Comment to: Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space (N. Asakage).

Modern high-definition laparoscopy has often revealed new visions of the structures known for centuries, and discovery of new structures like 'rectusial fascia', additional morphology of the 'preperitoneal fascia' and multiple Retzius spaces greatly facilitated accurate and judicious dissection for seamless laparoscopic inguinal hernioplasty. Dr. N. Asakage's presentation of inguino-pelvic fascial anatomy and its embryology [Asakage N. Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space. Hernia 2018 Feb 27. https://doi.org/10.1007/s10029-018-1746-8 (Epub ahead of print)] is excellent and fascinating, albeit with certain reservations highlighted herein.

Posterior rectus canal: not a single anatomical entity & morphology - a laparoscopic study during TEP hernioplasty.

OBJECTIVES: 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. MATERIAL AND METHODS: 3-midline-port technique through posterior rectus sheath approach; Initial telescopic dissection under direct CO2 insufflation followed by instrument dissection. RESULTS: 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. CONCLUSION: 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.

Isolated corrosive pyloric stenosis without oesophageal involvement: an experience of 21 years.

BACKGROUND AND STUDY AIMS: Corrosive ingestion is common in Asia and it is a frequent cause of morbidity secondary to intense fibrotic reaction and stricture formation of the oesophagus. Isolated corrosive pyloric stenosis without oesophageal involvement is an uncommon phenomenon. PATIENTS AND METHODS: All consecutive patients, with corrosive ingestion in the last two decades, were reviewed and analysed. Eleven out of 201 patients with corrosive ingestion had isolated gastric outlet obstruction. RESULTS: Patients' age ranged from 11 to 29 years with a male:female ratio of 1.75:1. All patients developed pyloric stenosis following ingestion of solution of acids. Barium study revealed complete/near-complete gastric outlet obstruction in all patients. On laparotomy, there was gastric dilatation in 10 patients, who underwent posterior gastrojejunostomy, whereas the stomach was contracted in one patient, and hence anterior gastrojejunostomy was performed. Seven patients were completely relieved of their symptoms; persistent postprandial epigastric fullness and/or dyspepsia was observed in four patients whose gastrojejunostomy stoma was found adequate on barium study, suggestive of gastric motility disorder. We did not encounter gastrojejunostomy-related complication of stomal ulcer/stenosis in our patients. CONCLUSION: Isolated corrosive pyloric stenosis is not as rare as is commonly thought. Gastrojejunostomy is effective, although a fair percentage of patients appear to develop gastric motility disorder secondary to corrosive injury.

Foreign body granuloma in the anterior abdominal wall mimicking an acute appendicular lump and induced by a translocated copper-T intrauterine contraceptive device: a case report.

INTRODUCTION: Intrauterine contraceptive devices may at times perforate and migrate to adjacent organs. Such uterine perforation usually passes unnoticed with development of potentially serious complications. CASE PRESENTATION: A 25-year-old woman of North Indian origin presented with an acute tender lump in the right iliac fossa. The lump was initially thought to be an appendicular lump and treated conservatively. Resolution of the lump was incomplete. On exploratory laparotomy, a hard suspicious mass was found in the anterior abdominal wall of the right iliac fossa. Wide excision and bisection of the mass revealed a copper-T embedded inside. Examination of the uterus did not show any evidence of perforation. The next day, the patient gave a history of past copper-T Intrauterine contraceptive device insertion. CONCLUSIONS: Copper-T insertion is one of the simplest contraceptive methods but its neglect with inadequate follow-up may lead to uterine perforation and extra-uterine migration. Regular self-examination for the "threads" supplemented with abdominal X-ray and/or ultrasound in the follow-up may detect copper-T migration early. To the best of our knowledge, this is the first report of intrauterine contraceptive device migration to the anterior abdominal wall of the right iliac fossa.