| Purpose1.The aim of this study was to observe and describe the fascial layers,communications,spaces,derivatives and anatomical landmarks related to laparoscopic trans-umbilical totally extraperitoneal hernioplasty,through an anatomical study and a laparoscopic surgery observation.And explore a better way to establish the preperitoneal space,separate the hernia sac of laparoscopic trans-umbilical totally extraperitoneal hernioplasty.2.This study also retrospectively analyzed the efficacy and safety of sharp fascia dissection of laparoscopic trans-umbilical totally extraperitoneal hernioplasty.Method1.8 groin area of 4 adult male specimens fixed by formalin were observed,and intraoperative observation and postoperative review video method were used for 20 patients treated with totally laparoscopic extraperitoneal inguinal hernia repair in our hospital to observe,analyze and describe the anatomical characteristics of abdominal front wall and groin area.The layers,communications and anatomical landmarks of fascia were researched.2.We establish the preperitoneal space by a sharp fascia dissection basing on previous anatomical study of fascia,and evaluate its feasibility.A retrospectively analysis was carried out for 96 patients treated by laparoscopic trans-umbilical totally extraperitoneal hernioplasty from 2018-01-01 to 2018-06-30 in our hospital,according to the surgical method for establishing the preperitoneal space,they were divided into observation group(n=:52)and control group(n=44).Sharp fascia dissection was performed to establish the preperitoneal space in observation group.Telescopic dissection was used to establish the preperitoneal space in control group,the treatment data,baseline characteristics and postoperative complications were compared between the two groups.Results1.Anatomic observation resultsa)abdominal front wallⅰ In the caudal side of umbilicus,the tissues between the rectus abdominis and peritoneum including:the epimysium of rectus abdominis,superficial layer of transversalis fascia,interlayer fat of transversalis fascia,deep layer of transversalis fascia,umbilical bladder fascia and extraperitoneal fat.ⅱ The epimysium of rectus abdominis is in front of the posterior layer of rectus sheath;through this membrane,the free lower edge of posterior layer of rectus sheath is seen,which is called "arcuate line".ⅲ Posterior to the rectus abdominis,following a thin superficial layer of transversalis fascia and a thick deep layer of transversalis fascia.There is an interlayer space between the two layers of transversalis fascia,and the space contains interlayer fat.ⅳ Deep in the posterior layer of transversalis fascia,there is an umbilical bladder fascia.The umbilical bladder fascia distributes from the umbilicus to the bladder.The space between the posterior layer of transversalis fascia and umbilical bladder fascia is filled with loose connective tissue.b)groin areaⅰ The transversalis fascia and the rectus abdominis form a longitudinal dense adhesion,which is called as a "space separation ligament".The preperitoneal space of the anterior abdominal wall is divided into Retzius’space and Bogros’space by this ligament.ii The transversalis fascia wraps the deferent duct,testicular vessels,and reproductive femoral nerves,forming a transverse fascia "reproductive sheath".iii Incise the anteromedial wall of the transversalis fascia sheath,we can see an indirect inguinal hernia,if the peritoneum enters into the inguinal canal.iv The anterolateral transversalis fascia of the sheatht thickening to form the tractus iliopubicus;on the lateral side of the transversalis fascia,lateral femoral cutaneous nerve is locating between the musculus trasversus abdominis and transversalis fascia.The outer and lower edge of the peritoneal reflex is located in the outer part of the sheath.v The anteromedial,anterior,anterolateral and lateral wall of the indirect hernial sac is transversalis fascia,genitourinary fascia is posterior to the peritoneal sac.2.There was no significant difference in gender,age,BMI(body mass index),type of inguinal hernia,classification of inguinal hernia,the site of hernia(left and right)and comorbidity between the two groups.Compared to telescopic dissection,sharp fascia scissors dissection has a significant advantage in term of operation time(68.7±22.39 vs 80.4±20.43,P=0.009)and intraoperative blood loss(10.2±5.25 vs 16.4±11.52,P=0.002)..and has a low incidence of postoperative foreign body sensation(3.8%vsl5.9%,P=0.043),There were no recurrences or deaths.And there was no significant difference in postoperative hospital stay,hospitalization expenses,VAS score on the first postoperative day,short-term postoperative complications and postoperative chronic pain,(P>0.05).Conclusion1.Abdominal front wall:the fusion fascial space between the deep layer of transversalis fascia and the umbilical bladder fascia is a natural surgical space for the medial dissection of laparoscopic trans-umbilical totally extraperitoneal hernioplasty.The posterior layer of rectus sheath,arcuate line,the umbilical branch of inferior epigastric artery,interlayer fat of transversalis fascia,the pubic symphysis,the pectineal ligament,the external iliac vein and the bladder are anatomical landmarks for the medial dissection.2.groin area:the deferent duct and testicular vessels are covered with a genitourinary fascia,which continues from the prerenal fascia.Between the genitourinary fascia and the deep layer of transversalis fascia there is a natural surgical space for free the hernial sac.Space between the genitourinary fascia and anterior,external,posterior wall of the transversalis fascia is a surgical plane for free the peritoneal reflex.The inferior epigastric artery,the tractus iliopubicus,and the internal ring are anatomical landmarks for the lateral dissection of laparoscopic trans-umbilical totally extraperitoneal hernioplasty.3.Sharp fascia scissors dissection follows the principle of fascial space anatomy,and operates under a direct vision in the natural surgical space during the creation of preperitoneal space,maximum maintain the integrity of fascia,reduce the secondary damage.It’s is safe and effective.And it has the advantages of less intraoperative bleeding,shorter operation time,and lower incidence of postoperative foreign body sensation compared with telescopic dissection.It can be chosen as one of the methods to establish the preperitoneal space. |
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