"Triangle of pain"

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A Moment in History

William S. Halsted, MD
(1852 – 1922)

American anatomist, teacher, and surgeon, William Stewart Halsted was born in New York City, USA to a wealthy family of English origin. His father was involved in charitable work and Governor and trustee to a city hospital. Not a brilliant student initially, Halsted took an undergraduate in Liberal Arts in Yale, CT., after which he entered the Medical College of Physicians at the Columbia College, where he excelled.

As a second-year medical student Halsted applied and obtained a position in surgery at a local hospital. In here he learned about Lister’s antiseptic technique and became an adamant proponent of it to reduce infection. In 1877 Halsted obtained his MD. After a short time as House Physician at the New York Hospital, Halsted traveled to Europe to further his education studying for two years at the Universities of Vienna, Leipzig, and W?rzburg.

Besides being at the forefront of surgical and antiseptic techniques (introducing the use of rubber gloves in surgery), Halsted was extremely concerned with the way medical students were taught in the US. He pioneered bedside clinical round discussions with the medical students after two years of basic sciences studies. Halsted developed the idea of a patient chart; he also developed the residency program for medical students in use today.

Halsted is probably the most influential researcher and surgeon at the turn of the century. He dedicated time to the study of intestinal anastomoses and the use of silk as a suture material. His experimental work in 1887 proved that the inclusion of the submucosa layer in an anastomosis was mandatory, as well that a single layered anastomosis was enough to attain closure. Perhaps Halsted’s most important contribution was the application and use of the scientific method to surgical questions. Halsted’s principles set the standards used today in surgical suturing and surgical stapling.

He also pioneered the development and surgical techniques for radical mastectomy as a treatment for breast cancer.

As a side effect of this studied in anesthesia and the use of cocaine for anesthesia, Halsted became addicted to this substance, a problem that followed him through the years. Without impairing his capacity as a researcher and a surgeon, Halsted eventually recovered. He died in Baltimore in 1922 as a complication to surgery.

Sources:
1. Dubay, A. D., & Franz, G. M. (2003). Acute Wound Healing: The Biology of Acute Wound Failure. Surg Clin NA, 83, 463-481.
2. Halsted, W. S. (1887). Circular Suture of the Intestine - An Experimental Study. Am J Med Sci, 436-461.
3. “William Stewart Halsted: his life and contributions to surgery” Osborne, P. Lancet Oncol 2007; 8: 256–65
4. “William Stewart Halsted: Surgical pioneer” Burress, P Endoc Today (2010), 8: (2) 22
5. “William Stewart Halsted (1852–1922) Neurological stamp” Haas, LF J Neurol Neurosurg Psych 2000;69:641
Original image courtesy of "Images from the History of Medicine" at www.nih.gov

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Details: Published: November 21, 2014

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Image property of: CAA.Inc.. Artist: M. Zuptich.

The so-called "triangle of pain" is a misnomer coined by laparoscopic hernia surgeons who observed the anatomy of the inguinofemoral region from the posterior aspect and refers to an inverted "V" shaped area which should be avoided because of the potential to damage nerves when placing staples, tacks, or sutures to anchor a mesh during a laparoscopic herniorrhaphy.

An example of a similar situation with terminology is the so-called "triangle of doom". It is also not a triangle, as it only has two boundaries. similarly, it does indicate an area where it is dangerous to place staples or sutures during laparoscopic hernia surgery.

The "triangle of pain" is an inverted "V" shaped area with its apex at the internal (deep) inguinal ring. It is bound anteriorly by the iliopubic tract / inguinal ligament and by the testicular (spermatic) vessels posteromedially. This "triangle" has no defined posterolateral boundary. although you can see it in drawings by some authors.

The reason why this area should be avoided and not place staples or sutures to anchor a hernia mesh is that there are several nerves which usually cannot be seen as they run just deep to the endoabdominopelvic fascia.These nerves can suffer damage or entrapment when performing a laparoscopic herniorrhaphy and cause pain (hence the name of the area) as well as motor and sensory disorders.

The nerves are:

• Lateral femoral cutaneous nerve: arising from the ventral rami of L2 and L3, this nerve provides sensory innervation to the anterior skin of the thigh

• Femoral nerve: arising from the ventral rami of L2, L3, and L4, this nerves provides motor and sensory innervation to the anterior compartment of the thigh as well as sensory branches to the hip joint

• Genitofemoral nerve: arising from the ventral rami of L1 and L2, this nerve divides anterior to the psoas major muscle into two branches. The genital branch of the genitofemoral nerve enters the inguinal canal and provides sensory and motor innervation to the scrotum and cremaster muscle, as well as the labia majora and mons pubis. The femoral branch of the genitofemoral nerve enters the "triangle of pain" region and passes inferior to the inguinal ligament to provide sensory cutaneous innervation to the superior aspect of the thigh.

The image shows a posterior view of the inguinal region. The "triangle of pain" is depicted in yellow. The iliopubic tract / inguinal ligament is shown by a blue dotted line while the testicular vessels boundary is shown by a red dotted line. The blue arrow points to the aberrant obturator artery (Corona Mortis).

Thanks to Steve Pearson for suggesting this term. Medical illustration by Mark J. Zuptich.

Clinical anatomy of the inguinofemoral hernias, as well as abdominal and perineal hernias are some of the lecture topics developed and delivered to the medical devices industry by Clinical Anatomy Associates, Inc. For more information Contact Us.

"Triangle of pain"

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