Arcuate Line of Douglas: A Prospective Study of Laparoscopic Live Surgical Anatomy during TEPP Hernioplasty

Contrary to traditional textbook teaching, arcuate line anatomy, currently an important landmark during laparoscopic total extraperitoneal preperitoneal (TEPP) hernioplasty had been known to vary frequently in various cadaveric studies reported over the last century. Sixty eight TEPP hernia repair was performed in 60 adult patients through posterior rectus sheath approach, utilizing 3-midline-port technique and only telescopic dissection. The so-called classical arcuate line (normal-sited single sharp well-defined) was observed in only 46 % of the 68 successful TEPP hernioplasties in adult male patients with primary inguinal hernia, and in the remaining 54 %, arcuate line was of 6 variant types which included the high single sharp well-defined (4.4 %), low single sharp well-defined (4.4 %), normal-sited single ill-defined (14.7 %), low single ill-defined (5.9 %), multiple, i. e. , both primary and secondary (4.4 %), and absent (20.6 %). In patients with incomplete posterior rectus sheath, arcuate line was found situated, in general, at the 1/3rd of the umbilico-pubic distance. Secondary arcuate line was also documented in 50 % of the cases with complete posterior rectus sheath. Arcuate line had non-mirror anatomy on the two sides of the body in 62.5 % of patients with bilateral inguinal hernias. Arcuate line did not represent termination of posterior rectus sheath in 14.7 % of our cases.