Preperitoneal vas deferens infiltration in high-risk prostate cancer.

Objectives: The objective of this study is to evaluate the prevalence and the importance of preperitoneal vas deferens (VD) infiltration in high-risk prostate cancer (PCa). Patients and Methods: In this prospectively designed study, we included 332 high-risk PCa patients with a Briganti score >5%, who were treated by robot-assisted radical prostatectomy between July 2017 and February 2022 at the Urology Department, SLK Kliniken Heilbronn. In addition to the standard histological analysis of the distal VD, which was attached to the prostate specimen, we analysed the infiltration status of preperitoneal VD in this cohort. The preperitoneal VD, which represents the middle part of ductus deferens and extends between the internal inguinal ring and obturator fossa, was resected during extended pelvic lymphadenectomy. Distal and preperitoneal VD status was registered together with preoperative and postoperative disease characteristics. Descriptive analysis methods and logistic regression analysis were used. Results: Briganti score of the target cohort had a median value of 19%, while 235 patients (70.8%) of the group demonstrated a locally advanced disease. The Grade Group at prostatectomy specimen was at least 3 for 286 patients (86.1%). Distal VD infiltration was found in 20 patients (6%) and preperitoneal VD infiltration in two patients (0.6%). Distal VD infiltration was not associated with an increased possibility for positive surgical margins or nodal status among pT3b patients, while both patients with preperitoneal VD infiltration were characterized by highly aggressive disease in locally advanced stage and bilateral distal VD infiltration. Conclusions: PCa extension along VD may reach a more proximal point of VD than the reported from the existing data infiltration of VD adjacent to seminal vesicles. This rare manifestation of PCa local extension may be the intermediate step to the rare cases of recurrence in the testicles. However, more robust data are needed to confirm the aforementioned hypothesis. Distal VD infiltration seems to have no additional prognostic value among patients with infiltrated seminal vesicles.

A visual method of establishing preperitoneal space for totally visceral sac separation in ventral hernia repair.

OBJECTIVE: To explore a method of visually establishing preperitoneal space. In this paper, the procedure is described in detail and its safety and efficacy evaluated. METHODS: A retrospective style was adopted. The clinical data of 33 patients who accepted the total visceral sac separation (TVS) procedure from December 2019 to November 2021 were collected. Observation indices included location and area of abdominal defect; surgical method and duration of operation to establish preperitoneal space and any postoperative complications; developments during follow-up. Follow-up was performed up to December 2021 using outpatient examination and telephone interview to detect any complications of incision or recurrence of ventral hernia. RESULTS: For operative indices, all patients underwent the TVS procedure successfully except for one who had to be converted to laparoscopic intraperitoneal onlay mesh (IPOM) due to failure to establish preperitoneal space. The time required to establish preperitoneal space was 185.75 ± 44.37 s and the duration of hospital stay was 8.27 ± 1.42 days. No complications, such as abdominal bleeding or digestive tract injury, occurred during hospitalization. No complications of incision were observed during follow up, which lasted 2-24 months with an average of 7 months. CONCLUSIONS: Preliminary results of the novel attempt to establish the preperitoneal space visually confirmed this to be a safe and feasible method. However, the sample size used here was small, with a short follow up. The details and notes need to be further discussed.

Prevention and treatment strategies for hematoma after laparoscopic inguinal hernia repair / 中华消化外科杂志

Laparoscopic inguinal hernia repair (LIHR) has been widely used in clinical practice and has become the main surgical method for inguinal hernia repair. Although hematoma after LIHR is less common than seroma, it may lead to more serious complications and should be paid enough attention. Currently, the prevention and treatment strategies for hematoma after LIHR are still lacking in sorting and summary. The authors elaborate on the prevention and treatment of hematoma after LIHR, aiming at providing references for clinical surgeons to ensure the life safety of patients and promote rapid recovery after surgery.

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance.

PURPOSE: Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide. METHODS: Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers. RESULTS: Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia. CONCLUSIONS: We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.

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.

Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space.

BACKGROUND: There has been confusion in the anatomical recognition when performing inguinal hernia operations in Japan. From now on, a paradigm shift from the concept of two-dimensional layer structure to the three-dimensional space recognition is necessary to promote an understanding of anatomy. ANATOMY AND EMBRYOLOGY: Along with the formation of the abdominal wall, the extraperitoneal space is formed by the transversalis fascia and preperitoneal space. The transversalis fascia is a somatic vascular fascia originating from an arteriovenous fascia. It is a dense areolar tissue layer at the outermost of the extraperitoneal space that runs under the diaphragm and widely lines the body wall muscle. The umbilical funiculus is taken into the abdominal wall and transformed into the preperitoneal space that is a local three-dimensional cavity enveloping preperitoneal fasciae composed of the renal fascia, vesicohypogastric fascia, and testiculoeferential fascia. The Retzius' space is an artificial cavity formed at the boundary between the transversalis fascia and preperitoneal space. In the underlay mesh repair, the mesh expands in the range spanning across the Retzius' space and preperitoneal space.

