Retzius Space: Not A Single Anatomical Entity: New Insights, Simplified & Illustrated in A Laparoscopic Study during TEPP Hernioplasty for Inguinal Hernia

ABSTRACT

Background: Casual internet surfing at times proves extremely rewarding with astonishing results. Chance finding of an unknown old PhD thesis prompted documentation of detailed description of retropubic spaces supplementary to the author’s recent publication (Ansari MM. Ann Int Med Den Res 2017; 3(5) SG25-31.). Methods: Prospective study in adult patients with inguinal hernia who underwent laparoscopic total extra-peritoneal preperitoneal (TEPP) hernioplasty through standard 3-midline-port technique at J. N. Medical College, Aligarh between 2010 and 2015. Results: Under excellent fibre-optic light and magnified view during preperitoneal laparoscopy, multiple potential retropubic spaces were observed in the retropubic region, ranging from 4 to 7 in number. A total of four fissile potential retropubic spaces were recognized in 46 cases of TEPP hernioplasty when the posterior rectus sheath was incomplete (single- or double-layered) and the preperitoneal fascia as well as transversalis fascia was single-layered; a total of five fissile potential retropubic spaces were observed when preperitoneal fascia was double-layered along with presence of a single- or double-layered incomplete posterior rectus sheath (N=8); a total of five fissile potential retropubic spaces was also observed when the preperitoneal fascia was single-layered and the posterior rectus sheath was found single-layered but complete extending upto the pubic bone (N=10); a total of six fissile potential retropubic spaces were observed when the preperitoneal fascia was double-layered along with the presence of a single-layered complete posterior rectus sheath (N=3); and a maximum of seven fissile potential retropubic spaces was recognized, given the presence of a double-layered complete posterior rectus sheath and a double-layered preperitoneal fascia at the same time (N=1). Conclusion: Instead of a single Retzius space, multiple loosely fissile potential interfascial spaces (4-7) were documented in retropubic region, necessitating re-evaluation of Retzius space anatomy, in order to help TEPP hernia surgeon to execute the procedure with ease, rapidity and safety.