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A D V E R T I S E M E N T
A D V E R T I S E M E N T
A wide lower flap is created, clearly exposing all anatomic landmarks. The no-mans land of vascular structures between the vas and spermatic vessels is seen below. Medial to the vessels the pectineal ligament (Cooper's) leads up to the pubis and origin of the rectus muscle. Lateral to the rectus is the transversus aponeurotic arch (falx inguinalis) and transversus muscle covered by the transversalis fascia. Following the fibers of the transversus laterally across the deep ring leads down to the lateral end of the iliopubic tract.
A D V E R T I S E M E N T
The mesh will be anchored by staples (or tacks) into pectineal ligament, pubis, rectus muscle and transversus muscle. The inferior epigastric vessels may be divided but this is usually not necessary. Their position is kept in view and staples can be placed on either side. The last lateral staple is placed above the iliopubic tract to avoid injuring the lateral femoral cutaneous nerve which runs just below the iliopubic tract two centimeters medial to the anterior superior iliac spine (lateral to the deep ring). Some surgeons advocate a double layer repair with a smaller patch, cone, umbrella or butterfly of mesh in the defect itself for added support. A single layer repair is shown in the following steps.
Notes:
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A D V E R T I S E M E N T
The mesh is rolled and introduced through a large port. A convenient way of rolling the mesh is in a double scroll (Dudai) with a loose suture temporarily holding the lateral roll. The lateral roll is held in its center and positioned in the center of the inguinal floor. The medial roll is unfurled toward the pubis, maintaining orientation to the underlying landmarks.
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This page was last modified on 3/1/1998.
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