Rives Technique for the Primary Larger Inguinal Hernia Repair: A Prospective Study of 1000 Repairs.

OBJECTIVE: We report a prospective study of repairs using the Rives technique of the more difficult primary inguinal hernias, focusing on the immediate post-operative period, clinical recurrence, testicular atrophy, and chronic pain. A mesh placed in the preperitoneal space can reduce recurrences and chronic pain. METHODS: For the larger primary inguinal hernias (Types 3, 4, 6, and some 7), we favour preperitoneal placement of a mesh, covering the myopectineal orifice by means of a transinguinal (Rives technique) approach. The Rives technique was performed on 943 patients (1000 repairs), preferably under local anaesthesia plus sedation in ambulatory surgery. RESULTS: The mean operative time was 31.8 min. Pain assessment after 24 h with an Andersen scale and a categorical scale gave two patients with intense pain on the Andersen scale, and four patients who thought their state was bad. Surgical wound complications were below 1%, and urinary retention was 1.2% mostly associated with spinal anaesthesia and, in one case, bladder perforation. There was spermatic cord and testicular oedema with some degree of orchitis in 17 patients. The clinical follow-up of 849 repairs (86.4%), mean (range) 30.0 (12-192) months, gave five recurrences (0.6%), three cases (0.4%) of testicular atrophy, and 37 (4.3%) of post-operative chronic pain (8 patients with visual analogue scale of 3-10). CONCLUSIONS: The Rives technique requires a sound knowledge of inguinal preperitoneal space anatomy, but it is an excellent technique for the larger and difficult primary inguinal hernias, giving a low rate of recurrences and chronic pain.

Comparison between tension-free inguinal hernia repair with mesh plug and tension-free repair of preperi-toneal space with middle abdominal incision / 实用医学杂志

Objective To conduct a comparative study on postoperative complications and patients′quali-ty of life between tension-free inguinal hernia repair with mesh plug(Rutkow operation)and tension-free repair of preperitoneal space with middle incision of lower abdomen(Open TEP operation).Methods A retrospective anal-ysis of 122 cases of inguinal hernia was conducted.And 62 cases of Open TEP operation were concluded into obser-vation group and 60 cases of Rutkow operationinto control group. The basic information of the surgery,postopera-tive complications and the score of quality of life before and after treatment were compared between 2 groups. Results No bladder injury,ductus deferens damage,infections or hematoma on incisions were found after opera-tion and no relapse,patch rejection,infections or atrophia testiculi were seen during the follow-up. The incision pain of observation group lasted shorter than that of control group(P<0.01),while other operational indexes show no great difference(P > 0.05). The incidence of postoperative complications of observation group was 11.29%, much lower than that of control group(P<0.01).Both PCS and MCS scores of 2 groups after treatment increased obviously as compared with those before treatment(P<0.01),but the rise in observation group were more signifi-cant(P<0.01).Conclusion Less postoperative pain and complications,and better life quality are found in the treatment of inguinal hernia with open TEP operation outperforms Rutkow operation.

A combined preperitoneal and inguinal approach for redo orchiopexy.

