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Pathways of the preperitoneal plane: from the “fatty triangle” in Rives to the “fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute to Prof. Schumpelick.

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Abstract

Purpose

Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model and its influence in retromuscular preperitoneal dissections.

Methods

Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated.

Results

The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt’s fascia, and pararenal fats, forming the lateral prong of the trident. The peritoneum not covered by the preperitoneal fatty trident was easy to break. Three pathways could be tracked following the distribution of this fat that facilitated the dissection of the preperitoneal space to prepare the landing zone of the meshes in hernia repair.

Conclusion

The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow three specific pathways to find our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

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Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Having learned of the recent death of Prof. Schumpelick, we would like to thank him in these lines for his enormous contribution to hernia surgery. We want this article, inspired by his teachings, to be a small tribute to his person.

Funding

The cadavers used in this study come from courses funded by WL Gore & Associates, Inc. Flagstaff, AZ, USA.

Author information

Authors and Affiliations

  1. Grupo de Investigación de Pared Abdominal Compleja, Hospital Universitario del Henares, Universidad Francisco de Vitoria, Carretera Pozuelo-Majadahonda km. 1.8, 28223, Pozuelo de Alarcón, Spain

    M. Á. Garcia-Urena, A. de Robin Valle de Lersundi, M. Medina Pedrique, X. Rial Justo & A. Cruz Cidoncha

  2. Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 2, 28220, Majadahonda, Spain

    J. Lopez-Monclus & J. Munoz-Rodriguez

  3. Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, M-607, 9,100, 28034, Madrid, Spain

    L. A. Blazquez Hernando

  4. Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Alvaro Cunqueiro, Estrada de Clara Campoamor 341, 36213, Vigo, Spain

    M. Nogueira Sixto

Authors
  1. M. Á. Garcia-Urena
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  9. J. Munoz-Rodriguez
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Correspondence to J. Lopez-Monclus.

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Supplementary Information

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Video 1: Video clip of a cadaver lab dissection showing the preperitoneal dissection at the epigastric area following the rhomboid fat. This preperitoneal dissection can be made before the lateral release of the posterior rectus sheath in a PCS. (MP4 326507 kb)

Video 2: Video clip of a cadaver lab dissection showing the retroinguinal dissection under the linea arcuata to find, laterally, the Bogros space as the gate to the paracolic gutters and Toldt's fascia (MP4 94791 kb)

Video 3: Video clip of an incisional hernia repair by E-TEP approach. It shows the crossover remarking the importance of the midline preperitoneal fat (MP4 360772 kb)

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Garcia-Urena, M.Á., Lopez-Monclus, J., de Robin Valle de Lersundi, A. et al. Pathways of the preperitoneal plane: from the “fatty triangle” in Rives to the “fatty trident" in extended retromuscular abdominal wall reconstruction. A tribute to Prof. Schumpelick.. Hernia 27, 395–407 (2023). https://doi.org/10.1007/s10029-022-02602-0

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