Intertransversalis Fascia Approach in Urologic Laparoscopic Operations

Home , Extraperitoneal space, Rectus sheath, Transversalis fascia

ORIGINAL ARTICLE Intertransversalis Fascia Approach in Urologic Laparoscopic Operations

Gang Li, MD; Yeyong Qian, MM; Hongwei Bai, MD; Zhigang Song, MM; Baofa Hong, MB; Jinfeng Jia, MB; Bingyi Shi, MM; Xu Zhang, MD

Objectives: To study the clinical anatomy of the trans- taken from the intertransversalis fascia approach in ULOs, versalis fascia (TF) and to explore the intertransversalis micrographs were obtained to examine the microscopic fascia approach in urologic laparoscopic operations structure of the TF, and the color atlas of TF anatomy (ULOs). (cross and sagittal sections) was drawn.

Design: Prospective study. Results: The TF is a general plane of connective tissue lying between the inner surface of the transversus abdo- Setting: Two academic hospitals. minis and the extraperitoneal fat. It can be divided into 2 layers (superficial and deep), with an amorphous fi- Other Participants: Data from 1217 urologic laparo- broareolar space between them. The intertransversalis fas- scopic or open operations and 10 laparoscopic hernia cia approach in ULOs is the approach between the 2 lay- repairs were analyzed between January 1, 2009, and ers of the TF. April 30, 2011. Findings from 3 fresh autopsies were also included. Conclusions: The intertransversalis fascia approach is described for the first time, to our knowledge. Surgeons Main Outcome Measures: The anatomy of the TF was can obtain a clean, clear, and bloodless operating space studied and the intertransversalis fascia approach was ex- in ULOs using the intertransversalis fascia approach. plored in ULOs; furthermore, they were proved in the open operations and fresh autopsies. Photographs were Arch Surg. 2012;147(2):159-167

N UROLOGIC RETROPERITONEAL tablishment of the operating space for ret- and extraperitoneal laparo- roperitoneal and extraperitoneal laparoscopic operations, surgeons need scopic operations. In this research, we to dilate the potential fascial space study the clinical anatomy of the TF and into a larger space for further op- explore the intertransversalis fascia ap- Ieration. Therefore, it is important to iden- proach for urologic laparoscopic opera- tify the retroperitoneal or extraperitoneal tions (ULOs). fascia and fascial spaces. If the balloon dissector is placed in the exact fascial space, METHODS See Invited Critique at end of article ENROLLMENT Between January 1, 2009, and April 30, 2011, a clean and clear space without hemorrhage in 309 and 301 Hospitals of PLA, data from can be achieved after balloon dilatation, 1217 urologic laparoscopic or open opera- which will undoubtedly benefit further op- tions and 10 laparoscopic hernia repairs were eration. Otherwise, the normal fascial lay- analyzed (Table). Findings from 3 fresh au- ers will be destroyed by the dilation, and topsies were also included. the fascial space will be filled with blood Author Affiliations: Institute of and fiber, which will affect the next ma- SURGICAL TECHNIQUE Organ Transplant of Chinese nipulation. PLA, 309 Hospital of PLA, According to Gray’s Anatomy, the trans- Intertransversalis Fascia Approach (Drs Li, Bai, and Jia and Messrs versalis fascia (TF) is a thin layer of con- During Retroperitoneal Laparoscopic Qian and Shi), and Departments Left Nephrectomy of Urology (Drs Li and Zhang nective tissue lying between the inner sur- and Mr Hong) and Pathology face of the transversus abdominis and the The patient is placed in the right lateral decu- (Mr Song), 301 Hospital of extraperitoneal fat.1 It is one of the most bitus position with overextension. A 2-cm in- PLA, Beijing, China. important anatomical markers during es- cision is made below the 12th rib in the pos-

