title: Hybrid NOTES transvaginal intraperitoneal onlay mesh in abdominal wall hernias: an alternative to traditional laparoscopic procedures.
abstract: BACKGROUND
  Abdominal wall hernias are increasingly treated by laparoscopic placement of an intraperitoneal onlay mesh (IPOM). We present an alternative technique for women: the laparoscopic-assisted transvaginal IPOM.
  
  
  METHODS
  Before surgery, all patients underwent a gynecological examination. The patients agreed to IPOM repair via a transvaginal approach, and written informed consent for surgery was obtained. Pneumoperitoneum was established with a Veress needle at the umbilicus. This access was subsequently dilated to 5 mm (VersaStep), and a 5-mm laparoscope was inserted. Under laparoscopic view, the transvaginal trocars (12-mm VersaStep and 5-mm flexible accesses) were safely inserted after lifting the uterus with a uterus manipulator. After preparation of the falciform ligament, the ligamentum teres and the preperitoneal fat, a lightweight composite mesh was introduced through the transvaginal access and fixed with absorbable tacks using the double-crown technique.
  
  
  RESULTS
  From September 2011 to December 2012, we performed six laparoscopic-assisted transvaginal IPOM procedures (one epigastric, three umbilical, two combined epigastric and umbilical hernias; all were primary hernias). In the initial phase, only patients with small or medium primary abdominal wall hernia were selected (max. 3 cm diameter). Median hospital stay was 3 days (range 2-6 days). One minor complication occurred perioperatively (second-degree skin burn to the labia majora). At 1-year follow-up, we identified one recurrence in a high-risk patient with a body mass index higher than 35 kg/m(2). No infection and no mortality were observed.
  
  
  CONCLUSIONS
  Although no final conclusion can be made regarding the presumed non-inferiority of this technique in terms of recurrence and mesh infection compared with traditional laparoscopic IPOM, laparoscopic-assisted transvaginal IPOM is a feasible alternative to treat abdominal wall hernias.
authors.affiliation: Department of Surgery, Kantonsspital Baden, 5404, Baden, Switzerland. alexandre.descloux@ksb.ch.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Descloux
authors.affiliation: Department of Surgery, Kantonsspital Baden, 5404, Baden, Switzerland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Pohle
authors.affiliation: Department of Surgery, Kantonsspital Baden, 5404, Baden, Switzerland.
authors.forename: Antonio
authors.initials: A
authors.lastname: Nocito
authors.affiliation: Department of Surgery, Kantonsspital Baden, 5404, Baden, Switzerland.
authors.forename: Andreas
authors.initials: A
authors.lastname: Keerl
mesh_terms: D000328:Adult; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D046449:Hernia, Abdominal / Q000601:surgery*; D059685:Herniorrhaphy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D010537:Peritoneum / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D013526:Surgical Mesh; D016896:Treatment Outcome; D014621:Vagina
keywords: Abdominal wall hernia; IPOM; Mesh; NOTES; Transvaginal