Trans-gastric Ventral Abdominal Wall Placement of a Biologic Mesh

We proposed a feasibility study to determine if biologic mesh may be safely placed in the abdomen in a transgastric fashion, as a precursor to attempting transgastric ventral hernia repair.
Six swine underwent upper endoscopy after decontamination of the stomach with povidone-iodine (Betadine). Under endoscopic guidance the gastric wall was perforated. A plastic overtube was introduced into the abdominal cavity over the endoscope. A 13x15cm Surgisis Gold mesh with 4 pre-placed corner sutures was delivered down the overtube. Transfascial suture passers and endoscopic graspers were used to externalize the sutures and add 4 additional fixation sutures. The gastrotomy was closed transabdominally using the suture passer. The pigs were sacrificed at 2 weeks.
One anesthesia death occurred at operation. One pig was sacrificed early due to sepsis and the small bowel was found to be eroded into a mesh fixation suture with resultant gross peritonitis. This infection may have been secondary to a suture-passer bowel injury. Although the mesh was still intact, it was not as well incorporated into the abdominal wall as in the other pigs. Bacteria were cultured from 3/5 mesh specimens. Multiple intra-abdominal bacteria were found in the peritoneum remotely from the mesh in the same 3/5 animals. Mesh appeared intact in 4/5 animals; one pig had multiple scattered intraperitoneal abscesses and delamination of the mesh around an infected fluid collection. Other mesh findings included one intralaminar hematoma and one intralaminar seroma. Variable adhesions to mesh were present, from none to extensive. Histologic evaluations demonstrated inflammatory cells progressing into the mesh material, the first stage of Surgisis mesh incorporation. Median mesh size was 115.5cm2 (Range 95.7-166.3cm2) and median contraction was 40.8% (Range 14.7-50.9).
Totally endoscopic trans-gastric delivery and fixation of mesh on the anterior abdominal wall is feasible and Surgisis mesh remained intact despite bacterial contamination of the peritoneum. The most difficult portions of the procedure involved manipulating the gastric overtube and this most likely led to bacterial seeding of the peritoneal cavity. Significant challenges still remain in designing ideal systems for mesh delivery that exclude gastric spillage. A mesh that is tolerant of bacterial exposure is necessitated in this procedure.

Session: Podium Presentation

Program Number: S043

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