Overview
Definition:
The Intraperitoneal Onlay Mesh (IPOM) plus technique is a laparoscopic or open surgical approach for ventral hernia repair where a synthetic or composite mesh is placed directly on the intraperitoneal surface of the abdominal wall, overlying the defect, without being suturalized to the posterior rectus sheath
The "plus" signifies enhancements such as pre-peritonealization or the use of specific fixation devices to improve outcomes and reduce complications compared to standard IPOM.
Epidemiology:
Ventral hernias, including incisional and umbilical hernias, are common, occurring in 2-11% of patients undergoing abdominal surgery
Incisional hernias are the most frequent type, with recurrence rates varying significantly based on repair technique, patient factors, and surgeon experience
IPOM techniques are widely used for large or complex ventral hernias.
Clinical Significance:
Ventral hernias can cause pain, disfigurement, and lead to serious complications like incarceration and strangulation, necessitating prompt surgical intervention
The IPOM plus technique aims to provide durable hernia repair with reduced recurrence and morbidity, making it a crucial topic for surgical residents preparing for DNB and NEET SS examinations.
Indications
Primary Indications:
Large ventral hernias (>4 cm defect size)
Recurrent hernias after previous repairs
Patients with poor tissue quality or multiple comorbidities that preclude tension-free primary repair
Initial repair of large primary hernias where a mesh is deemed necessary for durability.
Contraindications:
Active infection at the surgical site or systemically
Significant contamination of the hernia contents (e.g., enterocutaneous fistula)
Uncontrolled coagulopathy
Patients with unrealistic expectations or poor adherence to postoperative instructions
Incarcerated or strangulated hernias with bowel compromise that requires bowel resection may necessitate alternative techniques or open repair.
Timing Of Repair:
Elective repair is preferred for asymptomatic or minimally symptomatic hernias to allow for optimal patient preparation and minimize surgical risk
Emergency repair is indicated for symptomatic hernias with signs of incarceration or strangulation.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to assess hernia characteristics, comorbidities, and prior surgical interventions
Assessment of nutritional status and smoking history, as these impact wound healing and recurrence
Optimization of medical conditions like diabetes, hypertension, and anemia.
Imaging:
Ultrasound or CT scan of the abdominal wall can delineate hernia anatomy, defect size, and presence of adhesions or entrapment
MRI may be useful in complex cases
Preoperative imaging is crucial for planning the extent of mesh coverage and fixation strategy.
Anesthesia Considerations:
General anesthesia is typically required for laparoscopic IPOM plus
Epidural anesthesia may be an option for some open repairs
Close monitoring of hemodynamics and ventilation is essential, particularly in patients with respiratory compromise or severe obesity.
Bowel Preparation:
Routine bowel preparation is generally not necessary unless there are specific concerns for bowel injury or planned bowel manipulation during open repair.
Procedure Steps
Laparoscopic Approach:
Port placement in adequate distance from the hernia defect
Creation of a pre-peritoneal space by dissecting plane between the peritoneum and the transversalis fascia, or within the properitoneal space
Mobilization and reduction of hernia contents
Placement of appropriately sized IPOM mesh to overlap the defect by at least 5 cm in all directions
Fixation of the mesh using tacks, sutures, or fibrin glue, judiciously applied to minimize peritoneal irritation
Closure of fascial defect if feasible, or overlapping technique.
Open Approach:
Incision over the hernia sac
Dissection of the hernia sac from the abdominal wall
Reduction of hernia contents
Creation of a pre-peritoneal space by dissecting between the peritoneum and the transversalis fascia
Placement of IPOM mesh to cover the defect with adequate overlap
Securing the mesh with sutures or fibrin glue
Direct fascial closure if possible, or overlapping techniques for large defects.
Mesh Selection:
Composite meshes (e.g., dual-sided with pore size and barrier properties) are often preferred for IPOM plus to reduce visceral adhesions
Monofilament polypropylene or ePTFE meshes are also used
The choice depends on defect size, patient factors, and surgeon preference.
Fixation Methods:
Various fixation methods are employed, including absorbable or non-absorbable tacks, sutures passed through the mesh and abdominal wall (carefully avoiding bowel injury), or fibrin sealant
Minimizing fixation points over the visceral side is crucial to prevent adhesions.
Postoperative Care
Pain Management:
Multimodal pain management is essential, including opioids, NSAIDs, and regional anesthesia (e.g., transversus abdominis plane blocks)
Adequate pain control facilitates early mobilization and reduces risk of pulmonary complications.
Mobilization And Activity:
Early ambulation is encouraged
Restrictions on heavy lifting and strenuous activity for 4-6 weeks are typically advised, with gradual return to normal activities as tolerated
Patient education on activity restrictions is paramount.
Drainage Management:
Surgical drains may be used in certain cases, particularly in contaminated fields or extensive dissections, to monitor for fluid collections or bleeding
Drains are typically removed when output is minimal.
Monitoring For Complications:
Close monitoring for signs of infection (fever, wound erythema, drainage), seroma, hematoma, mesh migration, and bowel obstruction
Regular clinical assessment and prompt investigation of any suspicious symptoms.
Complications
Early Complications:
Seroma formation
Hematoma
Wound infection
Mesh site infection
Pain
Nausea and vomiting
Ileus
Injury to adjacent organs (bowel, bladder, blood vessels).
Late Complications:
Chronic mesh infection
Mesh migration or extrusion
Hernia recurrence
Chronic pain
Adhesions leading to bowel obstruction
Fistula formation (enterocutaneous or enteromesenteric).
Prevention Strategies:
Meticulous surgical technique to minimize tissue trauma and dead space
Judicious use of drains
Appropriate mesh selection and fixation
Prophylactic antibiotics
Preoperative optimization of patient comorbidities
Patient education on activity restrictions
Careful adherence to sterile protocols
Using composite meshes with anti-adhesive barriers.
Prognosis
Recurrence Rates:
Recurrence rates for IPOM plus techniques are generally lower than open non-mesh repairs, but can still occur
Studies report recurrence rates ranging from 2% to 15% depending on technique, mesh type, fixation, and patient factors.
Factors Affecting Prognosis:
Defect size and complexity
Patient comorbidities (obesity, diabetes, smoking)
Previous hernia repair attempts
Surgical technique and surgeon experience
Mesh type and fixation method
Postoperative adherence to activity restrictions.
Long Term Outcomes:
IPOM plus techniques, when performed appropriately, offer durable repair for ventral hernias, restoring abdominal wall integrity and function
Long-term outcomes are generally favorable, with sustained relief of symptoms and reduced recurrence rates compared to historical methods.
Key Points
Exam Focus:
Understand the definition of IPOM plus, distinguishing it from standard IPOM
Recognize indications for mesh repair and specific contraindications
Key laparoscopic steps include pre-peritoneal dissection and mesh placement with adequate overlap
Know common early and late complications and their management
Emphasize the importance of mesh selection and fixation.
Clinical Pearls:
Achieve a minimum 5 cm overlap of the defect with the mesh
Be judicious with fixation to minimize bowel adhesions
Consider composite meshes for better bio-compatibility
Thorough preoperative optimization of patients is crucial for success
Aggressive pain management and early mobilization are key to reducing pulmonary complications.
Common Mistakes:
Insufficient mesh overlap
Excessive fixation of the mesh directly to bowel
Inadequate dissection of the pre-peritoneal space
Ignoring patient comorbidities
Failure to counsel patients adequately on postoperative restrictions, leading to early recurrence
Mismanagement of mesh infections.