|Year : 2022 | Volume
| Issue : 3 | Page : 260-265
Anatomic pattern and variations of the ilioinguinal nerve as it travels throughout the anterior abdominal wall: Cadaveric study
Ahmed Onayzan Alshammari1, Fauwaz Fahad Alrashid1, Anas Abdulqader Fathuldeen1, Eyad Mohammed Khalifah1, Abdalla Ahmed Elamin2, Abubaker El Elhaj2, Saadeldin Ahmed Idris3
1 Department of Surgery, College of Medicine, University of Ha'il, Ha'il, Saudi Arabia
2 Department of Anatomy, College of Medicine, University of Ha'il, Ha'il, Saudi Arabia
3 Department of Surgery, College of Medicine, University of Ha'il, Ha'il, Saudi Arabia; Department of Surgery, Faculty of Medicine, Alzaeim Alazhari University, Khartoum, Sudan
|Date of Submission||26-Oct-2021|
|Date of Acceptance||02-Aug-2022|
|Date of Web Publication||15-Sep-2022|
Prof. Saadeldin Ahmed Idris
Department of Surgery, College of Medicine, University of Ha'il, Ha'il
Source of Support: None, Conflict of Interest: None
Introduction: Ilioinguinal nerve (IIN) is repeatedly damaged during surgeries as well as through the application of local anaesthesia to the lower abdominal wall. This study aimed to identify the variations of the IIN during its course in the anterior abdominal wall. Materials and Methods: A cross-sectional study on formalin-preserved cadavers was carried out after approval by the ethical committee, Alzaeim Alazhari University (January 2018–May 2020). Cadavers satisfied the inclusion criteria were dissected bilaterally to expose and map the IINs from their lateral emergence on the anterior abdominal wall to their termination in the midline in reference to the internal and external inguinal rings as well as the fixed bony landmarks. The collected data were compared on both sides using SPSS version 21.0. Results: Fifty-four IINs were identified (77 cadavers). Double nerve was observed in 8.44%. IINs derived from L1, L1-3 and L3 in 98.1%, 1.3% and 0.6%, respectively. On the right side, in 3 corpses, the nerves aberrantly ascend from L3 or L1-3, whereas this deviant was not seen on the left side. The mean distance from the umbilicus was 9.2 cm ± 1.1 cm (equal on both sides). The mean distance from the deep ring was 1.5 cm ± 0.4 cm, it was closed on the right compared to the left (P = 0.87). It emerges 0.9 cm–6 cm from the anterior superior iliac spine, this was closed on the right than the left (P = 0.9). It was not attached to the external oblique muscle on the right side, whereas it did in 3.2% on the left (P = 0.03). The mean distance from the superficial ring was 1.9 cm ± 0.8 cm, almost the same on both sides. The mean distance from the inguinal ligament was 2.4 cm ± 0.5 cm, it was closed on the right than on the left (P = 0.98). Its mean thickness was 1.97 mm ± 0.44 mm and 1.88 mm ± 0.43 mm on the right and left sides, respectively. Conclusion: IIN demarcates variants not generally quoted in anatomical manuals.
Keywords: Anatomy, anterior abdominal wall, ilioinguinal nerve, neurography, variation
|How to cite this article:|
Alshammari AO, Alrashid FF, Fathuldeen AA, Khalifah EM, Elamin AA, Elhaj AE, Idris SA. Anatomic pattern and variations of the ilioinguinal nerve as it travels throughout the anterior abdominal wall: Cadaveric study. Adv Hum Biol 2022;12:260-5
|How to cite this URL:|
Alshammari AO, Alrashid FF, Fathuldeen AA, Khalifah EM, Elamin AA, Elhaj AE, Idris SA. Anatomic pattern and variations of the ilioinguinal nerve as it travels throughout the anterior abdominal wall: Cadaveric study. Adv Hum Biol [serial online] 2022 [cited 2022 Oct 7];12:260-5. Available from: https://www.aihbonline.com/text.asp?2022/12/3/260/356108
| Introduction|| |
Chronic abdominal wall pain is a broad term, it has no unified definition, but it is generally denoted as a constant moderate pain that persists for more than 3 months after the intervention., It is usually localised in the lower abdomen, thighs and genitals,,, and encompasses many aetiologies, including benign nerve compression known as entrapment of ilioinguinal nerve (IIN).,, In addition, pain can be caused by nerve damage induced by administration of local anesthetics during surgery, sutures, staples, meshes and adhesions. As well as it might be associated with the inflammatory response to prosthetic mesh material (Shadhu K)., The placement of a lateral port in laparoscopic or robotic surgeries and facial closure using the Carter–Thomason device also can be a cause.
