natural orifice surgery has evolved from a preclinical setting into a common occurrence at the university of california san diego ( ucsd ) . with close to 40 transvaginal cases ,
the laparoscopic repair of recurrent umbilical defects , or defects greater than 3  cm in size , has been shown to decrease recurrence rates .
we have chosen to further investigate the benefits of laparoscopy by applying a natural orifice approach .
one of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation .
patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites .
in addition , patients with recurrent incisional hernias may , likewise , be at increased risk .
we believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias . to this end ,
a preclinical research protocol in transvaginal incisional herniorrhaphy was undertaken in a porcine model . after obtaining comfort with the technical procedure ,
here , we describe what we believe to be the first natural orifice transluminal endoscopic surgical ( notes ) approach to the repair of an abdominal wall hernia .
the patient is a 38-year - old female with a painful recurrent umbilical hernia who was repaired 8  years prior with a polypropylene - based mesh .
the patient has had three children since the time of her repair and had a recurrence of her umbilical hernia , which was approximately 2    2  cm in size .
the patient denied any obstructive signs or symptoms , but rated her daily pain at the site as 5/10 .
her past medical and surgical history is only pertinent for a cesarean section and the aforementioned hernia repair . the risks , benefits , and alternatives to a transvaginal incisional hernia repair
she was consented under an approved ucsd transvaginal incisional hernia repair institutional review board ( irb ) protocol .
importantly , all current ucsd notes protocols stipulate that an abdominal port be utilized for visualization of the transvaginal access .
the patient was brought to the operating room , sequential compression devices applied , 1  g of cefazolin was given , and general anesthesia induced without complication .
the patient was placed in the lithotomy position and prepped and draped in standard sterile fashion .
a lower left quadrant 5-mm trocar was placed below the pubic hairline using optical assistance .
a well incorporated mesh was noted in the umbilical region with a small herniation of falciform material through a 2-cm defect superiorly .
given that the mesh was well incorporated and peritonealized , it was left in place .
a uterine retractor was then placed and a 15-mm dual - lumen trocar ( applied medical ) was placed through the retrocervical cul - de - sac .
the dual - lumen trocar allows for placement of the scope , as well as another 5-mm rigid or flexible instrument .
the herniated falciform was then dissected free of the fascial edges using a combination of endoscopic and flexible instrumentation delivered through the vaginal port .
next , the peritoneum was cleared superiorly approximately 4  cm using the same method .
having dissected the facial edges free , the defect was then re - approximated primarily in the manner of franklin et al . .
this was done transcutaneously using a suture passer through the center of the skin overlying the defect , and sequentially passing an 0-ethibond suture approximately 1  cm lateral to each fascial edge .
next , a 7    7-cm flex hd acellular human dermis mesh ( johnson & johnson ) was inserted through the vaginal trocar once four anchoring ethibond sutures were tied to the corners .
a needle passer was passed in four quadrants , tacking the mesh in a transfascial manner .
lastly , a protack ( autosuture ) device was used to anchor the remainder of the material to the patient s anterior abdominal wall at approximately 1-cm intervals circumferentially ( fig . 
2final view of the hernia repair entrance of the vaginal trocar final view of the hernia repair the abdomen was inspected and had good hemostasis ; the 5-mm abdominal port was removed .
the gynecology team then closed the patient s vaginal access site with a 2 - 0 vicryl suture in a running fashion .
the 5-mm trocar was removed and the skin closed with a 4 - 0 monocryl suture .
the patient was admitted to the hospital for observation as per the irb and was discharged on postoperative day 2 in good health . at 6  weeks
she was then seen at 3 and 5  months and is still completely satisfied with her repair .
the repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible , and the result of our initial case was exceptional .
however , there are still significant obstacles which must be addressed before this approach can be widely utilized .
some have suggested that blind or primary access of the vagina for natural orifice surgery is safe [ 3 , 4 ] .
we do not agree . at this time , we still believe that visualization of the trocar insertion through the vagina is necessary .
though all of the key steps of the described operation were performed utilizing the vaginal access port , we still believe that blind access to the abdomen with a trocar through the vagina may put the patient at risk for visceral or vascular injury .
an additional concern in the application of natural orifice surgery to the repair of ventral hernias is the selection of the proper material for the hernia repair .
several authors have described the preclinical technical aspects of notes hernia repair in a cadaver or animal model , and most have questioned whether a prosthetic material can be used in regard to potential mesh infection [ 5 , 6 ] .
we believe this to be a very valid point . additionally , many recurrent ventral hernias have also had prior implantation of prosthetic materials , as did this patient .
her mesh was firmly incorporated and peritonealized . given this , we decided to progress with the operation . had the initial mesh been exposed or not incorporated , we would have abandoned the notes approach in favor of a more traditional method .
we do not believe that there is sufficient preclinical data from our own laboratory , or others , to advocate the placement of a prosthetic device in the face of transvaginal or transgastric abdominal access .
therefore , we used a biologic material for the repair . the use of biologic materials for abdominal wall reconstruction in contaminated or infected fields is well established . however , there is increasing concern that the re - herniation rate will be unacceptably high if the material is used to bridge the defect , rather than to buttress an appropriately re - approximated fascia .
fascial re - approximation was fairly simple with this small defect , but this severely limits the patient population which may benefit from a natural orifice approach to ventral hernias .
for the procedure to have widespread utilization , prosthetic devices will have to be used .
one of the main benefits that we have seen in our transvaginal cholecystectomy population has been the reduction of postoperative pain . while our patient was fairly comfortable postoperatively , she still experienced some pain ( 5/10 ) at the transfacial fixation sutures on postoperative day 1 . whether or not these sutures are still necessary when using a material that is ultimately absorbed or incorporated is questionable .
there are no large case series from which to draw observations in regard to the laparoscopic placement of biologic materials for the repair of ventral hernias .
given the minimal penetration of the abdominal tacks into the posterior fascia once passed through biologic material , we still believe them to be necessary .
the initial application of natural orifice techniques to the repair of an abdominal wall defect was technically feasible and clinically successful .
the patient presented here did very well postoperatively , with minimal complaints of pain or any signs of infection .
the outcome from this operation was encouraging and we look toward further investigation to answer the aforementioned questions noted in this paper .
 introductionnatural orifice surgery has evolved from a preclinical setting into a common occurrence at the university of california san diego ( ucsd ) . with close to 40 transvaginal cases , 
 we have become comfortable with this technique and are exploring other indications . 
 one of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation . 
 patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites . 
 in addition , patients with recurrent incisional hernias may , likewise , be at increased risk . 
 we believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias . here , we describe what we believe to be the first natural orifice transluminal endoscopic surgical ( notes ) approach to the repair of an abdominal wall hernia.methodsthe patient is a 38-year - old female with a painful recurrent umbilical hernia , previously repaired 8  years prior with a polypropylene - based mesh . 
 the patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.resultsthe patient had no intraoperative or postoperative complications . at 5  months 
 follow up , the patient had no complaints , no evidence of hernia recurrence , and was very pleased with her result.conclusionsthe repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible , and the result of our initial case was exceptional 
 . however , there are still significant obstacles which must be addressed before this approach can be widely utilized . 
 these obstacles include safe entrance into the abdominal cavity via a transvaginal approach , the proper mesh to be placed during the repair , and the risk of infection . 
Introduction
Methods
Results
Discussion
Conclusion