|Year : 2014 | Volume
| Issue : 3 | Page : 80-83
Complete posterior rectus sheath and total extra-peritoneal hernioplasty
Maulana Mohammed Ansari
Department of Surgery, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||15-Dec-2014|
Maulana Mohammed Ansari
B 27 Silver Oak Avenue, Street No. 4 End, Dhorra Mafi, Aligarh 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Variations in rectus sheath formation have been reported with little realization of its importance to the laparoscopic surgeons doing total extra-peritoneal preperitoneal (TEPP) hernioplasty. Observation of complete rectus sheath during laparoscopic mesh hernioplasty for inguinal hernia through TEP approach and its surgical implication are presented here. Materials and Methods: Setting - Elective. Location for the study - J. N. Medical College and Hospital, A. M. U., Aligarh. Study design - Prospective with effective from April 2010 to August 2013. Study population - Adults (≥18 years). Data collection - Instant documentation and video recording. Method of analysis - All data were computed through on-line calculators (www.graphpad.com/quickcalcs/and http://epitools.ausvet.com.au/). Results: Thirty-five TEPP hernioplasties were carried out in a period of 3 years. All patients were males, with an overall mean age of 48.7 ± 13.4 years. Posterior rectus sheath (PRS) was found complete in four patients with a mean age of 47.28 ± 09.74, and was associated with significantly increased surgical difficulties during the procedure. On Visual Analog Score, endoscopic vision was 4.3 ± 0.6 (4.0-5.5), and the ease of the procedure was 4.5 ± 0.8 (4.0-6.0) that is, both were less than satisfactory. Operating time was 3.1 ± 0.7 h (3.25-4.0). Out of four patients, peritoneal injury occurred in three patients, surgical emphysema in one patient, and postoperative seroma in one patient. Conclusions: PRS was complete in 11.43% of cases studied that was associated with an increased level of surgical difficulties and a higher rate of complications.
Keywords: Absent arcuate line, arcuate line, complete posterior rectus sheath, posterior rectus sheath, total extra-peritoneal, total extra-peritoneal anatomy, total extra-peritoneal hernioplasty, total extra-peritoneal preperitoneal
|How to cite this article:|
Ansari MM. Complete posterior rectus sheath and total extra-peritoneal hernioplasty. Saudi Surg J 2014;2:80-3
| Introduction|| |
Total extra-peritoneal (TEP) (TEP preperitoneal [TEPP]) mesh repair for treatment of inguinal hernia is now a well-recognized technique with proven efficacy, low failure rate, and reduced postoperative pain.  In contrast to our general belief, anatomy of the preperitoneal tissues of the groin is reported to be complex , and is poorly understood by most practicing surgeons. ,,, Poor understanding of the extra-peritoneal anatomy of the groin and inadequate dissection of the preperitoneal tissues have been regarded as the most important cause of difficulties during TEP hernioplasty with a long steep learning curve , that has led to its reluctant adoption and unpopularity by the surgical fraternity in spite of the better results and obvious advantages. 
In recent years, wide anatomic variations have been reported by several investigators that received, surprisingly, little attention of not only the anatomists but also the practicing surgeons.  This prompted the author to do a prospective study of the live surgical anatomy of the infraumbilical posterior rectus sheath (PRS) during the laparoscopic mesh repair of an inguinal hernia through the TEPP approach.
| Materials and Methods|| |
A prospective study was carried out in the Department of Surgery, J. N. Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India, under clearance from the Institutional Ethics Committee and written informed patient consent from April 2010 to August 2013. The study included only adult male patients above 18 years of age who had uncomplicated primary inguinal hernia, and patients with American Society of Anesthesiologists (ASA) Grade I and II only were considered for inclusion. Patients with complicated or recurrent hernia, age <18 years, severe co-morbid disease (ASA Grade III-V), refusal for the laparoscopic approach and previous lower abdominal surgery were excluded from the study. Morphology (nature and extent) of the infraumbilical PRS was taken as the sole primary outcome measure. Surgical implications (endoscopic vision and ease of procedure, operating time [hours], conversion to transabdominal preperitoneal/open hernioplasty, intraoperative peritoneal injury, surgical emphysema and postoperative seroma) were considered as the secondary outcome measures. The surgical technique as reported earlier  was followed.
Online calculators were utilized for the statistical analysis by the unpaired t-test (www.graphpad.com/quickcalcs/) for the numeric data and by the 2-tailed z-test (http://epitools.ausvet.com.au/) for the nonnumeric data. Nonnumeric data were measured on Visual Analog Score of 1-10. Mean ± standard deviation was used for all statistical analysis wherever appropriate. A P < 0.05 was considered as significant.
| Results|| |
Thirty-five TEPP hernioplasty were carried out in 31 patients in a single surgical unit over a period of 39 months. All patients were males, and the overall mean age of the patients was 48.7 ± 13.4 years (range 18-80 years). In four out of 31 patients (12.9%), the traditionally described arcuate line (AL) [Figure 1]a was found absent with the complete infra-umbilical PRS extending down up to the pubic symphysis, and the mean age of these patients was 47.28 ± 09.74 years (range 19-72 years). The nature of the infra-umbilical complete PRS was found aponeurotic throughout in two out of four patients, musculo-aponeurotic in one patient and grossly attenuated with thickened aponeurotic bands in one patient [Figure 1]b-h. In one patient with bilateral inguinal hernia (right indirect and left direct), PRS was found complete tendinous on the right side while it was incomplete with sharp, well-defined AL on the left side.
