Urogenital fascia anatomy study in the inguinal region of 10 formalin-fixed cadavers: new understanding for laparoscopic inguinal hernia repair

Abstract

Purpose To investigate the urogenital fascia (UGF) anatomy in the inguinal region, to provide anatomical guidance for laparoscopic inguinal hernia repair (LIHR). Methods The anatomy was performed on 10 formalin-fixed cadavers. The peritoneum and its deeper fascial tissues were carefully dissected. Results The UGF’s bilateral superficial layer extended and ended in front of the abdominal aorta. At the posterior axillary line, the superficial layer medially reversed, with extension represented the UGF's deep layer. The UGF's bilateral deep layer medially extended beside the vertebral body and then continued with the transversalis fascia. The ureters, genital vessels, and superior hypogastric plexus moved between both layers. The vas deferens and spermatic vessels, ensheathed by both layers, moved through the deep inguinal ring. From the deep inguinal ring to the midline, the superficial layer extended to the urinary bladder’s posterior wall, whereas the deep layer extended to its anterior wall. Both layers ensheathed the urinary bladder and extended along the medial umbilical ligament to the umbilicus and in the sacral promontory, extended along the sacrum, forming the presacral fascia. The superficial layer formed the rectosacral fascia at S4 sacral vertebra, and the deep layer extended to the pelvic diaphragm, terminating at the levator ani muscle. Conclusion The UGF ensheaths the kidneys, ureters, vas deferens, genital vessels, superior hypogastric plexus, seminal vesicles, prostate, and urinary bladder. This knowledge of the UGF’s anatomy in the inguinal region will help find correct LIHR targets and reduce bleeding and other complications.

The “Y”-shaped Denonvilliers’ fascia and its adjacent relationship with the urogenital fascia based on a male cadaveric anatomical study

“…In addition to the one and two-layer theories regarding Denonvilliers’ fascia, Ghareeb et al [ 9 ] proposed a “multilayer” theory based on an anatomical study. Combining the UGF theory reported in our previous study [ 12 ] and the findings of other reports in the literature, we believe that the first layer of “Denonvilliers’ layer” reported by Ghareeb et al [ 9 ] is the true Denonvilliers’ fascia and that the second and third layers represent the visceral layer of the UGF. This conclusion was reached because these two layers extend along the posterior wall of the urinary bladder and the ventral side of the seminal vesicles and prostate and densely adhere to Denonvilliers’ fascia at the caudal end of the prostate.…”

“…Except for the one layer and the two-layer theory, W. M. Ghareeb et al [9] carried out an anatomical study and detailed the "multilayer" theory of the Denonvilliers' fascia. Combining the UGF theory reported by our previous study [12] and comprehending the literature, we believed that the rst layer of the "Denonvilliers' layer" was narrated by W. M. Ghareeb et al [9] was the actual Denonvilliers' fascia. Yet the second and third layers should be the visceral layer of UGF since it extended along the posterior wall of the urinary bladder and the ventral side of the seminal vesicles and prostate and at the caudal of the prostate densely cohered to the Denonvilliers' fascia.…”

“…To date, current studies did not expatiate on the shape of the Denonvilliers' fascia in the sagittal position and the association with adjacent fasciae, especially whether the Denonvilliers' fascia was continued from the peritoneum by the combination of the anatomical observation and the histology study. Besides, our previous anatomical study [12] showed that the visceral layer of UGF, which extended along the posterior wall of the urinary bladder and continued down along the seminal vesicles and prostate ventrally, was adjacent to the Denonvilliers' fascia.…”

“…To date, no studies have described the shape of Denonvilliers’ fascia on the sagittal plane or its association with adjacent fasciae by anatomical observation and histology, especially whether Denonvilliers’ fascia continues from the peritoneum. Our previous anatomical study showed that the visceral layer of the urogenital fascia (UGF), which extends along the posterior wall of the urinary bladder and continues down along the seminal vesicles and prostate ventrally, is adjacent to Denonvilliers’ fascia [ 12 ].…”

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance

“…In the 5th week of human embryonic development, the cloacal side of the mesonephric duct sends ureteral buds to the dorsal side of the embryo and extends into the caudal end of the mesonephric ridge [ 42 , 46 ], inducing differentiation into the metanephrogenic tissue, i.e., the human permanent kidney. The above embryonic developmental process verifies that the renal fascia accompanies the development of the urogenital system to migrate to the pelvis, which is similar to the idea proposed by Muntean [ 50 ], Diarra [ 21 ] and Yi Li [ 41 ] through dissection. Yang [ 61 ] et al observed the continuation of the renal fascia into the pelvis and wrapped the ureter, reproductive vessels, and hypogastric nerves, calling it the urogenital–hypogastric sheath.…”