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on March 6, 2012 the laparoscopic view. Then, we divide the urachus high above Table. Operations Involved in This Study the bladder using a hook electrocautery device, identify the 2 layers of the TF, and separate the intertransversalis fascia space No. for further operation (Figure 1C). Operation Performed Urologic operations Obtaining a Sample for Histologic Examination Retroperitoneal laparoscopic adrenalectomy 233 Retroperitoneal laparoscopic (partial) nephrectomy 588 A piece of tissue was cut from the abdominal wall in the left Retroperitoneal laparoscopic nephroureterectomy 74 middle axillary line below the 12th rib (thickness from the peri- Retroperitoneal laparoscopic pelvilithotomy/ 15 toneum to the transversus abdominis) during fresh autopsy. ureterolithotomy Retroperitoneal laparoscopic nephropyeloplasty 34 Retroperitoneal laparoscopic unroofing of kidney cyst 80 OUTCOMES Extraperitoneal laparoscopic radical prostatectomy 76 Laparoscopic radical/partial cystectomy 32 Photographs of the intertransversalis fascia approach in ULOs Excision of carcinoma of urachus 1 were taken (Figures 2, 3, and 4). The color atlas of TF anatomy Lumbar nephrectomy 13 (cross and sagittal sections) was drawn (Figure 5). And the Laparonephrectomy 24 Kidney transplantation 35 microscopic structure of the TF was observed by microscope Radical/partial cystectomy 5 (Figure 6). Suprapubic prostatectomy 7 Total 1217 RESULTS Laparoscopic hernia repairs Transabdominal preperitoneal repair 8 Total extraperitoneal repair 2 COLOR ATLAS OF TF ANATOMY Total 10 The TF is a general plane of connective tissue lying between the inner surface of the transversus abdominis and terior axillary line. The muscular layer, lumbodorsal fascia, and the extraperitoneal fat, and it can be divided into 2 layers: superficial layer of the TF are bluntly divided. Then, the fore- superficial and deep (Figure 5). The superficial layer of finger is inserted to separate the space between the 2 layers of the TF closely covers the internal surface of the transver- the TF bluntly. A balloon dissector is placed into the inter- sus abdominis and the aponeurosis; thus, dissection be- transversalis fascia space, and 600 mL of gas is infused to main- tain the balloon dilatation (Figure 1A). The gas is then evacu- tween them is relatively difficult. An amorphous fibro- ated, and the balloon dissector is removed. Under the guidance areolar space is filled with fat and loose fibrous tissue of the forefinger extending into the space through the inci- between the superficial and deep layers of the TF. The fi- sion, a 10-mm puncture cannula is inserted 2 cm above the su- ber matrix in the space becomes thick and dense in the perior border of the iliac crest in the midaxillary line. The lapa- region of the myopectineal orifice, and fatty tissue be- roscope is placed through the trocar, and the carbon dioxide comes abundant in the retroperitoneal region. There is also insufflator is connected with a pressure of 14 mm Hg. Other a loose amorphous fibroareolar space between the deep trocars are then inserted under the laparoscopic view. layer of the TF and the peritoneum, which is filled with fat and loose fibrous tissue and contains the medial um- Intertransversalis Fascia Approach During bilical ligament, median umbilical ligament, and bladder Extraperitoneal Laparoscopic Radical Prostatectomy in the central aspect of the lower anterior abdominal wall. Superiorly, the 2 layers of the TF fuse and blend with The patient is placed in a Trendelenburg position. A 1.5-cm the fasciae covering the inferior surface of the dia- incision is made at the base of the umbilicus, the anterior rec- phragm. Anteriorly, the superficial layer of the TF forms tus sheath is incised transversely, and the rectus abdominis muscles are pulled aside bluntly. Using blunt forefinger dis- a continuous sheet covering the inner surface of the trans- section along the surface of the posterior rectus sheath, the su- versus abdominis and the posterior rectus sheath (or rec- perficial layer of the TF is torn, and then the space between tus abdominis), and the deep layer of the TF covers the the 2 layers of the TF is reached by the forefinger. A balloon outer surface of the peritoneum. Posteriorly, the 2 lay- dilator is inserted into the intertransversalis fascia space, and ers join together and form a continuous sheet anterior 1200 mL of gas is infused to develop the space (Figure 1B). The to the lumbar fascia, but the binding site of these 2 lay- gas is then evacuated, and the balloon dissector is removed. A ers keeps moving. For example, these 2 layers join to- 10-mm puncture cannula is inserted at the umbilicus inci- gether in the outer edge of the quadratus lumborum sion. The laparoscope is placed through the trocar, and the car- muscle on the renal hilum plane and in the outer edge bon dioxide insufflator is connected with a pressure of 14 of the psoas major muscle on the third lumbar vertebra mm Hg. Other trocars are then inserted under the laparoscopic view. plane. Inferiorly, the TF is continuous with the pelvic fascia, which can also be divided into 2 layers. The super- Intertransversalis Fascia Approach During ficial layer covers the inner surface of the inguinal re- Transperitoneal Laparoscopic Partial Cystectomy gion, iliacus, psoas major muscle, and external iliac vessels and forms the opening of the deep inguinal ring. The deep Pneumoperitoneum is established using open trocar place- layer covers the former half of bladder and prostate and ment and the Hasson technique. The laparoscope is placed forms a conical sheath around the vas deferens and sper- through the trocar, and the insufflation pressure is main- matic vessel in males (or the round ligament of the uterus tained at 14 mm Hg. The other trocars are then placed under in females) as the internal spermatic fascia.

