Posterior Rectus Sheath: A Prospective Study of Laparoscopic Live Surgical Anatomy during Total Extraperitoneal Preperitoneal Hernioplasty

Abstract

Aim: Posterior rectus sheath (PRS) recently assumed great importance during laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty. However, literature is scanty and cadaveric. Novel observations on live PRS anatomy are reported here. Materials and methods: Totally, 60 male patients with primary inguinal hernia underwent 68 TEPP hernioplasties. Standard 3-midline-port technique was used with telescopic dissection. Data were analyzed as mean ± standard deviation (SD). Results: All patients were male with mean age and body mass index of 50.1 ± 17.2 years (18–80) and 22.6 ± 2.0 kg/m2 (19.5–31.2) respectively. The classically described PRS (normal-length whole tendinous) was found in only 46% of the cases, while in the remaining 54%, the PRS was found as variant types, which included short whole-tendinous (4.4%), long whole tendinous (LWT) (4.4%), complete-length whole tendinous (8.8%), normal-length partly tendinous (NPT) (11.8%), long partly tendinous (LPT) (10.3%), normal-length thinned-out (NTO) (1.5%), complete-length thinned-out (4.4%), normal-length grossly attenuated (1.5%), complete-length grossly attenuated (4.4%), complete-length partly tendinous (CPT) (1.5%), and complete-length musculo-tendinous (CMT) (1.5%). Additionally, anatomy of the PRS was not a mirror image on the two sides of the body in 75% of patients with bilateral hernias. No hernia recurrence occurred in mean follow-up of 33 months. Conclusion: Posterior rectus sheath varied markedly in its extent and morphology, resulting in its categorization of 12 types. Truly new visions of the structures known for centuries are realized under excellent perspective and magnification of laparoscopy, and, therefore, continued anatomic research is strongly recommended. Clinical significance: Crisp, precise knowledge of preperitoneal anatomy is of paramount importance for timely identification of its variations in order to perform a seamless laparoscopic hernia repair with better outcome.