Anatomical observations on 30 cadavers: new insights into the relationship between the posterior wall of the inguinal canal and the cremaster.

PURPOSE: Clarify the composition of the Posterior wall of the Inguinal Canal(PWIC), the location and composition of the Transverse Fascia(TF), and the tissue origin of the Cremaster(C) by observing the anatomy of the inguinal region of the cadaver. METHODS: 30 cadavers were dissected to observe the alignment of the muscles and fascia of the inguinal canal and the anterior peritoneal space. the anatomical levels of the posterior wall of the inguinal canal and the alignment of the Spermatic Cord(SC) were observed. RESULTS: (1) The posterior wall of the inguinal canal was white, bright, and tough tendon membrane-like tissue; (2) the transverse fascia was a thin fascial tissue with only one layer of membranous structure located in the abdominal wall under the abdominal wall on the side of the blood vessels of the peritoneal cavity; (3) the internal oblique muscle and its tendon membrane, and the transversus abdominis muscle and its tendon membrane extended on the surface of the spermatic cord, and fused and continued to the cremaster on the surface of the spermatic cord. CONCLUSIONS: 1. PWIC is mainly composed of Internal oblique muscle of abdomen (IOMA), Aponeurosis of internal oblique muscle of abdomen (AIOMA), Transverse abdominal muscle (TAM), and Transverse abdominal aponeurosis(TAA) as the following four types: (1) TAM and AIOMA fused to form a tendinous layer; (2) IOMA and TAM form the posterior wall of the muscle in the PWIC; (3) IOMA and AIOMA continue in the PWIC; 4) TAM and TAA continue in the PWIC. 2.TF is a thin fascial tissue with only one layer of membrane structure, TF is not involved in the composition of PWIC, so this fascia has nothing to do with resisting the occurrence of inguinal hernia. 3. The spermatic cord that travels in the inguinal canal is fixed to the lower wall of the inguinal canal by the tendon membrane of the cremaster, which is organized from the internal oblique and transversus abdominis muscles and their tendon membranes, The inguinal canal is a musculotendinous canal.

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance.

PURPOSE: Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide. METHODS: Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers. RESULTS: Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia. CONCLUSIONS: We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.

Schwann cell-specific Pten inactivation reveals essential role of the sympathetic nervous system activity in adipose tissue development.

There is increasing evidence that the sympathetic nervous system (SNS) plays an important role in adipose tissue development. However, the underlying molecular mechanism(s) associated with this remains unclear. SNS innervation of white adipose tissue (WAT) is believed to be necessary and sufficient to elicit WAT lipolysis. In this current study, mice with Schwann cell (SC)-specific inactivation of phosphatase and tensin homolog (Pten) displayed enlarged inguinal white adipose tissue (iWAT). This serendipitous observation implicates the role of SCs in mediating SNS activity associated with mouse adipose tissue development. Mice with SC-specific Pten inactivation displayed enlarged iWAT. Interestingly, the SNS activity in iWAT of SC-specific Pten-deficient mice was reduced as demonstrated by decreased tyrosine hydroxylase (TH) expression level and neurotransmitters, such as norepinephrine (NE) and histamine (H). The lipolysis related protein, phosphorylated hormone sensitive lipase (pHSL), was also decreased. As expected, AKT-associated signaling pathway was hyperactivated and hypothesized to induce enlarged iWAT in SC-specific Pten-deficient mice. Moreover, preliminary experiments using AKT inhibitor AZD5363 treatment ameliorated the enlarged iWAT condition in SC-specific Pten-deficient mice. Taken together, SCs play an essential role in the regulation of SNS activity in iWAT development via the AKT signaling pathway. This novel role of SCs in SNS function allows for better understanding into the genetic mechanisms of peripheral neuropathy associated obesity.

Evaluating a low-fidelity inguinal canal model.

PURPOSE: The inguinal canal anatomy is of paramount clinical significance due to the common occurrence of direct and indirect inguinal hernias. However, the inguinal canal is often an area of great difficulty for medical students to understand. The aim of this study was to evaluate the use of a low-cost, low-fidelity inguinal canal model as a teaching and learning aid. METHODS: A low-fidelity inguinal canal model was introduced as a learning aid in an anatomy tutorial on the inguinal region. Students were randomised into intervention (n = 66) and control (n = 40) groups. Following the tutorial, all students completed a multiple-choice question quiz on the inguinal canal. The intervention group also completed a questionnaire evaluating the positive and negative aspects of the model. RESULTS: Students taught with the inguinal canal model achieved higher scores (mean: 88.31% vs 81.7%, p = 0.087). Positive aspects of the model as described by the students included its simplicity and ability to improve their three-dimensional understanding of the inguinal canal. Students requested more hands-on time with the model during the tutorial. CONCLUSION: The present study supports current literature in that low-fidelity anatomy models are a useful adjunct to aid students' learning of complex anatomical concepts. Students may benefit from creating their own inguinal canal model to retain as a personal study tool.

