Anatomy, Abdomen and Pelvis, Inguinal (Crural, Pouparts) Ligament


Article Author:
Kavin Sugumar


Article Editor:
Mohit Gupta


Editors In Chief:
Susan Jeno
Sarah Fabiano


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/9/2019 11:36:08 AM

Introduction

Gabrielle Falloppio first discovered the inguinal ligament (or Poupart ligament) in 1562, which was further described by Francois Poupart, the famous French anatomist.[1] The ‘tendinous’ anatomy of the inguinal ligament, stretching from the anterior superior iliac spine (ASIS) to the pubic tubercle (PT) with its grooved superior surface, was later discussed in detail by Cunningham. It forms by the folding of the inferior extent of the external oblique aponeurosis. The importance of the inguinal ligament in surgery stems from the fact that it is an important landmark and integral component of groin hernia repair and inguinal disruption (sportsman groin). Among the most commonly performed surgeries in the world is inguinal hernia repair, done on more than 20 million people per annum. The lifetime occurrence of groin hernia which includes visceral or adipose tissue protrusions through the inguinal or femoral canal is 27 to 43% in men and 3 to 6% in women.[2][3] Inguinal hernias are almost always symptomatic, and surgery being the only cure. Acquiring detailed knowledge of inguinal anatomy is essential for surgeons operating on groin hernias.

Structure and Function

The most superficial of the anterior abdominal wall musculature is the external oblique muscle, which arises from the posterior aspect of the lower eight ribs. The muscle fibers are directed almost horizontally in its upper portion to oblique in the middle and lower portions where they continue as an aponeurosis. The fibers fan out and are inserted from above to below into the xiphoid process, linea alba, pubic crest, pubic tubercle, and anterior half of the iliac crest. The obliquely arranged anteroinferior fibers of the aponeurosis fold on themselves inwards to form the inguinal ligament, running between the anterior superior iliac spine and the pubic tubercle. The inguinal ligament is connected below to the fascia lata of the thigh, which results in its caudally directed convexity. The ligament bridges the neurovascular and muscular structures that pass from the deep pelvis to the thigh.[4] The structures that lie deep to the inguinal ligament from lateral to medial are[5]: (Figure 1)

  • The lateral femoral cutaneous nerve
  • Femoral nerve
  • External iliac artery to femoral artery
  • Femoral vein to external iliac vein
  • Femoral ring with deep inguinal lymphatic channels and lymph nodes
  • The muscles from lateral to medial include iliacus, psoas, pectineus, and adductor longus

The mid-inguinal point is an important surgical landmark, which forms the midpoint of the imaginary line that joins the anterior superior iliac spine and the pubic symphysis. Deep to this point, the external iliac artery continues as the femoral artery, passing from the pelvic cavity to the lower limb. Palpation of the femoral artery is only possible below the inguinal ligament at the mid-inguinal point. The midpoint of the inguinal ligament (the midpoint between the ASIS and the pubic tubercle) is just lateral to the mid-inguinal point. It is an important surgical landmark of the deep inguinal ring, that lies 0.5 inches above the midpoint of the inguinal ligament.[6] The inguinal ligament is rounded and oblique laterally, whereas medially it is grooved and becomes more horizontal. The superior surface of the inguinal ligament is grooved and forms the floor of the inguinal canal and contains the ilioinguinal nerve and the spermatic cord in males and round ligament in females.

Attachments of the inguinal ligament:

The inguinal ligament attaches below to the fascia lata which is the deep fascia of the thigh. Superiorly it gives origin to the internal oblique from lateral two thirds, transverses abdomens from lateral one thirds, and cremaster muscle from the middle third.

Extensions:

At the medial end, the inguinal ligament fans out when attaching to the pubic tubercle which is called the lacunar ligament or Gimbernat ligament. The apex of the lacunar ligament is at the pubic tubercle, anteriorly attached to the inguinal ligament and posteriorly attached to the pectinate line, while the base lies laterally. The pectinate ligament (ligament of Cooper) is a lateral extension from the base of the lacunar ligament that is attached to the pecten pubis. 

Few reflected fibers of the inguinal ligament travel superomedially at an angle of 45 degrees initiating at the lateral crus of the superficial inguinal ring and decussates with fibers of the opposite side at the lines alba just anterior to the pyramidal muscle (if present), and if not present, is attached to the rectus sheath. Reflected fibers of the inguinal ligament are also called the Colle ligament, triangular fascia or reflex ligament. In a study from 2009, 83% of cadavers had a reflected inguinal ligament.[7] 

Inguinal ligament: a ligament or tendon?

