The peritoneum the view from within

Hernia sacs are composed of peritoneum and they may contain intra-abdominal viscera. From within they consist of the peritoneum, then a loose layer of extraperitoneal fat, then the deep membranous lamina of fascia transversalis, then the vessels such as the epigastric vessels in the space of Bogros, then the stout anterior lamina of fascia transversalis, then the muscles and aponeuroses of the abdominal wall. The preperi-toneal space lies in the abdominal cavity between the peritoneum internally and transversalis fascia externally. Within this space lies a variable quantity of adipose tissue, loose connective tissue and membraneous tissue, and other anatomical entities such as arteries, veins, nerves and various organs such as the kidneys and ureters. The clinically significant parts of the preperitoneal space include the space associated with the structural elements related to the myopectoneal orifice of Fruchaud, the prevesical space of Retzius, the space of Bogros and retroperitoneal periurinary space. The myopectineal orifice of Fruchaud represents the potentially weak area in the abdominal wall, which permits inguinal and femoral hernias. The preperitoneal space lies deep to the supra-vesical fossa and the medial inguinal fossa is the prevesical space of Retzius. The space of Retzius contains loose connective tissue and fat but more importantly vascular elements such as an abnormal obturator artery and vein. Bogros' space, which is a triangular area between the abdominal wall and peritoneum, can be entered by means of an incision through the roof and floor of the inguinal canal through which the posterior preperitoneal approach for hernia repair can be achieved. In the groin these muscles and aponeuroses are variously absent over the inguinal and crural canals. The myopectineal orifice of Fruchaud, which is divided into two parts by the inguinal ligament (Fig. 14.8). This concept of one groin aperture is relevant for mesh repairs, whether anterior open operation or posterior laparoscopic operation. The boundaries of the myopectineal

Fascia transversalis Anterior lamina Posterior lamina

Inferior epigastric artery and vein

External

Fascia transversalis Anterior lamina Posterior lamina

Inferior epigastric artery and vein

External oblique oblique

Inguinal ligament

Fascia iliaca Psoas

IIiac artery and vein

Femoral artery and vein oblique oblique

Inguinal ligament

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