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INTRODUCTION

Test Taking Tips

  • Know the anatomy of the femoral canal. Try to know the various approaches to fixing a femoral hernia, and be aware of the different scenarios regarding femoral hernias, like when to use mesh versus primary repair, depending on the viability of the hernia contents.

  • Know what complications can occur during a laparoscopic hernia repair. Tacks put out laterally can damage the lateral femoral cutaneous nerve. Tacks placed on the inferior aspect of the Cooper ligament can potentially injure the corona mortis.

  • The historical hernia repairs are still important know.

ANATOMY

What are the 9 layers of the abdominal wall?

  • Skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum

What is the portion of the external oblique aponeurosis that extends from the anterosuperior iliac spine to the pubic tubercle called?

  • Inguinal (Poupart) ligament

FIGURE 13-1

Cross-sectional anatomy of the abdominal wall above and below the arcuate line of Douglas. The lower right abdominal wall segment shows clearly the absence of an aponeurotic covering of the posterior aspect of the rectus abdominis muscle inferior to the arcuate line. Superior to the arcuate line, there are both internal oblique and transversus abdominis aponeurotic contributions to the posterior rectus sheath. (Reproduced with permission from Moore KL, Dalley AF. Clinically Oriented Anatomy, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.)

FIGURE 13-2

The Hesselbach triangle as originally described (left) and as accepted today (right). Note that part of supravesical fossa lies within the triangle. (Modified with permission from Nyhus LM, Condon RE. Hernia, 4th ed. Philadelphia, PA: JB Lippincott; 1995.)

What directions do the fibers of the external oblique course?

  • Superolateral to inferomedial

What directions do the fibers of the internal oblique course?

  • Inferolateral to superomedial

What directions do the fibers of the transversus abdominis course?

  • Transverse

Where does the aponeurosis, which is originally divided into anterior and posterior lamella that envelops the rectus abdominis muscle, begin to course anteriorly to the rectus abdominis muscle and become part of the anterior rectus sheath?

  • Semicircular line (of Douglas/arcuate line)

What are the borders of the Hesselbach triangle?

  • Inguinal ligament inferiorly, lateral margin of the rectus sheath medially, and inferior epigastric vessels laterally

What makes up the floor of the Hesselbach triangle?

  • Transversalis fascia

What structures course through the preperitoneal space?

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