Anatomy

The inguinal region is the lowermost part of the anterolateral abdominal wall. It extends between the
the ASIS, which is a bony prominence just inferomedial to the iliac crest, and the pubic tubercle, which is
another bony prominence palpable lateral to the pubic symphysis at the midline. The pubic tubercle
continues to the symphysis pubis as the pubic crest.This region is where structures exit and enter the
abdominal cavity, and are potential sites of herniation.

To be able to have an understanding in the pathophysiology, diagnosis, and management of inguinal

hernias, one must be oriented to the normal anatomy of this region, starting with the anterior
abdominal wall.

The anterior abdominal wall is composed of many layers. From superficial to deep it comprises of the
skin, superficial fascia, which forms two layers: the Camper’s fascia which contains fat, and the Scarpa’s
fascia, which is thin and membranous. Deep to the superficial fascia are the abdominal muscles which
are subdivided into three flat muscles and two vertical muscles. The three flat muscles are, from
superficial to deep, the external oblique, with its fibers running inferomedially, internal oblique, with its
fibers running perpendicularly with that of the external oblique, except for its lowermost fibers, which
run somewhat inferomedially, and the transversus abdominis, with its fibers running transversally and
the lowermost fibers are parallel with that of the internal oblique. The two vertical muscles are the
rectus abdominis and the pyramidalis muscles which lie in the midline.

Each of the three flat muscles is covered on its anterior and posterior surfaces by a layer of deep (or
investing) fascia, so the deepest structure of this muscular layer is the transversalis fascia. It is important
to note that the origin and insertion points of this muscles in the pelvis lie along the iliac crest, ASIS,
pubic tubercle, and pubic crest, leaving an area devoid of muscular covering. This allows
accommodation of the various structures passing through the inguinal region, but also makes this area
inherently weak.

The deepest layer of the abdominal wall is the parietal peritoneum which reflects onto abdominal
viscera as the visceral peritoneum, creating the peritoneal cavity.

The Inguinal Canal

An important landmark in the inguinal region is the inguinal ligament. It spans from the ASIS to the pubic
tubercle. Situated just above and parallel to the lower half of the inguinal ligament is the inguinal canal.
It is a slit-like, cone-shaped passage, measuring 4-6cm. It contains the spermatic cord in males, the
round ligament of the uterus in females, and the ilioinguinal nerve in both sexes. It extends from the
deep to the superficial inguinal rings.

The deep (internal) inguinal ring is the entrance to the inguinal canal and is a hiatus of the transversalis
fascia. The superficial (external) inguinal ring is where the contents of the inguinal canal exit. It is a
hiatus in the external oblique aponeurosis just above and lateral to the pubic crest. The ring is actually
triangular, with its apex pointing laterally towards the ASIS and its sides are the crura formed from a
split that occurs in the external oblique aponeurosis. The lateral crus is the stronger and it inserts into
the pubic tubercle. The medial crus is thin and attaches to the pubic crest. Fibers from the aponeurosis
of external oblique and overlying fascia pass from one crus to the other to form the intercrural fibers,
which help prevent the crura from spreading apart and some of the same fibers continue downwards
towards the spermatic cord to form the external spermatic fascia. Hence the ‘ring’ appears less of a
discrete opening.

The inguinal ligament is actually the thick lower border of the aponeurosis of external oblique. Its medial
half is curled in on itself, forming a shelf or a gutter-like floor upon which the spermatic cord rests. At
the medial end, most of its fibers insert into the pubic tubercle but some pass posteriorly to attach to
the superior pubic ramus, forming the arching lacunar ligament (of Gimbernat). Some of these fibers
continue to run laterally along the pecten pubis as the pectineal ligament (of Cooper). This structure has
clinical significance as a firm structure to which sutures can be anchored in the surgical repair of hernias.
Some of the more superior fibers of the inguinal ligament fan upwards and medially behind the
superficial inguinal ring and external oblique and crosses the linea alba to blend with the lower fibers of
the contralateral external oblique aponeurosis. These fibers form the reflected inguinal ligament.
Another structure worth mentioning is the conjoint tendon which is formed by the arched fibers of
internal oblique and transverses abdominis.