Close relationship between the short round ligament and the ovarian prolapsed inguinal hernia in female infants.

PURPOSE: The aim of this study was to clarify the relationship between the length of the round ligament and the presence of a patent processus vaginalis (PV) based on the hypothesis that a short round ligament is the cause of ovarian inguinal hernia in female infants. METHODS: Between April 2011 and March 2017, 132 girls underwent laparoscopic surgery for inguinal hernia. Before surgery, the presence of ovarian prolapse was diagnosed. We observed the internal inguinal ring laparoscopically and examined the diameter of the PV orifice as well as the round ligament length. Medical records and video records were reviewed to evaluate PV patency and round ligament length. RESULTS: Seventeen of the 132 cases had an ovarian inguinal hernia; all of them were infants. In all infants, with or without a prolapsed ovary, the round ligament was short, causing the ovary and fallopian tube to be close to the hernia orifice over the pelvic brim. In girls aged over 12 months, the round ligament lengths on the hernia side, contralateral open PV side, and contralateral closed PV side were 33.0 ± 9.3, 36.8 ± 7.5, and 41.4 ± 8.5 mm, respectively. The round ligament length in open PV was significantly shorter than in the closed PV, but the difference was smaller in older patients. CONCLUSION: The round ligament, which is the female gubernaculum in the fetus, was shorter in the open PV than in the closed PV in younger girls. The short round ligament results in the ovarian prolapsed hernia.

The fascial connections of the pectineal ligament.

In clinical settings, the pectineal ligament forms a basic landmark for surgical approaches. However, to date, the detailed fascial topography of this ligament is not well understood. The aim of this study was to describe the morphology of the pectineal ligament including its fascial connections to surrounding structures. The spatial-topographical relations of 10 fresh and embalmed specimens were dissected, stained, slice plastinated, and analyzed macroscopically, and in three cases histological approaches were also used. The pectineal ligament is attached ventrally and superiorly to the pectineus muscle, connected to the inguinal ligament by the lacunar ligament and to the tendinous origin of rectus abdominis muscle and the iliopubic tract. It forms a site of origin for the internal obturator muscle, and throughout its curved course, the ligament attaches to both the fasciae of iliopsoas and the internal obturator muscle. However, dorsally, these fasciae pass free from the bone, while the pectineal ligament itself is adhered to it. The organ fasciae are seen apart from the pectineal ligament and its connections. The pectineal ligament seems to form a connective tissue junction between the anterior and medial compartment of the thigh. This ligament, however, is free to other compartments arisen from the embryonal gut and to the urogenital ridge. These features of the pectineal ligament are important to consider during orthopedic and trauma surgical approaches, in gynecology, hernia and incontinence surgery, and in operations for pelvic floor and neovaginal reconstructions. Clin. Anat. 32:961-969, 2019. © 2019 Wiley Periodicals, Inc.

Age-related changes in inguinal region anatomy from 0 to 19 years of age.

Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.

The round ligament of the uterus: Questioning its distal insertion.

PURPOSE: Classically, the round ligament of the uterus (RLU) attaches distally in the ipsilateral labia majora. This attachment has rarely been described in adults. That is why we have performed an anatomical study focused on this distal ending. PATIENTS: We performed in 2015 the cadaveric dissection of 19 RLU. METHODS: In all cases, the RLU was individualized on its entire length from its uterine origin to the inguinal canal. Then this canal was open from its internal orifice to its external orifice. We described the distal attachment of the RLU according four areas: before the internal inguinal ring, after the external inguinal ring, under the pubic bone and in labia majora. RESULTS: We found 3 types of distal attachments with first an attachment after the external inguinal ring in more than half of cases (52.6%). Then, before the internal inguinal ring (26.3%) and under the pubic bone (22.1%). No RLU was found inlabia majora. However, the proximal attachment seems constant at the antero-superior face of uterus, near the tubo-uterine junction like its pelvic path under the broad ligament. CONCLUSION: In adult, the RLU is a structure, which begins at the cranio-ventral part of the uterine bottom near the tubo-uterine junction. Then it passes under the broad ligament and reaches the inguinal canal, that it crosses in more half of cases. However, 3 distal attachment areas have been identified but never in the labia majora. Indeed, some anatomical information available in anatomical treaties seems not correct and should be amended.

