Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

Current status of single-port versus multi-port approach in laparoscopic inguinal hernia mesh repair: an up-to-date systematic review and meta-analysis

A meta-analysis was conducted to provide an up-to-date comparison of single-port and multi-port approach, in laparoscopic inguinal hernia mesh repair. This meta-analysis was performed on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic databases (MEDLINE, Web of Science and Cochrane Central Register of Controlled Clinical Trials) were systematically screened. Fixed Effects or Random Effects model was used, according to the Cochran Q test. In total 16 eligible studies were found. There was no statistically significant difference, regarding unilateral operation duration, between the two approaches, in TEP (OR - 4.61; 95% CI - 9.70, 0.47, p = 0.08) or TAPP (OR - 1.96; 95% CI - 4.89, 0.97, p = 0.19) procedures. Similarly, in both operative modalities, no superiority of either approach was proven, in terms of conversion rate (TEP OR 0.69, p = 0.48; TAPP OR 5.46, p = 0.31), length of hospital stay (TEP WMD 0.00, p = 0.76; TAPP WMD - 0.11, p = 0.42) and overall complication rate (TEP OR 1.10, p = 0.51; TAPP OR 0.74, p = 0.43). Overall, single-port and the established multi-port approach in inguinal hernia mesh repair, are equivalent, regarding the postoperative outcomes. Given several limitations, further RCTs, of higher methodological and quality level are required.

Feasibility of transumbilical flexible endoscopic preperitoneoscopy (FLEPP) and its utility for inguinal hernia repair: experimental animal study

BACKGROUND AND STUDY AIMS

Various NOTES (natural orifice translumenal endoscopic surgery) hernia repair techniques have been described. The aim of this study was to evaluate the feasibility of a transumibilically introduced conventional double-channel flexible endoscope for performing preperitoneoscopy (FLEPP, flexible endoscopic preperitoneoscopy technique) and to perform totally extraperitoneal (TEP) inguinal hernia meshplasty in an animal model.

MATERIAL AND METHODS

The study was done in 2 steps on 8 swines weighing 25 to 30 kg each: (1) establishing feasibility of preperitoneal dissection of the inguinal region using a conventional double-channel flexible gastroscope and making bed for mesh placement and (2) placement of a polypropylene mesh in the inguinal region to cover the myopectineal orifice.

RESULTS

The flexible endoscope provided good vision and maneuverability to identify preperitoneal structures--namely, the arcuate line, insertion of rectus abdominis on pubis symphysis, inferior epigastric vessels, deep inguinal ring, spermatic cord, pubic symphysis, and psoas muscle--without causing any damage to any of the structures. The spermatic cord could be dissected to identify the vas deference. A 9 × 7 cm(2) oval mesh was successfully placed over the myopectineal orifice of Fruchaud with good overlap. Average time required for the complete FLEPP procedure (including mesh placement) was 55 minutes (range 45-90 minutes).

CONCLUSIONS

This study demonstrates, for the first time, the feasibility of the transumbilical FLEPP technique and its utility for performing TEP inguinal hernia repair with prosthetic mesh placement in a swine model.

Feasibility and safety of functional cholecystectomy by pure NOTES: a pilot animal study

BACKGROUND

NOTES cholecystectomy has become one of the hottest areas of research. But most of the cases need the assistance of the laparoscope. This study is conducted to evaluate the feasibility and safety of a newly proposed operative method-functional cholecystectomy by pure NOTES.

MATERIALS AND METHODS

The functional cholecystectomy was performed on eight female miniature pigs. An incision was made on the vaginal wall, and an endoscope was inserted into the peritoneal cavity to create a pneumoperitoneum to expose the intra-abdominal viscera, gallbladder, and cystic duct. The cystic duct was isolated and closed with a clip. Then, an injection needle was inserted into the gallbladder to suck up the bile. After the gallbladder was washed with saline, an incision was made on the wall of the gallbladder, and the tip of the endoscope was inserted into the gallbladder cavity. After the endoscope was withdrawn, the gallbladder incision was closed with clips in four pigs and was suspended in the other four pigs. The vaginal incision was closed with clips. All the animals were closely monitored and euthanized 28 days after the procedure. Necropsy was performed.

