A ligament to identify the inferior limit of dissection in minimally invasive surgery for inguinal hernia


  • Sujith Philip Department of Gastrointestinal Surgery, Believers Church Medical College Hospital, Tiruvalla, Kerala, India
  • Geethu Rachel Iype Department of Gastrointestinal Surgery, Believers Church Medical College Hospital, Tiruvalla, Kerala, India
  • Meera Muralee Department of Gastrointestinal Surgery, Believers Church Medical College Hospital, Tiruvalla, Kerala, India




Minimally invasive surgery, Inguinal hernia repair, Ligament


Background: Minimally invasive surgery has recently become the approach of choice for surgeons for inguinal hernia repair. Subsequent to excellent visualisation of the preperitoneal space by high definition and 4K systems during laparoscopy and robotic surgery, as well as increasing use of multi detector CT scans to visualise abdomen, our knowledge of the anatomy of the posterior view of inguinal region has been enhanced. However, recurrence after surgery for groin hernia continues to be an issue during its learning curve especially for laparoscopic repair. One cause for recurrence is the infolding of the mesh after its placement in the preperitoneal space. A reason for this is inadequate dissection of the peritoneal fold especially inferomedially. The peritoneum has to be dissected inferomedially till the point where the vas deferens turns medially. During the course of a randomised study done to compare Transabdominal preperitoneal mesh repair with Totally extraperitoneal mesh repair for Inguinal hernia, a structure was seen passing from the medial aspect of the vas deferens where it turned medially

Methods: Prospective analysis of 106 consecutive patients who underwent laparoscopic inguinal hernia was done to identify the presence of such a ligament.

Results: This study demonstrates the existence of a ligamentous structure from the vas deferens to the posterior lamina of subparietal layer of peritoneal space at the site where the vas turns medially.

Conclusions: Identification and division of this ligament will help to ensure complete dissection of the peritoneum inferiorly as well as creaseless placement of mesh thus preventing recurrence.


Muysoms F, Van Cleven S, Kyle-Leinhase I, Ballecer C, Ramaswamy A. Robotic-assisted laparoscopic groin hernia repair: observational case-control study on the operative time during the learning curve. Surg Endosc. 2018;32(12):4850-9.

Daes J, Felix E. Critical view of the myopectineal orifce. Ann Surg. 2017;266(1):e1-2.

Furtado M, Claus CMP, Cavazzola LT, Malcher F, Bakonyi-Neto A, Saad-Hossne R. Systemization of laparoscopic inguinal hernia repair (TAPP) based on a new anatomical concept: inverted y and fve triangles. Arq Bras Cir Dig. 2019;32(1):e1426.

Siddaiah-Subramanya M, Ashrafi D, Memon B, Memon MA. Causes of recurrence in laparoscopic inguinal hernia repair. Hernia. 2018;22(6):975-86.

Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc. 2020;34(4):1458-64.

Molmenti EP, Balfe DM, Kanterman RY, Bennett HF. Anatomy of theretroperitoneum: observations of the distribution of pathologic fluid collections. Radiology. 1996;200:95-103.

Yasukawa D, Aisu Y, Hori T. Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World J Gastrointest Surg. 2020; 12(7):307-25.

Lorenz A, Augustin C, Konschake M, Gehwolf P, Henninger B, Augustin F, Öfner D. The preperitoneal space in hernia repair. Front Surg. 2022;9:869731.

Manda SR, Philip S, Rajesh C N, Sam SM, Varma D. A prospective randomised study comparing transabdominal pre-peritoneal versus totally extra-peritoneal laparoscopic approaches for inguinal hernia repair. Kerala Surg J. 2022;28:67-70.

Adstrum S. Fascial eponyms may help elucidate terminological and nomenclatural development. J Bodyw Mov Ther. 2015;19:516-25.

Ma L, Chung KC. In defense of eponyms. Plast Reconstr Surg. 2012;129:896e-8.

Wu D, Hu W, Li Y. Small gauze, big skill the application of gauze in laparoscopic gastrointestinal surgery. Ann Laparosc Endosc Surg. 2017;2:6.






Original Research Articles