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The preperitoneal approach to the groin and the inferior epigastric vessels

  • Applied Anatomy
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Abstract

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

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References

  1. Nyhus LM (1964) The preperitoneal approach and iliopubic tract repair of all groin hernias. In: Nyhus LM, Harkins HN (eds) Hernia, first edition. JB Lippincott, Philadelphia, pp 271–294

  2. Bogros AJ (1823) Essai sur l’anatomie chirurgicale de la region iliaque et description d’un nouveau procédé pour faire la ligature des artèries epigastrique et iliaque externe. Th Paris, no. 153. Didot le Jeune, Paris

  3. Rouvière H (1912) Anatomie humaine descriptive, topographique et fonctionelle. Masson Edit, Paris

  4. Morton T (1841) The surgical anatomy of inguinal herniae, the testis, and its coverings. Taylor and Walton, London

  5. Cooper AP (1807) The anatomy and surgical treatment of crural and umbilical hernia. Longman, London, pp 3-4

  6. Mackay JY (1889) The relations of the aponeurosis of the transversalis and internal oblique muscles to the deep epigastric artery and to the inguinal canal. In: Cleland J (ed) Memoirs and Memoranda in Anatomy, Vol. 1. Williams and Norgate, London, pp 143–146

  7. Retzius AA (1858) Some remarks on the proper design of the semilunar lines of Douglas. Edinb Med J 3:865–867

    Google Scholar 

  8. Annandale T (1876) Case in which a reducible oblique and direct inguinal and femoral hernia existed on the same side and were successfully treated by operation. Edinb Med J 21:1087–1091

    Google Scholar 

  9. Bassini E (1887) Nuovo metodo operativo per la cura radicale dell’Ernia inguinale. Atti d. XII Congr d. ass. Med Ital 2: 179

    Google Scholar 

  10. Halsted WS (1889) The radical cure of hernia. Bull Johns Hopkins Hosp 1:12

    Google Scholar 

  11. Chevasse TF (1882) On a method of operating in strangulated umbilical hernia. Lancet 1:865

    Google Scholar 

  12. Niven J (1861) A new operation for the relief of hernia. Lancet 1:276

    Google Scholar 

  13. Annandale T (1873–1874) On a method of operating in certain cases of strangulated hernia. Edinb Med J 19:209–211

    Google Scholar 

  14. Tait L (1883) On the radical cure of exomphalos. Br Med J 2:1118

    Google Scholar 

  15. Kelly HA (1898) Femoral hernia. Operative Gynecology. D. Appleton Co, New York 2:490–491

  16. Lichtenstein IL, Shore JM (1974) Simplified repair of femoral and recurrent inguinal hernias by a “plug” technique. Am J Surg 28:439–444

    Article  Google Scholar 

  17. Gillion L (1891) Un nouveau procédé de herniotomie, laparotomie pour hernie ombilicale. Clinique (Brux) 5:758–760

    Google Scholar 

  18. Moschcowitz AV (1907) Femoral hernia: a new operation for the radical cure. JAMA 48:896–900

    Google Scholar 

  19. Robins CR (1909) Rectus incision for reduction of strangulated hernia with a report of a case of strangulated hernia in the sac of an undescended testicle. Old Dom J Med Surg 8:324–326

    Google Scholar 

  20. Bates VC (1913) New operation for the cure of indirect inguinal hernia. JAMA 60:2032–2033

    Google Scholar 

  21. LaRoque GP (1919) The permanent cure of inguinal and femoral hernia: a modification of standard operative procedures. Surg Gynecol Obstet 29:507–511

    Google Scholar 

  22. Wilkinson BW (1967) LaRoque intra-abdominal approach for removal of hernia sac of inguinal and femoral hernia. W V Med J 63:142–146

    CAS  PubMed  Google Scholar 

  23. Ger R (1982) The management of certain abdominal herniae by intra-abdominal closure of the neck of the sac. Ann R Coll Surg Engl 64:342–344

    CAS  PubMed  Google Scholar 

  24. Cheatle GL (1920) An operation for the radical cure of inguinal and femoral hernia. Br Med J 68–69

  25. Cheatle GL (1921) An operation for inguinal hernia. Br Med J 2:1025–1026

    Google Scholar 

  26. Henry AK (1936) Operation for femoral hernia by a midline extraperitoneal approach. With a preliminary note on the use of this route for reducible inguinal hernia. Lancet 1:531–533

    Article  Google Scholar 

  27. Musgrove JE, McCready FJ (1949) The Henry approach to femoral hernia: report of two cases. Surgery 26:608–611

    Google Scholar 

  28. Mikkelsen WP, Berne CJ (1954) Femoral hernioplasty: suprapubic extraperitoneal (Cheatle-Henry) approach. Surgery 35:743–748

    CAS  PubMed  Google Scholar 

  29. Nyhus LM, Stevenson JK, Listerud MB, Harkins HN (1959) Preperitoneal herniorrhaphy: a preliminary report in fifty patients: with particular reference to the importance of transversalis fascia analogues. West J Surg Obstet Gynecol 67:48–54

    Google Scholar 

  30. Stoppa R, Quintyn M (1969) Les déficiencies de la paroi abdominale chez le sujet agé: Colloque avec le practicien. Sem Hop Paris 45:2182

