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  • 1. Hernia (2005) 9: 79–83 DOI 10.1007/s10029-004-0240-7 A PP L IE D AN A T OM Y R. C. Read The preperitoneal approach to the groin and the inferior epigastric vessels Received: 12 February 2004 / Accepted: 20 April 2004 / Published online: 5 June 2004 Ó Springer-Verlag 2004 Abstract Preperitoneal, a word coined by Nyhus in the terior, extraperitoneal, internal, or radical, which had 1960s, has been applied not only to posterior approaches been used previously. It denoted an approach based on that he, Stoppa, and Wantz popularized but to anterior transection of the transversalis fascia and repair of groin exposures of the groin, which divide the transversalis defects within a space next to the peritoneum. This plane fascia. This assumes that all give similar views of the containing fat is where, it was supposed, the inferior easily cleaved space of Bogros. However, accumulated epigastric vessels pass from their origin, the external iliac anatomical observations reveal the transversalis fascia as artery and vein, to the rectus muscle. having not one but two layers. The inferior epigastric vessels run between rather than in the preperitoneal space, which is avascular and has its own fascia lining History the peritoneum. Historical evidence shows that both the midline Cheatle-Henry and lateral Ugahary-Kugel Given the definition outlined above, the preperitoneal approaches, which transect the abdominal wall, provide approach to the groin began in 1823 with Bogros [2]. He excellent exposure of the avascular preperitoneal space. recommended dividing the roof and floor of the inguinal However, neither the unilateral posterior McEvedy canal anteriorly, not for herniation but aneurysm of the approach nor the anterior approach does, as only part of iliac or inferior epigastric arteries. This operation was the musculature and fasciae are retracted. The inferior designed before the introduction of antisepsis to avoid epigastric vasculature and posterior lamina transversalis the risk of peritonitis, which was previously encountered fascia, which remain in situ, block the view. Unless they after celiotomies performed for proximal ligation are disrupted or circumvented, neither of the latter (Hunterian). approaches or subsequent repairs should be labeled Bogros observed, ‘‘The external iliac artery termi- preperitoneal. nates without a serosal cover. ... The peritoneum extending from the anterior abdominal wall to the iliac Keywords Preperitoneal Æ Groin Æ Inferior epigastric fossa leaves in front a space 13.5 to 15.5 mm wide.’’ vessels ` Rouviere (1912) [3] added, ‘‘The outer layer of the peritoneum, in the shape of a gutter, concave above and behind, is in contact with the soft tissues of the iliac fossa from 1 to 1.5 cm above the inguinal ligaments. The Introduction peritoneum thus demarcates with a dihedral angle formed by the fascia transversalis anteriorly and the Preperitoneal, a term promoted 40 years ago by Nyhus fascia iliaca inferiorly, a triangular prismatic interval and Condon [1], was preferred over properitoneal, pos- filled with adipose tissue called the space of Bogros.’’ Further, Bogros described the inferior epigastric vessels as ‘‘first passing inferiorly, overlying the parent R. C. Read external iliac vessels, then turning anteriorly to enter the University of Arkansas for Medical Sciences, Little Rock, Ark., USA abdominal wall.’’ Morton (1841) [4] agreed and, like E-mail: read@post.harvard.edu Cooper (1807) [5], described the transversalis fascia as Tel.: +1 301 545-1934 bilaminar. In addition, the former stated that the infe- Fax: +1 301 545-0323 rior epigastric vessels run between these layers. Mackay Present address: R. C. Read (1889) [6] likewise observed penetration of the fascial 304 Potomac Street, Rockville, MD 20850, USA envelope by this vasculature. Retzius (1858) [7], unaware
