Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

2. Groin Pain: A Neurologic and Musculoskeletal…
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Epigastric vessels
Myopectineal
orifice
Iliopubic
tract
Cooper’s ligament
Lacunar ligament
Obturator vessels
Obturator n.
Internal spermatic
vessels
External iliac a. and v.
Vas deferens
Iliopsoas muscle
Fig. 2.2. Laparoscopic view of the internal ring (from Wagner et al. [ 1 ], with
kind permission © McGraw-Hill Education).
through the internal ring are best appreciated from the laparoscopic
view, which is illustrated in Fig. 2.2 [ 1 ].
The external ring is a triangular opening in the aponeurosis of the
external oblique muscle. To form the external ring, the aponeurosis
splits into a lateral crus, which attaches to the pubic tubercle, and a
medial crus attached to the pubic crest. The two crura are held together
by intercrural fibers at the apex of the triangular opening. The ilioinguinal
nerve and the cord structures destined for the scrotum (or the round
ligament into the labium majus in the female) pass through the external
ring where fibers from the external oblique continue downward to form
the third covering of the cord, the external spermatic fascia.
Some authors refer to a “ third ring ” which is deep and slightly lateral
to the internal ring, and is formed by an opening in the preperitoneal
fascia [ 2 , 3 ]. This ring transmits the gonadal vessels and the vas from the
visceral space of the preperitoneum into the parietal space of the preperitoneum,
where they are joined by the genital branch of the genitofemoral
nerve. These fascial planes and spaces, and the structures they
contain, are illustrated from an axial view in Fig. 2.3 . Mesh placement
during laparoscopic repair should be in the visceral compartment;