Hesselbach's triangle

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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: June 26, 2015

Hesselbach's triangle

Hesselbach’s triangle is a triangular region in the lower posterior aspect of the anterior abdominal wall (see yellow inset in the image). It is bound medially by the lateral border of the rectus abdominis muscle, superolaterally by the inferior (deep) epigastric vessels (label “C”) and by the inguinal ligament inferolaterally.

Hesselbach’s triangle is described as the area where a direct inguinal hernia will extrude from posterior to anterior, to protrude directly (hence the name) through the external (superficial) inguinal ring.

Franz Kaspar Hesselbach (1759-1816) was a German surgeon and anatomist who described inguinofemoral hernias in detail, publishing several books on the subject. His name is attached to several regions and structures:

• Hesselbach’s triangle, described in this article

• Hesselbach’s fascia. Known as the cribriform fascia, this perforated fascia covers the saphenous opening in the superior femoral region.

• Hesselbach’s ligament. Also known as the interfoveolar ligament, this is a thickening of the transversalis fascia in relation to the inferior (deep) epigastric vessels.

If you click on the picture, an original image by Hesselbach will appear. This image shows a defect in Hesselbach’s triangle, setting the stage for a direct inguinal hernia, as well as the interfoveolar ligament. Incidentally, Hesselbach's triangle as described today is not the area described originally by Dr. Hesselbach, where the lower border of the triangle was Cooper's ligament.

Initial image property of:CAA.Inc.. Artist:M. Zuptich. Secondary image by F.K. Hesselbach.

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.

Hesselbach's triangle

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