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Concept: Transversalis fascia


Coskun hernia repair technique has been reported to be an effective new fascia transversalis repair with its short-term follow-up results. Our aim is to determine the results of Coskun hernia repair technique and to compare it with Lichtenstein technique.

Concepts: Comparison, Transversalis fascia


The transversalis fascia plane block is a relatively new truncal block that targets the iliohypogastric and ilioinguinal nerves. It is gaining wider usage for its reliability to block these nerves as compared with the transversus abdominis plane block. The case presented here appears to be the first time that motor weakness has resulted from this block technique. It is suspected that central and proximal spread of local anesthetic toward the psoas muscle may have resulted in a partial lumbar plexus block.

Concepts: Muscle, Transversus abdominis muscle, Iliac crest, Lumbar plexus, Transversalis fascia, Iliohypogastric nerve, Ilioinguinal nerve, Psoas major muscle


The traditional inflatable penile prosthesis (IPP) reservoir placement is below the transversalis fascia in the space of Retzius. In 2002, Dr. Steve Wilson described ectopic reservoir placement, thereby providing a safe and effective alternative for implant surgeons. This new approach obviated the need for a second incision and decreased operative times during surgery. In the manuscript, he also described the introduction of a reservoir lock-out valve, which prevents autoinflation of the penile implant. The development of lockout valves and flat reservoirs has contributed to the early success and feasibility of submuscular placement techniques. Thirteen years after Dr. Wilson’s pivotal study, this technique should be in the armamentarium of all urologic prosthetic surgeons. Accordingly, in certain subsets of patients, ectopic/ submuscular reservoir site placement should be considered a safe, effective alternative to standard reservoir placement in the space of Retzius. Hakky T, Lentz A, Sadeghi-Nejad H, Khera M. The evolution of the inflatable penile prosthesis reservoir and surgical placement. J Sex Med 2015;12(suppl 7):464-467.

Concepts: Medicine, Surgery, Implants, Prosthetics, Amputation, Penis, Medical equipment, Transversalis fascia


A patient diagnosed with extensive abdominal wall necrotising fasciitis from a perianal abscess was managed with a novel aeration technique using adapted 36-French tubes. A total of 14 drains were placed in the plane of the transversalis fascia after surgical debridement. The drains were left open to allow drainage of liquefactive contents and aeration of the abdominal wall tissues. An extended course of intravenous antibiotics were administered and the patient was ventilated in the intensive therapy unit. The patient was reoperated after 2 weeks, at which time the drains were removed. The patient made a full recovery, and was discharged with follow-up.

Concepts: Medicine, Tissues, Necrosis, Abdomen, Plane, Debridement, Transversalis fascia


Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor.

Concepts: Surgery, Hernia, Pubic symphysis, Femoral triangle, Thigh muscles, Transversalis fascia, Athletic pubalgia, Adductor longus muscle


To introduce the technique of anatomical retroperitoneoscopic retroperitoneal lymph node dissection (ARRPLND) was performed in 12 consecutive patients with a clinical stage I nonseminomatous germ-cell tumor (NSGCT) between February 2008 and October 2010. All procedures were performed using a modified template nerve-sparing approach. The retroperitoneal space was adequately expanded using double gasbags. After the retroperitoneal fat was cleared, two relatively bloodless planes were entered consecutively to expose the lymph node and permit dissection. Dissection proceeded first in the plane between the anterior renal fascia and posterior peritoneum, and secondly in the avascular plane between the posterior renal fascia and transversalis fascia. The proximal spermatic vein was clipped at the initial stage. En bloc resection of the lymph tissue and fat between the anterior renal fascia and posterior renal fascia were performed. Three patients (25%) had pathologic stage IIA disease and received adjuvant chemotherapy. No recurrence was observed during follow-up ranging from 26 to 58 months. The median operative time was 205 min (range: 165-430 min) and median estimated blood loss was 320 ml (range: 100-1200 ml). There were two intraoperative complications (Clavien grade II) and one open conversion due to perforation of the peritoneum. Postoperative complications (Clavien I) developed in three patients. Normal antegrade ejaculation recovered by 1 month following the operation. Our preliminary results indicate that ARRPLND is technically feasible and associated with satisfactory clinical outcomes for clinical stage I NSGCT. Further studies are necessary to evaluate this technique.

