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The Formation Ofabdomino-Perinealsacs Clinical J. Anat. (1984), 138, 4, pp. 603-616 603 With 14 figures Printed in Great Britain The formation of abdomino-perineal sacs by the fasciae of Scarpa and Colles, and their clinical significance* B. F. MARTIN Department of Pathology, University of Birmingham, Birmingham B15 2TJ (Accepted 23 September 1983) INTRODUCTION By the middle of the nineteenth century the existence of a membranous layer on the deep aspect of the superficial fascia of the lower abdominal wall was well known. This layer was first mentioned by Scarpa (1809) in a report on hernia, but his descrip- tion was far from clear (Tobin & Benjamin, 1944). In addition, Colles (1811) had demonstrated in the perineum a membranous layer attached to the conjoined rami of the ischium and pubis, so determining the forward passage of urine from the perineum following urethral rupture. In 1854, Struthers made a detailed study of the membranous fascia, showing that the abdominal and perineal components are in direct continuity. He suggested that the use of a short, specific name for each component would be advantageous and, although the original descriptions were incomplete, proposed that they be referred to as the fascia of Scarpa and the fascia of Colles. His account of the fascia may be summarised as follows. The fascia of Colles (membranous layer of superficial perineal fascia) is attached to the base of the triangular ligament, or true deep fascia of the perineum (perineal membrane), and both are continuous with the fascia over the levator ani muscle. Laterally, the fascia is attached to the rami of the ischium and pubis; from there it crosses the origins of the gracilis and adductor longus muscles and becomes con- tinuous with Scarpa's fascia, which is attached to the fascia lata just below the inguinal ligament. Traced forwards from the triangular ligament it enters the scrotum, where it blends with the common superficial fascia and continues around the sperm- atic cord into Scarpa's fascia. Colles' fascia thus forms a closed pouch in the peri- neum (the superficial perineal pouch or space in current terminology), which opens forwards into the scrotum, and thence into a wide space between Scarpa's fascia and the aponeurosis of the external oblique muscle, which contains lax cellular tissue. He noted that the fascia is more distinctly membranous at its attach- ment sites, where it separates from the overlying layer. Although he described a dissection procedure for demonstrating the attachment of Scarpa's fascia in the groin, and showed that the superficial vessels and transverse group of inguinal lymph nodes lie in the space between it and the fatty layer, he did not trace it far above the groin but assumed its upward continuation. His observations on the relationships of the fascia to hernia and urinary extravasation will be presented later. * This investigation was undertaken whilst the author was in post in the Department of Anatomy, University of Birmingham. 20 ANA 138 604 B. F. MARTIN Accounts of the fascia by more recent investigators (Wesson, 1953) have not differed significantly from that of Struthers, and current textbooks of anatomy (Williams & Warwick, 1980) and surgical anatomy (DuPlessis, 1975) provide a similar description, although it is now recognised that on entering the scrotum the superficial layer loses its fat, acquires smooth muscle, and is known as the scrotal dartos muscle. A similar layer, known as the penile dartos, ensheathes the penile shaft as far as the coronary sulcus. Deep to the dartos, a dense membranous layer also ensheathes the shaft and is closely adherent to the tunica albuginea. Originally described by Buck (1848), it was reinvestigated by Wesson (1923, 1953), who stated that it arises from the deep fibres of the suspensory ligament of the penis, reinforced by an aponeurosis from the ischiocavernous muscles, and extends from the tri- angular ligament (the perineal membrane) to the coronary sulcus. He confirmed Buck's description of its arrangement in a figure ofeight, one compartment enclosing the corpora cavernosa and the other the corpus spongiosum. He also noted that the fasciae of Scarpa and Colles, together with the penile dartos, which he regarded as a continuation of Colles' fascia, are adherent to the superficial fibres of the sus- pensory ligament (the fundiform ligament). Not all investigators, however, have been convinced that the subcutaneous tissue of the lower abdominal wall is composed of two distinct layers, or that deep attach- ments exist. In their study of normal cadavers and those in which extravasation of urine had either occurred clinically or been simulated, Tobin & Benjamin (1944, 1949) concluded that the deep membranous layer of the superficial fascia is created by dexterous dissection of a cleavage plane and, furthermore, their histological studies of the lower abdominal wall revealed only interlacing collagen bundles within a single