Fascial Anatomy of the Inguinal Region

Abstract

The overwhelming majority of all hernias in humans occur in the area of the inguinal canal and the femoral canal. Approximately 750,000 inguinal hernias are repaired annually in the United States. In the past, most were repaired by an anterior approach. Consequently, most surgeons are familiar with the inguinal anatomy from the anterior perspective. As laparoscopic techniques were applied to inguinal hernia repair, it became important to understand the inguinal anatomy from a new and largely unfamiliar preperitoneal perspective. The recent literature on laparoscopy describes the musculoaponeurotic, vascular, and nervous structures of the inguinal area from a transabdominal or preperitoneal vantage point. However, there remains significant confusion regarding the transversalis fascia and the multilayered preperitoneal fascia. The etiology of inguinal hernia involves the transversalis fascia, the peritoneum, and the preperitoneal fascia. The latter two structures are especially important in the case of congenital indirect hernias that develop as a consequence of a patent processus vaginalis. There is also a general misunderstanding regarding the presence of the posterior rectus sheath below the level of the arcuate line.