Transversalis Fascia and Preperitoneal Fascia: A Laparoscopic Study of Live Surgical Anatomy during TEPP Hernioplasty – Final Report and Literature Review

Abstract

Background: Despite excellent perspective, bright lighting and high magnification afforded by preperitoneal laparoscopy, there is still little agreement among the practicing surgeons and anatomists about transversalis and preperitoneal fascias. Methods: Study Setting -Elective Clinical; Design -Prospective; Population -Adults (≥18 years); Place -J. N. Medical College Hospital, A. M. U., Aligarh; Procedure: Laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty; Technique: Standard 3-midline-port technique; Method: Telescopic and instrument dissection; Data collection -Intraoperative documentation and/or video recording; Data analysis -SPSS (v. 21).Results: Sixty eight TEPP hernioplasties (Unilateral TEPP 52; Bilateral 8) were successful in 60 patients. Transversalis fascia was of three types -single diaphanous layer (60%), single membranous layer associated with little/no fat (15%) and thin flimsy layer (25%). Preperitoneal fascia was observed as a definite single membranous layer in 83% of the cases, and as a double membranous layer in the remaining 17%. Internal spermatic fascia was found as an extension analog of the preperitoneal fascia in all cases in the present study, with formation of a secondary internal inguinal ring at its beginning. Easily fissile avascular plane was consistently present between preperitoneal fascia and transversalis fascia, suggesting different embryological origins. Conclusion: Preperitoneal laparoscopy of inguino-pelvic region confirmed regular presence of easily recognizable preperitoneal fascia distinct from transversalis fascia in all cases, with an easily fissile avascular preperitoneal plane in between them. Transversalis fascia was invariably unilaminar but preperitoneal fascia was at times bilaminar. Instead of transversalis fascia, preperitoneal fascia formed internal spermatic sheath with a secondary internal inguinal ring.

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

“…[3] Fourthly, the Anatomical preperitoneal retropubic space (Space III) bounded anteriorly by the preperitoneal fascia and posteriorly by the parietal peritoneum [ Figure 1,3,5,7,9,11,13 and 15-16], corresponded to the Hayes' umbilical vesical retrofascial space. In presence of the double-layered preperitoneal fascia as reported earlier by the author, [9,11] there was found a potential space (Space IIIB) between the two layers of the double-layered preperitoneal fascia [Figure 5,7,11,13], which corresponded to the Hayes' umbilical vesical interfascial space and its upward extension, i.e., the Hayes' supravesical space [ Figure 15 and 16]. [3] In presence of a complete posterior rectus sheath as reported earlier by the author as well as by others, [6,9,[21][22][23][24][25] the complete posterior rectus sheath further divided the classical retropubic space (Space I) into two fissile potential spaces (Space IA and IB) [ Figure 9 and 11], or it might mean that the classical retropubic space was bounded posteriorly by both the complete posterior rectus sheath and the transversalis fascia, in addition to the preperitoneal fascia (single/double-layered) and the parietal peritoneum [ Figure 10 and 12].…”

“…[8,11] In our study, the transversalis fascia was found invariably single-layered in all of the 68 cases of the inguinal hernia operated. However, seven combinations of twin anatomic variations of the posterior rectus sheath and preperitoneal fascia were recorded, namely, (1) single-layer incomplete posterior rectus sheath and single-layer preperitoneal fascia (64.7%); (2) double-layer incomplete posterior rectus sheath and single-layer preperitoneal fascia (2.9%); (3) single-layer incomplete posterior rectus sheath and double-layer preperitoneal fascia (4.4%); (4) double-layer incomplete posterior rectus sheath and double-layer preperitoneal fascia (7.4%); (5) single-layer complete posterior rectus sheath and single-layer preperitoneal fascia (13.2%); (6) singlelayer complete posterior rectus sheath and doublelayer preperitoneal fascia (4.4%); (7) double-layer complete posterior rectus sheath and double-layer preperitoneal fascia (1.5%) [ Table 2].…”

“…Four fascial layers were observed in the retropubic region, namely, (1) Retropubic fascia (in all cases of TEPP hernioplasty, i.e., N=68) covering the terminal part and tendon of the rectus abdominis muscle and in continuity of the Rectusial fascia, the condensed thickened posterior epimysium of the rectus abdominis muscle, as reported earlier by the author, [9] (2) Complete posterior rectus sheath (N=14), which was double-layered in one case, as reported earlier by the author, [6,10] (3) Transversalis fascia (in all cases, i.e., N=68), which was always found single-layered but at times diaphanous, as reported earlier by the author, [7,11] and (4) Preperitoneal fascia (in all cases of TEPP hernioplasty, i.e., N=68), which was double-layered in 12 cases [ Table 1], as reported earlier by the author. [8,11] In our study, the transversalis fascia was found invariably single-layered in all of the 68 cases of the inguinal hernia operated.…”

“…In terms of the traditional textbook teaching with no recognition of the preperitoneal fascia, the classical retropubic space was bounded posteriorly by the transversalis fascia and the parietal peritoneum only [ Figure 17]. However, it has now been well established beyond doubt that the preperitoneal fascia is a definite anatomical entity, [8,11,21,23,[26][27][28][29][30][31][32] and therefore, in the classical terms, the traditional retropubic space (Space I) was found bounded posteriorly by atleast three fascial layers, viz., the transversalis fascia, the preperitoneal fascia and the parietal peritoneum [ Figure 1], a clinical situation observed during 65% of the TEPP hernioplasties performed in the present study. In the clinical situation 1 (N=44) with single-layer incomplete posterior rectus sheath and single-layer preperitoneal fascia [ Figure 1], the preperitoneal retropubic space in classical terms was appeared to be bounded anteriorly by two fascial layers, i.e., the transversalis fascia and the preperitoneal fascia, and in this situation, the preperitoneal fascia was likely to be confused as the so-called 'posterior lamina' of the transversalis fascia (proper); and moreover, the traditional Retzius space might be considered bounded posteriorly by three layers, viz., the singlelayered transversalis fascia, the single-layered preperitoneal fascia and the parietal peritoneum [ Figure 1].…”

Lumbo-iliac surgical space: anatomical study and implications in the laparoscopic approach of chronic inguinal pain

“…El espacio extraperitoneal comprende a su vez otros tantos en función de las fascias que contiene. Los trabajos de Arregi, y recientemente de Ansari, nos han mostrado los planos parietales inguinales sin distorsión 7,8 . Entre la «nueva» fascia preperitoneal y la transversalis, a nivel anterolateral, encontramos los compartimentos descritos por Retzius (retropúbico) y Bogros (retroinguinal).…”