Absent external oblique musculo-aponeurotic complex during inguinal hernioplasty: a case report and review of literature.

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Regulation of testicular descent.

Testicular descent occurs in two morphologically distinct phases, each under different hormonal control from the testis itself. The first phase occurs between 8 and 15 weeks when insulin-like hormone 3 (Insl3) from the Leydig cells stimulates the gubernaculum to swell, thereby anchoring the testis near the future inguinal canal as the foetus grows. Testosterone causes regression of the cranial suspensory ligament to augment the transabdominal phase. The second, or inguinoscrotal phase, occurs between 25 and 35 weeks, when the gubernaculum bulges out of the external ring and migrates to the scrotum, all under control of testosterone. However, androgen acts mostly indirectly via the genitofemoral nerve (GFN), which produces calcitonin gene-related peptide (CGRP) to control the direction of migration. In animal models the androgen receptors are in the inguinoscrotal fat pad, which probably produces a neurotrophin to masculinise the GFN sensory fibres that regulate gubernacular migration. There is little direct evidence that this same process occurs in humans, but CGRP can regulate closure of the processus vaginalis in inguinal hernia, confirming that the GFN probably mediates human testicular descent by a similar mechanism as seen in rodent models. Despite increased understanding about normal testicular descent, the common causes of cryptorchidism remain elusive.

A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space.

INTRODUCTION: The primary concern for many prosthetic urologic surgeons in placing the three-piece inflatable penile prosthesis (IPP) is the concept of "blind reservoir placement." Extensive reports permeate the literature regarding bladder, bowel, vascular, and various hernial complications occurring while attempting to place the reservoir into the retropubic space. However, despite these widely documented complications, there is a paucity of published literature on surgically pertinent anatomical measurements of the retropubic space relating to reservoir placement. The focus of this project was to evaluate the special relationships and anatomical measurements of the retropubic space to better aid the surgeon in the safe placement of the reservoir. AIM: Analyses of the spatial measurements of reservoir placement into the retropubic space with a focus on utilizing a penoscrotal approach were conducted. In addition, we reviewed and evaluated the published literature for important contributions surrounding the various surgical techniques during placement of a penile prosthesis reservoir. METHODS: Cadaveric pelvic specimens were dissected to determine the distance and angulation (in degrees) from the inguinal ring to several critical anatomic structures in the pelvis. This format was utilized to simulate the basic features of reservoir placement into the classic retropubic space. We also reviewed and evaluated the published literature for important contributions describing the various surgical techniques in the placement of penile prosthesis reservoirs into the retropubic space. MAIN OUTCOME MEASURES: Anatomic measurements were obtained from the inguinal ring to the bladder, external iliac vein, and superior origin of the dorsal suspensory ligament at the anterior apex of the pendulous penis. The angle was measured from the inguinal ring to these structures and recorded. We also reviewed the published literature for various penoscrotal IPP surgical techniques involving placement of the reservoir into the retropubic space to further supplement the pertinent spatial relationships data acquired in this study. RESULTS: Of the 28 cadavers, 3 were excluded because of signs of major pelvic surgery, and an additional 6 sides were excluded because of unilateral fibrosis/surgery or difficulty in exposure. Distance to the decompressed bladder was 5-8 cm (average 6.45 cm) at a 15-30 (22.8) degrees medial measurement from the inguinal ring. The filled bladder was 2-4 cm (average 2.61 cm) from the inguinal ring. The external iliac vein distance from the inguinal ring was 2.5-4 cm (average 3.23 cm) at a 20-60 (36.4) degrees lateral measurement from the inguinal ring. Heretofore, the published literature does not appear to have detailed measurements that are provided in this study. CONCLUSIONS: These anatomical measurements of the retropubic space demonstrate the importance of decompressing the bladder and avoiding deep dissection lateral to the inguinal ring, as the external iliac vein is much closer than currently espoused. We feel that these data are significant to the surgeon proceeding with reservoir placement during IPP surgery.

Inguinal lymph nodes: size, number, and other characteristics in asymptomatic patients by CT.