Neuropathy due to ilioinguinal and/or iliohypogastric nerves (IHNs) is a well-known complication subsequent to surgery of the lower abdomen and pelvis. These nerves are most vulnerable to injury intraoperatively when using low transverse skin incision during appendectomy, inguinal hernia, urological or gynaecological surgeries.
Injury can also occur in the deeper layers of the abdominal muscles and has been reported after abdominoplasty, and the creation of transversus abdominis muscle (TRAM) flap during breast reconstruction.
The inguinal pain is difficult to explain and has a significant impact on the quality of life,, and possesses a burden on psychosocial and economic status. Even though the prevalence of iatrogenic nerve damage during surgery is unidentified accurately, generally it is ranging from 0% to 67%,, it affects 5.6%–30.9% of females and 2%–17% of males.
Knowing the detailed anatomy of the anterior abdominal wall will assist doctors in preventing intraoperative nerve injury and diagnosing and managing abdominal wall pain if present postoperatively. Usually, the IIN arises from the ventral branch of the first lumbar nerve. It appears on the lateral edge of the psoas major, with or just below the IHN. It goes obliquely through the broad abdominal muscles before piercing the internal oblique muscle and then passes through the inguinal canal inferior to the spermatic cord.
Anatomical variations might exist; hence they may influence operative surgery. Therefore, precise knowledge of the variability of the IIN is the key to improving the interventional performance of open and laparoscopic surgery in addition to preventing its damage. This study aims at evaluating the course of the IIN in the anterior abdominal wall, bewaring physicians of different variations that might be causing iatrogenic IIN injury during surgical intervention or application of local anaesthesia to the region which may have undesirable consequences.
| Materials and Methods|| |
A multi-centric prospective cross-sectional study was conducted in the Department of Anatomy at 11 Medical Colleges, in Khartoum state, Sudan, between January 2018 and May 2020 and revised in August 2021. Ethical approval was obtained by the acceptance of the proposal by the faculty board – Faculty of medicine, Alzaiem Alazhari University, as well as the 11 colleges' authority agreement was also taken before conducting the study.
A simple random sample of cadaveric dissection with an intact inguinal region that was dissected within the study period was enrolled in the study. Due to the possibility of disturbing anatomy cadavers with previously dissected IIN and specimens with pathology, surgical incision or traumatic damage were excluded from the study.
Predetermined variables were included in the study questionnaire
Dissection of the entire length of the nerve was performed through an anterior approach. Landmarks such as the xiphoid process, costal margin, pubic symphysis, pubic tubercle and umbilicus were identified. Three different incisions were made, the first of which was made vertically from the xiphoid process along the linea alba to the symphysis pubis without transecting the umbilicus. The second is an oblique incision made along the costal margin from the xiphoid process to the mid axillary line. Whereas, the third transverse incision was made beneath and parallel to the inguinal ligament, from the symphysis pubis to the anterior superior iliac spine (ASIS), ending at the mid axillary line. Thereafter, the skin was carefully reflected laterally to the mid axillary line [Figure 1].
The cutaneous branches distributing to the inguinal and ventromedial thigh were carefully examined till their exit at the level of the inguinal ligament and superficial inguinal ring (S. I. R) on the external oblique aponeurosis (EOA). The distance of emergence of IIN in the relation to ASIS as well as the distance of the nerve from the inguinal ligament, umbilicus and pubic tubercle was measured with the help of rural and thread. For further dissection, the removal of subcutaneous tissue was done, and the exposure of anterior abdominal muscles was completed. The sites at which the nerve pierces the muscles of the abdominal wall were marked, and the distances from these to easily palpable skeletal and soft-tissue points (tip of the 12th rib, iliac crest, ASIS, upper border of symphysis pubis and inguinal ligament) were determined. The different distances of the nerve from the inguinal ligament, pubic tubercle, ASIS, umbilicus and Mc Burney's point were measured, these landmarks were determined by coloured pins.
