Posterior Rectus Sheath: A Prospective Study of Laparoscopic Live Surgical Anatomy during Total Extraperitoneal Preperitoneal Hernioplasty

Abstract

Aim: Posterior rectus sheath (PRS) recently assumed great importance during laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty. However, literature is scanty and cadaveric. Novel observations on live PRS anatomy are reported here.Materials and methods: Totally, 60 male patients with primary inguinal hernia underwent 68 TEPP hernioplasties. Standard 3-midline-port technique was used with telescopic dissection. Data were analyzed as mean ± standard deviation (SD).Results: All patients were male with mean age and body mass index of 50.1 ± 17.2 years (18-80) and 22.6 ± 2.0 kg/m 2 (19.5-31.2) respectively. The classically described PRS (normal-length whole tendinous) was found in only 46% of the cases, while in the remaining 54%, the PRS was found as variant types, which included short whole-tendinous (4.4%), long whole tendinous (LWT) (4.4%), complete-length whole tendinous (8.8%), normal-length partly tendinous (NPT) (11.8%), long partly tendinous (LPT) (10.3%), normal-length thinned-out (NTO) (1.5%), complete-length thinned-out (4.4%), normal-length grossly attenuated (1.5%), complete-length grossly attenuated (4.4%), complete-length partly tendinous (CPT) (1.5%), and complete-length musculo-tendinous (CMT) (1.5%). Additionally, anatomy of the PRS was not a mirror image on the two sides of the body in 75% of patients with bilateral hernias. No hernia recurrence occurred in mean follow-up of 33 months. Conclusion:Posterior rectus sheath varied markedly in its extent and morphology, resulting in its categorization of 12 types. Truly new visions of the structures known for centuries are realized under excellent perspective and magnification of laparoscopy, and, therefore, continued anatomic research is strongly recommended.Clinical significance: Crisp, precise knowledge of preperitoneal anatomy is of paramount importance for timely identification of its variations in order to perform a seamless laparoscopic hernia repair with better outcome.

Optical illusions quintuple during laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty: A case report

“…2A). With a little more telescopic dissection, it was realized that the arcuate line was not really primary (termination of posterior rectus sheath) but secondary in nature (Illusion 1) and the posterior rectus sheath continued inferior to the in-transit secondary arcuate line in a grossly attenuated form upto the pubic bone, a clinical situated reported earlier by the author [4,5] . The upper aponeurotic part of the complete posterior rectus sheath (C-PRS) above the secondary arcuate line was initially misidentified as the classical incomplete posterior rectus sheath (Illusion 2), and the grossly attenuated lower part of this C-PRS was misidentified as the transversalis fascia (Illusion 3) (Fig.…”

“…Experience of laparoscopic TEPP hernioplasty on one side benefitted the author for the contralateral side because of the mirror anatomy on the two sides of the body in this patient, and the contralateral repair was performed smoothly and rapidly without any anatomical illusion. However, this may not be necessarily true for all cases because non-mirror anatomy has been reported in the posterior rectus sheath extent (50%), posterior rectus sheath morphology (37.5%), posterior rectus sheath extent & morphology both (75%) [4] ; and similarly nonmirror anatomy has been also documented in the arcuate line position (50%), arcuate line morphology (37.5%), and arcuate line position and morphology both (62.5%) [5] .…”

“…Morphological variations in the fascial abdomino-inguinal anatomy are known since but has been re-emphasized recently for their surgical significance during newer surgical approaches of modern laparoscopy [3][4][5][6][7][8][9][10] , where even the thinnest fascial layers and tissues are visualized very clearly under the excellent lighting, high magnification and internal perspective, and all the same, projected in real time on to the video monitors for the collective wisdom of not only the whole surgical team but also the audience far from the operation theatre. Multilaminated fascial layers are potentially prone to optical illusion, especially for the young surgeon not well-versed with the older literature outside the traditional textbooks of surgery and anatomy.…”