The argument of the taxonomy of the inguinal ligament of being either a tendon versus ligament continues, as they both broadly include a similar type of connective tissue composition. Grossly, ligaments and tendons get classified according to their connections; either bone to bone for ligaments or skeletal muscle to the bone for tendons. However, the inguinal ligament that arises from the aponeurosis of the external oblique aponeurosis and connects the ASIS to the pubic tubercle does not fall neatly into either of the above basic definitions. Another consideration is that the function of a musculoskeletal ligament is to stabilize a joint between two bones. Although separate in children, mature adults have ileum and pubic bones fused into a single pelvic bone. Therefore, there is no joint to be stabilized by the inguinal ligament. According to previous literature, ligaments provide stability to joints and hence must always be preserved during surgery, and never to be divided intra-operatively. Since tenotomy of the inguinal ligament is continued to be performed by surgeons for patients with inguinal disruption, it poses questions over the anatomical classification of the inguinal ligament.[1]

Embryology

In all vertebrates, somitic dermatomyotomes give rise to the musculature of the body. The myocytes of the ventral body wall develop from the lateral or hypaxial half of the dermomyotome, and ventral branches of spinal nerves innervate them. The hypaxial muscle differentiates into three separate layers, which becomes apparent by the end of the sixth week of embryonal development. These muscles, depending on their position in the following stages, correspond to external oblique (outer layer), internal oblique (middle layer) and transverse abdominal muscles (inner layer).[8]

Blood Supply and Lymphatics

The external iliac artery that exits the pelvis immediately deep to the inguinal ligament, and continues as the femoral artery which runs through the femoral triangle (bound by the inguinal ligament, the sartorius, and the abductor longus muscle), parallel to the femoral vein and the deep inguinal lymphatics through the femoral canal.[9]

Nerves

Two nerves pass immediately deep to the inguinal ligament. They are:

The lateral cutaneous femoral nerve of the thigh usually arises from the posterior division of the L2 and L3 spinal nerves. It courses from the lumbar spinal roots through the pelvis, in a direction towards the ASIS. At this point, it leaves the pelvis by traveling beneath the inguinal ligament, anterior to the ASIS, and in the thigh it divides into two branches, viz the anterior and posterior divisions, providing sensory innervation for the skin of the anterolateral and lateral aspects of the thigh.[10]

The femoral nerve arises from the posterior divisions of ventral rami of L2, L3, and L4, passes through the pelvis, deep to the inguinal ligament, just lateral to the femoral artery and enters the femoral triangle where it supplies muscles and cutaneous innervation of the thigh.

Surgical Considerations

The inguinal ligament and the lacunar ligament form the anterior and medial wall of the femoral ring respectively, which if weakened can lead to herniation of abdominal contents through a narrow neck leading to a femoral hernia.[6] A Laugier hernia is the protrusion of abdominal contents through a weakness in the lacunar ligament. 

A groin injury, sportsman groin, and inguinal disruption are synonyms for diffuse chronic groin pain syndrome, which affects athletes performing high-intensity exercise, which is usually unresponsive to conservative therapy.[11] One of the etiologies of inguinal disruption is inguinal ligament dehiscence. Hence, the inguinal ligament is a target for use as a tendon for therapeutic strategies in the management of inguinal disruption among athletic groups.

Clinical Significance

The clinical significance of the inguinal ligament cannot be understated, as it an important landmark for diagnosis and while performing inguinal surgery. The inguinal ligament serves to help differentiate the type of groin hernia clinically. If the hernia bulge occurs above the inguinal ligament, it is considered to be an inguinal hernia, and when the bulge occurs below the inguinal ligament, it is a femoral hernia. Any inguinal hernia arising within the Hesselbach triangle (triangle bound by the lateral border of rectus sheath medially, inguinal ligament below and inferior epigastric artery laterally) is a direct inguinal hernia, whereas if it arises lateral to the triangle through the deep inguinal ring, it is an indirect inguinal hernia.


  • Image 9966 Not availableImage 9966 Not available
    Illustration drawn by Dr. Kavin Sugumar, MBBS, M.S
Attributed To: Illustration drawn by Dr. Kavin Sugumar, MBBS, M.S

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Abdomen and Pelvis, Inguinal (Crural, Pouparts) Ligament - Questions

Take a quiz of the questions on this article.

