Retzius Space: Not A Single Anatomical Entity: New Insights, Simplified & Illustrated in A Laparoscopic Study during TEPP Hernioplasty for Inguinal Hernia

Abstract

Background: Casual internet surfing at times proves extremely rewarding with astonishing results. Chance finding of an unknown old PhD thesis prompted documentation of detailed description of retropubic spaces supplementary to the author's recent publication (Ansari MM. Ann Int Med Den Res 2017; 3(5): SG25-31.). Methods: Prospective study in adult patients with inguinal hernia who underwent laparoscopic total extra-peritoneal preperitoneal (TEPP) hernioplasty through standard 3-midline-port technique at J. N. Medical College, Aligarh between 2010 and 2015. Results: Under excellent fibre-optic light and magnified view during preperitoneal laparoscopy, multiple potential retropubic spaces were observed in the retropubic region, ranging from 4 to 7 in number. A total of four fissile potential retropubic spaces were recognized in 46 cases of TEPP hernioplasty when the posterior rectus sheath was incomplete (single-or double-layered) and the preperitoneal fascia as well as transversalis fascia was single-layered; a total of five fissile potential retropubic spaces were observed when preperitoneal fascia was double-layered along with presence of a single-or double-layered incomplete posterior rectus sheath (N=8); a total of five fissile potential retropubic spaces was also observed when the preperitoneal fascia was single-layered and the posterior rectus sheath was found single-layered but complete extending upto the pubic bone (N=10); a total of six fissile potential retropubic spaces were observed when the preperitoneal fascia was doublelayered along with the presence of a single-layered complete posterior rectus sheath (N=3); and a maximum of seven fissile potential retropubic spaces was recognized, given the presence of a double-layered complete posterior rectus sheath and a double-layered preperitoneal fascia at the same time (N=1). Conclusion: Instead of a single Retzius space, multiple loosely fissile potential interfascial spaces (4-7) were documented in retropubic region, necessitating re-evaluation of Retzius space anatomy, in order to help TEPP hernia surgeon to execute the procedure with ease, rapidity and safety.

Avascular Spaces of the Female Pelvis—Clinical Applications in Obstetrics and Gynecology

“…In his research study, Ansari observed multiple potential spaces in the retropubic region. He concluded that the Retzius space needs to be re-evaluated and re-defined for anatomist and practicing surgeons [32]. We totally agree with Ansari, as in the retropubic region, there are fascial layers and spaces, which have not been mentioned in anatomical textbooks or during surgical dissection.…”

“…The urachus (median umbilical ligament) lies on the inner aspect of the anterior abdominal wall dorsal to the fascial layers (umbilical vesical fascia, umbilical prevesical fascia, transversalis fascia). The urachus and both medial umbilical ligaments are used as landmarks, just above the bladder dome, as the site for the peritoneal incision [31,32]. After cutting the median umbilical ligament, dissection proceeds in the ventro-lateral direction up to the retropubic space boundaries.…”

“…Vesicovaginal space boundaries: ventrally-trigone of bladder; dorsally-pubocervical fascia, vagina (inferior part); laterally-cranial portion of vesicouterine ligament; cranially-peritoneal reflection between the dome of the bladder and the low uterine segment; caudally-junction of the proximal and middle thirds of the urethra. Below the caudal limit of vesicovaginal space, the anterior wall of the vagina and the posterior wall of the urethra fuse [5,10,11,[32][33][34] (Figure 11).…”

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

“…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).…”

Surgical Anatomy of Fasciae and Cellular Spaces of Subperitoneal Storey of Female Pelvis

“…Последними исследованиями было доказано наличие нескольких фасциальных слоев внутри пространства Ретциуса, поэтому не совсем верно считать его единым анатомическим образованием [29]. Вдоль передней поверхности мочевого пузыря к пупку тянется пузырнопупочная или предпузырная фасция [9].…”