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The intertransversalis fascia approach is the approach between the 2 layers of the TF. Photographs of the intertransversalis fascia approach were taken during retroperitoneal laparoscopic left nephrectomy (Figure 2),

extraperitoneal laparoscopic radical prostatectomy 1 (Figure 3), and transperitoneal laparoscopic partial cys- 2 3 tectomy (Figure 4). We can see the superficial and deep 4 layers of the TF, the fat, and the white reticular fibers be- 5 tween the 2 layers. The retroperitoneal space, extraperi- 6 7 toneal space, Retzius space, and Bogros space are parts 9 of the space between the 2 layers of the TF. The inferior epigastric vessels penetrate the superior layer of the TF as it originates from the external iliac vessels and run in the matrix between the 2 layers (Figure 3C) and then they penetrate the superficial layer of the TF at the level of B the linea arcuata and run into the rectus sheath (Figure 5A-C). Moreover, the superficial branch of the deep dorsal vein of the penis in the Retzius space also penetrates the superior layer of the TF and drains into 1 2 the deep dorsal vein of the penis (Figures 5D and 3E). 3 4 5 HISTOLOGIC EXAMINATION OF THE TF 6 7 8 Seven layers of structure, from the transversus abdomi- 9 nis to the peritoneum, can be observed under the microscope in the left middle axillary line below the 12th rib (Figure 6). The histologic examination further proves the 2-layer structure of the TF.

COMMENT

C In traditional open surgery, surgeons do not adequately as- sess the TF and fascial spaces, which are usually cut open as a single fascial plane. During the ULO, surgeons need to find the correct potential fascial space and dilate it into a larger space for further operation. Therefore, it is impor-

tant for surgeons to grasp the anatomy of the TF and fas- 1 cial spaces. In this study, we described the intertransver- 2 salis fascia approach for the first time, to our knowledge, 3 which will help surgeons obtain a clean and clear operating space without hemorrhage during the ULO. 4 There has been much confusion about the exact defi- 5 nition, anatomy, composition, and significance of the TF 6 and fascial spaces.1-16 Cooper originally described the structure of the TF in 1804 as a thin layer of fascia extending upward from the superficial femoral arch (ie, inguinal ligament) and covering the internal surface of the abdominal muscle aponeurosis2; then he defined it as the TF in 1844.3 Some other scholars had different views on the definition of the TF. Skandalakis et al4 illustrated it as “the entire connective tissue sheet lining the muscu- Figure 1. Balloon dilation in the intertransversalis fascia space. A, The balloon lature of the abdominal cavity.” Their description was also dissector is inserted into the intertransversalis fascia space from the incision 5 6 below the 12th rib in the posterior axillary line. B, The balloon dissector is accepted by Spangen. Braus defined the TF as all the inserted into the intertransversalis fascia space from the incision at the base of tissue between the transversus abdominis and the peri- the umbilicus. C, The 2 layers of the transversalis fascia (TF) are separated in toneum. Condon7 noted that the “TF covers the internal the peritoneum. 1 indicates peritoneum (blue); 2, fascial space between the deep layer of the TF and the peritoneum; 3, deep layer of the TF (red); 4, fascial surface of the transversus abdominis muscle and apo- space between the 2 layers of the TF; 5, superficial layer of the TF (green); neurosis, separating them from the underlying preperi- 6, fascial space between the superficial layer of the TF and the transversus toneal fat and peritoneum.” Neil1 stated in Gray’s Anatomy: abdominis; 7, transversus abdominis; 8, linea alba; and 9, balloon dissector.

