NOTES Transgastric Hernia Repair in a Porcine Model
Comments: Our procedure begins with a PEG-type transgastric abdominal access. A wire is placed percutaneously into the stomach, a balloon is passed over the wire into the abdominal cavity, and the balloon is inflated. The endoscope exits the stomach into the abdominal cavity by following the balloon as we push out over the guidewire. Once the Savary is in place, the endoscope is removed and the mesh introducer system is introduced into the abdomen. One can see that this is simply and esophageal stent introducer. The Savary tip is pushed out and the inner tube is used to extrude the hernia mesh into the abdominal cavity (somewhat aseptically). The introducer is then removed and the endoscope is reinserted.
The hernia mesh is about 10 x 10 or 10 x 12 cm piece of typical hernia mesh, and it has been placed over the outside of the animal's abdomen where the hernia defect is simulated. A tracing is made of the edges of the hernia mesh. The edges also have sutures attached to them. There are long sutures attached to teach edge. The cardinal suture is found endoscopically, and the cardinal suture is passed through a needle and prolene suture loop that are placed through a stab wound in the abdominal wall. As the suture and needle are pulled out through the stab wound, the cardinal suture is bulled out of the abdomen wall and can be used to anchor the mesh at the region of the stab wound. The second cardinal suture is grasped in a similar fashion and is pulled through the prolene suture loop. And as the prolene suture and the needle are removed, the second of the two long tails of the cardinal suture is pulled out through the stab wound. The cardinal sutures can then be tied together and the knot can be buried in the stab wound. The stab wound is then closed with Steri Strips. We can see the suture disappearing here.
We will show a second example of this with one of the other edges. This is the right-hand edge. The prolene suture and needle are once again inserted through a stab wound. The forceps are pushed through the loop, one of the edge sutures is grasped, and the forceps are pulled back. This allows us to entrap that suture and pull it out when the needle and the prolene suture are withdrawn. This is done twice for each of the four edges of the mesh. Again, once each suture is pulled through and the pair is on the skin side of the abdominal wall, they can be tied together inside the stab wound and buries, thus anchoring he mesh securely to the abdominal wall. The loop is passed here again while we pull the second suture through.
Once the four edges are secured to the abdominal wall in this fashion, we still need to tack up the corners using the mesh clips (tacks). We have developed a special clip for this purpose which is made of Nitinol. This clip has three prongs at each end, and is small enough to be loaded into a 19-ga needle. Once it is loaded into the needle, the needle can be embedded into the abdominal wall and the track can be pushed out part way. As the needle is retracted, the remaining three prongs of the track will anchor the mesh to the abdominal wall. We can see the needle here being plunged into the corner of the mesh as it is held into place by rat –tooth forceps in the left-hand channel of the double-channel endoscope. As the needle is withdrawn, the inner tines will flip out, holding the mesh firmly in place.
This is shown in slightly more close-up view here. Again, the rat-toothed forceps are holding the mesh in place. The preloaded needle is inserted through the right channel. The needle is exposed and plunged into the abdominal wall. The stylet inside the needle is used to push the tack part-way out. And then the needle is withdrawn exposing the inner tines which then grasp the mesh and hold it tightly against the abdominal wall.
As you can imagine, this becomes very tedious, and the scope is not a stable platform for pushing long needles into tough fascia. So we have developed a second way to deploy the tacks. We have placed them in a 19-ga needle which is pushed directly through the skin into the abdomen. A stylet is used to push the tack half way out, as the needle is withdrawn the track engages the mesh and holds it against the abdominal wall. This is shown again here. A needle is placed through the skin directly into the mesh. A stylet is used to push the tack half-way out, and the needle is withdrawn, the stylet deploys the remainder of the tack which embeds itself in the abdominal wall as the tines spread open. This causes the hernia mesh to adhere tightly to the abdominal wall such that no abdominal viscera can penetrate under the edges.
Our hernia repair is now complete.
| Contributed by: |
David J. Desilets, MD, PhD
|
|
Citation: Desilets, DJ (Jun 01 2009). NOTES Transgastric Hernia Repair in a Porcine Model. The DAVE Project. Retrieved Feb, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=854 Times viewed since Feb 2006: 2290 |
|
