title: Feasibility of transumbilical flexible endoscopic preperitoneoscopy (FLEPP) and its utility for inguinal hernia repair: experimental animal study.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Department of Gastrointestinal and Endocrinal Surgery, University of Strasbourg, Strasbourg, France. dr_paragd@yahoo.com
authors.forename: Parag
authors.initials: P
authors.lastname: Dhumane
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Donatelli
authors.forename: Hyunsoo
authors.initials: H
authors.lastname: Chung
authors.forename: Bernard
authors.initials: B
authors.lastname: Dallemagne
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000818:Animals; D005240:Feasibility Studies; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000295:instrumentation* / Q000379:methods; D010535:Laparoscopy / Q000295:instrumentation* / Q000379:methods; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation* / Q000379:methods; D019919:Prosthesis Implantation; D013085:Spermatic Cord / Q000601:surgery; D013526:Surgical Mesh; D013552:Swine