Curriculum · Surgery
Triangles of doom and pain in laparoscopic groin surgery
Why the two triangles exist
Seen from inside in a laparoscopic groin repair, the internal ring is the apex of two triangles that open away from it. The medial one holds the iliac vessels and the lateral one holds the nerves of the thigh, and between them they cover the two things a tack can do to a patient who came in with a hernia: bleeding, or pain for years.
Both triangles share that apex at the internal ring, which is why they are set out together.
Triangle of Doom
In a TAPP laparoscopic repair the Triangle of Doom is bounded:
- Medial border: the vas deferens
- Lateral border: the testicular vessels
- Base: the peritoneal reflection, which the picture names the posterior proximal margin
Its contents are the external iliac artery and the external iliac vein, EIA and EIV, with the femoral nerve posteriorly. The gonadal branch of the genitofemoral nerve runs at its lateral margin, alongside the testicular vessels.
What to know: no fixation, no tacks and no staples, should be placed here, and the risk is catastrophic bleeding.
The wrong answers offered for its borders are worth reading once, because each puts in a real part from elsewhere: medially the inferior epigastric vessels with the apex at the deep ring; medially the pubic tubercle with the inferior epigastric vessels laterally; and medially Cooper's ligament with the pectineal ligament laterally.