  • 2. 80 of Bogros’ lateral preperitoneal space, described a sim- (GPRVS), who made this preperitoneal exposure pop- ilar one in the midline, anterior to the bladder and be- ular. Laparoscopists followed by adopting the essentials ` hind the pubis. Rouviere (1912) [3] pointed out that the of his technique in their most widely used repair (TEP) two communicated. [31]. Annandale (1876) [8] repeated Bogros’ operation, but In 1959, visiting professor John Bruce of Edinburgh for herniae, amputating the inferior epigastric vessels. recommended to Nyhus that the operation of McEvedy He described severing the inguinal and femoral sacs (1950) [32] would be better suited for most protrusions flush with the peritoneal cavity. Bassini (1887) [9] fol- that are unilateral, even though it had been restricted to lowed, but from below, preserving the vasculature, lay- cases of femoral herniation, which, being anteromedial ing his triple layer on top, as did Halsted (1889) [10]. to the inferior epigastric vasculature, are easily dealt Immediately after the introduction of antisepsis by with. This procedure begins {as modified by McNaught Lister, there was enthusiasm in the U.K. for intraperi- (1956) [33] and Reay-Young (1956) [34]} with a sup- toneal release of incarcerated and strangulated herniae, rainguinal transverse skin incision. The underlying an operation that had been carried out, when taxis anterior rectus sheath and lateral abdominal muscula- failed, intermittently since the Brahmins. Crompton ture with the transversalis fascia (anterior lamina) are (1860) [11], Niven (1861) [12], and Annandale (1873) [13] then transected and retracted inferio-medially, leaving were the leaders. Lawson Tait, a gynecologist, noting the the rectus muscle and its blood supply, the inferior epi- ease of incidental femoral herniorrhaphy while operat- gastric vessels, behind. ing for ovarian cyst, recommended ‘‘elective’’ median To reach the space of Bogros, Nyhus reported abdominal section for reducible herniation [14]. ‘‘ligation of the inferior epigastric artery and vein were Advantages emphasized were ease of pulling out rather routine.’’ [1] Later, he preserved them, performing his than pushing back protrusions, access to Gimbernat’s iliopubic tract repair in front. Condon [35] with his ligament, given the rare need for its incision to enlarge anterior variant did the same. Usher (1959) [36], the first the defect, less hemorrhage since abnormal arteries can to undertake preperitoneal prosthetic repair of the groin be seen, ease of intestinal resection, no risk of reductio (also from below, with parietalization of the spermatic en masse, ease of repair, and lack of injury to the cord), did likewise. However, Rives (1967) [37] who inguinal canal. followed, divided them, as did his students, Flament In the U.S., Kelly (1898), chief of gynecology at et al. (2001) [38]. Nevertheless, other surgeons per- Johns Hopkins, like Lawson Tait, repaired an incidental forming anterior preperitoneal prosthetic repair, e.g., femoral hernia. However, he employed intraperitoneally Schumpelick (1990) [39], Read (1993) [40], and Wantz a glass marble [15], thus introducing, long before Lich- and Fischer (2002) [41] left the inferior epigastric vas- tenstein and Shore (1974) [16], the prosthetic plug to culature alone. Similarly, Gilbert (2002) [42] insinuates herniology. A number of surgeons, including Gillion the deep lamina of his prosthetic device deep to the (1891) [17], Moschcowitz (1907) [18], Robins (1909) [19], blood vessels. Wantz (1991) [43], when he introduced his Bates (1913) [20], LaRoque (1919) [21], and Wilkinson unilateral GPRVS through the modified McEvedy pos- (1967) [22] adopted the posterior intraperitoneal terior preperitoneal approach, divided the epigastric approach to reducible abdominal herniation before Ger vessels. He again, like Nyhus with his tissue repair, then (1982) [23], who used it to introduce laparoscopic repair (1993) [44] left the vasculature alone. of groin herniae. Cheatle [24] was the first to perform posterior pre- peritoneal repair of groin herniation, initially using a Discussion paramedian or midline incision, later a Pfannenstiel (1921) [25]. He introduced this approach ‘‘because a Both Nyhus and Wantz, the modern proponents of the succession of cases from below presented difficulties in unilateral preperitoneal approach to the groin, included the efficient excision of the sac which demonstrated an stylized illustrations (Fig. 1) taken from the Cheatle- extraperitoneal component.’’ The inferior epigastric Henry procedure in descriptions of their posterior vessels were retracted with the recti abdominis. Like McEvedy technique. Further, they portrayed amputa- laparoscopists, 70 years later, he noted on the side tion of the inferior epigastric vessels, long after this opposite to unilateral protrusion ‘‘unsuspected and maneuver had been discontinued in most of their potential sacs (dimples).’’ Henry [26] rediscovered the patients. The impression conveyed was that the modified operation that had been ignored. He emphasized pre- McEvedy operation provides the same exposure of the peritoneal pouches with their true and false necks. preperitoneal space of Bogros as the Cheatle-Henry Again, the procedure was not employed until Musgrove procedure. Thus, Wantz and Fischer (2002) [41] and McCready (1949) [27] and Mikkelsen and Berne asserted, ‘‘Unilateral GPRVS is the Stoppa procedure (1954) [28] used it, but only for unilateral femoral her- applied to a single groin.’’ If this is so, why, as history nioplasty. Nyhus et al. (1959) [29] treated all groin her- has shown, does the vasculature block the view in the niation with this approach as Cheatle and Henry had. unilateral but not the bilateral operation? Nevertheless, it was Stoppa (1969) [30], encasing the The explanation lies in the original definition of peritoneum with a prosthetic wrap in difficult cases preperitoneal, v. supra. This was based on anatomical
  • 3. 81 transversalis fascia are elevated with the McEvedy pro- cedure. The rectus muscle, which remains, is retracted medially, but the inferior epigastric vessels are pulled with it, and both they and the underlying posterior lamina transversalis fascia cover the preperitoneal space of Bogros (Fig. 3). Thus, the median section in the Cheatle-Henry operation immediately exposes the spaces of Retzius and Bogros, while with the McEvedy approach, after only a part of the abdominal wall is transected, further dis- section is required. In particular, the posterior lamina, transversalis fascia has to be disrupted medial and lat- eral to the inferior epigastric vessels and the latter amputated or circumvented. Only then can preperito- neal division of hernial sacs be accomplished. Early in my experience with preperitoneal herniorrhaphy (1967) [47], I realized that there was a distinct difference be- tween the two approaches. The McEvedy procedure was labeled as pre-extraperitoneal to distinguish it from the preperitoneal Cheatle-Henry. A better term for the for- mer would have been prevascular. Tissue or prosthetic repair with the Cheatle-Henry approach is routinely conducted in the avascular, easily cleaved preperitoneal space. Surgeons beginning to use the modified unilateral McEvedy procedure did likewise Fig. 1 Illustration of the view from the preperitoneal approach. In: Nyhus LM, Condon RE (eds) (1995) Hernia, 4th Edition. by transecting the inferior epigastric vessels and pos- Philadelphia: JP Lippincott Co, p 158 (with permission) terior lamina, transversalis fascia. However, later most preserved the vasculature by removing the posterior lamina around it and inserting sutures or mesh behind the vessels. Nevertheless, Nyhus conducted his posterior iliopubic tract repair in front of the vasculature. He called it preperitoneal even though the identical anterior iliopubic tract repair (Condon) was not so labeled. In contrast, Wantz and Fischer described their unilateral anterior prevascular (Fig. 4) and retrovascular mesh placement as well as the posterior retrovascular insertion GPRVS along with their original preperitoneal proce- dure, which included division of the inferior epigastric vessels. This confusion in the use of the term preperitoneal is not related to the fact that the Cheatle-Henry procedure provides bilateral exposure, whereas the McEvedy is unilateral. The latter was introduced and subsequently used for a time only for femoral herniation, which arises medial to the inferior epigastric vessels. If incision is made lateral to them, as Ugahary (1998) [48] and Kugel Fig. 2 Preperitoneal approach through the linea alba. Exposure is (2002) [49] do, the vasculature is no longer in the way, internal to the inferior epigastric vessels retracted with the recti and the preperitoneal space is entered immediately, as in abdomines [26] (reprinted with permission from Elsevier) the Cheatle-Henry approach. The fundamental difficulty is therefore anatomical. interpretations now known to be erroneous (Read 1992) The transversalis fascia can no longer be considered ‘‘a [45]. The transversalis fascia has not one but two layers continuous layer of endoabdominal fascia which com- that insert onto Cooper’s ligament. The inferior epi- pletely encloses the abdominal cavity’’ (Condon 1964) gastric vessels pass between these two laminae, not [50] or ‘‘lining the abdominal cavity like a bag’’ (Lampe through the preperitoneal space, which is avascular 1964) [51]. This role is filled by the preperitoneal fascia, (Tyson and Reichle, 1972) [46]. Whereas, in the Cheatle- which had been described by a number of investigators Henry approach, the entire abdominal wall (including deep to what they considered to be a monolaminar the vasculature) is retracted (Fig. 2), only the anterior transversalis fascia attached to muscles, aponeuroses, rectus sheath, lateral musculature, and anterior lamina and the bony framework of the abdominal wall
