Ansari Maulana Mohammed
Department of General Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India.
Turk J Surg. 2019 Dec 16;35(4):299-308. doi: 10.5578/turkjsurg.4334. eCollection 2019 Dec.
Posterior rectus canal assumed immense importance with newer laparoscopic technique of total extra-peritoneal pre-peritoneal (TEPP/TEP) hernioplasty for inguinal hernia. However, scientific study of live surgical anatomy of posterior rectus canal is almost totally lacking in the English literature, and hence the present study was conducted.
3-midline-port technique through posterior rectus sheath approach; Initial telescopic dissection under direct CO2 insufflation followed by instrument dissection.
68 TEPP hernioplasties were successful in 60 patients with mean age of 50.1 ± 17.2 years (range 18-80) and mean BMI of 22.6 ± 2.0 kg/m2 (range 19.5-31.2). Rectusial fascia was a definite anatomical entity, dividing traditional posterior rectus canal into two channels, namely, true retromuscular space and true posterior rectus canal (T-PRC). Rectusial fascia was variable, i.e., thick diaphanous (n= 47), thick membranous (n= 13), thin membranous (n= 3) and thin flimsy (n= 5). Posterior rectus sheath (PRS) was also variable, incomplete (n= 54) and complete (n= 14). Incomplete PRS showed seven variations in both extent and/or morphology. Complete PRS show five morphological variations. Transversalis fascia demonstrated three morphological variations, namely, single diaphanous (n= 41), single membranous (= 10) and thin flimsy (n= 3). TEPP hernioplasty was readily feasible through avascular true posterior rectus canal.
Posterior rectus canal is divided by 'rectusial fascia' into two channels, namely, true retromuscular space and true posterior rectus canal, latter being proper avascular plane of dissection for TEPP hernioplasty. Rectusial fascia, posterior rectus sheath and transversalis fascia showed morphological variations. Timely recognition of variable real-time anatomy is recommended to perform adequate proper surgical dissection for seamless TEPP hernioplasty with ease, rapidity and safety.
随着腹股沟疝全腹膜外腹膜前（TEPP/TEP）疝修补术这种更新的腹腔镜技术的出现，腹直肌后间隙变得极为重要。然而，英文文献中几乎完全缺乏对腹直肌后间隙活体手术解剖的科学研究，因此开展了本研究。
采用经腹直肌后鞘入路的三中线端口技术；在直接二氧化碳气腹下进行初始的腹腔镜下分离，随后进行器械分离。
60例患者成功实施了68例TEPP疝修补术，患者平均年龄为50.1±17.2岁（范围18 - 80岁），平均体重指数为22.6±2.0kg/m²（范围19.5 - 31.2）。腹直肌筋膜是一个明确的解剖结构，将传统的腹直肌后间隙分为两个通道，即真正的肌后间隙和真正的腹直肌后间隙（T - PRC）。腹直肌筋膜形态各异，即厚而透明（n = 47）、厚膜状（n = 13）、薄膜状（n = 3）和薄而脆弱（n = 5）。腹直肌后鞘（PRS）也各不相同，不完整（n = 54）和完整（n = 14）。不完整的PRS在范围和/或形态上有七种变异。完整的PRS有五种形态变异。腹横筋膜表现出三种形态变异，即单一透明（n = 41）、单一膜状（n = 10）和薄而脆弱（n = 3）。通过无血管的真正腹直肌后间隙进行TEPP疝修补术很容易实施。
腹直肌后间隙被“腹直肌筋膜”分为两个通道，即真正的肌后间隙和真正的腹直肌后间隙，后者是TEPP疝修补术合适的无血管解剖平面。腹直肌筋膜、腹直肌后鞘和腹横筋膜表现出形态变异。建议及时识别可变的实时解剖结构，以便轻松、快速且安全地进行充分恰当的手术分离，实现无缝的TEPP疝修补术。