RESULTS

The functional cholecystectomy was successfully completed in all eight pigs. No severe intraoperative complications occurred. The animals recovered well postoperatively. At necropsy, no macroscopic signs of intraperitoneal infection or bile leakage in the peritoneal cavity were observed, and the clips were still present on the cystic duct in a good position in all cases. The gallbladder incision healed, with no sign of bile leakage or injury to the adjacent organs.

CONCLUSIONS

We successfully performed the functional cholecystectomy by transvaginal approach on pigs, which appears to be feasible, safe, and convenient. Functional cholecystectomy provides a new fitting path to pure NOTES.

Feasibility of Endoscopic Transoral Surgical Lung Biopsy in a Live Canine Model

Background. The feasibility of using a transoral approach to the thoracic cavity has not yet been measured in humans or animals. The present study aimed to evaluate the feasibility of transoral surgical lung biopsy (TOLB) in 10 canines. Methods. Through an incision over the vestibulum oris, a homemade metal tube was introduced into the thoracic cavity under endoscopic guidance and used as a working channel of surgical lung biopsy. TOLB was performed on the predetermined lung lobe by using an electrocautery loop and endoscopic grasper. Results. Successful surgical lung biopsy was achieved in 8 of 10 animals in a mean time of 132 minutes (range 130-190 minutes). There were no major intraoperative or postoperative complications, and all animals survived for 2 weeks after surgery. Autopsy showed no evidence of vital structure injury, mediastinitis, or empyema. Conclusions. TOLB was demonstrated to be safe and feasible in a canine model.

Critical analysis of hot topics in NOTES

Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.

Initial experience from the transgastric endoscopic peritoneoscopy and biopsy: a stepwise approach from the laboratory to clinical application

BACKGROUND AND AIM

Natural-orifice translumenal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transcolonic, transvaginal or transvesical routes. The aim of the present study was to evaluate the safety and feasibility of transgastric endoscopic peritoneoscopy and biopsy from laboratory to clinical application.

METHODS

With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle-knife and through-the-scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. After 2 weeks, another transgastric endoscopic exploration was performed in a different location of the stomach. The peritoneal cavity was examined before the gastric incision was closed. After 4 weeks of observation, necropsy was performed. In the clinical application, after gastric lavage, the first step was the creation of the gastrotomy under general anesthesia, sometime under direct vision of the laparoscopic scope. Then the endoscope can be maneuvered in the peritoneal cavity. And peritoneoscopy and biopsy were performed. Biopsies can be obtained from any suspicious areas using punch biopsy forceps. The gastrotomy was then closed with clips. The gastroscopy was examined after one week.

RESULTS

Twenty-eight transgastric endoscopic peritoneoscopies and biopsies in pigs and a total of five transgastric human endoscopic peritoneoscopies and biopsies have been performed. All procedures were completed satisfactorily in the pig model and all patients. There were no intraoperative or postoperative complications.

CONCLUSIONS

The advantages of peritoneoscopy and biopsy appeared to be enhanced by this approach. Patients had minor postoperative pain and minimal scarring. It is safe and feasible for us to use transgastric endoscopic peritoneoscopy and biopsy in humans.

Natural orifice translumenal endoscopic surgery

PURPOSE OF REVIEW

Since its introduction in 2000, natural orifice translumenal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world. In this article, we will review the progress in the field of NOTES and present the latest publications that provide some answers and solutions to the barriers suggested by the Natural Orifice Surgery Consortium for Assessment and Research white paper.

RECENT FINDINGS

Because of the first human NOTES procedure by Rao and Reddy, more pioneering procedures, including transgastric and transvaginal cholecystectomies, appendectomies, and hernia repairs, have been performed. Although NOTES researchers continue to experiment with new innovative equipment and procedures in the lab, more structured work, including randomized controlled trials, has been published.

SUMMARY

In the last several years, there has been growing interest in NOTES, which has translated into exciting animal research work and publication of randomized controlled trials. Additionally, preliminary NOTES human procedures have been successfully performed. When suitable instruments become available, the subsequent step should be comparing NOTES with current laparoscopic approaches. Superiority or even equality of NOTES to laparoscopic surgery would be the best argument for advancing and integrating implementation into clinical practice.