  • 4. 82 Fig. 3 a Photograph and b diagram of view through the McEvedy approach. A Retracted anterior rectus sheath. B Pubic vein. C Inferior epigastric vessels. D Secondary internal inguinal ring. E Preperitoneal fat in space of Bogros. F Spermatic vessels beneath posterior lamina transversalis fascia. G Hernial sac. H Internal abdominal ring. I Rectus muscle and tendon. J Posterior lamina transversalis fascia. In: Nyhus LM, Condon RE (eds) (1995) Hernia, 4th Edition. J.P. Lippincott Co, Philadephia, p 61 (with permission) (Mackay, 1889 [6]; Lytle, 1945 [52]; Lampe, 1964, [51] surgical, as opposed to cadaveric, dissection. He also and Fowler, 1975 [53]). However, Arregui (1997) [54] has points out that the epigastric vessels supply the identified laparoscopically a preperitoneal fascia beneath abdominal wall but not the underlying vas deferens, which are the median and lateral umbilical ligaments. lateral umbilical ligaments, or bladder, which are nour- This layer is the floor of the avascular preperitoneal ished by branches of the internal iliacs. These important space. It is distinct from the overlying posterior lamina studies of Arregui, accomplished in the operating room, of the transversalis fascia, which supports the inferior point to the continuing importance of surgical anatomy. epigastric vasculature running in the abdominal wall Further, in the new age of laparoscopy and prosthetic beneath the anterior lamina, transversalis fascia. He repair, they reinforce the concept that ‘‘the proper states, ‘‘a proper preperitoneal dissection for laparo- anatomic location of groin herniorrhaphy’’ [55] may yet scopic or open preperitoneal repair depends on a good be the preperitoneal space of Bogros. understanding of these fasciae,’’ which are better seen by Conclusion The term preperitoneal should only be used to charac- terize an approach to the groin if it provides enough exposure of the space of Bogros beneath the inferior epi- gastric vessels to allow herniation to be repaired therein. Addendum One of the reviewers of this manuscript pointed out that Henry Fruchaud, in the famous Anatomie Chirurgicale des Hernies de l’aine (Paris: G. Doin, 1956) ‘‘seems to have a view similar to yours expressed in two of the abundant figures of his book.’’ Since his works have not been translated into English, I was unaware of this foresight. Conflict of interest: No information supplied References Fig. 4 Infrainguinal placement of Mersilene mesh (GPRVS) in 1. Nyhus LM (1964) The preperitoneal approach and iliopubic front of the inferior epigastric vessels, showing bunching around tract repair of all groin hernias. In: Nyhus LM, Harkins HN their origin. From: Munshi IM, Wantz GE (1996) J Am Coll Surg (eds) Hernia, first edition. JB Lippincott, Philadelphia, pp 271– 182:421 (with permission) 294
  • 5. 83 2. Bogros AJ (1823) Essai sur l’anatomie chirurgicale de la region ´ 30. Stoppa R, Quintyn M (1969) Les deficiencies de la paroi ´ ´ iliaque et description d’un nouveau procede pour faire la liga- ´ abdominale chez le sujet age: Colloque avec le practicien. Sem ` ture des arteries epigastrique et iliaque externe. Th Paris, no. Hop Paris 45:2182 153. Didot le Jeune, Paris 31. Dulucq JL (1992) Treatment of inguinal hernia by insertion of ` 3. Rouviere H (1912) Anatomie humaine descriptive, topo- a subperitoneal patch under preperitoneoscopy. Chirurgie graphique et fonctionelle. Masson Edit, Paris 118:83–85 4. Morton T (1841) The surgical anatomy of inguinal herniae, the 32. McEvedy PG (1950) Femoral hernia. Ann R Coll Surg Engl testis, and its coverings. Taylor and Walton, London 7:484–496 5. Cooper AP (1807) The anatomy and surgical treatment of 33. McNaught GHD (1956) Femoral hernia: the rectus sheath crural and umbilical hernia. Longman, London, pp 3-4 operation of McEvedy. 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