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Defining the position of the deep inguinal ring using findings at laparoscopic inguinal hernia repair
Wei Hwang Wan1, Ee Lee Daniel Tan
1Department of Surgery, Alexandra Hospital, Jurong Health Services, 378 Alexandra Road, Singapore 159964, Singapore.
Purpose:
We aim to establish the surface marking of the deep inguinal ring by laparoscopy and investigate if the patient's build influences it.
Methods:
Sixty consecutive patients undergoing laparoscopic hernia repairs were studied. The bony landmarks, anterior-superior iliac spine (ASIS) and pubic tubercle (PT), and the two traditional landmarks, the mid-inguinal point (MIP) and midpoint of inguinal ligament (MPIL), were marked on the anaesthetized patient before the surgery. The deep ring was located by indenting the surface until laparoscopy shows the deep ring being occluded.
Results:
The true surface marking of the deep ring was found to lie at a mean distance of 9.6 mm medial to the MPIL landmark and 4.5 mm lateral to the MIP, approximately one-third of the distance from the MIP to the MPIL. Multivariate analysis confirmed that age, gender, race, BMI or pelvic habitus did not vary it.
Conclusions:
The deep ring is located under a point just lateral to the MIP, which is the midpoint of a line drawn joining the ASIS and pubic symphysis. This should be taught to future generations of medical students as the point to apply occluding pressure to differentiate clinically between direct and indirect inguinal hernias.
