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

Abstract

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.