Locating the arcuate line of Douglas: Is it of surgical relevance?

Abstract

Ventral hernia formation is a common complication of rectus abdominis musculocutaneous flap harvest. The site and extent of harvest of the flap are known contributing factors. Therefore, an accurate location of the arcuate line of Douglas, which marks the lower extent of the posterior wall of the rectus sheath, may be relevant before harvesting the flap. This study is aimed at determining the position of the arcuate line in relation to anatomical landmarks of the anterior abdominal wall. Arcuate lines were examined in 80 (44 male, 36 female) subjects, aged between 18 and 70 years, during autopsies and dissection. The position of the arcuate line was determined in relation to the umbilicus, pubic symphysis, and intersections of rectus abdominis muscle. Sixty four (80.4%) cases had the arcuate line. In most cases (52), this line was located in the upper half of a line between the umbilicus and the pubic symphysis. Most males (93%) had the arcuate line, while more than a third of females did not have it. In all these cases, the line occurred bilaterally as a single arcade, constantly at the most distal intersection of the rectus abdominis muscle. Consequently, the arcuate line is most reliably marked superficially by the distal tendinous intersection of the rectus abdominis muscle. Harvesting of the muscle cranial to this point will minimize defects in the anterior abdominal wall that may lead to hernia formation.

Retzius and Bogros Spaces: A Prospective Laparoscopic Study and Current Perspectives

“…In the remaining 60 patients, a total of 68 TEPP hernioplasties (52 Unilateral and 8 Bilateral) was performed successfully. During the initial telescopic dissection, the posterior rectus canal was always found bounded anteriorly by the variably condensed and thickened posterior epimysium of the rectus abdominis muscle, i.e., the rectusial fascia reported earlier by the author, [19,20] and bounded posteriorly either only by the complete posterior rectus sheath (20% reported in 2010 by Mwachaka et al [21] ; 21% reported in 2017 by Ansari [22,23] ) or by the incomplete posterior rectus sheath (80% reported in 2010 by Mwachaka et al [21] ; 79% reported in 2017 by Ansari [22,23] ) in the upper part above the arcuate line of Douglas and transversalis fascia in the lower part below the arcuate line of Douglas [ Figure 2]. …”

“…TEPP hernioplasty was carried out consistently by the same 3-midline port technique [ Figure 1] as reported earlier by the author. [15][16][17][18][19][20][21][22] Dissection in the posterior rectus canal was performed unhurriedly with gentle controlled to-and-fro movements of the 0º 10-mm telescopic. Further dissection in the pelvis and inguinal region was carried out by blunt/sharp instrument dissection under low settings of electrocautery.…”

Posterior rectus sheath variations: surgical significance and clinical implications for laparoscopic hernia surgeons

“…[7][8][9][10][11] In contrast to the general belief, anatomy of the groin is reported to be complex, especially in presence of anatomic variations reported by several investigators that received little/no attention of anatomists and practicing surgeons alike. 8,10,[12][13][14][15] In 2001, Robert Bendavid declared that 'Nothing goes as far forward preventing complications as the surgeon's awareness and fear of them'. 16 Recently the author has reported an exhaustive laparoscopic study on the anatomic variations in the posterior rectus sheath (PRS) observed during the TEPP hernioplasty.…”

Interspinous Line: Relations with Other Landmarks (Xiphisternum, Umbilicus, Pubic Symphysis and Arcuate Line of Douglas) and Importance for Surgeons

“…Therefore, it may not be an optimal criterion for stoma siting as was also evident from a high incidence the unsatisfactory siting of the stoma in 36-55% of patients in different categories of Al-Momani's series [5]. This may be a reflection of two factors, viz., firstly, the arcuate line position is reported to be highly variable [10-12, 17,18,21,22, 42-46], being significantly higher in the overweight/obese individuals [12,17,43,47]; secondly, the level of the anterior interspinous line may also vary depending upon the body habitus and gender of the individual. Present study is limited by absence of female patients.…”