INTRODUCTION: Redo orchiopexy involves a hazardous dissection inside the inguinal canal (IC) where scar tissue encircles the testicular vessels (TesV), vas deferens (VD), and the testis. OBJECTIVE: The aim was to describe and evaluate a combined preperitoneal and inguinal approach (CPI) through a single cutaneous incision and accomplish this task as safely as possible, at the same time permitting additional maneuvers for cord lengthening. MATERIAL AND METHODS: We prospectively studied eight patients aged from 2.7 to 13 years (mean 7 years) reoperated for failed orchiopexy using the CPI approach. Reoperation took place 12 months to 11 years (mean 4.4 years) after the initial operation. Through a single transverse skin crease incision over the IC, at the level of the deep inguinal ring (DIR), we gained access to both the preperitoneal space (PPS) and the IC. We first entered the PPS, the peritoneum is retracted, and the VD and TesV are seen entering the DIR. They are gently dissected and two vascular lacets are passed around them. We introduce the backside of an anatomic forceps through the DIR, just under the anterior IC wall, until it is impeded by adhesions and then incise above the forceps, thus protecting the cord structures. Through that opening we transpose one of the lacets that encircle the VD and TesV and exercise traction upon them (figure, 1), revealing step by step the points where adhesiolysis must take place (figure, 2). The testis is dissected last of all and delivered back, through the DIR, into the PPS. There, the TesV and VD are freed from their retroperitoneal attachments (figure, 3). Finally, the testis is fixed into a Dartos pouch. RESULTS: In all cases the testes were relocated to the scrotum without any mishaps. All testes were inside the scrotum at first month examination and with good consistency. At 6 months, one testis ascended at mid-scrotum. At 2 years they all retained their position and their good standing, according to clinical and ultrasonographic findings. DISCUSSION: Several procedures of redo orchiopexies have been published so far, most of them rely on the surgeon's dexterity for good results. The CPI procedure offers a practical maneuver to protect the cord elements while dissecting and also exposes all the regions where dissection will offer lengthening of the cord. CONCLUSION: Our results have demonstrated that the CPI can be considered as a safe and efficient procedure for redo orchiopexy.

Methods of OP mesh spreading in preperitoneal tension-free repair of inguinal hernia via open anterior approach / 中华普通外科杂志

Objective To evaluate methods of OP mesh spreading in preperitoneal tension-free repair of inguinal hernia via open anterior approach.Methods The clinical data of 1 528 cases underwent preperitoneal tension-free repair of inguinal hernia via open anterior approach from March 2012 to April 2015 was analyzed retrospectively.The methods of mesh crimp spreading, pectineal ligament suture fixation, pubic tubercle suture fixation and auxiliary support were used.Results The mesh crimp spreading method was used in 1 021 cases, pectineal ligament suture fixation method was used in 64 cases, pubic tubercle suture fixation method was used in 48 cases, auxiliary support method was used in 395 cases.Meshes were all well spreaded.Conclusions The four methods of mesh spreading are effective, simple, convenient and easy to use in preperitoneal tension-free repair of inguinal hernia via open anterior approach.

Anterior preperitoneal repair of extremely large inguinal hernias: An alternative technique.

INTRODUCTION: Standard open anterior inguinal hernia repair is nowadays performed using a soft mesh to prevent recurrence and to minimalize postoperative chronic pain. To further reduce postoperative chronic pain, the use of a preperitoneal placed mesh has been suggested. In extremely large hernias, the lateral side of the mesh can be insufficient to fully embrace the hernial sac. We describe the use of two preperitoneal placed meshes to repair extremely large hernias. This 'Butterfly Technique' has proven to be useful. Hernias were classified according to hernia classification of the European Hernia Society (EHS) during operation. Extremely large indirect hernias were repaired by using two inverted meshes to cover the deep inguinal ring both medial and lateral. Follow up was at least 6 months. VAS pain score was assessed in all patients during follow up. Outcomes of these Butterfly repairs were evaluated. Medical drawings were made to illustrate this technique. A Total of 689 patients underwent anterior hernia repair 2006-2008. PRESENTATION OF CASE: Seven male patients (1%) presented with extremely large hernial sacs. All these patients were men. Mean age 69.9 years (range: 63-76), EHS classifications of hernias were all unilateral. Follow up was at least 6 months. Recurrence did not occur after repair. Chronic pain was not reported. DISCUSSION: Open preperitoneal hernia repair of extremely large hernias has not been described. The seven patients were trated with this technique uneventfully. No chronic pain occurred. CONCLUSION: The Butterfly Technique is an easy and safe alternative in anterior preperitoneal repair of extremely large inguinal hernias.

Clinical research of tension-free herniorrhaphy using Kugel patch in 355 inguinal hernias / 国际外科学杂志

Objective To explore the clinical effects of Kugel surgical treatment for inguinal hernia.Methods Operative time,chornic pain,complications and charges of 355 patients with inguinal hernias were analyzed retrospectively.Results Recurrences occurred in 1 patient,during a mean followl-up of 36 months (range:7-85).The average operation time was 35.4 min (range:20-130),average surgical charges were 6 253 yuan.Postoperaive chronic pain appeared in 6 patients.There are 3 cases of sermoa,1 case of haematoma and 2 case of wound infection.Conclusion The Kugel inguinal hernia repair is safe and effective,with the advantage of mild pain and prompt recovery after operation,and a low risk of complications and recurrence.