Concepts: Kidney, Cancer, Oncology, Blood, Cancer staging, Germ cell tumor, Germ cell, Transversalis fascia


Classically, two inguinal rings are defined: internal and external. We previously introduced a third one, the secondary internal inguinal ring, deep to the classic internal. Here, we present a fourth ring, the secondary external inguinal ring, initially described by McGregor (Surg Gynecol Obstet 49:273-307, 1929), but now forgotten. Embryologically, this ring may be formed by evagination of Scarpa’s fascia during testicular descent. Anatomically, it is located 2 cm below the pubic tubercle. It is formed by Scarpa’s fascia that covers the spermatic cord anteriorly; medial and lateral fascial reflections delineate the ring and form the spermatic cord canal. The cord is attached to the posterior wall of the canal. The canal ends at the entrance of the scrotum, where Colles' fascia fuses with coverings of the cord. Adjoining the secondary external ring, at the same surgical layer and communicating with the subcutaneous abdominal space, are four subcutaneous pouches: laterally, the superficial inguinal pouch; medially, the perineal, femoral, and pubic pouches. Surgically, an inguinoscrotal hernia passes though the secondary external ring and obtains an extra outer layer by entering the spermatic cord canal. Underdevelopment of the ring leads to incomplete testicular descent or ectopic testis. We recommend reconstruction of Scarpa’s ring after orcheopexies and herniotomies in children. After urethral rupture distal to the urogenital diaphragm, urine may fill the subcutaneous abdominal space, pouches, and scrotum, due to their communication around the secondary external ring. In females, this ring was not found, possibly because of the non-descent of the ovaries through (and beyond) the inguinal canal.

Concepts: Testicle, Inguinal hernia, Pelvis, Spermatic cord, Deep inguinal ring, Transversalis fascia, Superficial inguinal ring, Inguinal canal


Operations undertaken for inguinal hernia repair are the most common elective surgical procedures. According to the current guidelines, Lichtenstein’s tension-free method is the gold standard for elective hernia operations. The most common types of implanted mesh are polypropylene and composite mesh. We herein present Lichtenstein’s operation using a biological hemostatic mesh (Tachosil) used for transversalis fascia reinforcement, and our results after a 3-year follow-up period for 52 patients implanted with Tachosil mesh are reported. According to our results, the biological mesh can be safely implanted during hernia repair with the same recurrence rate and lower postoperative pain and complications compared to hernia repair with polypropylene mesh implantation.

Concepts: Surgery, Inguinal hernia, Hernia, Polypropylene, The Current, Hernias, Fascia, Transversalis fascia


Introduction.  Traditional placement of inflatable penile prosthesis (IPP) reservoirs and/or artificial urinary sphincter (AUS) balloons into the space of Retzius may be challenging following major pelvic surgery. Aim.  The aim of this study is to report our 1-year experience using a novel technique for high balloon/reservoir placement beneath the rectus abdominus muscle, thus completely obviating deep pelvic dissection during prosthetic urologic surgery. Methods.  A retrospective review of all patients who underwent IPP and/or AUS placement between June 2011 and June 2012 was performed. All had AUS balloons and/or IPP reservoirs placed in a submuscular location by bluntly tunneling through the external inguinal ring into a potential space between the transversalis fascia and the rectus abdominus muscle using a long, angled, lung grasping clamp. Main Outcome Measures.  Patient demographics, perioperative outcomes, and initial follow-up patient-reported outcomes were reviewed. Results.  During the study period, 120 submuscular balloons/reservoirs were inserted in 107 consecutive patients who underwent placement of an IPP (61 patients), AUS (33 patients), or both (13 patients). Among our 48 most recent patients, 41 (85%) reported they were totally unable to feel their balloon/reservoir, and all but two patients reported no bother from the submuscular balloon/reservoir placement. Of the 120 total submuscular balloons and reservoirs, surgical time and outcomes of the prosthetic procedures appeared similar to those placed using traditional methods; two reservoirs required revision surgery for repositioning. Conclusions.  High submuscular placement of genitourinary prosthetic balloons and reservoirs via a transscrotal approach is both safely and effective, while avoiding deep retropubic dissection. Morey AF, Cefalu CA, and Hudak SJ. High submuscular placement of urologic prosthetic balloons and reservoirs via transscrotal approach. J Sex Med **;**:**-**.

Concepts: Prosthetics, Artificial organ, Pubic symphysis, Rectus abdominis muscle, Linea alba, Deep inguinal ring, Anders Retzius, Transversalis fascia