Page 39 - World Journal of Laparoscopic Surgeons

WJOLS

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
11
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