The clinical anatomy of laparoscopic inguinal hernia repair.

Laparoscopic approaches for abdominal surgery are being used with increasing frequency. Their advantages are sometimes negated by the disturbing incidence of postoperative sequelae. In the case of inguinal hernia repair, these are often the result of failing to understand that the anatomy of the anterior approach to the abdominal wall cannot necessarily be directly applied to laparoscopy. The inguinal ligament, easily identified in an anterior approach, is only seen laparoscopically after removal of the iliopubic tract, a key structure which lies in the plane of the original defect of most groin hernias. Thus, an understanding of the incompletely trilaminar anterior abdominal wall, including the iliopubic tract, is the foundation for effective inguinal hernia repair using any approach (anterior or posterior) or technique (sutures, mesh or staples). Laparoscopic inguinal hernia repair has produced an increase in the frequency of debilitating neuropathies, most notably of the lateral femoral cutaneous nerve (LFCN). This is directly related to the variable intrapelvic course of this nerve or its branches. In more than 13% of the 114 pelves we examined, the LFCN was within 0.5 cm of the iliopubic tract or in the vertical plane of the anterior superior iliac spine, key lateral landmarks and anchoring sites for mesh in laparoscopic hernia repairs. Medial landmarks also have variable features. These data indicate that the identity of anatomical landmarks and the variability of other structures will continue to be important in the successful development of new laparoscopic techniques.