It is the area where direct inguinal hernias protrude.
In human anatomy, the inguinal triangle is a region of the abdominal wall. This triangle is also known as the eponymous Hesselbach triangle.
Hesselbach’s triangle, or the inguinal triangle, is a triangular area in the lower part of the anterior abdominal wall within the groin.
It is the anatomical triangle used to define the inguinal hernia; it corresponds to an area of weakness in the anterolateral wall of the abdomen.
Franz Kaspar Hesselbach (1759-1816), the German anatomist and surgeon, discovered the ligament, the fascia, and the inguinal trigone. This area was named the Hesselbach triangle.
Hesselbach triangle anatomy
Today the Hesselbach triangle is defined as the area bounded by:
- At its superolateral border, by the inferior epigastric or deep epigastric vessels.
- In its medial border, by the lateral wall of the anterior rectus muscle of the abdomen of the rectus sheath, also called the linea semilunaris.
- At its lower edge or base of the triangle, it comprises the inferior inguinal ligament or Poupart’s ligament (inferolateral edge).
Clinical significance of the Hesselbach triangle
The inguinal triangle contains a depression called the medial inguinal fossa, through which direct inguinal hernias protrude through the abdominal wall.
This source of direct hernias is characterized by a pseudo hernial sac, formed by the membrane space where the transverse abdomen and the internal oblique aponeurosis join into one.
It is an area of weakness of the transverse fascia.
- Direct inguinal hernias occur through Hesselbach’s triangle
- Indirect inguinal hernias pass laterally to the inferior epigastric, levers toward the deep inguinal ring, and are lateral to Hesselbach’s triangle.
Risk factors for an inguinal hernia
- Gender predisposition, the male ratio by 9 to 1.
- The lifetime risk of suffering from an inguinal hernia is 10%.
- Children represent 5% of inguinal hernia cases.
- Average weight (lower risk in obese men).
- Tall stature.
- Chronic cough.
- Advanced age.
Types of inguinal hernias
Indirect inguinal hernia (outside the Hesselbach triangle).
- It enters through the internal inguinal ring into the lateral to the inferior epigastric inguinal canal.
- The channel carries the spermatic cord in men and the round ligament in women.
- It can result in scrotal hernia in men.
- Most commonly on the right in males (because the migration of the testicle is delayed to the left in development).
- Weakened inner abdominal ring of fascia.
- Decreased muscle tone.
- Increased abdominal pressure.
Direct inguinal hernia
- The hernia sac passes into Hesselbach’s triangle (medial inguinal fossa).
- Posterior inguinal wall tears.
- A hernia develops medially to inferior epigastric vessels.
- It usually occurs in males.
- Congenital weakness of the musculature of the medial inguinal fossa in some cases.
- Acquired transverse abdominal muscle deficiency.
Inguinal hernia repair
The Lichtenstein repair consists of a thin patch of polypropylene mesh that covers the Hesselbach triangle and the area of the indirect hernia.
It is considered a tension-free repair because the mesh is sutured in place without bringing the ligaments or tissues together as in all other repairs.
The mesh splits at its upper end to wrap tightly around the spermatic cord and its associated structures in the normal position of the internal inguinal canal.
A mesh plug is placed in the inner ring next to the spermatic cord or Hesselbach’s triangle, depending on the type of hernia.
The plug is firmly attached to the surrounding tissues and partially impedes the hernia defect.
A mesh patch, sized to cover the inguinal canal floor, is sutured medially to the pubic tubercle.
The inferior aspect of the mesh is sutured to the edge of the inguinal ligament (known as the “edge of the shelf”).
The superior aspect of the mesh is sutured to the joint tendon.
A slot is cut in the lateral edge of the mesh to accommodate the spermatic cord, which passes through this opening and extends over the mesh patch.
The resulting mesh tails are laterally sutured together around the spermatic cord, recreating the inner ring.