    CAS  PubMed  Google Scholar 

  31. Dulucq JL (1992) Treatment of inguinal hernia by insertion of a subperitoneal patch under preperitoneoscopy. Chirurgie 118:83–85

    CAS  PubMed  Google Scholar 

  32. McEvedy PG (1950) Femoral hernia. Ann R Coll Surg Engl 7:484–496

    CAS  PubMed  Google Scholar 

  33. McNaught GHD (1956) Femoral hernia: the rectus sheath operation of McEvedy. J R Coll Surg Edinb 1:309–311

    CAS  PubMed  Google Scholar 

  34. Reay-Young PS (1956) Repair of femoral hernia. Lancet 2:1217–1218

    Article  Google Scholar 

  35. Condon RE (1978) Anterior iliopubic tract repair. In: Nyhus LM, Condon RE (eds) Hernia, second edition. JB Lippincott, Philadelphia, pp 195–211

  36. Usher FC, Gannon JP (1959) Marlex mesh: A new plastic mesh for replacing tissue defects. Arch Surg 78:131–138

    Google Scholar 

  37. Rives J (1967) Surgical treatment of the inguinal hernia with Dacron patch. Principles, indications, technique and results. Int Surg 47:360–361

    CAS  PubMed  Google Scholar 

  38. Flament JB, Avisse C, Palot J-P, Rives J (2001) The Rives technique: treatment of groin hernias with Mersilene mesh by an inguinal approach. In: Bendavid R (ed) Abdominal Wall Hernias. Springer Berlin Heidelberg New York, pp 401–405

  39. Schumpelick V (1990) Atlas of hernia surgery. B.C. Decker, Inc., Philadelphia

  40. Read RC, Barone GW, Hauer-Jensen M, Yoder G (1993) Properitoneal prosthetic placement through the groin. Surg Clin North Am 73:545–555

    Google Scholar 

  41. Wantz GE, Fischer E (2002) Unilateral giant prosthetic reinforcement of the visceral sac. In: Nyhus and Condon’s Hernia, fifth edition. Fitzgibbons RJ Jr, Greenburg AG (eds) Lippincott, Williams, and Wilkins, Philadelphia, pp 219–227

  42. Gilbert AI, Graham MF (2002) Tension-free hernioplasty using a bilayer prosthesis. In: Nyhus and Condon’s Hernia, fifth edition. Fitzgibbons RJ Jr, Greenburg AG (eds) Lippincott, Williams, and Wilkins, Philadelphia, pp 173–180

  43. Wantz GE (1991) Atlas of hernia surgery. Raven Press, New York

  44. Wantz GE (1993) The technique of giant prosthetic reinforcement of the visceral sac performed through an anterior groin incision. Surg Gynecol Obstet 176:497–500

    CAS  PubMed  Google Scholar 

  45. Read RC (1992) Cooper’s posterior lamina of transversalis fascia. Surg Gynecol Obstet 174:426–434

    PubMed  Google Scholar 

  46. Tyson RR, Reichle FA (1972) Retropubic femorofemoral bypass: a new route through the space of Retzius. Surgery 72:401–403

    Google Scholar 

  47. Read RC (1967) Pre-extraperitoneal approach to inguinofemoral herniorrhaphy. Am J Surg 114:672–677

    Google Scholar 

  48. Ugahary F, Simmermacher RKJ (1998) Groin hernia repair via a gridiron incision: An alternative technique for preperitoneal mesh insertion. Hernia 2:123–125

    Google Scholar 

  49. Kugel RD (2002) The Kugel approach to groin hernias. In: Nyhus and Condon’s Hernia, fifth edition. Fitzgibbons RJ Jr, Greenburg AG (eds) Lippincott, Williams, and Wilkins, Philadelphia, pp 229–235

  50. Condon RE (1964) The anatomy of the inguinal region and its relationship to groin hernias. In: Nyhus LM, Harkins HN (ed) Hernia, first edition. JB Lippincott, Philadelphia, pp 14–56

  51. Lampe EW (1964) Transversalis fascia. In: Nyhus LM, Harkins HN (eds) Hernia, first edition. JB Lippincott, Philadelphia, pp 57–61

  52. Lytle WJ (1945) Internal inguinal ring. Br J Surg 32:441–446

    Google Scholar 

  53. Fowler R (1975) The applied surgical anatomy of the peritoneal fascia of the groin and the ‘secondary’ internal inguinal ring. Aust N Z J Surg 45:8-14

    CAS  PubMed  Google Scholar 

  54. Arregui ME (1997) Surgical anatomy of the preperitoneal fasciae and posterior transversalis fasciae in the inguinal region. Hernia 1:101–110

    Google Scholar 

  55. Read RC (1993) The proper anatomic location for groin herniorrhaphy. Contemp Surg 43:99–102

    Google Scholar 

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Addendum

One of the reviewers of this manuscript pointed out that Henry Fruchaud, in the famous Anatomie Chirurgicale des Hernies de l’aine (Paris: G. Doin, 1956) “seems to have a view similar to yours expressed in two of the abundant figures of his book.” Since his works have not been translated into English, I was unaware of this foresight.

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  1. R. C. Read

    Present address: , 304 Potomac Street, Rockville, MD 20850, USA

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    R. C. Read

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Read, R.C. The preperitoneal approach to the groin and the inferior epigastric vessels. Hernia 9, 79–83 (2005). https://doi.org/10.1007/s10029-004-0240-7

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