Page 48 - World Journal of Laparoscopic Surgeons
P. 48

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-
                                                 1
          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
                                                  6
          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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