Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

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 clogs 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 x 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 clogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal on-lay 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. (Gastrointest Endosc 2009; 70:126-30.)