Changes of important anatomical structures in the inguinal region after a herniorrhaphy: observations during treatment of recurrent hernia using TEP

In this study we will describe important anatomical structures in the inguinal region as well as their changes after a herniorrhaphy, as they were seen during treatment of 135 recurrent hernias between 1993 and 2003 using TEP. We observed in most cases an upwardly curving arc-shaped deflection of the inguinal ligament and ileopubic tract, which may be due to tension caused by the attachment of the fascia transversalis and M. obliquus internus to the inguinal ligament. This leads to extension of the femoral canal and the lacuna vasorum. The femoral canal gets wider. This explains the regular occurrence of femoral hernias after a herniorrhaphy. Due to herniorrhaphy, damage is caused to Henle’s loop, the retroparietal spermatic sheath as well as the urogenital fascia. These structures were either only partially or even no longer visible on recurrent operations. The internal inguinal ring has a lip-shaped appearance with a forward tilt in nearly all cases after a herniorrhaphy, whereas with TEP a view into the inguinal canal is practically impossible through the internal inguinal ring. Furthermore, using TEP we often saw especially in large primary hernias with a long medical history tough connective tissue lying upon the inguinal sack. This covering has so far not been described in the literature and is also present on recurrent hernias after a herniorrhaphy.