateral inguinal hernia.
  • All our patients had an uneventful recovery.

There were no recurrences, mesh infection or chronic pain with mean follow up period of 3.2 years (range 6 months to 10 years). Spigelian hernia is named after Adriaan van Spieghel, who described the semilunar line. However, the hernia was first described by Klinkosch in 1764.

  • The hernia appears to peak in the 4 th to 7 th decades.
  • The male to female ratio is 1:1.18.
  • Spigelian hernias are very uncommon and constitute only 0.12% of all abdominal wall hernias.
  • Spigelian hernia can be congenital or acquired.
  • Perforating vessels may weaken the area in spigelian fascia and a small lipoma or fat enters here which gradually leads to hernia formation.

Spigelian hernia may be related to stretching in the abdominal wall caused by obesity, multiple pregnancies, previous surgery or scarring. Spigelian hernia has been described as a complication of chronic ambulatory peritoneal dialysis (CAPD). The spigelian aponeurosis is widest between 0 and 6 cm cranial to the interspinous plane and 85-90% of the hernias occur within this “spigelian hernia” belt,

The hernial ring is a well-defined defect in the aponeurosis. The hernial sac, surrounded by extraperitoneal fat, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique, or lying in the rectus sheath alongside the rectus muscle.

Site of spigelian hernia belt The diagnosis of a spigelian hernia is difficult; few surgeons suspect it, it has no characteristic symptoms, and the hernia may be interparietal with no obvious mass on inspection or palpation. Only 50% of cases are diagnosed preoperatively.

It may present as a swelling adjacent to the iliac crest. The patient may have a classic lump when he/she stands up. The lump is painful if the patient stretches and disappears on lying down. Sometimes the local discomfort can be confused with peptic ulceration. Rarely the hernia can enter the rectus sheath and can be confused with spontaneous rupture of rectus muscle or with a hematoma in the rectus sheath.

Ultrasound is recommended as first line imaging investigation. With this aid, the correct diagnosis was obtained in 19 of 24 cases studied. Ultrasonic scanning of the semilumar line should be under taken in all patients with obscure abdominal pain associated with bulging of the belly wall in the standing patient.

The advantages of real time ultrasonography is the ability to perform examination in both supine and upright positions and while patient performs a Valsalva maneuver. Now CT scanning with close thin sections is considered the most reliable technique to make the diagnosis in doubtful cases. The use of oral contrast medium during the examination is recommended so that any bowel content can be identified.

The increasing availability of the magnetic resonance imaging (MRI) may be of benefit in the preoperative evaluation of these difficult cases. The differential diagnosis includes appendicitis and appendiceal abscess, a tumor of the abdominal wall or a spontaneous hematoma of the rectus sheath or even acute diverticulitis.

Spigelian hernias are treacherous and have a real risk of strangulation. The risk of strangulation is higher because of sharp fascial margin around the defect. Richter type of hernia has also been reported to occur with spigelian hernia. For this reason, surgery should be advised in all patients. Surgery can be performed either by open technique or by laparoscopically.

Carter and Mizes performed first intraabdominal laparoscopic repair of spigelian hernia in 1992. They used sutures to close the defect. After that there have been multiple reports of successful management of spigelian hernia by laparoscopy. In these reports, mesh is placed either intraperitoneally or extraperitoneally after creating a peritoneal flap by trans abdominal approach.

  1. In the only prospective randomized controlled trial comparing conventional versus laparoscopic management of spigelian hernia (11 conventional and 11 laparoscopically) there was significant advantage in terms of morbidity and hospital stay in laparoscopy group.
  2. There have also been case reports of management of spigelian hernia by total extraperitoneal approach.
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The advantage of extraperitoneal placement of mesh is that Prolene mesh can be used, which decreases the cost of procedure, also, incidence of complications like intestinal obstruction and fistulization of bowel is expected to decrease (which can occur with intraperitoneal placement of mesh).

As compared to transabdominal extraperitoneal approach, the TEP approach eliminates the complications related to violation of peritoneal layer to reach the preperitoneal space. The need to close the peritoneal flap with tacks or sutures (in TAPP approach) also increases the operative time and cost. Spigelian hernias are clinically elusive often until strangulation occurs.

If diagnosed, operation should always be advised. These can be repaired successfully by laparoscopic method (intraperitoneal or extraperitoneal approach) to confer all advantages of laparoscopy to patients. Source of Support: Nil Conflict of Interest: None declared.1.

Carter JE, Mizes C. Laparoscopic diagnosis and repair of Spigelian hernia: Report of case and technique. Am J Obstet Gynecol.1992; 167 :77–8.2. Chowbey PK, Sharma A, Khullar R, Baijal M, Vashistha A. Laparoscopic ventral hernia repair. J Laparoendoscopy Adv Surg Tech.2000; 10 :79–84.3. Gedeban TM, Neubauer W.

