Posterior rectus sheath variations: surgical significance and clinical implications for laparoscopic hernia surgeons

Maulana M. Ansari


Background: Laparoscopic hernia surgeon needs accurate knowledge of not only of target inguinal region but also of adjacent access areas, but he/she is severely constrained by absence of research work on laparoscopic live surgical anatomy in literature.

Methods: Prospective study in patients who underwent laparoscopic total extra-peritoneal preperitoneal (TEPP) inguinal hernioplasty through 3-midline-port technique at Jawaharlal Nehru Medical College Hospital, Aligarh between 2010 and 2015.

Results: Sixty-eight TEPP repairs were performed in 60 adult patients. Overall incidence of conversion to Open/TAPP hernioplasty was 4% of all cases, but conversion secondary to the anatomic variation of short PRS was seen in only 1.4% of all cases. The endvision and ease of procedure (EOP) were 8.20±1.33 and 7.27±2.05 visual analog score respectively, and both of them were adversely affected in presence of variant PRS anatomy. Average operation time (OT) for unilateral TEPP hernioplasty was 1.9 hours and it was adversely affected in presence of variant PRS anatomy. Overall incidence of surgical emphysema was 16%, and its development was significantly more in presence of variant PRS anatomy. Overall incidence of peritoneal injury, postoperative seroma, infection and chronic pain was 28%, 10%, 6.7% and 1.5% respectively, but they were not affected by variant PRS anatomy.

Conclusions: Posterior Rectus Sheath Variations had significant impact on the intra-operative working but did not affect post-operative clinical outcome. Keen observation, timely recognition of anatomic variations and judicious dissection are essential keys for smooth conduct of the well-organized TEPP hernioplasty with ease, safety, rapidity and better results.


Anatomic variations, Laparoscopic inguinal anatomy, Posterior rectus sheath, Posterior rectus sheath variations, Surgical significance, TEPP anatomy

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