Dissection of the anterior abdominal wall and the deep inguinal region from a laparoscopis perspective

Abstract

The usual dissection by medical students of the anterior abdominal wall and the inguinal region proceeds from superficial to deep; special emphasis is placed on the sheath of the rectus abdominis muscle and lateral muscular layers. We suggest an alternate approach to dissection of this region that has the following advantages: (1) sparing of delicate deep structures not often fully appreciated by students; (2) provision of an opportunity to visualize the region from a laparoscopic surgeon's vantage point; (3) considerably reduced time spent dissecting and identifying structures and relationships, especially peritoneal reflections important in laparoscopic procedures. Our dissection begins with bilateral subcostal incisions through the entire thickness of the anterior abdominal wall and peritoneum, which extend laterally and inferiorly to the level of the anterior superior iliac spines, thereby forming a large, inverted, U-shaped flap. This flap is reflected inferiorly, allowing abdominal viscera to be dissected, and ultimately removed en bloc. The flap is then drawn cranially and stretched somewhat to approximate its position when the abdomen is inflated with CO2 during laparoscopic procedures. Major landmarks, including the deep inguinal ring, are noted and the flap is again reflected inferiorly for dissection beginning with the peritoneum and transversalis fascia. This method of dissecting the anterior abdominal wall and inguinal region results in more facile and timely identification of both superficial and deep structures of the anterior abdominal wall and inguinal region, and provides a clinically relevant demonstration of anatomy from a laparoscopic perspective.

Variations in the inferior pelvic pathway of the lateral femoral cutaneous nerve: Implications for laparoscopic hernia repair

“…T o improve the success of this procedure, inguinal anatomy (Condon, 1995) from the laparoscopic perspective (Quinn et al, 1995) must be understood in all its variations. Spaw and colleagues (1991) have recommended that stapling be avoided in the area where the spermatic vessels and the ductus (vas) deferens form the apex of a "triangle of doom," in which lie the external iliac vessels hidden by peritoneum.…”

“…4). T h e increasing incidence of laparoscopic repair of inguinal hernias and the key role of the I P T in this approach indicate that future editions of anatomy texts should include discussions of the location and significance of the IPT, as illustrated in current surgical texts and clinical studies (Condon, 1995;Quinn et al, 1995;Gilroy et al, 1992;Spaw et al, 1991).…”

Anatomy of the peritoneal aspect of the deep inguinal ring: Implications for laparoscopic inguinal herniorrhaphy

“…This is now being corrected in several undergraduate programs where students are instructed to study the anterior abdominal wall from the internal (or posterior) aspect (Quinn et al, 1995). The conjoint tendon, pectineal ligament and iliopubic tract are used in securing the margins of prosthetic materials, usually by stapling, and in so doing there are several important structures that must not be damaged.…”

Liquid-injection for preperitoneal dissection of transabdominal preperitoneal (TAPP) inguial hernia repair

“…In an attempt to improve the safety and effectiveness of TAPP repair, we have adopted liquid-injection technique to facilitate the process of peritoneal dissection in the appropriate plane [7]. Technical errors, such as when dissection occurs in the wrong plane, can lead to inadvertent injury.…”