vTEP: A Novel Transvaginal Extraperitoneal Approach to Inguinal Hernia Repair-a Proof-of-Concept Surgical Video.

STUDY

OBJECTIVE

To demonstrate a novel transvaginal total extraperitoneal (vTEP) approach for inguinal hernia repair using retroperitoneal vaginal natural orifice transluminal endoscopic surgery (vNOTES).

DESIGN

Proof-of-concept surgical video.

SETTING

Imelda Hospital, Bonheiden, Belgium, multidisciplinary gynecology-general surgery team.

INTERVENTIONS: A 70-year-old woman with symptomatic left-sided inguinal hernia and concomitant pelvic organ prolapse. The procedure was clinically indicated. Formal institutional review board review was not required locally. A written consent for video recording and publication was obtained and archived. After hydrodissection of the anterior vaginal wall, a midline vaginal incision was made and the pubocervical fascia transected. The bladder was dissected from the pubocervical fascia and the dissection continued laterally through the paravesical space toward the arcus tendineus fasciae pelvis. The obturator fossa is accessed retroperitoneally over the arcus tendineus fasciae pelvis. This part of the dissection is identical to the technique first developed and described in 2019 as a new retroperitoneal vNOTES approach to sentinel node dissection for endometrial cancer [1]. A GelPOINT V-Path port was inserted, and carbon dioxide was inflated. The obturator nerve, external iliac vessels, and psoas muscle were identified. The peritoneum was dissected from the psoas and abdominal wall to expose the inguinal region (Bogros space). A 15.7 × 10.3 cm polypropylene mesh (3DMax Light Mesh; Bard BD, Franklin Lakes, NJ) was introduced transvaginally and positioned to cover the inguinal defect. The vaginal incision and pubocervical fascia were subsequently closed. vTEP applies the principles of extraperitoneal hernia repair to a vaginal natural orifice approach, building on previously described retroperitoneal vNOTES access to the pelvic sidewall [1-3]. The procedure was completed successfully, demonstrating the technical feasibility of transvaginal extraperitoneal inguinal hernia repair using vNOTES.

CONCLUSION

vTEP represents a novel scarless alternative to conventional totally extraperitoneal or transabdominal preperitoneal inguinal hernia repair [2]. Relevance lies in retroperitoneal vNOTES access, pelvic sidewall anatomy, and the potential role of gynecologic surgeons in multidisciplinary scarless extraperitoneal surgery. Further studies are required to evaluate long-term outcomes, reproducibility, and procedural safety.