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Figure 2. Intertransversalis fascia approach during retroperitoneal laparoscopic left nephrectomy. A, Posteriorly, the 2 layers of the transversalis fascia (TF) fuse in the outer edge of the quadratus lumborum muscle. B, Superiorly, the 2 layers of the TF fuse and blend with the fascial covering of the inferior surface of the diaphragm. C, Posteriorly, the binding site of the 2 layers of the TF keeps moving inferiorly and interiorly from the quadratus lumborum muscle to the psoas major muscle. D, Anteriorly, the 2 layers of the TF fuse in the anterior axillary line and superficially cover the peritoneum in the anterior abdominal wall; deeper to the deep layer of the TF, it is the perirenal fascia near the quadratus lumborum muscle and the peritoneum near the anterior axillary line. E, Incising the deep layer of the TF near the peritoneal fold and dissecting between the deep layer of the TF and the underlying perirenal fascia, we can then reach the peritoneum. F, Incising the perirenal fascia, we can see the deep perirenal fat. 1 indicates the superficial layer of the TF (covering the interior surface of the transversus abdominis); 2, superficial layer of the TF (covering the anterior surface of the quadratus lumborum muscle); 3, superficial layer of the TF (covering the anterior surface of the psoas major muscle); 4, superficial layer of the TF (covering the inferior surface of the diaphragm); 5, deep layer of the TF (superficially covering the perirenal fascia); 6, deep layer of the TF (superficially covering the peritoneum); 7, deep layer of the TF (superficially covering the peritoneum fold line); 8, binding line of the 2 layers of the TF; 9, white reticular fibers between the 2 layers of the TF; 10, fat between the 2 layers of the TF; 11, peritoneum; 12, perirenal fascia; and 13, perinephric fat.

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Figure 3. Intertransversalis fascia approach during extraperitoneal laparoscopic radical prostatectomy. A, The space between the 2 layers of the transversalis fascia (TF) in the region of the anterior inferior abdominal wall. B, The space between the 2 layers of the TF in the left anterior inferior abdominal wall. C, The inferior epigastric vessel runs between the 2 layers of the TF. D, The space between the 2 layers of the TF in the left inguinal region. E, Cutting off the superficial branch of the deep dorsal vein of the penis embedded in the fat in the Retzius space. F, Cutting off the superficial branch of the deep dorsal vein of the penis and cleaning up the fat in the Retzius space, then we can then see the deep layer of the TF superficially covering the prostate. 1 Indicates the superficial layer of the TF (covering the interior surface of the rectus abdominis muscle); 2, superficial layer of the TF (covering the interior surface of the transversus abdominis); 3, superficial layer of the TF (covering the interior surface of the pubis); 4, deep layer of the TF (superficially covering the peritoneum); 5, deep layer of the TF (superficially covering the left external iliac vessel); 6, deep layer of the TF (superficially covering the bladder); 7, deep layer of the TF (superficially covering the prostate); 8, white reticular fibers between the 2 layers of the TF; 9, fat between the 2 layers of the TF; 10, left inferior epigastric vessel (running through the space between the 2 layers); 11, left pubic vein; 12, superficial branch of the deep dorsal vein of the penis; 13, Retzius space; and 14, Bogros space.

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Figure 4. Intertransversalis fascia approach during transperitoneal laparoscopic partial cystectomy. A, After establishment of pneumoperitoneum, we can see the posterior aspect of the median umbilical ligament and the bladder. B, The peritoneum and urachus are incised, and the transversalis fascia (TF) is exposed. C, The TF is incised, and the rectus abdominis is exposed. D, The 2 layers of the TF are identified. E, The space between the 2 layers of the TF was bluntly separated. F, We can reach the Retzius space between the 2 layers of the TF. 1 indicates peritoneum (covering the interior surface of the median umbilical ligament); 2, peritoneum (covering the interior surface of the bladder); 3, peritoneum; 4, fat between the peritoneum and the deep layer of the TF; 5, deep layer of the TF; 6, superficial layer of the TF; 7, white reticular fibers between the 2 layers of the TF; 8, fat between the 2 layers of the TF; 9, rectus abdominis muscle; 10, white reticular fibers between the rectus abdominis muscle and the superficial layer of the TF; and 11, pubis.

