The prepped vaginal canal may be a sterile conduit for ventral hernia mesh insertion: a prospective comparative study

Hybrid NOTES transvaginal intraperitoneal onlay mesh in abdominal wall hernias: an alternative to traditional laparoscopic procedures

INTRODUCTION

Abdominal wall hernias are increasingly treated by laparoscopic placement of an intraperitoneal onlay mesh (IPOM). We present an alternative technique for women: the laparoscopic-assisted transvaginal IPOM.

METHODS

Before surgery, all patients underwent a gynecological examination. The patients agreed to IPOM repair via a transvaginal approach, and written informed consent for surgery was obtained. Pneumoperitoneum was established with a Veress needle at the umbilicus. This access was subsequently dilated to 5 mm (VersaStep), and a 5-mm laparoscope was inserted. Under laparoscopic view, the transvaginal trocars (12-mm VersaStep and 5-mm flexible accesses) were safely inserted after lifting the uterus with a uterus manipulator. After preparation of the falciform ligament, the ligamentum teres and the preperitoneal fat, a lightweight composite mesh was introduced through the transvaginal access and fixed with absorbable tacks using the double-crown technique.

RESULTS

From September 2011 to December 2012, we performed six laparoscopic-assisted transvaginal IPOM procedures (one epigastric, three umbilical, two combined epigastric and umbilical hernias; all were primary hernias). In the initial phase, only patients with small or medium primary abdominal wall hernia were selected (max. 3 cm diameter). Median hospital stay was 3 days (range 2-6 days). One minor complication occurred perioperatively (second-degree skin burn to the labia majora). At 1-year follow-up, we identified one recurrence in a high-risk patient with a body mass index higher than 35 kg/m(2). No infection and no mortality were observed.

CONCLUSION

Although no final conclusion can be made regarding the presumed non-inferiority of this technique in terms of recurrence and mesh infection compared with traditional laparoscopic IPOM, laparoscopic-assisted transvaginal IPOM is a feasible alternative to treat abdominal wall hernias.

Hybrid transvaginal incisional hernia repair

AIM

Natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) is a new approach that allows surgical manipulations and specimen extractions through the natural orifices such as the vagina. There have been limited numbers of cases about the adaptation of NOTES for ventral hernia repairs. Here, we aimed to present two more cases and highlight our technical differences compared with the previously reported instances.

PATIENTS AND METHODS

Two patients (43 and 46 years old; body mass index of 29 and 30 kg/m(2), respectively) were treated with hybrid transvaginal incisional hernia repairs. Two 5-mm abdominal trocars were used to monitor transvaginal access, adhesiolysis, dissection of the hernia, and tuckering of the mesh. A 15-mm transvaginal trocar was used for scope and mesh introduction into the abdomen. Defects were 3-5 cm in diameter.

RESULTS

A rigid 5-mm laparoscope was used. The composite synthetic meshes were, respectively, 11 and 13 cm in diameter. These were passed through the vagina without any protection such as a bag or sheath. No conversion or additional port was required. Respective operative times were 120 and 180 minutes, and the patients were discharged uneventfully on the second day. One patient had seroma, which was managed conservatively (aspiration of 20 mL on Day 7). There were no recurrences after 7 and 13 months, respectively.

CONCLUSIONS

Conventional laparoscopic equipment can be used for hybrid transvaginal incisional hernia repair. An anti-adhesive synthetic mesh can be inserted through the vaginal trocar without protective devices. The main advantage of this technique is to avoid 10-15-mm abdominal trocars, which increase the risk of trocar-site hernias themselves.