Transversalis Fascia: Historical Aspects and its Place in Contemporary Inguinal Herniorrhaphy

Abstract

Since the introduction of the term "fascia transversalis" by Sir Ashley Cooper in 1840, this thin layer of tissue has been discovered, denied, and redefined. The transversalis fascia was originally described as a bilaminar membrane. Although most subsequent descriptions do not reflect this analysis, some authors, especially in the surgical literature, believe that a posterior lamina of the transversalis fascia exists. Others believe that the posterior lamina of the transversalis fascia is, in fact, part of the preperitoneal fascia. The usefulness of the transversalis fascia and its derivatives or analogues; e.g., the crura of the deep inguinal ring, have also been extensively discussed. The aim of this paper is to provide a brief survey of the historical literature concerning the transversalis fascia and a discussion of some of the contemporary views on its morphology and significance in current laparoscopic hernia repair.

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

“…[61] Confusions and misunderstandings are continued regarding the extraperitoneal fascial tissues among the practicing surgeons and anatomists alike since the time (1804) of Sir Astley Paston Cooper. [22,24,31,32,49,62] Even direct examination of the live surgical anatomy under excellent perspective and high magnification with clear definition of the various fascial planes under the focused bright lighting of the intraperitoneal and preperitoneal laparoscopy did not help much to alleviate the ever prevailing confusions and misunderstandings/ misinterpretations, and little/no agreement exists among the practicing surgeons and anatomists regarding the interparietoperitoneal fascial tissues, especially the transversalis fascia and the preperitoneal fascia. [22,49] In 1997, Maurice Arregui lamented that 'Unlike the anterior anatomy of the inguinal abdominal wall, little in the current English literature exists about the preperitoneal fascia and conflicting information abounds regarding the transversalis fascia.…”

“…[70,71] In 1998, Colborn and Skandalakis documented the constant presence of a tissue-paper like membrane covering the preperitoneal fat in their innumerable cadaveric and surgical dissections, [46] and this was found fairly tough at times, although they did not capitalize on the term 'preperitoneal fascia'. Regular presence of the preperitoneal fascia was strongly supported by Memon and associates, [49,73] who emphatically cautioned against common mistake of its interpretation as the 'posterior lamina of transversalis fascia'. Preperitoneal fascia was recognized as the 'extraserosal' fascia by the Terminologia Anatomica (1998) as a definite anatomical entity distinct from the innermost layer (transversalis fascia) of the parietal wall.…”

“…Presence of a thin membranous preperitoneal fascia was first reported in a large cadaveric study (500 body halves) in 1960 by Anson et al [67] Anson's observations were strongly supported by Lampe. [68] The preperitoneal fascia was called as the 'Fascia of Anson' by Redman or 'Fascia of Lampe' by Condon and Memon et al [47][48][49] Presence of the preperitoneal fascia was undeniably confirmed in two clinical studies of live surgical anatomy by Australian Paediatric surgeon Dr. Robert Fowler in 1975 and Arkansas Urologist Dr. John Redman in 1996. [5,47] Fowler observed that there is 'a loose fissile plane' between the preperitoneal fascia and the transversalis fascia, [25] and that the deep inferior epigastric vessels 'serve as a guide to the recognition and separation of the preperitoneal fascia from the transversalis fascia' (which contain the vessels).…”

“…Preperitoneal fascia was recognized as the 'extraserosal' fascia by the Terminologia Anatomica (1998) as a definite anatomical entity distinct from the innermost layer (transversalis fascia) of the parietal wall. [49] Moreover, Amid and Hiatt documented in 2008 that Read and Skandalakis frequently referred to this fascia as the dividing membrane in the preperitoneal space between the transversalis fascia and the peritoneum, but this layer remained largely unknown to surgeons not familiar with the older literature. [74] In 2000, Folscher et al described this fascia as the urogenital fascia.…”

“…[92,103] The bi-laminar description of the Transversalis fascia by Sir Astley Cooper, [31,32,104] has been hotly contested with a number of stalwarts of the field on either side of the debate. [49,102] Cooper's bi-laminar concept of transversalis fascia was supported by stalwart investigators including Morton (1841) [105] Mackay (1889), [106] Little (1945), [90] and Read (1992), [51] but other equally reputed researchers including McVay and Anson (1940), [107] Condon (1995), [48] and Mirilas (2008 and [71,108] maintained emphatically that the transversalis fascia consisted simply of a single layer. Confusions and misinterpretations of the cadaveric inguinal anatomy are continued even today despite two laparoscopic studies reported in the literature: the first study on the laparoscopic cadaveric anatomy of groin by Colborn & Skandalakis (1998), [46] in soft unfixed cadavers, and the second study on the laparoscopic live surgical anatomy of groin by Maurice Arregui (1997), [22] in patients of inguinal hernia undergoing laparoscopic hernioplasty, mainly by total extraperitoneal approach.…”