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on March 6, 2012 1 2 10 3 4 11 12 13 14 5 6 15 A D 26 Left 39 Left 38 5 9 47 8 3 7 36 4 37

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Figure 5. Clinical anatomy of the transversalis fascia (TF). A, Cross plane below the 12th rib. B, Cross plane of the anterior superior iliac spine. C, Cross plane above the deep ring. D, Cross plane of the superior border of the pubic symphysis. E, Sagittal plane from the linea alba. 1 indicates peritoneum (blue); 2, fascial space between the deep layer of the TF and the peritoneum; 3, deep layer of the TF (red); 4, fascial space between the 2 layers of the TF; 5, superficial layer of the TF (green); 6, fascial space between the superficial layer of the TF and the transversus abdominis; 7, transversus abdominis; 8, obliquus internus abdominis muscle; 9, obliquus externus abdominis muscle; 10, linea alba; 11, inferior epigastric artery; 12, posterior rectus sheath; 13, rectus abdominis muscle; 14, anterior rectus sheath; 15, abdominal cavity; 16, colon; 17, Gerota (perirenal) fascia; 18, perinephric fat; 19, left kidney; 20, fascia lumbodorsalis; 21, latissimus dorsi muscle; 22, quadratus lumborum muscle; 23, psoas major muscle; 24, iliacus; 25, left common iliac artery; 26, left external iliac vein; 27, left gonadal artery; 28, iliopsoas muscle; 29, sartorius muscle; 30, rectum; 31, obturator internus muscle; 32, levator ani muscle; 33, coccyx; 34, right seminal vesicle; 35, prostate; 36, bladder; 37, obturator vein; 38, pubis; 39, obturator externus muscle; 40, median umbilical ligament; 41, medial umbilical ligament; 42, umbilicus; 43, Retzius space; 44, Bogros space; 45, retroperitoneal fat; 46, vas deferens; 47, superficial branch of the deep dorsal vein of the penis; and 48, pubic symphysis.

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on March 6, 2012 By summarizing these former scholars’ research out- A puts, combining the knowledge of urology and hernia and 1 abdominal surgery, and breaking the limits of different 2 disciplines, we explored the layers, range, and structure of the TF in its entirety and established the theory of the 3 intertransversalis fascia approach for ULOs for the first 4 time, to our knowledge.

