The Ligaments of Cooper and Thomson
The surgery of groin hernias can be considered in two stages: the handling of the hernial sac, which necessitates dissection, resection, and reduction, and the parietal reconstruction, which calls upon the existing anatomical structures. Prosthetic materi
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Introduction The surgery of groin hernias can be considered in two stages: the handling of the hernial sac, which necessitates dissection, resection, and reduction, and the parietal reconstruction, which calls upon the existing anatomical structures. Prosthetic material may be required to bridge a defect when the dissection is completed and the structures identified to which a prosthesis might be anchored. In man, the inferior borders of the internal oblique and transversus muscles are far removed from the pubic ramus and its pectineal ligament of Cooper. There exists between them an area called the myopectineal orifice, covered by the transversalis fascia and its reinforcements. This is a zone of relative weakness, divided by the inguinal ligament into two parts, inferior (femoral) and superior (inguinal). On the posterior aspect of the inguinalligament, the transversalis fascia consolidates inferiorly into a tract, the iliopubic bandelette of Thomson. These substantial anatomic structures (the pectineal ligament of Cooper, the posterior portion of the inguinal ligament, the iliopubic tract of Thomson) are the key structures used in several herniorrhaphy procedures. "There cannot be any surgery of groin hernias without a close look at the anatomy of the inguinal area."l
History
The Pectineal Ligament In 1543, Vesalius 2 described the os coccyx, the abdominal wall and the inguinal area. In 1561, Franco,3 in his treatise on herniae, shows an interest in their treatment. It is to Sir Astley Cooper that we owe the first description, in 1804, of the ligament of the pubis: "The pubis is covered by a ligamentous expansion, which forms a remarkable strong ridge above the iliopectineal line, extending from the spine of the pubis outwards, jutting above the bone along that line. "4,5 This area of the groin has been particularly well studied because of its surgical importance, and the pectineal ligament of Cooper has been the subject of several descriptions. Its morphological significance and its origin remain nevertheless quite controversial. Charpy, in 1891, wrote: "The pectineal crest of the pubis is a con92 R. Bendavid et al. (eds.), Abdominal Wall Hernias © Springer Science+Business Media New York 2001
fluence of several fibrous parts: the aponeurosis of the pectineus, and, behind, the ligament of Gimbernat, the posterior crus of the inguinal ring . . . and lastly, the transversalis fascia reinforced by the ligaments of Henle and Hesselbach .... "6-8 Testut, in 1911, identified elements arising from the "adminiculum linea alba."9 Bardeleben, in 1912, considered the ligament of Cooper to be a thickening of the pectineal muscle fascia reinforced by fibers from various origins: interfoveolar ligament, falx inguinalis, Colles' ligament, as well as fibers from the conjoined tendon, from the psoas minor, and elements from the adminiculum linea alba.l° The conception that the ligament of Cooper originates as a thickening of the fascia of the pectineus muscle along the bony crest of the pubis was taken up and further elabora
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