Take Quiz
A 65-year-old male is to undergo wide local excision for a soft tissue tumor of the chest wall of size 7X5 cm. Due to the large defect size post excision, a rotational myocutaneous flap is planned to fill the defect created. This muscle decided to be used for the flap arises from the lower eight ribs and travels anteromedially to insert into the anterior iliac crest and linea alba. Which of the following is formed from the aponeurosis of this anterior abdominal muscle?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 49-year-old male is to undergo wide local excision of a myxofibrosarcoma on the anteromedial aspect of the right thigh of size 3X3 cm. As the patient is a case of end-stage renal disease and high risk for general anesthesia, a local nerve block is to be performed to anesthetize the anteromedial surface of the thigh, during surgery. If this area is to anesthetized, at what surgical landmark must the local anesthetic be given to cause the desired effect?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 32-year-old female construction worker comes to the emergency department with excruciating pain in her right groin for 3 hours, along with one episode of vomiting. She passed stools last night, which was non-bloody and semi-solid in consistency. On physical examination, her vitals are pulse rate: 105/min, blood pressure: 100/82 mm Hg, in distress and temperature: 99.7 degrees F. On examining her right groin, she has a tender swelling with surrounding redness that suddenly appeared 2 hours ago in the right groin while lifting heavy equipment. The swelling is located just below the imaginary line joining the anterior superior iliac spine and pubic tubercle. The surgical team decides that this patient requires emergency surgery. What structure must be divided intraoperatively, to relieve the distress in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 42-year-old male is brought to the emergency department after being shot in the left thigh at a hunting trip. He has difficulty breathing, sweating, and palpitations. On examination, he is pale, with a pulse rate of 110/min, blood pressure in the right arm in the supine position is 95/68 mm Hg, and has a lacerated gunshot wound in his mid-thigh anteriorly that is actively bleeding. The emergency care provider starts this patient on an intravenous drip of Ringer's lactate stat and applies direct pressure over the open wound. At what site must the provider apply the pressure to stop active from the wound?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 47-year-old female is diagnosed clinically with a right-sided femoral hernia. An open inguinal approach to repair the hernia defect is planned. During the procedure, the hernia sac is noted to contain omentum and reduceable contents through the femoral canal into the peritoneal cavity. The connective tissue forming the anterior wall of the femoral canal is seen to have multiple extensions that have various attachments. Which of the following extensions travel medially and decussates with fibers of opposite side?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A surgical oncologist begins dissecting the groin in a patient with squamous cell penile cancer, metastatic to bilateral superficial inguinal lymph nodes. He begins by dissecting the vertical and horizontal groups of lymph nodes and connective tissue surrounding the femoral vessels. He dissects the superficial inguinal lymph nodes with the upper boundary of the dissection being a fibrous band above. This fibrous connective tissue band forms the superior border of the femoral triangle and is attached below to the fascia lata. Which of the following structures that pass deep to this band of tissue, lies most laterally?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Abdomen and Pelvis, Inguinal (Crural, Pouparts) Ligament - References

References

Clelland AD,Varsou O, A qualitative literature review exploring the role of the inguinal ligament in the context of inguinal disruption management. Surgical and radiologic anatomy : SRA. 2019 Mar;     [PubMed]
International guidelines for groin hernia management. Hernia : the journal of hernias and abdominal wall surgery. 2018 Feb;     [PubMed]
Kingsnorth A,LeBlanc K, Hernias: inguinal and incisional. Lancet (London, England). 2003 Nov 8;     [PubMed]
Ishiguro S,Yokochi A,Yoshioka K,Asano N,Deguchi A,Iwasaki Y,Sudo A,Maruyama K, Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesthesia and analgesia. 2012 Dec;     [PubMed]
Doklamyai P,Agthong S,Chentanez V,Huanmanop T,Amarase C,Surunchupakorn P,Yotnuengnit P, Anatomy of the lateral femoral cutaneous nerve related to inguinal ligament, adjacent bony landmarks, and femoral artery. Clinical anatomy (New York, N.Y.). 2008 Nov;     [PubMed]
Koliyadan SV,Narayan G,Balasekran P, Surface marking of the deep inguinal ring. Clinical anatomy (New York, N.Y.). 2004 Oct;     [PubMed]
Tubbs RS,McDaniel JG,Burns AM,Kumbla A,Cossey TD,Apaydin N,Comert A,Acar HI,Tekdemir I,Shoja MM,Loukas M, Anatomy of the reflected ligament of the inguinal region. Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie. 2009;     [PubMed]
Mekonen HK,Hikspoors JP,Mommen G,Köhler SE,Lamers WH, Development of the ventral body wall in the human embryo. Journal of anatomy. 2015 Nov;     [PubMed]
Yu SK,Chung TT,Yeh CC,Cherng CH,Lin SL, A patient with femoral triangle anatomy transposition challenges NAVY rule. Journal of clinical anesthesia. 2018 Feb;     [PubMed]
Anloague PA,Huijbregts P, Anatomical variations of the lumbar plexus: a descriptive anatomy study with proposed clinical implications. The Journal of manual     [PubMed]
Paksoy M,Sekmen Ü, Sportsman hernia; the review of current diagnosis and treatment modalities. Ulusal cerrahi dergisi. 2016;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Physical Therapy. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Physical Therapy, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Physical Therapy, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Physical Therapy. When it is time for the Physical Therapy board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Physical Therapy.