Let's simplify and clarify the anatomy and surgery of groin hernias

Abstract

A detailed knowledge of the anatomy of the inguinal trigone is necessary in the repair of all groin hernias. Inadequate surgical dissection creates, we are convinced, the diverse anatomic and surgical opinions. The posterior inguinal floor is comprised of two areas: a superior lateral (indirect hernia) and a medial inferior (direct hernia) area. Hernial defects through these areas divide the floor into a medial and lateral division. The medial division is formed by the aponeurosis of the transversus abdominis muscle (conjoined tendon) and the underlying transversalis fascia. The lateral division is formed by the specialized transversalis fascia. The hernia repairs utilizing the inguinal ligament are not anatomic or physiologic because the repairs are performed anterior to the fascial defect in the posterior inguinal floor. Superior lateral defects in the posterior inguinal floor are repaired by defining the medial and lateral divisions usually to the level of the femoral vessels. Inferior medial defects in the posterior inguinal floor are repaired by opening the floor completely and defining the medial and lateral divisions. The same repair is used in all recurrent and large indirect hernias. Femoral hernias are always acquired and are defects in the transversalis fascia lateral to the ligamentous portion of the lacunar ligament. Repair is always approached through the posterior inguinal floor. An essential step necessary to obtain proper exposure of the transversalis fascia prior to any repair is to separate it completely from the underlying but anatomically separate inguinal ligament. Marlex® mesh is utilized in multiple recurrent inguinal hernias with total destruction of the posterior inguinal floor.