DAMAGE TO THE INGUINOFEMORAL NERVES DURIN G HERNIA REPAIR - AN ANATOMICAL DANGER OF TRADITIONAL AND LAPAROSCOPIC TECHNIQUES

Laparoscopic techniques currently constitute an alternative proposed f or the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the ana tomical relations of these nerves with the subperitoneal fascia transv ersalis and inguinal fossae. An anatomical study consisting of dissect ion of nonembalmed cadavres, allowed, after evisceration, dissection o f the lumbar plexus and its terminal branches, particularly those supp lying the inguinofemoral region: iliohypogastric and ilio-inguinal ner ves, the genitofemoral nerve, the femoral nerve and the lateral cutane ous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguin al ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterio r parietal peritoneum describes three folds formed by the outline of t he epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring fro m Hesselbach's triangle, the zone of weakness of direct inguinal herni a. The iliac psoas muscle pass laterally underneath the inguinal ligam ent, while the external iliac vessels, subsequently becoming the femor al vessels, are located medially. Pectineal ligament lies on the poste rior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, eithe r transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pect ineal ligament and anterior abdominal wall. On the other hand, the ner ves at risk of being damaged are situated laterally: the ilio-inguinal and iliohypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cuta neous nerve of the thigh under the inguinal ligament close to the ante rior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal l igament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament t o avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.