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

Maulana M. Ansari

doi:10.18203/2349-2902.isj20180375

Authors

Maulana M. Ansari Department of Surgery, J. N. Medical College, Aligarh Muslim University, Aligarh, Utter Pradesh, India

DOI:

https://doi.org/10.18203/2349-2902.isj20180375

Keywords:

Anatomic variations, Laparoscopic inguinal anatomy, Posterior rectus sheath, Posterior rectus sheath variations, Surgical significance, TEPP anatomy

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.

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References

Brooks JD. Applied Laparoscopic Anatomy: Abdomen and Pelvis. 1997;158(2):681-2.

Li LJ, Zheng XM, Jiang DZ, Zhang W, Shen HL, Shan CX, et al. Progress in Laparoscopic Anatomy Research: A Review of the Chinese Literature. World J Gastroenterol. 2010;16(19):2341-7.

Marks SC, Gilroy AM, Page DW. The clinical anatomy of laparoscopic inguinal hernia repair. Singapore Med J. 1996;37(5):519-21.

Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendoscopic Surg. 1991;1:269-77.

Rosser J. The anatomical basis for laparoscopic hernia repair revisited. Surg Laparosc Endosc. 1994;4(1):36-44.

Avisse C, Delattre JF, Flament JB. The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications. Surg Clin North Am. 2000;80(1):35-48.

Faure JP, Doucet C, Rigourd PH, Richer JP, Scepi M. Anatomical pitfalls in the technique for total extra peritoneal laparoscopic repair for inguinal hernias. Surg Radiol Anat. 2006;28(5):486-93.

Lange JF, Rooijens PPGM, Koppert S, Kleinrensink GJ. The preperitoneal tissue dilemma in totally extraperitoneal (TEP) laparoscopic hernia repair. Surg Endosc. 2002;16:927-30.

Colborn GL, Skandalakis JE. Laparoscopic inguinal anatomy. Hernia. 1998;2:179-91.

Arregui ME. Surgical anatomy of the pre-peritoneal fasciae and posterior transversalis fasciae in the inguinal region. Hernia. 1997;1:101-10.

Liem MS, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers G J, Meijer WS, et al. The learning curve of totally extraperitoneal laparoscopic hernia repair. Am J Surg. 1996;171:281-5.

Rizk NN. A new description of the anterior abdominal wall in man and mammals. J Anat. 1980;131(3):373-85.

Monkhouse WS, Khalique A. Variations in the composition of the human rectus sheath: a study of the anterior abdominal wall. J Anat. 1096;145:61-6.

Mwachaka P, Odula P, Awori K, Kaisha. Variations in the Pattern of Formation of the Abdominis Rectus Muscle Sheath among Kenyans. Int J Morphol. 2009;27(4):1025-9.

Mwachaka PM, Saidi HS, Odula PQ, Awori KO, Kaisha WO. Locating the arcuate line of Douglas: is it of surgical relevance. Clin Anat. 2010;23(1):84-6.

Bendavid R. The transversalis fascia: new observations. In: Robert Bendavid, Jack Abrahamson, Maurice E. Arregui, Jean Bernard Flament, Edward E. Phillips (eds.) Abdominal Wall Hernias: Principles and Management. Spinger-Verlag, New York; 2001:97-100.

Ansari MM. Posterior Rectus Sheath: A Prospective Study of Laparoscopic Live Surgical Anatomy during TEPP Hernioplasty. World J Lap Surg. 2017;10(3).

Ansari MM. Effective Rectus Sheath Canal: Does It Affect TEP Approach for Inguinal Mesh Hernioplasty. J Exp Integr Med. 2013;3(1):73-6.

Ansari MM. Complete posterior rectus sheath and total extra-peritoneal hernioplasty. Saudi Surg J. 2014;2(4):80-3.

Ansari MM. Arcuate Line Variations: Are they important for TEP surgeons? Kuwait Med J. 2015;47(4):313-6.

Ansari MM. Rectusial Fascia: A New Entity of Laparoscopic Live Surgical Anatomy. Open Access J Surg. 2017;3(4):1-5.

Ansari MM. Surgical significance of rectusial fascia during TEPP hernioplasty. Int. J Sci Appl Res. 2017;4(7):13-21.

Ansari MM. Arcuate Line of Douglas: A Prospective Study of Laparoscopic Live Surgical Anatomy during TEPP Hernioplasty. Int J Sci Res. 2017;6(6):2348-63.

Deurenberg P, Weststrate JA, Seidell JC. Body mass index as a measure of fatness: age- and sex-specific prediction formulas. Br J Nutr. 1991;65:105-14.

Ansari MM. Thesis for PhD (Surgery) titled- ‘A Study of Laparoscopic Surgical Anatomy of Infraumbilical Posterior Rectus Sheath, Fascia Transversalis and Pre-Peritoneal Fat/Fascia during TEPP Mesh Hernioplasty for Inguinal Hernia’, Aligarh Muslim University, Aligarh, India, 2016’.

Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia. Surg Endosc. 2011;25(9):2773-843.

Putnis S, Berney CR. Totally extraperitoneal repair of inguinal hernia: techniques and pitfalls of a challenging procedure. Langenbecks Arch Surg. 2012;397:1343.

Berger D. Evidence-Based Hernia Treatment in Adults. Deutsches Ärzteblatt Int Dtsch Arztebl Int. 2016;113:150-8.

Katkhouda N. Advanced Laparoscopic Surgery: Techniques and Tips. 2nd Ed. London, Springer; 1998:149-168.