Fascia Transversalis - A Study of Live Surgical Anatomy during Laparoscopic Total Extra-Peritoneal Hernioplasty

There is still little agreement among the anatomists and surgeons about the definition, nature, extent, attachments or functions of the transversalis fascia even when during laparoscopic surgery, structures are magnified, and various fascial planes are more clearly defined than in open surgery. In the present study while doing laparoscopic total extraperitoneal preperitoneal (TEP/TEPP) mesh hernioplasty for inguinal hernia (N=30), Transversalis fascia was found as a single membranous layer in suprainguinal region, but diaphanous (outer fibro-fatty and inner membranous layers) in inguinal and infra-inguinal regions in 70%, but it was thin flimsy throughout in 30%. Transversalis fascia was observed posterior to the complete posterior rectus sheath/fascia when present (13%), or posterior to the Rectusial fascia (77%)/epimysium (10%) when posterior rectus sheath was incomplete with Arcuate line. Transversalis fascia transiently split to ensheathe deep inferior epigastric vessels in all cases. Transversalis fascia did not enter into inguinal canal but stopped at deep ring, forming two lateral thickened fascial extensions/slings as the two crura of deep ring and one medial thickened fascial extension/sling running from deep ring towards pectineal ligament, although pectineal fascia over the pectineal ligament was well-defined in only 23%. A well-defined Transversalis fascial thickening, the Iliopubic tract, was observed in 77%. In all 30 cases, Transversalis fascia was found quite distinct from the preperitoneal fascia/fat which ensheathed the cord structures and entered the inguinal canal, forming the internal spermatic fascia; moreover, Transversalis fascia and preperitoneal fascia/fat had separate neurovascular supply with presence of an easily fissile avascular plane in between.