PURPOSE: The purpose of this study was to establish normative data for the CT appearance of inguinal lymph nodes. MATERIALS AND METHODS: After Institutional Review Board approval, search of the radiology information system identified 500 consecutive CT examinations of the pelvis. Patients were included if no lower extremity or perineum pathology, or history of malignancy at the time of CT examination, and a clinical note documenting no tumor at least 2 years after the CT. The final study group was 77 patients. CT examinations were retrospectively reviewed and bilateral inguinal lymph nodes were characterized by size (short axis and largest size in general), number, and presence of fat attenuation. RESULTS: The mean short-axis inguinal lymph node size was 5.4 mm (range 2.1-13.6 mm), measured at 8.8 mm two standard deviations above the mean. The mean number of superficial and deep inguinal lymph nodes was 10.7 (range 3-18) and 1.2 per patient (range 1-2), respectively. Superficial and deep inguinal nodes showed internal fat attenuation in 85 and 78% of nodes, and were oval in shape in 95 and 78%, respectively. CONCLUSION: Inguinal lymph nodes in asymptomatic patients have a mean short axis of 5.4 mm, a short axis of 8.8 mm at two standard deviations above the mean, and are multiple and symmetric in size and number (4-20 per patient). Normal inguinal lymph nodes were commonly oval in shape and contained fat, although such findings may be absent in smaller lymph nodes.

Revisiting the anatomy of the ilio-inguinal/iliohypogastric nerve block.

BACKGROUND: The ilio-inguinal/iliohypogastric nerve block (INB) is one of the most common peripheral nerve block techniques in pediatric anesthesia, which is largely due to the introduction of ultrasound (US) guidance. Despite the benefits of US guidance, the absence of an US machine should not deter the provider from performing INB, considering that many institutions, especially in developing countries, cannot afford to provide ultrasound machines in their anesthesiology departments. The aim of this study was to revisit the anatomical position of the ilio-inguinal and iliohypogastric nerves in relation to the anterior superior iliac spine (ASIS), in a large sample of neonatal cadavers, and compare the results with a similar group in a previously published US-guided study. METHODS: With Ethics Committee approval, the ilio-inguinal and iliohypogastric nerves were carefully dissected in 54 neonatal cadavers. RESULTS: In the total sample, the ilio-inguinal nerve was found to be 2.2 ± 1.2 mm from the ASIS, on a line connecting the ASIS to the umbilicus. The iliohypogastric nerve was on average 3.8 ± 1.3 mm from the ASIS. For the entire sample, the optimal needle insertion site was 3.00 mm from the ASIS. Although there is a strong correlation between the needle insertion point and the weight of the neonate, this will only 'fit' for 60% of the population. CONCLUSION: The linear regression formula; needle insertion distance (mm) = 0.6 × weight + 1.8 can be used as a guideline for the position of the ilio-inguinal and iliohypogastric nerves.

Reappraisal of the ligament of Henle (ligamentum inguinale internum mediale; Henle, 1871): a topohistological study using Korean foetuses.

Ligament of Henle is one of muscle-associated connective tissues of the rectus abdominis muscle, but it has been confused with the conjoint tendon (a common aponeurosis for insertion of the inferomedial end of the obliquus internus and transversus abdominis muscles). To reconsider the inguinal connective tissue structures, we examined 20 mid-term foetuses (10 males and 10 females) at approximately 14-20 weeks of gestation (crown rump length 100-170 mm). In female horizontal sections, we consistently found the ligament of Henle asa wing-like aponeurosis extending from the lateral margin of the rectus tendon behind the superficial inguinal ring. The ligament was separated from and located behind the conjoint tendon. In all male foetuses, instead of the ligament, the conjoint tendon was evident behind the superficial ring and it winded around the posterior aspect of the spermatic cord. Therefore, although a limited number of specimens were examined, the ligament of Henle was likely to be a female-specific structure. The ligament of Henle, if developed well, may provide an arch-like structure suitable for a name "falx inguinalis" instead of the inferomedial end ofthe conjoint tendon. In addition, a covering fascia of the iliopsoas muscle joined the posterior wall of the inguinal canal in male, but not in female, specimens.

[Radical operations of inguinal hernias with the temporary translocation of inguinal nerves].

This article presents the results of anatomic researches of the innervations of the inguinal area, performed for studying an arrangement of the main nerves of the inguinal area in relation to the operation access and the area of plasty of the posterior wall of the inguinal canal. The method of temporary translocation of inguinal nerves is developed for their preservation at radical operations of inguinal hernias. Long-term experience of surgical treatment of inguinal hernias with the temporary translocation of inguinal nerves is summarized.

A new method of spermatic cord mobilization in herniorrhaphy.