Laparoscopic repair of bilateral Spigelian and Inguinal hernias. Surg Endosc.1998; 12 :1424.4. Kasiranjan K, Lopez J, Lopez R. Laparoscopic technique in the management of Spigelian hernia. J Laparoscopy Adv Surg Tech.1997; 7 :385.5. Tarnoff M, Rosen M, Brody F.

  1. Planned totally extraperitoneal laparoscopic Spigelian hernia repair.
  2. Surg Endosc.2002; 16 :359.6.
  3. Moreno-Egea A, Aguayo JL, Girela E.
  4. Treatment of spigelian hernia using totally extraperitoneal laparoscopy ambulatory surgery.
  5. Surg Endosc.2002; 16 :1806.7.
  6. Howlihan TJ.
  7. A review of Spigelian hernia.
  8. Am J Surg.1976; 131 :734–5.8.

Klinkosch JT. Programma Quo Divisionem Herniarum, Novumque Herniae Ventralis Specium Proponit. Rotterdam: Benam; 1764.9. Spagen L. Spigelian hernia. World J Surg.1989; 13 :573–80.10. Weiss J, Lernan OZ, Nilson S. Spigelian hernia. Ann Surg.1974; 180 :836–9.11.

Engeset J, Youngson GG. Ambulatory peritoneal dialysis and hernia complications. Surg Clin North Am.1984; 64 :385–92.12. Opson RO, Davis WC. Spigelian hernia: Rare or obscure? Am J Surg.1968; 116 :842–6.13. Read RC. Observation on the aetiology of spigelian hernia. Ann Surg.1960; 152 :1004–9.14. Campos SM, Walden T.

Images in clinical medicine: Spigelian hernia. N Engl J Med.1997; 336 :1149.15. Rogers FB, Camp PC. A strangulated Spigelian hernia mimicking diverticulitis. Hernia.2001; 5 :51–2.16. Moreno-Egea A, Carrrasco L, Girela E, Martin JG, Aguayo JL, Canteras M. Open vs.

What is a McVay repair?

In the McVay repair, the conjoined (transversus abdominis and internal oblique) tendon is sutured to the Cooper ligament with interrupted nonabsorbable sutures.

What is a Lichtenstein hernia repair?

A Lichtenstein repair of a direct hernia is a tension-free mesh repair. The direct hernia is isolated from the cord structures, and then invaginated back into the abdominal cavity. The defect in the wall is then closed by suture, after which the mesh is fixed to bridge the defect.

What is the purpose of TAPP?

Teachers and Parents as Partners, or TAPP (previously known as Conjoint Behavioral Consultation; CBC), creates a bridge between home and school to promote successful outcomes for students with academic and behavioral concerns.

What is the apex of the triangle of doom?

The apex of the triangle of doom is formed by the deep inguinal ring. Medially, it is bounded by the ductus deferens, and laterally, by the testicular vessels. The external iliac artery and vein form its contents.

What is the Myopectineal orifice of Fruchaud?

Discussion – Inguinal hernia is the most common problem in general surgery. The mesh-based repair was usually performed in both open and laparoscopic repairs as recommended by the international guideline for groin hernia management ( 2 ). The good inguinal hernia repair outcome consists of multiple factors, such as understating the anatomy, optimizing the surgical material, and right surgical techniques ( 11 – 14 ).

Myopectineal orifice (MPO), which was described by Dr. Henri Fruchaud in 1956, is a well-defined weak area in the lower anterior abdomen that most frequently occurs in an inguinal hernia. The MPO boundary consisted of the lateral boundary as the iliopsoas muscle; medial boundary as the rectus sheath and rectus abdominis muscle, superiorly as the arching fibers of the transversus abdominis and internal oblique muscle and tendons; and the interior boundary as the iliopectineal line and Cooper’s ligament and Pecten pubis ( 5, 15 ).

Understanding and identifying the MPO’s delineation are essential for surgeons in surgical repair nowadays. The inguinal anatomy should be identified during the surgical approach, both in open and laparoscopic techniques. The hernia sac should be dissected from the MPO, and the prosthetic mesh should cover the entire MPO and extend 3–5 cm beyond the MPO’s boundaries to prevent a mesh migration, resulting in recurrence.

  1. The main result of our study, MPO measurements in a Thai cadaver revealed that the dimensions were equal to the mean MPO width and height of 7.13 ± 0.14 cm and 6.66 ± 0.32 cm, respectively.
  2. The mean MPO area, using elliptical area equation, is 37.26 ± 0.027 cm 2,
  3. One of the considerations in determining the optimal mesh size for hernia patients is the MPO dimension.

Through systematic searching, our results were similar to those of Wolloscheck T. who reported the MPO dimension in the cadaveric study with a mean width of ~7.8 ± 3 cm and a mean height of 6.5 ± 1.9 cm ( 5 ). While the mean MPO area measurement was different from the Ndung’u BM study that was calculated with a trapezoid pattern and the mean area was 7 ± 1.29 cm 2 ( 16 ).

