Miedema Brent W, Bachman Sharon L, Sporn Emanuel, Astudillo J Andrés, Thaler Klaus
Department of Surgery, University of Missouri, One Hospital Drive, MC422 McHaney Hall, DC075.00, Columbia, MO 65212, USA.
Surg Endosc. 2009 Jun;23(6):1212-8. doi: 10.1007/s00464-009-0352-3. Epub 2009 Mar 5.
Incisional hernia repairs have a risk of wound complications that may be decreased using a natural orifice transluminal endoscopic surgery (NOTES) approach. The aim of this study was to determine the feasibility and safety of transgastric mesh placement to the anterior abdominal wall in a porcine model as a precursor to future studies of NOTES ventral hernia repair.
The procedure was done under sterile conditions with a double lumen endoscope using a plastic overtube. The endoscope was placed in the stomach preloaded with an overtube. Entrance of the endoscope and overtube into the peritoneal cavity was performed with the percutaneous endoscopic gastrostomy (PEG) technique. A 13 x 15 cm Surgisis Gold mesh with four corner sutures was delivered through the overtube. Transfascial suture passer and endoscopic grasper were used to externalize the sutures and attach the mesh to the anterior abdominal wall. The gastrotomy was closed with a transabdominal gastropexy. The pigs were sacrificed at 2 weeks.
Mesh placement was performed in five pigs. Operative time was 215 min (standard deviation, SD 99 min). The most difficult portion of the procedure involved manipulating the gastric overtube, likely exposing the mesh to bacteria in the stomach. Culture-positive abscesses were present at the mesh in 3/5 animals. The mesh appeared intact in 4/5 animals; one of the infected meshes had delamination of 50% of the mesh. Adhesions to the mesh surface varied from 2% to 100%. At 2 weeks, median mesh size was 116 cm2 (range 96-166 cm2) and median contraction was 41% (range 15-51%). Histologic evaluations demonstrated marked inflammation and fibrosis progressing into the mesh material.
Totally endoscopic transgastric delivery and fixation of a biologic mesh to the anterior abdominal wall is feasible. Challenges remain in designing systems for mesh delivery that exclude gastric content. Once these problems can be surmounted NOTES ventral hernia repair may become an option in man.
切口疝修补术存在伤口并发症风险，采用自然腔道内镜手术（NOTES）方法可能会降低该风险。本研究的目的是在猪模型中确定经胃将补片放置于前腹壁的可行性和安全性，作为未来NOTES腹疝修补术研究的前期准备。
在无菌条件下，使用双腔内镜和塑料外套管进行该手术。将预先装有外套管的内镜置入胃内。采用经皮内镜胃造口术（PEG）技术将内镜和外套管送入腹腔。通过外套管送入一块带有四个角缝线的13×15 cm Surgisis Gold补片。使用经筋膜缝线推送器和内镜抓钳将缝线引出并将补片固定于前腹壁。胃切开处采用经腹胃固定术关闭。术后2周处死猪。
对5头猪进行了补片放置。手术时间为215分钟（标准差，SD 99分钟）。该手术最困难的部分是操作胃外套管，这可能使补片暴露于胃内的细菌中。3/5的动物补片处出现培养阳性的脓肿。4/5的动物补片外观完整；其中一块感染的补片有50%的补片分层。补片表面的粘连程度从2%到100%不等。术后2周，补片的中位面积为116 cm²（范围96 - 166 cm²），中位收缩率为41%（范围15 - 51%）。组织学评估显示有明显的炎症和纤维化延伸至补片材料中。
完全内镜下经胃将生物补片输送并固定于前腹壁是可行的。在设计排除胃内容物的补片输送系统方面仍存在挑战。一旦这些问题能够解决，NOTES腹疝修补术可能成为人类的一种选择。
