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                                                                                            Posterior Rectus Sheath
          College, Aligarh Muslim University, Aligarh, Uttar  fixation of an 11-mm optical trocar, the initial dissection
          Pradesh, India, during a period w.e.f. April 2010 to  in posterior rectus canal was performed with unhurried
          November 2015. All patients with inguinal hernia were  to-and-fro movements of the 0° 10-mm laparoscope
          operated under the ethical clearance of our Institutional  with careful observation and documentation of PRS
          Ethics Committee and written informed consent.      extent and morphology. Two 5-mm working ports were
                                                              placed in the midline lower down for further dissection
          Selection Criteria for Recruitment in the Study     (Fig. 1) in the retropubic and inguinal regions for mesh
                                                              placement.
          •  Patient’s choice under the informed consent.
          •  Patient’s good financial status: The existing financial   As  per  the traditional  teaching  through major
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             circumstances of the patients including patients’   anatomy textbooks,  the anterior rectus sheath is con-
             ability to expend extra money for the laparoscopic   sidered as complete as it is covering the whole length of
             procedure (our institution charges double for the   the rectus abdominis muscle, while the PRS is consid-
             laparoscopic hernioplasty as compared with the open   ered incomplete, as it covers the undersurface of only
             hernioplasty).                                   the upper two-thirds of the rectus abdominis muscle
          •  Preoperative feasibility of laparoscopic hernioplasty   and ends short of the pubic symphysis with formation
             based on the preanesthetic check-up (PAC) in outpa-  of an Arcuate line (of Douglas). Based on two factors,
             tient department.                                viz., firstly, our present understanding based on current
                                                                      11-13
          •  Availability of functioning laparoscopic equipment   literature   that the Arcuate line is generally present at
             and instruments.                                 about one-thirds of the distance from umbilicus to the
          •  Availability of the expertise (laparoscopic surgeon).  pubic symphysis (U-PS), and secondly, the maximum
                                                              U-PS  of 18.0  cm recorded  in  the present  study,  the
          Inclusion Criteria of the Study                     infraumbilical incomplete PRS (IC-PRS) was arbitrarily
                                                              divided into three categories for further reference and
          •  Patients with age more than 18 years             discussion: (1) The classical normal-length PRS (U-AL
          •  Patients with uncomplicated fully reducible primary   3–6 cm), (2) the short PRS (U-AL <3 cm), and (1) the long
             inguinal hernia                                  PRS (U-AL >6 cm), where U-AL represents the distance
          •  Patients with American Society of Anesthesiologists   from umbilicus to the arcuate line. The PRS extending
             (ASA) grades I to II only                        up to the pubic symphysis with/without formation of an
          •  Written informed consent for laparoscopic repair of   arcuate line was considered as the complete PRS (C-PRS)
             inguinal hernia                                  in the present study.
                                                                 The demographic data of age, weight (measured
          Exclusion Criteria of the Study                     without footwear), height, and occupation of the patients

          •  Patient’s refusal for laparoscopic repair        were recorded. Body mass index (BMI) was calculated
          •  Patients with age less than 18 years             by the formula of weight in kilogram divided by the
          •  Patients with severe comorbid disease (ASA grades   square of the height in meters as recommended in 1991
             III–V)
          •  Patients with recurrent inguinal hernia
          •  Patients with complicated inguinal hernia (irreducible/
             inflamed/obstructed/strangulated)
          •  Patients with femoral and other groin hernia
          •  Patients with history of lower abdominal surgery


          Surgical Technique
          Under general anesthesia with patient supine, the dis-
          tance between the umbilicus and the upper border of the
          pubic symphysis was first measured and, thereafter,
          the laparoscopic TEPP hernioplasty was performed with
          the standard 3-midline port technique as reported earlier
          by the author. 9,10  Access to the posterior rectus canal was   Fig. 1: Port placement for laparoscopic TEPP hernioplasty for right
          obtained by open method through a 2 cm infraumbilical   inguinal hernia: F, foot end of patient; H, head end of patient; 1,
                                                              infraumbilical site with optical port (11 mm) in situ; 2 and 3, site
          incision in skin and anterior rectus sheath ipsilateral    for working ports (5 mm); 4, marking for upper border of pubic
          to the side of inguinal hernia. After placement and     symphysis
          World Journal of Laparoscopic Surgery, January-April 2018;11(1):12-24                             13
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