This document discusses the key anatomical landmarks for laparoscopic inguinal hernia repair. It outlines 9 key landmarks for the trans-abdominal pre-peritoneal (TAPP) approach and 12 landmarks to recognize after the peritoneal reflection for the total extra-peritoneal (TEP) approach. Important structures discussed include the inferior epigastric artery, triangles of Hesselback, Doom and Pain, Cooper's ligament, ilio-pubic tract, and the lateral femoral cutaneous nerve. A thorough understanding of the regional anatomy is essential for accurate surgical treatment of hernias.

2. Laparoscopic Anatomyof Inguinal Region
Dr.S.Easwaramoorthy
MS FRCS (Eng) FRCS (Glas) Hon FRCS (Edin)
Consultant surgeon, Lotus hospital, Erode, TN
EC Member, IAGES South Zone

3. “ No disease of the human body, belonging to the
Province of the surgeon, requires in its treatment,
A better combination of accurate anatomical knowledge
With surgical skill than hernia in all its variants”
Sir Astley Paston Cooper, 1804

5. TAPP Vs TEP

7. TAPP: 9 Key Landmarks
Median Umbilical ligament
Medial Umbilical Ligament
Lateral Umbilical ligament
Vas
Gonadal vessels
Deep ring
Supravesical fossa
Medial inguinal fossa
Lateral inguinal fossa

8. A: Median Umbilical ligament
B: Medial Umbilical ligament
C: Lateral Umbilical ligament

9. Medial Umbilical Ligament
•Obliterated Umbilical artery
•Medial end of dissection

10. Lateral Umbilical Ligament
Inferior Epigastric artery
•Direct/Indirect hernia
•Hesselback’s triangle
•Risk of bleeding
C

11. Hesselback’s Triangle

12. Triangle of Doom
Vas/round ligament
Gonadal vessels

13. Deep Ring

14. Trapezoid of Disaster (Rt Side)
Triangle of Doom
Triangle of Pain
4. Vas
5. Deep ring
6. Spermatic vessels
7. Triangle of pain
8.Triangle of Doom

15. After Peritoneal Reflection
12 Landmarks to Recognize
3 Vessels
•Inferior epigastric artery
•Iliac vessels
•Corona Mortis
3 Nerves
•Genitofemoral N
•Lateral femoral cutaneous N
•Femoral N
3 Triangles
Hesselbeck’s
Triangle of Doom
Triangle of Pain
3 Ligaments
Cooper’s Ligament
Lacunar ligament
Ilio Pubic tract

16. Importance of Inferior Epigastric Artery

17. Corona Mortis

18. Transversalis Fascia
• Deep Ring
• Iliopubic tract
• Bilaminar membrane
– Vascular space
– Preperitoneal space
• Space of Bogros
• Space of Retzius

19. Iliopubic tract

20. Importance of Ilio Pubic tract

21. No staples please…

22. Triangle of Pain
•Lateral Femoral Cutaneous N
•Femoral Br of GFN
•Femoral N
We don’t see
Ilio hypogastric N
Ilio inguinal N

23. Lateral Femoral Cutaneous N
Meralgia paraesthetica

24. Left Femoral ring and Femoral hernia
•Black arrow: Femoral ring
•Black line: Ilio pubic tract
•Straight arrow: In Epi A
•Curved arrow: Deep ring
•V: External iliac vein
•aa: External iliac artery

25. Space of Bogros

26. TEP

27. Anatomy of Rectus sheath

28. Space of Retzius
Cooper’s Ligament

29. Cooper’s Ligament
‘Light House’ during TEP!

30. TEP
Direct Hernia: Pseudosac Indirect Hernia

31. Pseudo sac of Direct Defect

32. Myopectineal Orifice of
Fruchand
Lateral: Ilio Psoas muscle
Medial: Rectus muscle
Inferior: Bony margin of Pubis
Superior: Arching fibres of
In.oblique and transversus

33. Suffice to say…
“I know more than hundred
surgeons whom I would
cheerfully allow to remove my
gallbladder but only
one to whom I should like to
expose my inguinal
canal.” – Sir Heneage Ogilvie
British Surgeon
1887-1991