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 laparo- scopic 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- ARCH SURG/ VOL 147 (NO. 2), FEB 2012 WWW.ARCHSURG.COM 159 ©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 be- tween 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 laparo- scopic view. plane. Inferiorly, the TF is continuous with the pelvic fas- cia, 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