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WJOLS

Maulana M Ansari 10.5005/jp-journals-10033-1327
RESEARCH ARTICLE

Posterior Rectus Sheath: A Prospective Study of

Laparoscopic Live Surgical Anatomy during Total
Extraperitoneal Preperitoneal Hernioplasty

Maulana M Ansari

ABSTRACT How to cite this article: Ansari MM. Posterior Rectus Sheath:
A Prospective Study of Laparoscopic Live Surgical Anatomy
Aim: Posterior rectus sheath (PRS) recently assumed great during Total Extraperitoneal Preperitoneal Hernioplasty. World
importance during laparoscopic total extraperitoneal preperito- J Lap Surg 2018;11(1):12-24.
neal (TEPP) hernioplasty. However, literature is scanty and cadav-
eric. Novel observations on live PRS anatomy are reported here. Source of support: Nil
Materials and methods: Totally, 60 male patients with primary Conflict of interest: None
inguinal hernia underwent 68 TEPP hernioplasties. Standard
3-midline-port technique was used with telescopic dissection.
Data were analyzed as mean ± standard deviation (SD). INTRODUCTION
Results: All patients were male with mean age and body The oversimplified traditional description of the ingui-
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mass index of 50.1 ± 17.2 years (18–80) and 22.6 ± 2.0 kg/m nal anatomy is still taught in our anatomy classrooms,
(19.5–31.2) respectively. The classically described PRS leading to a fixed mindset that often proves counter-
(normal-length whole tendinous) was found in only 46% of
the cases, while in the remaining 54%, the PRS was found as productive for instant recognition and precise dissec-
variant types, which included short whole-tendinous (4.4%), tion of the anatomical structures required during the
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long whole tendinous (LWT) (4.4%), complete-length whole laparoscopic surgery. This seems true not only for the
tendinous (8.8%), normal-length partly tendinous (NPT) upcoming young surgeons, but also the seasoned senior
(11.8%), long partly tendinous (LPT) (10.3%), normal-length surgeons. Inadequate understanding and improper dis-
thinned-out (NTO) (1.5%), complete-length thinned-out (4.4%),
normal-length grossly attenuated (1.5%), complete-length section of the preperitoneal anatomy is now regarded
grossly attenuated (4.4%), complete-length partly tendinous as the main cause of difficulties during the TEPP her-
(CPT) (1.5%), and complete-length musculo-tendinous (CMT) nioplasty, especially in presence of the wide anatomic
(1.5%). Additionally, anatomy of the PRS was not a mirror variations reported from time-to-time over the last
image on the two sides of the body in 75% of patients with 2-6
bilateral hernias. No hernia recurrence occurred in mean several decades, which received little/no attention of
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follow-up of 33 months. the anatomists and the practicing surgeons alike. In view
of the sparse/scanty research work on the laparoscopic
Conclusion: Posterior rectus sheath varied markedly in
its extent and morphology, resulting in its categorization of live surgical anatomy available in the literature, especially
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12 types. Truly new visions of the structures known for centuries in relation to the TEPP access anatomy, a prospective
are realized under excellent perspective and magnification of first-of-its-kind laparoscopic study of the PRS was under-
laparoscopy, and, therefore, continued anatomic research is taken and its partial observations were published as the
strongly recommended.
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interim result by the author in order to create a general
Clinical significance: Crisp, precise knowledge of preperito- awareness among the surgical fraternity, especially the
neal anatomy is of paramount importance for timely identifica- upcoming young hernia surgeons, and to get feedback
tion of its variations in order to perform a seamless laparoscopic
hernia repair with better outcome. from them to make the present study more illuminating
and fruitful at completion, which is presented herein.
Keywords: Clinical research, Laparoscopic live surgical Laparoscopic live surgical anatomy (morphology and
anatomy, Posterior rectus canal, Posterior rectus sheath, Pre-
peritoneal anatomy, Total extraperitoneal preperitoneal access extent) of the PRS is primarily addressed here with its
anatomy, Total extraperitoneal preperitoneal anatomy. possible clinical significance.

MATERIALS AND METHODS
Ex-Professor A prospective study was conducted in the form of a
Department of Surgery, Jawaharlal Nehru Medical College doctoral research for award of doctorate in surgery.
Aligarh, Uttar Pradesh, India Infraumbilical PRS was carefully studied under the

Corresponding Author: Maulana M Ansari, B-27, Silver Oak excellent perspective and magnification of the preperi-
Avenue, Street No. 4, Dhorra Mafi, Aligarh, Uttar Pradesh, India toneal laparoscopy. Laparoscopic TEPP was performed
Phone: +919557449212, e-mail: mmansari.amu@gmail.com
in the Department of Surgery, Jawaharlal Nehru Medical
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