Because of the curvature of each muscle layer, we selected an oval shape that would better cover the MPO region. The Wolloscheck T. and Ndung’u BM report was measured in Germany and Kenya, respectively. Even though ethnic differences may affect the MPO dimension, our study did not indicate substantial differences.

We chose to measure in cadaver because it allowed us to utilize the proper measurement tool and to measure in all dimensions with consistency. However, the disadvantages of the cadaveric study were that there was no actual hernia and cadaveric tissue would shrink from formalin fixation.

  • We solved the problem by performing a Monte-Carlo Simulation, which creates a simulation dataset by sampling available data repeatedly.
  • It has the advantage that the simulation data we collected is similar to a probability analysis or the chance of this data set being available in the future, allowing us to do a more precise analysis.

As for tissue shrinkage, Wolloscheck T’s report states that cadavers have 3% shrinkage. Therefore, we have increased the MPO area from the original measured value by 3%. The mesh material (polypropylene or polyester) and design (flat or anatomical mesh) have also contributed to clinical practice.

  1. However, its size continues to be a critical issue that remains controversial ( 17 ).
  2. Similarly, the mesh has shrinkage, which is reported differently: Harsløf, studied in Physiomesh in various mesh fixation types, has a shrinkage ranging from 17.7 to 35.7% ( 6 ).
  3. Uehnert’s study evaluated polyvinylidenfluoride (PVDF) meshes in an animal study and demonstrated 30% shrinkage in 30 days ( 7 ).

Silvestre’s study found the percentage of shrinkage was 7.8% for heavyweight mesh and 4.2% for lightweight mesh ( 8 ). Inguinal mesh size of 10 cm × 15 cm is usually available in the market; however, the ideal mesh size recommended to cover the MPO ranges from 3 in × 3 in to 3 in × 6 in (7.5 cm × 7.5 cm to 7.5 cm × 15 cm) ( 18 ).

What makes up Hesselbach’s triangle?

The Hesselbach triangle is located in the anterior abdominal wall bilaterally (on both the right and left sides) and has three major boundaries: the medial boundary consisting of the rectus abdominis muscle; the lateral boundary consisting of the inferior epigastric vessels, which supply the anterior abdominal wall

What are the boundaries of the triangle of doom in females?

Triangle of “doom”

UPDATED : The ” triangle of doom ” is a name given to a roughly triangular area in the posterior aspect of the anterior wall of the lower abdominopelvic region. It is used by surgeons repairing an inguinofemoral hernia with a mesh and they want to avoid large vascular structures, namely the external iliac artery and vein. The “triangle of doom” will be highlighted when you hover your cursor over the image. The so-called “triangle of doom” is a misnomer perpetuated by the first laparoscopic surgeons who observed the anatomy of the inguinofemoral region from the posterior aspect. It is neither a triangle (as it only has two boundaries), nor is it an (no such person – that is why is should not use uppercase). It does indicate an area where it is extremely dangerous to place staples or sutures during laparoscopic surgery. The “triangle of doom” is an inverted “V” shaped area with its apex at the internal (deep) inguinal ring. The “triangle of doom” is bound laterally by the gonadal vessels, and medially by the vas deferens in the male, or the round ligament of the uterus in the female. Within the boundaries of this area you can find the external iliac and vein.
It should be pointed out that although the “triangle of doom” landmark does protect the surgeon from damaging the external iliac vessels, a portion of these vessels lie outside of this area. In fact, there are several other areas of concern for neurovascular damage when performing a laparoscopic, The image also depicts other structures of anatomical importance for laparoscopic : • • • (a)• Inferior (deep) epigastric artery (c) Image property of:, Artist:,

Clinical anatomy of the inguinofemoral hernias, as well as abdominal and perineal hernias are some of the developed and delivered to the medical devices industry by : Triangle of “doom”

What are the contents of the inguinal canal?

INTRODUCTION – The inguinal canal is a complex diagonal passage in the lower abdomen that is delimited by the aponeuroses of three muscles: the external oblique, the internal oblique, and the transversus abdominis. In males, the inguinal canal is a passage for the spermatic cord (from the scrotum to the pelvis); in females, it contains the round ligament of the uterus and the ilioinguinal nerve ( 1 ),

Inguinal hernias develop when there is failure of neonatal obliteration of the processus vaginalis or, in adults, when elastic and collagen fibers become weakened. Such hernias can be classified as direct or indirect, depending on their position (medial or lateral) in relation to the lower epigastric artery.

Normal anatomical structures, such as the small intestine, colon, bladder, appendix, ovaries, and testicles, can protrude into the inguinal canal and be subject to various complications and neoplastic or non-neoplastic lesions. Although inguinal hernias are a common finding, other, less common, conditions can be found in the inguinal canal.