fascial layer. Although the superficial fatty layer is sometimes re- ferred to as the fascia of Camper, these authors found no reference to this layer in any of Camper's publications. In the present investigation, dissection of the fascia of the lower abdominal wall and its continuation into the perineum has been undertaken on embalmed cadavers and, in the light of the observations made, radiological studies on fresh cadavers performed. These studies confirm the arrangement and attachments of the mem- branous layer revealed by dissection. METHODS AND OBSERVATIONS Studies by dissection This part of the investigation was carried out on nineteen cadavers (nine males and ten females). The initial observations on the fascia of the abdominal wall were made on three male and three female specimens. More detailed studies of its overall distribution, including its perineal extension, were then undertaken on six males and seven females. In one male cadaver, the sac of a left indirect inguinal hernia was present and this specimen was considered separately. Following close dissection of the skin from the subcutaneous fascia, it was noted that the latter was very loosely attached to deeper structures just above the pubic tubercle. When the fascia was pinched up and incised, a subcutaneous sac with clearly defined margins was exposed. The sac was oval in form and oblique in direction. The long axis extended from the pubic tubercle to the mid-point of a vertical line between the anterior superior iliac spine and the costal margin. This point lay approximately at the level of the umbilicus or a little below it. In most cases the Superficialfascia ofabdomen andperineum 605 .i"...Y. .. F" . 7 "R .R. \ i..', BM>f ./r .' ..~ ~ ~ ~~~,.i. ·'- ., '.~. A ... Mt CR|j/\~~~~~~~~~~~~":.~:^......Y-~~~:~_,',' Fig. 1. Male cadaver. The subcutaneous abdominal sacs have been opened along their main axes. The right sac is shorter than average. Fig. 2. Female cadaver. The right sac is shorter than average. The outer margin of the sac crosses the inguinal ligament medial to the anterior superior iliac spine (arrow) and becomes attached to the crease-line of the groin (CR). See Figure 5. Fig. 3. Female cadaver. The entrances to the perineal pockets of the sac are separated by fascial bands. The medial pocket (L) is a little anterior to the others and is associated with the labium majus. The intermediate (R) is associated with the round ligament of the uterus and the lateral (P) with the superficial perineal pouch. Compare Figure 6. Fig. 4. Female cadaver. The whole of the fatty subcutaneous layer (held in outer forceps) has been reflected from the incisions into the sacs. The sacs are formed by Scarpa's membranous fascia (held in inner forceps), which does not extend beyond their attached margins. 20-2 606 B. F. MARTIN length of the axis was 18-20 cm but in four specimens the sac of one side was shorter than the other and measured 12-5 cm; examples are shown in Figure 1 (male) and Figure 2 (female). In one male specimen both sacs were only 12-5 cm in length. The deep surface of the subcutaneous fascia which enclosed the sac was formed by a thin membranous layer which was intimately adherent to the overlying fatty layer, whilst its free surface was smooth and glistening. This layer, which will be referred to as Scarpa's fascia, formed the margins of the sac by its adhesion to the thin layer of deep fascia covering the aponeurosis of the external oblique muscle, described by Gallaudet (1931). Inferiorly, the abdominal sac extended into the perineum by means of three pocket-like diverticulae, each of which admitted a finger. In the female, they were narrower and commonly occupied by adhesions, which needed to be broken down by finger pressure before they were clearly defined. It was found that they extended to the level of the clitoris. The diverticulae, referred to for convenience as pockets, originated just below the superior margin of the pubis, which was therefore taken to be the level at which Scarpa's fascia continued into the fascia of Colles. The entrances to the pockets, shown in Figure 3 (female) and Figure 6 (male), were formed by the subdivision of the perineal extension of the abdominal sac by two dense fascial bands. From each band a thin septum continued inferiorly and thereby subdivided the extension into three pockets. In both sexes the medial pocket lay a little anteriorly to the other two. Investigations to determine the overall distribution of Scarpa's fascia and the relationships of the pockets in the perineum were also commenced by removing the abdominal skin from the subcutaneous fascia and incising the abdominal sac along its axis. It was possible to separate Scarpa's fascia from the overlying fatty layer by commencing the dissection at the margins of the incision. The fatty layer was continuous with the general fatty layer of the abdominal wall, and this layer continued without interruption into the thigh.
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