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Scientific letter
Hybrid Transvaginal Ventral Hernia Repair
Eventroplastia transvaginal híbrida
Marcos Bruna
Corresponding author
, José Noguera, Isabel Martínez, Miguel Oviedo
Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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which was reductible&#44; along with an aponeurotic defect measuring 4<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46; We proceeded with the repair using a hybrid transvaginal approach&#44; starting with the preoperative administration of 2<span class="elsevierStyleHsp" style=""></span>g of amoxicillin-clavulanate and perineal&#47;vaginal lavage of diluted povidone-iodine solution&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">With the patient in the modified Lloyd-Davies position&#44; the surgeon stood on the left and the assistant surgeon stood between the patient&#39;s legs&#46; Pneumoperitoneum was created with a transumbilical Veress needle&#44; and then a 5-mm trocar was inserted in the left flank for the later use of forceps and the stapler to attach the prosthesis&#46; Through the orifice of the Veress needle&#44; a 3-mm trocar was introduced to provide access for mini-instruments &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was placed in forced Trendelenburg position&#46; With the laparoscope &#40;5<span class="elsevierStyleHsp" style=""></span>mm 0&#176; optics&#44; through the 5-mm port&#41; an extra-long optical trocar &#40;150<span class="elsevierStyleHsp" style=""></span>mm&#41; was inserted through the posterior vaginal fornix &#40;12<span class="elsevierStyleHsp" style=""></span>mm EndoPath<span class="elsevierStyleSup">&#174;</span> Xcel&#8482;&#41;&#44; which we later used to insert the mesh and optics &#40;10<span class="elsevierStyleHsp" style=""></span>mm and 30&#176;&#41;&#46; The transvaginal trocar was protected with a sterile plastic sheath and the pouch of Douglas was washed with a povidone-iodine solution &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; After releasing the omental adhesions of the hernia sac using the 2 abdominal ports as working channels and the transvaginal trocar to insert the 30&#176; optic&#44; we proceeded with the mesh placement &#40;Ethicon Physiomesh&#8482; Flexible Composite Mesh&#41;&#46; The patch was rolled up for insertion through the vaginal trocar without any further protection and subsequently fixed with 2 crowns of absorbable straps &#40;Ethicon Securestrap&#8482; 5<span class="elsevierStyleHsp" style=""></span>mm Absorbable Strap Fixation Device&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Afterwards&#44; the 3 and 10<span class="elsevierStyleHsp" style=""></span>mm trocars were removed under direct vision &#40;5<span class="elsevierStyleHsp" style=""></span>mm 0&#176; optic through the trocar of the left flank&#41; and the vaginal opening was closed vaginally with 2 polyglactin sutures &#40;910<span class="elsevierStyleHsp" style=""></span>2&#47;0&#41; and the abdominal skin with monofilament &#40;3&#47;0&#41;&#46; The patient had a favourable postoperative course and was discharged from the hospital 36<span class="elsevierStyleHsp" style=""></span>h after surgery and continued to be asymptomatic one month later&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The benefits of the laparoscopic approach in the treatment of ventral and abdominal wall hernias have been demonstrated in several studies&#44; including lower risk of wound infection and shorter hospital stay&#44; with recurrence rates that are lower than open surgery in many reports&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; in order to minimize parietal aggression&#44; mini-instruments have been developed&#44; which allow for dissecting&#44; resecting and manipulating different structures within the abdominal cavity through minimal 2&#8211;3<span class="elsevierStyleHsp" style=""></span>mm incisions with accuracy and safety&#46; The transvaginal approach aims to avoid abdominal incisions and provide aesthetic&#44; pain-related and structural benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Thus&#44; the combination of the benefits of these treatment approaches for abdominal wall disease is the basis for the development of the technique described&#46; It avoids having to make an abdominal incision for placement of the 10&#8211;12<span class="elsevierStyleHsp" style=""></span>mm trocar usually used for the placement of the mesh and stitches&#44; if necessary&#44; with the potential risk for recurrent incisional hernia of 1&#37;&#8211;6&#37; according to the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Other groups have proposed inserting this 10&#8211;12<span class="elsevierStyleHsp" style=""></span>mm trocar through the aponeurotic hernia defect itself while using other 5<span class="elsevierStyleHsp" style=""></span>mm ports&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> thus avoiding the creation of another fascial defect&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although septic complications associated with the transvaginal approach are rare &#40;less than 1&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> to prevent possible intraabdominal and mesh contamination from being introduced through the transvaginal trocar&#44; we applied the following measures&#58; preoperative antibiotic prophylaxis&#44; use of a sterile sheath for the entry of the transvaginal trocar in the perineum&#44; change of gloves before handling the prosthesis and lavages of the pouch of Douglas through the transvaginal trocar with a povidone-iodine solution diluted to 20&#37;&#46; Other complications associated with the transvaginal approach are mild and uncommon&#44; such as bleeding or local pain&#46; A period of sexual abstinence is recommended for 2&#8211;3 weeks&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We believe that the technique we present is simple&#44; safe and reproducible&#46; It is a valid option in selected cases of women with no history of pelvic surgery or gynaecological problems &#40;pelvic inflammatory disease&#44; endometriosis&#44; etc&#46;&#41; with umbilical hernias and aponeurotic defects smaller than 8<span class="elsevierStyleHsp" style=""></span>cm without contraindication for laparoscopic repair&#46; The use of flexible endoscopes with the transvaginal access may also be useful for improving visualization at distant points of the pelvis and lateral wall of the abdomen&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span>"
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