5 With laparoscopic exploration, structures are magni- fied, and the various fascial planes are more clearly de- 6 fined with blood flow. In open operations, the operat- 7 ing field is limited, but the anatomical features of the fasciae and fascial spaces in local areas can be further con- B A firmed. Using fresh cadavers, the fasciae are pale, easily disrupted, and difficult to distinguish without the ad- vantage of blood flow, but the operating field is unlim- ited. Therefore, we can obtain a more comprehensive pic- ture of the TF and fascial spaces by combining these 3 methods. Figure 6. Histologic examination of the transversalis fascia (TF). A, Enlarged The results of the present study support the opinion view (hematoxylin-eosin, original magnification ϫ12.5) of location A in B. that the TF is a general plane of connective tissue lying 1 indicates peritoneum; 2, fascial space between the deep layer of the TF and the peritoneum; 3, deep layer of the TF; 4, fascial space between the 2 layers between the inner surface of the transversus abdominis of the TF; 5, superficial layer of the TF; 6, fascial space between the and extraperitoneal fat. Moreover, it is a complex 3-di- transversus abdominis and the superficial layer of the TF; and 7, transversus mensional structure with 2 layers of fascia and an amor- abdominis. phous fibroareolar space filled with fat and loose fibrous tissue between them. Retroperitoneal laparoscopic left ne- “It is part of the general layer of fascia between the peri- phrectomy, extraperitoneal laparoscopic radical prosta- toneum and the abdominal wall.” tectomy, transperitoneal laparoscopic partial cystec- Cooper2,3 originally described the TF as a bilaminar tomy, and total extraperitoneal repair of hernia are actually structure. Mackay,8 Morton,9 and Read10 also agreed with accomplished via the intertransversalis fascia approach. the bilaminar structure of the TF. Mackay8 stated that the In fact, the retroperitoneal space, extraperitoneal space, inferior epigastric vessels originate from the external iliac Retzius space, and Bogros space comprise different parts vessels and penetrate the posterior layer of the TF. Mor- of the space between the 2 layers of the TF. The fat be- ton9 characterized the TF as sometimes being bilami- tween the 2 layers of the TF in the retroperitoneal re- nar, with the epigastric vessels lying in between. Read10 gion has been recognized as retroperitoneal fat or para- described 2 laminae of the TF inserting into the Cooper nephric fat.15 Moreover, the deep layer of the TF has been ligament, with the inferior epigastric vasculature in be- named the preperitoneal fascia13,14 or the lateral conal fas- tween. However, some scholars, such as McVay and An- cia.15 The inferior epigastric vessels and the superficial son11 and Condon,12 believed that the TF is a single- branch of the deep dorsal vein of the penis travel be- layer structure. Moreover, Anson et al13 and Arregui14 tween these 2 layers. The matrix in the space between named the posterior layer of the TF as the preperitoneal the 2 layers of the TF is asymmetrical. For example, near fascia. the level of the umbilicus lateral to the umbilical folds, The TF in the anterior inferior abdominal wall and the the 2 layers of the TF are intimately fused, and the in- groin region was mainly involved in these previous stud- tervening fatty tissue is sparse. The fibrous tissue be- ies, which were related to hernia and abdominal wall sur- tween the 2 layers of the TF becomes thick and dense in gery. However, the TF in the retroperitoneal region has the region of the myopectineal orifice, which can with- not been mentioned in these studies. stand abdominal pressure and prevent hernia. The in- Qiu et al15 studied the clinical anatomy of fasciae and tervening fatty tissue becomes abundant in the retroperi- fascia spaces in the retroperitoneal cavity by analyzing toneal region, which can protect the kidneys and ureters retroperitoneal laparoscopic operations, computed to- from external bumping. mographs and magnetic resonance images of patients, and In conclusion, the TF is a complex 3-dimensional struc- fresh autopsy. They found that the lateral conal fascia cov- ture. It can be divided into 2 layers, superficial and deep, ered the superficial surface of the posterior layer of the with an amorphous fibroareolar space between them. The perirenal fascia and that the TF covered the inner sur- intertransversalis fascia approach in ULOs is an ap- face of the transversalis abdominis. Posteriorly, the lat- proach between the 2 layers of the TF. Surgeons can ob- eral conal fascia and the TF fused at the lateral edge of tain a clean, clear, and bloodless operating space in ULOs the quadratus lumborum muscle. Anteriorly, the 2 lay- using the intertransversalis fascia approach. ers fused in the anterior axillary line. In addition, lateral conal fascia and the TF encircled the pararenal fat, and Accepted for Publication: August 30, 2011. the cavity formed by these 2 fasciae was called the para- Correspondence: Bingyi Shi, MM, Institute of Organ renal space. However, their study was localized to the ret- Transplant of Chinese PLA, 309 Hospital of PLA, Jia No.17 roperitoneal cavity, which did not extend to the ante- Heishanhu Rd, Haidian District, Beijing, PR China, 100091 rior abdominal wall. ([email protected]).

