Endoscopic anatomy of the groin; implication for Transabdmominal Preperitotoneal Herniorrhaphy

Hernia surgery is in many ways the quintessential case for demonstrating anatomy in action. Laparoscopic hernia surgery has a more recent history compared to open surgery. The demand for the procedure is increasing. The indications for laparoscopic herniorrhaphy include bilateral disease, recurrence following anterior repairs and patient preference. Anatomy of the lower anterolateral abdominal wall appreciated from a posterior profile compounds the challenge of a steep learning curve for the procedure. The iliopubic tract and Cooper’s ligaments, less obvious to anterior surgeons, are important sites for mesh fixation for laparoscopic surgeons. Their neural and vascular relations continue to receive plenty of mention in hernia literature as explanations for troublesome procedure-related morbidities. The one ‘rectangle’ (trapezoid of disaster), one ‘circle’ (of death) and two ‘triangles’ (of doom, of pain) geometric concepts denote application of anatomy in mapping the danger areas of the groin where dissection and staples for fixation should be minimized.