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
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