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                                                                                            Posterior Rectus Sheath
























          Graph 2: Distribution of the classical and 11 variant subtypes of PRS-morphology. Observed during TEPP hernioplasty (n = 68) in the different
          workers (n = 60); NWT: Normal-length whole-tendinous; SWT: Short whole-tendinous; LWT: Long whole-tendinous; CWT: Complete whole-
          tendinous; CMT: Complete musculo-tendinous; NPT: Normal-length partly tendinous; LPT: Long partly-tendinous; CPT: Complete partly-tendinous;
          NTO: Normal-length thinned-out; CTO: Complete thinned-out; NGA: Normal-length grossly attenuated; CGA: Complete grossly attenuated;
























          Graph 3: Correlation between PRS types and occupation; NWT: Normal-length whole-tendinous; SWT: Short whole-tendinous; LWT: Long
          whole-tendinous; CWT: Complete whole-tendinous; CMT: Complete musculo-tendinous; NPT: Normal-length partly tendinous; LPT: Long
          partly-tendinous; CPT: Complete partly-tendinous; NTO: Normal-length thinned-out; CTO: Complete thinned-out; NGA: Normal-length
          grossly attenuated; CGA: Complete grossly attenuated

          Clinical Outcome                                    groin dissections documented 43 variations in defects and
                                                              musculoaponeurotic insertions of the internal oblique and
          All 60 patients successfully underwent 68 TEPP hernio-
          plasties (unilateral TEPP 54; bilateral TEPP 8). There was   transversus abdominis in the inguinal region.
                                                                 The PRS in the present study was found neither closely
          no conversion due to the difficult dissection secondary   applied nor attached/adherent to the undersurface of the
          to the so-called adhesions or inflammatory reactions.   rectus abdominis muscle. Our observations were in full
          There was no recurrence of inguinal hernia after TEPP   agreement with those of other authors. 19-21  This anatomic
          hernioplasty in the mean follow-up period of 33 ± 17   feature really facilitates the technical feasibility of not only
          months (5–61 months).
                                                              the rectus sheath technique of the TEPP hernioplasty, but
                                                              also the smooth avascular telescopic dissection, obviating
          DISCUSSION
                                                              the need of the specialized dissecting balloon.
          Wide anatomic variations observed in the present study are   Classical teaching describes the PRS as incomplete with
          in tune with the several previous reports of gross cadaveric  formation of the Arcuate line of Douglas at its lower end. 19-
          dissections. 3-6,15-18  No report on the live surgical anatomy of   21  However, this anatomic disposition is often lacking, 17,18
          the rectus sheath was available in the English literature to  and wide variations in the rectus sheath formation have
                                                                                            2
          the best of the author’s knowledge. It is interesting to recall  been reported from time-to-time.  Twelve subtypes of
                              17
          that in 1960, Anson et al  in their classic publication on 500  the PRS were documented in various proportions in the
          World Journal of Laparoscopic Surgery, January-April 2018;11(1):12-24                             21
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