During the dissection procedure, each anatomical detail was documented photographically.
Data analysis was performed using SPSS version 21.0 for Windows SPSS version 21.0 (IBM, Armonk, NY, USA). All quantitative data were presented as mean values ± standard deviation. A Chi-square test (χ2) was used to compare the differences between the right and left nerves with a confidence level of 95%. A P < 0.05 is considered to be significant. The findings were expressed appropriately as tables or figures.
| Results|| |
The IIN was 100% identified bilaterally in 77 cadavers, yielding 154 IINs. Thirteen cadavers (8.44%) were seen to have a double nerve projection from one side and single nerve from contralateral side (double nerve in the left side of 8 corpuses and in the right of 5 corpuses). The difference observed in this anatomical variation on the two sides was not significant (P = 0.56) [Table 1].
|Table 1: Number of nerves on the right side versus left side among the study group (n=154)|
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The configurations of the origin of IIN were categorised according to contributions from the spinal nerve. The IIN merely came from the lumbar plexus in all cases. As regards the root origin, the IIN has mottled root origin from L1, L1-3 and L3 in 151 (98.1%), 2 (1.3%) and 1 (0.6%), respectively. On the right side, it was shown that in 3 corpses the IINs aberrantly ascend from the root origin of L3 or L1-3, whereas this deviant observation was not observed on the left side. Noteworthy, on the left side, it originated exclusively from the L1 spinal segment. Despite that, the difference was not significant (P = 0.217) [Table 2].
|Table 2: The root origin of the ilioinguinal nerve in the right side versus the left side among the study group (n=154)|
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In all specimens, the IINs on both sides constantly are emerging inferior or caudal to the IHN. In view of the distance of the IIN from the fixed point during its projection, the mean distance from the umbilicus was 9.2 cm ± 1.1 cm (range, 5 cm–11 cm) (right and left equal). Whereas the mean distance from deep inguinal ring was 1.5 cm ± 0.4 cm (range, 1 cm–2.2 cm) (right; 1.52 cm ± 0.39 cm [range, 1–2.2 cm], left; 1.53 cm ± 0.38 cm [range, 1 cm–2.2 cm]) (P = 0.87). The pattern of piercing TRAM was constant. It emerges 0.9 cm–6 cm from ASIS (mean distance; 4.2 cm ± 1.1 cm), (right: 4.201 cm ± 1.07 cm [range, 0.9 cm–6 cm], left: 4.23 cm ± 1.06 cm [range, 0.9 cm–6 cm]) [Figure 2]. This difference was insignificant (P = 0.9).
|Figure 2: Rt IIN piercing transversus abdominis muscle, Rt IIN: Right ilioinguinal nerve.|
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The IIN emerges and migrates superficially superior to the internal oblique muscle and deep to the TRAM, and then provides a muscular branch to the transversus abdominis [Figure 3], [Figure 4], [Figure 5].
|Figure 3: Rt IIN passing from behind the middle of the right kidney and supply motor branch to transversus abdominis muscle, Rt IIN: Right ilioinguinal nerve.|
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|Figure 4: Rt IIN passing from anterior to quadratus lumborum to inside transversus abdominis, and then between transversus abdominis and internal oblique muscles, Rt IIN: Right ilioinguinal nerve.|
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|Figure 5: Rt IIN and its muscular branch to transversus abdominis muscle, Rt IIN: Right ilioinguinal nerve.|
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The nerve then pierces the internal oblique muscle medially and is slightly inferior to ASIS. It then remains in the space between the external and internal oblique muscles for a short distance before they enter the EOA. On the right side, the IIN was not attached to the external oblique muscle, while the left nerve was attached to the external oblique muscle in 5 (3.2%) samples. These difference in the relationship of IIN with the external oblique muscle was significant P = 0.03 [Table 3].
|Table 3: Relation of the ilioinguinal nerve to external oblique aponeurosis in the right side versus left side (n=154)|
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During its travel, the mean distance from S. I. R was 1.9 cm ± 0.8 cm (range, 0.8 cm–3.5 cm). The mean distance from S. I. R on both sides was almost the same 1.8870 cm ± 0.76715 cm (range, 0.8 cm–3.5 cm).