In these patients, the endoscopic vision and the ease of the procedure were found less than satisfactory, and the operating time was significantly more, indicating the significantly increased difficulties encountered by the operator [Table 1]. Surgical complications occurred more in the presence of complete PRS as compared to the incomplete PRS although the differences were not found significant statistically [Table 2].
|Table 1: Surgical implications of complete posterior rectus sheath during laparoscopic TEP mesh hernioplasty for inguinal hernia (n=35) |
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|Table 2: Surgical complications during and after laparoscopic TEP mesh hernioplasty for inguinal hernia (n=35) |
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| Discussion|| |
In the lower half of the abdomen, the PRS is traditionally taught to be incomplete with the formation of a well-defined curved lower border which is commonly known as linea semicircularis or more popularly AL of Douglas that may be situated at variable level between the umbilicus and the pubic bone but sometimes even at the umbilicus or the pubic bone.  However, a sharp well-defined AL can appear only if all fibers of transversus abdominis and internal oblique (posterior lamina) shift suddenly at a definite level but often the transition is gradual, incomplete or even totally lacking.  Way back in 1960, Anson et al. reported that "occasionally, … the medial margin of the linea semicircularis is attached to the pubic crest, not to the linea alba;" in other words, PRS is often complete.  In a classic study of 80 cadavers, Rizk documented complete PRS with absent AL in 80% of cases:The complete PRS was of near normal thickness (tendinous) throughout its course in 10% of cases while it was gradually thinned out in 70% of cases; in another 15%, there was a complete PRS with thickened dense transverse aponeurotic bands at variable levels, and only in the remaining 5%, PRS was found incomplete.
In a first of its kind, Arregui in 1997 carried out an extensive laparoscopic study of the prefixed soft cadavers and elaborated in detail that the PRS is of variable thickness and continues down in an attenuated fashion into the inguinal area and is often imperceptible which most likely has accounted for the variability of its description in the literature.  It is of interest to note that in the opinion of some anatomists, the AL seen in the dissecting room is usually artificially created during dissection by removing the lower part of the PRS, considering it to be merely transversalis fascia. ,
In recent years, interestingly, Loukas et al. failed to find any instance of the complete PRS;  while on the other hand, Mwachaka et al. reported the complete PRS in about 20% of their cadaveric dissections, and these investigators also observed gender variation not yet reported in literature that is, incidence of the complete PRS was found much higher in the female cadavers (~30%) as compared to the male cadavers (only 7%). 
Author recorded the complete PRS in about 11% of male patients. Needle confirmation was felt desirable by the author to make a cleavage in the complete PRS at about ⅓ of the umbilico-pubic distance [Figure 1]e in order to enter the requisite preperitoneal space sufficient for further surgical dissection and mesh placement. It is also of the interest to note that the PRS formation may not be symmetrical on both sides as was observed in one of the patients in the present study. In an extensive cadaveric study covering both open (70) and laparoscopic (28) dissections, Colborn and Skandalakis in 1998 emphasized that in approximately 30% of cases, the laparoscopic anatomy of one side will not be a mirror image of the other side.  Variation of the complete PRS in the present study was associated with significantly increased level of surgical difficulties (poor endoscopic vision, increased surgical difficulty and operating time). Surgical complications (peritoneal injury, surgical emphysema and postoperative seroma) were seen in a much higher percentage of our patients, but these were not found statistically significant, possibly due to the smaller size of the study sample.
|Figure 1: Complete posterior rectus sheath (PRS) and rectus abdominis muscle (RA); (a) sharp well-defined arcuate line (arrow) with needle confirmation for placement of first working port; (b) tendinous complete PRS; (c) cleavage of tendinous complete PRS and placement of first working port; (d) tendinous complete PRS extending up to pubic bone; (e) attenuated complete PRS and needle confirmation for its cleavage; (f) musculoaponeurotic complete PRS; (g and h) grossly attenuated complete PRS and its cleavage|
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It is hard to believe that in the current era of popular advanced laparoscopy, the author did not find any study or research work in the literature that might have attempted to correlate the anatomic variations of the preperitoneal tissues in the inguinal and supra-inguinal area with the surgical outcomes of the TEP hernioplasty as has been witnessed so strongly in relation to the anatomic variations of the biliary anatomy. Therefore, the author fully endorses the strong recommendation of Avisse et al. given in 2000 that the anatomic research is still useful even if the anatomic structures are well known because the new surgical technique provides new vision of structures known for centuries.  Hence, it cannot be overemphasized that TEP surgeons should carry out the TEP approach carefully with keen observation of the frequent anatomic variations and judicious dissection for creation of proper cleavage and adequate surgical preperitoneal space for the mesh placement with safety.
| Conclusions|| |
Anatomic variation of the complete PRS with absent AL was observed in about 11% of TEP hernioplasty that significantly affected the surgical technique. Awareness of the knowledge and keen conscious observation for the possible presence of the complete PRS as well as its proper cleavage and judicious dissection into the requisite preperitoneal space is recommended in order to perform the TEP hernioplasty smoothly and safely with better results and minimal complications.
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[Table 1], [Table 2]