Together, the reflected ligament, the conjoint tendon, and the transversalis fascia, form a posterior wall
and separate the inguinal canal from extraperitoneal connective tissue and peritoneum, and provide
reinforcement against the occurrence of herniations at this region.

Spermatic Cord

The main occupant of the inguinal canal in males is the spermatic cord. It runs from the deep inguinal
ring then exits at the superficial inguinal ring, and ends in the scrotum. It contains the following
structures: the vas deferens, the testicular and cremasteric artery; the artery of the ductus deferens; the
pampiniform venous plexus; sympathetic and parasympathetic nerve fibers; the genital branch of the
genitofemoral nerve and, ; some lymphatic vessels, and is ensheathed in the following fascia: the
internal spermatic fascia, derived from the transversalis fascia; the cremasteric fascia, (from the internal
oblique muscle); and the external spermatic fascia, derived from the external oblique aponeurosis and
its investing fascia.

Hesselbach Triangle and Preperitoneal space

To further understand inguinal hernias. One must be familiar with the inside view of the peritoneal
cavity, on the infraumbilical part of the anterior abdominal wall. On this surface, there are five
peritoneal folds passing toward the umbilicus, one in the median plane and two on each side. The
median umbilical fold at the midline, then lateral to it is the medial umbilical fold, and then most lateral
is the lateral umbilical fold that covers the inferior epigastric vessels. Between the medial and the lateral
fold is a depression called the Hesselbach’s triangle, bounded inferiorly by the medial third of the
inguinal ligament, medially by the lateral border of the of the rectus abdominis, and laterally by the
inferior epigastric vessels. Immediately lateral to inferior epigastric vessels is the deep inguinal ring.
When viewed from the anterior surface, this area is related to the superficial inguinal ring, considered
by some as the weakest area in the anterolateral wall, reinforced only by the transversalis fascia, and
some extent of the conjoint tendon, and the reflected inguinal ligament, hence it is a potential site for
herniations.

An area of importance in the repair of an inguinal hernia, be it laparoscopically or the open procedure, is
the area between the transversalis fascia and the parietal peritoneum, termed Bogros’s (preperitoneal)
space. This area contains varying amounts of fat and vasculature and it is where prosthetic mesh is
placed in many hernia repairs. It actually corresponds to the retroperitoneum of the posterior wall of
the abdomen. Vasculature in this space include the inferior epigastric vessel and the external iliac artery
and vein which traverse the subinguinal space, and the gonadal vessels which enter the inguinal canal.
Nerves of interest in this space include the genitofemoral which arises from L1–L2 and divides into
genital and femoral branches. The genital branch supplies the ipsilateral scrotum and cremaster muscle.
The femoral branch supplies the skin of the upper anterior thigh. The lateral femoral cutaneous nerve
arises from L2–L3 to supply the lateral thigh.

Other nerves of interest in the inguinal region are the ilioinguinal and iliohypogastric which arise
together from the L1. At a point just medial to the anterior superior iliac spine, the ilioinguinal nerve
pierces the transversus and internal oblique muscles to enter the middle third of the inguinal canal. It
supplies the skin of the upper and medial thigh, the base of the penis, and upper scrotum. The
iliohypogastric nerve pierces the deep abdominal wall, then courses between the internal oblique and
transverses abdominis, supplying both. A common variant is for the iliohypogastric and ilioinguinal
nerves to exit around the superficial inguinal ring as a single entity.

Another structure worth noting is the iliopubic tract. It is the thickened inferior margin of the
transversalis fascia, which is seen in the place of the inguinal ligament when the inguinal region is
viewed from its internal aspect. It reinforces the posterior wall and floor of the inguinal canal. The
inguinal ligament and iliopubic tract span the myopectineal orifice, which encompasses the site of direct
and indirect inguinal and femoral hernias.

The preperitoneal anatomy seen in laparoscopic hernia repair led to characterization of important
anatomic areas of interest, known as the triangle of doom and the triangle of pain. The triangle of doom
is bordered medially by the vas deferens and laterally by the vessels of the spermatic cord. The contents
of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital
branch of the genitofemoral nerve.

The triangle of pain is a region bordered by the iliopubic tract and gonadal vessels, and it encompasses
the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves. The circle of
death is a vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric,
and external iliac vessels.