The mean distance of the IIN from the inguinal ligament throughout its migration was 2.4 cm ± 0.5 cm (range, 2 cm–3.5 cm) in the right was 2.3494 cm ± 0.47756 cm (range, 2 cm–3.5 cm), whereas, on the left side, it was 2.3506 cm ± 0.47673 cm (range, 2 cm–3.5 cm) (P = 0.98) [Figure 6].
|Figure 6: Lt IIN after piercing internal oblique and then running between internal and external oblique muscles, Lt IIN: Left ilioinguinal nerve.|
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During its emergence in the anterior abdominal wall, the thickness of right IIN ranges between 1 mm and 3 mm with a mean of 1.97 mm ± 0.44 mm, whereas, on the left side, it is ranging between 1 mm and 2.8 mm with a mean of 1.88 mm ± 0.43 mm.
| Discussion|| |
Regional nerves of the inguinal region have gained importance due to their anatomical variation and vulnerability to injuries. Although some variations and the absence of the IIN are rather frequent. Variations in the anatomical course of the IIN require that diligence is taken in their proper recognition.
The study showed that the IIN was identified in all dissected cadavers. In contrast, the incidence of absent IIN reported in the literature ranged between 2.5% and 22.2%.,,,, The detailed anatomy of the lumbosacral plexus was first described by Longnecker, and the variations in its formation and position were then presented by Hollinshead. In this prospective study of 77 cadaveric dissections, the anatomical course of the IIN nerve was consistent with that described in anatomical texts in 88.3% of cases and variable in the rest. The incidence of usual anatomical course was higher than that reported by Klaassen. et al. at School of Medicine, St. George's University, Grenada, West Indies, in their report, where they found that the IIN nerve was consistent with that described in anatomical texts in 48.1% of cases.
The current study revealed that the IIN has varied root origins in the lumbar plexus. This finding is inconsistent with the findings reported in the literature.,,,, The study found that the origin of the IIN somewhat differs from the descriptions existing in standard anatomical texts. It has been previously stated that the IINs are derived from L1,, and occasionally from T12. However, the current study identified multiple and different spinal nerves contribute to the formation of these nerves.
The variation seen in this study exemplifies the complex nature of nerve fibre origins for the IHN and IINs. However, readers cannot explain why a discrepancy exists between the data obtained from the current study and those reported by earlier authors. Due to the complexity of nerve fibre origin for the IHN and IINs, the sensory components that compose these nerves encompass a region of the spinal cord extending from T11 to L3, as opposed to only L1 and occasionally T12, as is found in many anatomical texts. However, according to Nyhus, communication between the genitofemoral, IIN or IHNs (as well as the lateral femoral cutaneous nerve) is common and this might result in sensory overlap. This is particularly important clinically during the administration of regional (spinal) anaesthesia.
In this study, the thickness of IIN was ranging between 1 mm and 3 mm. This was in agreement with the reported thickness of IIN in the previous studies when it ranged between 0.6 mm and 4.2 mm.,,
In this study, it was reported that piercing points of the IIN into the TRAM on the right and left sides at a distance from the ASIS was at least 0.9–6 cm. Whereas, Avsar et al., at Ankara, Turkey, stated that piercing points of the IIN into the TRAM at a distance from ASIS at least 3 cm–6.4 cm bilaterally, and piercing points for internal oblique muscle was 4.75 cm on the right and 5.09 cm on the left below and above the transverse line between both ASICs, whereas piercing points for external oblique was 1.9 cm–6 cm to the upper border of the symphysis pubis.
The study reported that the IIN pierces and merges through the internal oblique muscle medial and slightly inferior to the ASIS before travelling in the space between the internal and external abdominal oblique muscles for a short distance before piercing the EOA. Whereas in the study by Jamieson et al. in Chicago, in 91.7% of corpuses the IIN appears on the external aspect of the TRAM near the iliac crest. Its entry site into the internal oblique muscle was superolateral rather than inferomedial to ASIS. The EOA was located in a triangular area with a vertical height of 2 cm (measured upwards from the pubic tubercle) and an oblique distance of 3 cm.