Spermatic cord mobilization is a routine part of inguinal hernia repair, but the method of cord mobilization varies among surgeons. This study establishes an anatomic plane for spermatic cord mobilization. We studied the anatomy of the superficial cremasteric fascia in 105 male patients during herniorrhaphy for primary inguinal hernias. The mean patient age was 44.8 (18-71) years and mean body mass index was 24.1 kg/m(2) (21.5-27.1 kg/m(2)). The two layers of the superficial cremasteric fascia between the spermatic cord and the inguinal falx were incised to mobilize the cord. We found that spermatic cord mobilization during herniorrhaphy can be easily approached through an anatomic plane between the spermatic cord and the conjoined tendon with subsequent division of the superficial cremasteric fascia. None of the patients experienced any hemorrhage or nerve injury during cord mobilization. We found this method to be both safe and easy to learn.

A combined anatomical variation of inferior epigastric vessels.

During the routine gross anatomical dissection of the right inguinal region of a 45-year-old male cadaver, a variation was observed both in the inferior epigastric artery and the inferior epigastric vein. In this case, the right inferior epigastric artery originated from the femoral artery 13 mm inferior to the inguinal ligament. Additionally, in this cadaver, the single right inferior epigastric vein drained into femoral vein 8 mm inferior to the inguinal ligament. The distal origin of the inferior epigastric artery from the femoral artery and the lower drainage of the single inferior epigastric vein to the femoral vein must be taken into consideration by surgeons.

[Anatomic characteristics and clinic significance of the lateral femoral cutaneous nerve].

OBJECTIVE: To explore the reasons of poor sensation recovery after anterolateral thigh flap (ALTF) transplantation and to improve the design and sensation reconstruction of ALTF. METHODS: Lower limbs from 21 adult cadavers were chosen, and the lateral femoral cutaneous nerves (LFCN) were dissected. Their courses, shape, distribution and anatomic variation were observed, the distance from original sites of LFCN's posterior and anterior branches to the anterior superior iliac spine (ASIS) were measured, and the external diameter of their main trunks,after piercing out from the inferior margin of inguinal ligament or sending out their posterior branches and their anterior branches, were measured. RESULTS: The plane which the posterior branches sent out from the LFCN located at 4.8 (0~16.9) cm below the ASIS. The plane which the anterior branches sent out from the LFCN located at 14.2 (6.7~24.1) cm below the ASIS. There were 6 branches of the LFCN, namely ordinary three branches (9/21), high-level posterior branch (5/21), posterior branch absent (3/21), anterior branch absent (1/21), tiny branch, (2/21) and LFCN absent (1/21). The section of the LFCN was oblate, the external diameter of the LFCN,s main trunk after piercing out from the inferior margin of inguinal ligament or sending out its posterior branch and its anterior branch was 2.68 (1.18-4.52) mm, 2.18 (0.80-4.10) mm and 1.63 (0.44-2.60) mm, respectively. CONCLUSION: Poor sensation recovery after ALTF transplantation is due to anatomic variation of the posterior branch of the LFCN. The sensory recovery of ALTF may be improved if the 2/3 low to median part of the anterolateral thigh and the main trunk of the LFCN or its plane before sending out the anterior branch is chosen for anastomosis.

Groin pain beyond the hip: how anatomy predisposes to injury as visualized by musculoskeletal ultrasound and MRI.

OBJECTIVE: The purpose of this article is to show ultrasound and MRI examples of the normal anatomic structures and their resulting modifications from trauma and disease. CONCLUSION: Although groin pain from hip pathology is well recognized, lower anterior abdominal wall and anterior pelvis structures can be interrelated sources of pain.

Defining the position of the deep inguinal ring using findings at laparoscopic inguinal hernia repair.

PURPOSE: We aim to establish the surface marking of the deep inguinal ring by laparoscopy and investigate if the patient's build influences it. METHODS: Sixty consecutive patients undergoing laparoscopic hernia repairs were studied. The bony landmarks, anterior-superior iliac spine (ASIS) and pubic tubercle (PT), and the two traditional landmarks, the mid-inguinal point (MIP) and midpoint of inguinal ligament (MPIL), were marked on the anaesthetized patient before the surgery. The deep ring was located by indenting the surface until laparoscopy shows the deep ring being occluded. RESULTS: The true surface marking of the deep ring was found to lie at a mean distance of 9.6 mm medial to the MPIL landmark and 4.5 mm lateral to the MIP, approximately one-third of the distance from the MIP to the MPIL. Multivariate analysis confirmed that age, gender, race, BMI or pelvic habitus did not vary it. CONCLUSIONS: The deep ring is located under a point just lateral to the MIP, which is the midpoint of a line drawn joining the ASIS and pubic symphysis. This should be taught to future generations of medical students as the point to apply occluding pressure to differentiate clinically between direct and indirect inguinal hernias.