Original article
Experimental endoscopy
Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

https://doi.org/10.1016/j.gie.2008.10.019Get rights and content

Background

A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported.

Objective

Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH).

Design

Feasibility study with a nonsurvival canine model.

Interventions

Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 × 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed.

Results

Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur.

Limitations

Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used.

Conclusions

Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

Section snippets

Material and methods

The Maimonides Medical Center Institutional Animal Care and Use Committee approved all animal experiments.

Results

Five dogs underwent successful pure NOTES IPOM BIH. Excellent visualization of both inguinal canals was achieved through the anterolateral gastrotomy. The vas deferens and bladder, as well as the testicular, inferior epigastric, and iliac arteries and veins, were clearly identified and avoided. The location of the surgical sites in relation to the gastrotomy in a direct cephalad-caudad orientation allowed for constant horizon maintenance, one-to-one endoscope manipulation, and the preservation

Discussion

As enumerated in the white paper developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)/American Society for Gastrointestinal Endoscopy (ASGE) working group on NOTES,20 primary barriers to NOTES clinical adoption include difficulty maintaining spatial orientation and lack of an adequate multitasking platform. In contrast to previously reported NOTES procedures, BIH has 2 characteristics that make overcoming these obstacles less problematic. First, pathology

References (26)

  • J. Marescaux et al.

    Surgery without scars: report of translumenal cholecystectomy in a human being

    Arch Surg

    (2007)
  • R. Zorrón et al.

    NOTES transvaginal cholecystectomy: report of the first case

    Surg Inno

    (2007)
  • A.N. Kingsnorth et al.

    Management of abdominal hernias

    (2003)
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      The feasibility and advantages of different access routes to perform intra-peritoneal onlay mesh (IPOM) repair in ventral wall hernias using the NOTES technique has been demonstrated in experimental studies [5, 7, 8]. The technical aspects concerning the transfer and fixation of mesh as well as the choice and final closure of different access routes are still controversially discussed [4–8, 13]. In the present study, we assumed that fibrin sealant (FS) mesh fixation delivered by transgastric access (TGA) was beneficial in the attempt to minimize surgical invasiveness.

    • Natural orifice translumenal endoscopic surgery (N.O.T.E.S)

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      McGee et al have demonstrated in a porcine model that monitoring pressure through an endoscope is reliable and predictive of the true intra abdominal pressure, which can be improved upon and incorporated for the future.26 The surgical procedures that have been performed in animal models include appendicectomy, nephrectomy, cholecystectomy, spleenectomy etc to gynaecological procedures like hysterectomy, fallopian tube clipping, oophrectomy etc, which have been summarised in Table 1.5,14,27–32,50,51 N.O.T.E.S procedures successfully carried out in humans include appendicectomy, cholecystectomy, peritoneoscopy and intra abdominal biopsies etc, and a summary of the procedures that have been performed in the human population from different authors is tabulated in Table 2.

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. This study was supported by a generous unrestricted research grant from the Lifecell Corporation, Branchburg, NJ.

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