Avsar et al. at Ankara, Turkey, explored specifically the distance between the ASIS and the point, where the IIN penetrated the internal oblique abdominal muscle in 24 cadaveric specimens. They were able to identify that the IIN was 3 cm–6.4 cm distal from the ASIS on the right side and 2 cm–5 cm on the left side.
In the study by Ndiaye et al., Senegal, they reported that the IIN emerged from the internal oblique muscle, passing at 0.8 cm–1 cm of the inguinal ligament and 2 cm–3.33 cm from the ASIS. Whereas Mandelkow and Loeweneck at Munchen University reported that the IIN penetrates the internal oblique muscle 4 cm–5 cm medial to the ASIS and the EOA 1 cm–2 cm above the S. I. R.
In 3.2% (5/154), the IIN having emerged superficially through the fibres of the EOA proximal to the S. I. R, it then coursed downwards and laterally. In the other 35.06% (54/154), it was running in close contact with and parallel to the S. I. R fibres immediately at the point of its exit behind it. In both these positions, the nerve could be vulnerable to injury while slitting open the EOA and the S. I. R. Al-Dabbagh at Trafford General Hospital in Manchester mentioned the same observation but with a higher incidence.
The study revealed that the distance of the nerve from S. I. R during its travel was 0.8 cm–3.5 cm. This was comparable to observation revealed by Mandelkow and Loeweneck, who studied 44 adult human cadavers, and reported that the IIN penetrates the internal oblique muscle 4 cm–5 cm medial to the ASIS, and the EOA 1 cm–2 cm above the S. I. Rs.
In the same way, Klaassen et al. reported that the IIN emerged on average at 2.8 cm–6.1 cm (range, 1.1 cm–5.2 cm) medial and 4 cm–6.2 cm (range, 1.2 cm–4.8 cm) inferior to ASIS. Similarly, Ndiaye et al. reported that the IIN emerges at 2 cm–3.33 cm inside the ASIS.
The findings were found to support the earlier study by Moosman and Oelrich, at Michigan University, who studied 424 inguinal regions, and reported that the IIN courses within the abdominal wall between the transversus abdominis and internal oblique muscles medial to the ASIS, then perforate the internal oblique muscle, and can be identified beneath the EOA as it continues as a sensory trunk.
Bergman et al. reported that the IIN may be small and terminate near the iliac crest by joining the IHN. This in turn sends branches to replace the absent terminal part of the IIN.
It had been previously noted that the IHN and IINs may or may not arise from a common trunk, or these nerves may communicate at the iliac crest. In the event that the nerves join at the iliac crest, the IHN is typically reported to supply the missing IIN.
In this study, the IHN sends an anastomosis branch to join the IIN near the iliac crest, and then later continue to the inguinal canal normally. These findings were in consistent with the report by Ndiaye et al., which stated that the IIN appears behind the inguinal ligament and presents as a common trunk with the IHN in 13% and appearing as a single trunk in the reminder.
| Conclusion|| |
The current study provided a topographical diagram of the IINs in their course in the anterior abdominal wall. Cadaveric dissection of the nerve delineates variants not commonly highlighted in anatomical manuals. This must be taken into account when identifying this nerve.
The normal anatomy of IIN that was mentioned in most textbooks was seen only in 88.3%. It may originate from spinal nerves other than L1 and T12. The result of this study will help the surgeons and anaesthetics during local anaesthesia in understanding these variants to avoid iatrogenic nerve injury and its subsequent complications.
To broadcast this variant widely, there will be a need to carry out a larger study including both genders in the near future.
Limitations of the study
The limitations of the present study are mainly inherent to the relatively small sample size. This is created due to difficulties in finding intact cadavers. As well as the study included only male cadavers. This is created due to the lack of female cadavers during the study period.
Before the conduction, the protocol of this study was approved by the research ethical committee, Alzaeim Alazahri University, Khartoum, Sudan (Ethical approval No.: HREC0105/AAU.12/17).
We have to convey our appreciation to the technicians at the mortuary for sharing their pearls of prudence with us throughout the course of this project, without them this work could not see the light.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]