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Corrected on March 6, 2012 Author Contributions: Dr Li, Mr Qian, and Dr Zhang 5. Spangen L. Shutter mechanisms in the inguinal canal. In: Arregui ME, Nagan RF, contributed equally to the article. Study concept and de- eds. Inguinal Hernia Repair: Advances or Controversies? Oxford, UK: Radcliffe Medical Press; 1994:55-60. sign: Li and Shi. Acquisition of data: Li, Qian, Bai, Song, 6. Braus H. Anatomie des Menschen, Band I. Berlin, Germany: Julius Springer; Hong, Jia, Zhang, and Shi. Analysis and interpretation of 1921. data: Li, Qian, and Zhang. Drafting of the manuscript: Li, 7. Condon RE. Surgical anatomy of the transversus abdominis and transversalis Qian, Bai, Song, Hong, and Jia. Critical revision of the manu- fascia. Ann Surg. 1971;173(1):1-5. script for important intellectual content: Zhang and Shi. Sta- 8. Mackay JY. The relations of the aponeurosis of the transversalis and internal oblique tistical analysis: Li, Qian, Bai, Song, and Hong. Study su- muscles to the deep epigastric artery and to the inguinal canal. In: Cleland J, ed. Memoirs and Memoranda in Anatomy. Vol 1. London, UK: Williams & Norgate; pervision: Zhang and Shi. 1889:143-146. Financial Disclosure: None reported. 9. Morton T. The Surgical Anatomy of Inguinal Herniae, the Testis and Its Coverings. Additional Contributions: Bing Ma, MD, Department of London, UK: Taylor & Walton; 1841. General Surgery, 301 Hospital of PLA, provided techni- 10. Read RC. Cooper’s posterior lamina of transversalis fascia. Surg Gynecol Obstet. cal assistance. 1992;174(5):426-434. 11. McVay C, Anson BJ. Composition of the rectus sheath. J Anat Rec. 1940;77:213- 225. REFERENCES 12. Condon RE. The anatomy of the inguinal region and its relationship to groin hernia. In: Nyhus LM, Condon RE, eds. Hernia. 4th ed. Philadelphia, PA: JB Lippincott; 1. Neil RB. Anterior abdominal wall. In: Standring S, ed. Gray’s Anatomy: The Ana- 1995:16-72. tomical Basis of Clinical Practice. 39th ed. New York, NY: Churchill Livingstone; 13. Anson BJ, Morgan EH, McVay CB. Surgical anatomy of the inguinal region based 2004. upon a study of 500 body-halves. Surg Gynecol Obstet. 1960;111:707- 2. Cooper A. Of the anatomy of the parts concerned with inguinal hernia. In: The 725. Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. London, UK: 14. Arregui ME. Surgical anatomy of the preperitoneal fasciae and posterior trans- Longman & Co; 1804:4-6. versalis fasciae in the inguinal region. Hernia. 1997;1:101-110. 3. Cooper A. Of the anatomy of the parts concerned with inguinal hernia. In: The 15. Qiu JG, Chen XH, Yuan XX, et al. Clinical anatomy of fasciae and fascial spaces Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. Philadel- in retroperitoneal cavity. Chin J Clin Anat. 2009;27:251-255. phia, PA: Lea & Blanchard; 1844:26-27. 16. Mirilas P, Colborn GL, McClusky DA III, Skandalakis LJ, Skandalakis PN, Skan- 4. Skandalakis JE, Gray SW, Skandalakis LJ, Colborn GL, Pemberton LB. Surgical dalakis JE. The history of anatomy and surgery of the preperitoneal space. Arch anatomy of the inguinal area. World J Surg. 1989;13(5):490-498. Surg. 2005;140(1):90-94.

INVITED CRITIQUE Alternative Routes to the Summit Require Experienced Climbers

ust as there are often several approaches to ascend The intertransversalis fascia approach may be a fur- a mountain, each with its own pitfalls, the choice ther refinement for the laparoscopic surgeon who al- of an operative approach requires assessment of po- ready has experience using a retroperitoneal approach. J 1 tential perils. Li et al make a valuable contribution through their de- The retroperitoneal approach is more common in tailed work to illustrate the precise anatomical plane that China than it is in the United States. It is difficult to make may be key to a successful outcome. If one is going to broad statements regarding the superiority of one ap- take an alternative route to the mountaintop, it makes proach as it is likely the surgeon’s experience and com- sense to have a better understanding of the terrain. fort level, rather than technique, that determine suc- cess. As described by Li et al,1 the intertransversalis fascia Darius J. Unwala, MBChB (Hons), approach provides a clean, clear, bloodless field. How- MRCS (Eng), FRCSC (Urol), FACS ever, one of the chief concerns with the retroperitoneal approach, in general, is the smaller working space pro- Author Affiliation: Department of Urology, Princess Mar- vided. The transperitoneal approach may provide a gen- garet Hospital, Nassau, Bahamas. tler learning curve for beginners. Correspondence: Dr Unwala, Department of Urology, An expert laparoscopic surgeon should be familiar Princess Margaret Hospital, Shirley St, Nassau N4740, Ba- with both approaches. Patients with relative indications hamas ([email protected]). for a retroperitoneal approach, such as those with a his- Financial Disclosure: None reported. tory of abdominal surgery or extreme obesity, may ben- 1. Li G, Qian Y, Bai H, et al. Intertransversalis fascia approach in urologic lapa- efit. A retroperitoneal approach may also provide some roscopic operations. Arch Surg. 2012;147(2):159-167. 2. Ng CS, Gill IS, Ramani AP, et al. Transperitoneal versus retroperitoneal lapa- advantages during partial nephrectomies for posterior roscopic partial nephrectomy: patient selection and perioperative outcomes. renal tumors.2 J Urol. 2005;174(3):846-849.

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