Page 35 - World Journal of Laparoscopic Surgeons

Maulana M Ansari

Graph 4: Comparative morphology of the incomplete PRS: Ansari Graph 5: Comparative morphology of incomplete PRS: Ansari
vs Rizk: WT: Whole-tendinous; MT: Musculo-tendinous; PT: Partly vs Loukas; WT: Whole-tendinous; MT: Musculo-tendinous; PT:
tendinous (upper part tendinous and lower part fascia-like thinned- Partly tendinous (upper part tendinous and lower part fascia-like
out); TO: Thinned out throughout; GA: Grossly attenuated with thinned-out; TO: Thinned-out throughout; GA: Grossly attenuated
tendinous bands (numbers indicate percentage) with tendinous bands (numbers indicate percentage)

present study (NWT, SWT, LWT, CWT, NPT, LPT, CPT, posterior rectus fascia, and the transversalis fascia may
NTO, CTO, NGA, CGA, and CMT) based on its twin ana- stem from the erroneous anatomical preoccupation that
tomic features of morphology and extent (Tables 5 and 6, all fibres of the rectus sheath pass anterior to the rectus
vide supra). muscle below the arcuate line.”
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Way back in 1940, McVay and Anson reported the Rizk reported presence of the complete PRS in 98.75%
occurrence of the classical PRS, i.e., incomplete tendinous of the human cadavers (80 sides), and his observations
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PRS with a single sharp well-defined arcuate line (SWD-AL) were supported by Arregui. However, the present study

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in only 2 out of their 56 specimens (3.6%). Rizk also documented the complete PRS in only 21% during the
observed the classical PRS with SWD-AL in only 1.25% in laparoscopic TEPP hernia repair, which is in full agree-
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a study of 80 cadaver sides (Graph 4). Arregui described ment with its incidence of 20% in the cadavers studied
that the PRS is of variable thickness and almost always by Mwachaka et al. 6
continues below the arcuate line, if one is present, albeit In terms of the morphology of the complete PRS,
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in an attenuated form up to the symphysis pubis. Arregui observed in 1997 that the PRS was generally
The incomplete PRS was recently documented in only complete, being partly tendinous above the arcuate line
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80% of human cadavers by Mwachaka et al. This was and partly attenuated fascia-like below the arcuate line.
confirmed by the present observation of 79% incidence Present study documented five morphology types of
of the incomplete PRS in patients undergoing TEPP her- complete PRS, and this was in tune with four types
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nioplasty. These observations are in sharp contrast to the of morphology of the complete PRS reported by Rizk
other previous cadaveric studies. (Graph 6). However, the complete PRS was whole-tendi-
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Loukas et al observed three distinct types of the nous/musculo-tendinous PRS in only 50% of our cases
incomplete PRS in a study of 100 cadavers, viz., (1) gradual and variably attenuated PRS in the remaining 50%, while
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thinning with absent arcuate line (65%), (2) tendinous Rizk documented the normal thickness (tendinous) of
with well-defined arcuate line (25%), and (3) attenuated the complete PRS and its variable attenuation in 90 and
with thickened tendinous bands and double arcuate lines 10% of cases respectively (Graph 6).
(10%). The present study showed a reverse phenomenon Our observation of the musculo-aponeurotic complete
in the PRS anatomy, i.e., the incomplete PRS was tendi- PRS in only 1.5% of hernia repair is at variance with its
nous in a high percentage of 68% and variably attenuated much higher incidence of 11.5 and 57.5% in cadaveric
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in the remaining 32% of the cases (Graph 5). studies reported by Mwachaka et al and Monkhouse
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Anson et al documented that “occasionally … the and Khalique respectively. The musculo-tendinous
medial margin of the Linea Semicircularis is attached to PRS in the present study was seen in a young student
the pubic crest, not to the linea alba", i.e., the PRS was often accustomed to regular gymnasium exercises. This is
found complete extending up to the pubic symphysis in easily understandable, but may not be necessarily true. It
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their study. McVay supported Anson’s observations. In is unfortunate that other two investigators reporting its
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2001, Spitz and Arregui has pointed out that “Much higher incidence did not elaborate any correlation between
of the confusion regarding the preperitoneal fascia, the the PRS nature and the profession of the individuals.
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