Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Figure 13 Importance of upward view. A: The triangle of doom and triangle of pain configure a unique rhombus around the inferior epigastric artery (IEA). Adequate change of laparoscopic view during transabdominal preperitoneal (TAPP) is very important. B and C: Although downward view requires safe preservation of the vas deferens and gonadal vessels and sure exposure of Cooper’s ligament, downward view may easily mislead surgeons causing unexpected injuries of topographic nerves and vessels. D and E: Generally, a unique rhombus around the IEA seems to be a triangle on the upward view, and the abdominal rectal muscle (ARM) is simultaneously observed at the roof. Thus, intraperitoneal anatomy including the ARM should be simultaneously recognized by upward view, for optimal mesh placement during TAPP. ARM: Abdominal rectal muscle; VD: Vas deferens.