Feasibility of Transumbilical Flexible Endoscopic Preperitoneoscopy (FLEPP) and Its Utility for Inguinal Hernia Repair

Background and study aims. 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. Material and 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 cm² 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.