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

Abstract

INTRODUCTIONThe current revolution of laparoscopic surgery has markedly altered the manners in how surgeons perceive and manipulate the anatomic tissues and planes of the human body. 1 The advent of laparoscopic surgery has generated a new field of live surgical anatomy called the laparoscopic anatomy, and understanding of systematic laparoscopic anatomy can provide the operating surgeons a clear procedural approach, and would immensely benefit the laparoscopic surgeons in training.2 The laparoscopic posterior approach does not follow the anatomy of the anterior approach for inguinal hernia repair, and this approach is also unfamiliar to the majority ABSTRACT Background: Laparoscopic hernia surgeon needs accurate knowledge of not only of target inguinal region but also of adjacent access areas, but he/she is severely constrained by absence of research work on laparoscopic live surgical anatomy in literature. Methods: Prospective study in patients who underwent laparoscopic total extra-peritoneal preperitoneal (TEPP) inguinal hernioplasty through 3-midline-port technique at Jawaharlal Nehru Medical College Hospital, Aligarh between 2010 and 2015. Results: Sixty-eight TEPP repairs were performed in 60 adult patients. Overall incidence of conversion to Open/TAPP hernioplasty was 4% of all cases, but conversion secondary to the anatomic variation of short PRS was seen in only 1.4% of all cases. The endvision and ease of procedure (EOP) were 8.20±1.33 and 7.27±2.05 visual analog score respectively, and both of them were adversely affected in presence of variant PRS anatomy. Average operation time (OT) for unilateral TEPP hernioplasty was 1.9 hours and it was adversely affected in presence of variant PRS anatomy. Overall incidence of surgical emphysema was 16%, and its development was significantly more in presence of variant PRS anatomy. Overall incidence of peritoneal injury, postoperative seroma, infection and chronic pain was 28%, 10%, 6.7% and 1.5% respectively, but they were not affected by variant PRS anatomy. Conclusions: Posterior Rectus Sheath Variations had significant impact on the intra-operative working but did not affect post-operative clinical outcome. Keen observation, timely recognition of anatomic variations and judicious dissection are essential keys for smooth conduct of the well-organized TEPP hernioplasty with ease, safety, rapidity and better results.

Posterior rectus canal: not a single anatomical entity & morphology – a laparoscopic study during TEP hernioplasty

“…Posterior boundary of the true posterior rectus canal (TPRC) was also found highly variable in morphology as reported earlier by the author (Figure 1,3-7,11-15) (8,9). Complete posterior rectus sheath (C-PRS) forming the posterior boundary of the T-PRC was found whole-tendinous (CWT, 6), whole-thinned-out (CTO, 3), grossly-attenuated (CGA, 3), musculo-tendinous (CMT, 1), partly-tendinous (CPT, 1) ( Table 2).…”

“…Balloon dissector made of a surgical glove was used for the initial dissection within the posterior rectus canal in the first three patients of the study, and the direct telescopic dissection was carried under CO 2 insufflation at a pressure of 12 mmHg in the remaining patients of the study. Details of the surgical technique were consistently the same as reported earlier by the author (4,8,9,(11)(12)(13)(14)(15)(16)(17).…”

“…Posterior rectus canal, currently the most preferred approach for the laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty for the inguinal hernia, is traditionally taught to be bounded anteriorly by the fleshy rectus abdominis muscle and bounded posteriorly by the incomplete aponeurotic posterior rectus sheath in up-per part and the transversalis fascia in the lower part. Under excellent lighting and magnification of modern laparoscopy, not only new structures/tissue planes and phenomena have been discovered (2,4,8,9,(11)(12)(13)(14)(15)(16)(17)(23)(24)(25), but also the frequent anatomic variations often reported in the previous cadaveric studies were confirmed (7,(26)(27)(28)(29)(30)(31), which are visualized too clearly to refute even against the prior fixed mindset based on the traditional anatomy classroom teaching (2), although they rarely received the attention of the authors of the traditional textbooks of surgery &/or anatomy commonly read by the medical students. Current bilaminar/trilaminar concept of the posterior rectus sheath in cadaveric studies (27,30,32) is supported by the laparoscopic live anatomical findings of double-/multi-layered posterior rectus sheath ( Figure 15) (9,23).…”

“…In patients with incomplete posterior rectus sheath (PRS), the DIEV, was initially running within the transversalis fascia and then entered the retromuscular space by piercing the rectusial fascia above the arcuate line. In patients with the complete PRS (8,9,15), the DIEV was found to course within the retromuscular space from just above the symphysis pubis.…”

“…In the modern era, posterior rectus canal has assumed an immense importance with the development of the newer laparoscopic technique of total extra-peritoneal pre-peritoneal (TEPP/ TEP) hernioplasty through the posterior rectus approach for adult inguinal hernia. However, despite the current popularity of laparoscopic hernioplasty, scientific study of the live surgical anatomy of the posterior rectus canal is almost totally lacking in the English literature although acutely required because of the new preperitoneal perspective, high magnification with clear visualization of even thinnest fascial layers and recognition of newer visions of the structures, and need of the surgical precision in presence of the frequent anatomic variations (1)(2)(3)(4)(5)(6)(7)(8)(9). This paper highlights the laparoscopic live surgical anatomy of the posterior rectus canal as seen during the preperitoneal dissection for the laparoscopic TEPP hernioplasty of the primary inguinal hernias in adult patients.…”