Pathways of the preperitoneal plane: from the “fatty triangle” in Rives to the “fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute to Prof. Schumpelick.

García-Ureña, Miguel Ángel; López-Monclús, Javier; Lersundi, A de Robin Valle de; Hernando, Luis Alberto Blázquez; Pedrique, M Medina; Justo, X Rial; Cidoncha, Arturo Cruz; Sixto, M Nogueira; Rodríguez, Joaquín Manuel Muñoz

doi:10.1007/s10029-022-02602-0

Cited by 19 publications

(9 citation statements)

References 28 publications

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“…Our observations align with a recent cadaveric study by Urena et al, which reported a “trident” distribution of pre-peritoneal fat and proposed that the distribution of pre-peritoneal fat can serve as a useful guide for creating space for mesh placement. We believe that the central fat pad we follow for space creation corresponds to the middle prong of the “trident” pre-peritoneal fat [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Pre-peritoneal Fat as a Guide to Extended View Total Extraperitoneal (eTEP) Repair for Inguinal Hernia

Gupta,

Attri,

Iqbal Mir

et al. 2024

Cureus

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In the extra-peritoneal approach for inguinal hernias, pre-peritoneal space creation is one of the most crucial steps. In the absence of well-defined landmarks, it is difficult to identify the correct plane of dissection, and blind dissection can sometimes lead to peritoneal injury, resulting in loss of working space. In this article, we describe our technique of pre-peritoneal space creation by following the fatty tissue of the median umbilical ligament and fatty tissue along the rectus muscle. The data of all patients (total 84) who underwent surgery with this technique between January 2021 and May 2023 were retrieved and assessed for demographics, hernia type, and perioperative complications. Except for two peritoneal injuries, there were no other intraoperative complications.

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Section: Discussionmentioning

confidence: 99%

Pre-peritoneal Fat as a Guide to Extended View Total Extraperitoneal (eTEP) Repair for Inguinal Hernia

Gupta,

Attri,

Iqbal Mir

et al. 2024

Cureus

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“…12 Despite all the advantages mentioned above, choosing the preperitoneal layer for mesh insertion poses one technical challenge. On average, the midline preperitoneal fat is reported to span only 2.8 cm in width 13 at the level of umbilicus, and lateral to this area, the peritoneum becomes thinner and more tightly attached to the rectus sheath. Meticulous dissection is required to keep the peritoneum intact, otherwise a pneumoperitoneum would be generated by inadvertent peritoneal injury, which in turn could impede the surgery.…”

Section: Discussionmentioning

confidence: 99%

The endoscopic‐assisted or endoscopic mini‐ or less‐open preperitoneal (E/MILOP) approach for primary and incisional ventral hernia repair

Nakabayashi

Matsubara

Shimada

2023

Asian J Endoscop Surgery

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Introduction The endoscopic‐assisted or endoscopic mini‐ or less‐open sublay (E/MILOS) concept describes a contemporary approach of trans‐hernial repair of ventral hernia via sublay mesh placement. The term sublay often causes confusion, and preperitoneal placement of mesh should be considered as a distinctive approach. We hereby present our experience of a novel approach, the E/MILOP approach, for the repair of primary and incisional ventral hernias. Methods All patients who underwent E/MILOP between January 2020 and December 2022 were identified and their preoperative and perioperative characteristics, as well as postoperative outcomes, were retrospectively analyzed. The surgical procedure entailed an incision over the hernia defect and careful entrance into, and development of, the preperitoneal space trans‐hernially. A synthetic mesh was placed in the preperitoneal space and the defect was closed with sutures. Results A total of 26 patients with primary and/or incisional ventral hernias who underwent E/MILOP were identified. Three patients (11.5%) presented with two coexistent types of hernias, and out of a total of 29 hernias, there were 21 (72.4%) umbilical, four epigastric (13.8%) and four incisional (13.8%) hernias. The mean defect width was 2.7 ± 0.9 cm. All cases utilized a mesh with a mean mesh‐to‐defect ratio of 12.9. The mean postoperative stay was 1.9 days. Surgical site occurrence was observed in eight (30.1%) patients, but none required intervention. No recurrence was observed during a mean follow‐up period of 286.7 days. Conclusion The E/MILOP approach is a novel alternative for primary and incisional ventral hernia repair.

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“…This lateral limit has recently been called the “ambivium” [ 20 ]. Once we have dissected both lateral retromuscular spaces, then inferiorly, beyond the arcuate line and taking advantage of the distribution of preperitoneal fat [ 21 ], dissection continues by dissecting the Retzius space in the midline, the Bogros spaces laterally and exposing Cooper’s ligaments. Attention is given to the epigastric vessels, which, along with the surrounding adipose tissue, are preserved.…”

Section: Methodsmentioning

confidence: 99%

The Madrid Posterior Component Separation: An Anatomical Approach for Effective Reconstruction of Complex Midline Hernias

De Luca,

Medina Pedrique,

Morejon Ruiz

et al. 2024

J. Abdom. Wall Surg.

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IntroductionIn recent years, Posterior Component Separation (PCS) with the Madrid modification (Madrid PCS) has emerged as a surgical technique. This modification is believed to enhance the dissection of anatomical structures, offering several advantages. The study aims to present a detailed description of this surgical technique and to analyse the outcomes in a large cohort of patients.Materials and MethodsThis study included all patients who underwent the repair of midline incisional hernias, with or without other abdominal wall defects. Data from patients at three different centres specialising in abdominal wall reconstruction was analysed. All patients underwent the Madrid PCS, and several variables, such as demographics, perioperative details, postoperative complications, and recurrences, were assessed.ResultsBetween January 2015 and June 2023, a total of 223 patients underwent the Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23–40). According to the EHS classification, 139 patients had a midline incisional hernia, and 84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150 (67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%) superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four (1.9%) recurrences were assessed by CT scan with an average follow-up of 23.9 months (range 6–74).ConclusionThe Madrid PCS appears to be safe and effective, yielding excellent long-term results despite the complexity of abdominal wall defects. A profound understanding of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to facilitating a complete retromuscular preperitoneal repair without incision of the transversus abdominis. The extensive abdominal wall retromuscular dissection obtained enables the placement of very large meshes with minimal fixation.

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Pathways of the preperitoneal plane: from the “fatty triangle” in Rives to the “fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute to Prof. Schumpelick.

Cited by 19 publications

References 28 publications

Pre-peritoneal Fat as a Guide to Extended View Total Extraperitoneal (eTEP) Repair for Inguinal Hernia

Pre-peritoneal Fat as a Guide to Extended View Total Extraperitoneal (eTEP) Repair for Inguinal Hernia

The endoscopic‐assisted or endoscopic mini‐ or less‐open preperitoneal (E/MILOP) approach for primary and incisional ventral hernia repair

The Madrid Posterior Component Separation: An Anatomical Approach for Effective Reconstruction of Complex Midline Hernias

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