Overview
Definition:
Laparoscopic Incisional Hernia Repair (IPOM) is a minimally invasive surgical technique used to repair hernias that develop at the site of a previous surgical incision
It involves accessing the abdominal cavity laparoscopically to place a synthetic mesh prosthetic to reinforce the abdominal wall defect from the inside, thereby reducing tension on the repair.
Epidemiology:
Incisional hernias are a common complication following abdominal surgery, with reported incidence rates varying from 2% to 20%, depending on factors like surgical technique, wound closure, patient comorbidities, and infection
Laparoscopic repair is increasingly favored for its reduced morbidity and faster recovery, though recurrence rates are a key consideration.
Clinical Significance:
Incisional hernias can cause significant pain, discomfort, and functional impairment
They also pose a risk of complications such as incarceration and strangulation, necessitating timely and effective surgical intervention
Laparoscopic IPOM offers an alternative to open repair, potentially improving patient outcomes and cosmesis.
Indications
Indications For Surgery:
Symptomatic incisional hernias causing pain, discomfort, or functional limitations
Large or bulging hernias that are cosmetically concerning
Hernias with a history of incarceration or strangulation, or at high risk of these complications
Failed previous open or laparoscopic repairs.
Contraindications:
Absolute contraindications include uncontrolled sepsis, extensive intra-abdominal adhesions precluding safe laparoscopic entry or dissection, and severe coagulopathy
Relative contraindications may include morbid obesity, extensive prior abdominal surgeries making laparoscopic access difficult, or patient refusal of mesh repair or general anesthesia.
Preoperative Assessment:
Thorough history including symptom duration, character, and any prior surgeries
Physical examination to assess hernia size, reducibility, and skin integrity
Assessment of patient comorbidities (e.g., diabetes, COPD, obesity) and nutritional status
Review of previous surgical records and imaging if available.
Diagnostic Approach
History Taking:
Key history points include the onset and progression of the bulge, associated pain or discomfort, any history of incarceration or strangulation, and details of previous abdominal surgeries
Red flags include sudden severe pain, inability to reduce the hernia, nausea, vomiting, or fever, suggesting strangulation.
Physical Examination:
Inspection of the abdomen for visible bulge, skin changes, or surgical scars
Palpation to assess the size of the defect, reducibility of the hernia contents, and presence of tenderness
Cough impulse to confirm herniation
Auscultation for bowel sounds if strangulation is suspected.
Imaging Modalities:
Ultrasound is useful for initial assessment of hernia contents and defect size
CT scan is the preferred imaging modality for detailed evaluation of hernia anatomy, defect dimensions, presence of adhesions, and assessment of abdominal wall integrity
MRI may be used in specific cases.
Differential Diagnosis:
Differential diagnoses include rectus diastasis, lipomas, desmoid tumors, hematomas, and other abdominal wall masses
Imaging and examination help differentiate these from true incisional hernias.
Laparoscopic Ipom Procedure
Patient Positioning:
Supine position with arms abducted
The operating table may be flexed to increase intra-abdominal space.
Trocar Placement:
Typically requires 3-4 trocars
An initial Veress needle or open technique is used for pneumoperitoneum
Trocars are usually placed in a triangular configuration away from the hernia defect to allow optimal triangulation and instrument manipulation.
Dissection And Mesh Placement:
The primary goal is to dissect the hernia sac from the anterior abdominal wall
The peritoneum is incised and elevated from the underlying rectus sheath or transversalis fascia
The mesh (e.g., dual-layer composite mesh) is then introduced laparoscopically and fixed to the abdominal wall edges using tacks, sutures, or glue, ensuring adequate overlap beyond the defect.
Closure:
The fascial defect is typically not directly closed in IPOM
the mesh provides reinforcement
The trocar sites are closed at the end of the procedure
Care is taken to avoid injury to underlying bowel or omentum.
Postoperative Care
Pain Management:
Multimodal pain management including parenteral analgesics (opioids and NSAIDs), and potentially regional blocks
Early mobilization is encouraged.
Activity Restrictions:
Patients are usually advised to avoid strenuous activity, heavy lifting (>10-15 kg), and vigorous exercise for 4-6 weeks post-operatively to allow mesh integration and healing.
Monitoring:
Monitoring for signs of infection, bleeding, or recurrence
Patients are advised to report any new pain, swelling, redness, or fever
Follow-up appointments are scheduled at 2-4 weeks and 3-6 months post-surgery.
Dietary Recommendations:
Advise on a balanced diet to promote wound healing and prevent constipation
Adequate hydration is essential.
Complications
Early Complications:
Port-site bleeding or hematoma
surgical site infection (SSI), particularly seroma or cellulitis
mesh infection
visceral injury (bowel, bladder)
trocar-induced injuries
port-site hernia
Anesthesia-related complications.
Late Complications:
Hernia recurrence (most common late complication)
chronic mesh-related pain
mesh migration or erosion
adhesions
bowel obstruction due to adhesions
incisional hernia at port sites
seroma formation
skin sinus formation.
Prevention Strategies:
Meticulous surgical technique, proper port placement away from scar tissue, judicious use of tacks, appropriate mesh selection and fixation, accurate defect closure at port sites, prophylactic antibiotics, and thorough patient counseling on activity restrictions and warning signs.
Key Points
Exam Focus:
Understand indications vs
contraindications for laparoscopic IPOM
Differentiate IPOM from other hernia repairs (e.g., TAPP, TE)
Recognize complications and their management
Know mesh types and fixation methods
Recurrence rates and factors influencing them are crucial.
Clinical Pearls:
Adequate mesh overlap (minimum 5 cm beyond defect) is critical for reducing recurrence
In patients with significant adhesions, a pre-peritoneal approach or even conversion to open surgery might be necessary
Postoperative pain is often less with laparoscopic repair compared to open
Consider transversalis fascia inlay repair for very large defects.
Common Mistakes:
Inadequate mesh overlap
insufficient fixation leading to mesh migration
failure to identify and manage intra-abdominal adhesions
misjudging the defect size
treating incarcerated/strangulated hernias without adequate preoperative resuscitation
ignoring port-site hernia development.