NOTES transgastric abdominal wall hernia repair in a porcine model

INTRODUCTION

With approximately 1 million ventral and inguinal hernia repairs performed in the United States each year, even small rates of complications translate into large numbers of patients. Less invasive approaches that potentially lower morbidity deserve consideration, recognizing there are many technical considerations that currently limit their use. We describe a reproducible technique and lessons learned in our laboratory that answer some existing questions with regards to the use of NOTES for hernia repair.

METHODS

A non-survival porcine model with general anesthesia was utilized in all cases. Each animal underwent transgastric peritoneal access with a percutaneous endoscopic gastrostomy (PEG) technique, and the gastrotomy was dilated with a wire-guided balloon dilatation catheter. An Esophageal Z-stent delivery device (Cook Medical, Winston-Salem, NC) was modified ex-vivo to allow us to introduce and protect a 10 x 15 cm lightweight polypropylene hernia prosthetic with pre-placed sutures. Once deployed, the sutures were pulled through the abdominal wall using a looped spinal needle technique in combination with the flexible endoscope. After the four anchoring sutures were tied, proprietary endoscopically placed tacks (Cook Medical) were placed at regular intervals between the sutures to secure the edges of the prosthetic.

RESULTS

Hernia repairs were performed on five animals. In each case, we successfully completed prosthetic delivery and deployment into the peritoneal cavity, anchoring to the abdominal wall with full-thickness abdominal wall sutures, and endoscopically placed nitinol tacks. All prosthetics were deployed flat against the anterior abdominal wall. Operative times ranged from 65 to 120 min.

CONCLUSION

Transgastric abdominal wall hernia repair is feasible, consistent, and reproducible. In particular, the delivery system can successfully deliver the prosthetic across the gastric wall via a transoral route. Survival animal experiments investigating outcomes related to quality of repair, microbiology, adhesions, and visceral closure need to be done. Human studies are not recommended until these issues are formally investigated.

The feasibility of FS mesh fixation by a transgastric approach--an important benefit in future NOTES procedures?

BACKGROUND

Preserving the integrity of the abdominal wall is a major benefit in NOTES procedures. It may result in a decrease of postoperative (postOP) pain, infection, and port site hernia. This experimental study on intra-peritoneal onlay mesh (IPOM) repair was designed to apply meshes by a transgastric access (TGA) and to use a combination of transfascial sutures and fibrin sealant as fixation.

MATERIALS AND METHODS

Four abdominal wall defects were created by TGA under laparoscopic control in five nonsurvival and three survival pigs (4, 11, and 22 d observation period). Titanized polypropylene meshes were fixed transfascially by four polypropylene sutures using a "suture passer" device. Meshes were additionally fixed with 0.2 mL of fibrin sealant (FS) by an endoscopic application. TGA was closed with endoclips in the nonsurvival model and with laparoscopic suturing in survival pigs.

RESULTS

The three survival pigs were euthanized on the d 4, 11, and 22 postOP. The macroscopic evaluation revealed excellent integration of the meshes without signs of shrinkage, dislocation, or inflammation. Histology confirmed macroscopic findings.

CONCLUSIONS

Our findings confirm that IPOM repair of ventral hernia in an experimental NOTES hybrid procedure is feasible. This study also demonstrates the technical feasibility and the potential advantages of FS mesh fixation to further reduce trauma to the abdominal wall following the key principles of the NOTES approach.

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

Natural orifice translumenal endoscopic surgery (N.O.T.E.S) is a technique that allows access to the peritoneal cavity through natural orifices (oral, rectal, vaginal, vesical) without passing through the anterior abdominal wall. Rapid strides have been made in developing this technique, especially in animal models. Majority of research work in this field is originating from USA, while human clinical trials are being reported from India and Southern America. Morbidly obese patients and ITU patients are two target groups where N.O.T.E.S if implemented, will have the highest potential and bearing. With increasing evidence of safe practice in human models, questions on indications and feasibility of practice need to be addressed by rigorous research, strong evidence and collaboration between surgical centers worldwide.