Overview
Definition:
Laparoscopic umbilical hernia repair, specifically Intraperitoneal Onlay Mesh (IPOM) technique, is a minimally invasive surgical procedure to repair defects in the abdominal wall at the level of the umbilicus
It involves placing a synthetic mesh prosthesis directly on the peritoneum to reinforce the weakened area, thereby preventing recurrence
This approach offers potential benefits such as reduced postoperative pain, faster recovery, and smaller scars compared to open repairs.
Epidemiology:
Umbilical hernias are common, particularly in infants, but also affect adults
In adults, they are more prevalent in women, multiparous individuals, and those with risk factors like obesity, ascites, and chronic cough
Recurrence rates can be higher with smaller defects, and surgical intervention is often recommended for symptomatic hernias or those exceeding 2-3 cm in diameter to prevent incarceration or strangulation.
Clinical Significance:
Umbilical hernias can lead to significant morbidity if incarcerated or strangulated, potentially causing bowel obstruction and ischemia
Accurate diagnosis and timely surgical repair are crucial for preventing these life-threatening complications
Laparoscopic IPOM has emerged as a preferred method for many surgeons due to its favorable recovery profile and efficacy in preventing recurrence, making it a key topic for surgical trainees preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Symptomatic umbilical hernia causing pain, discomfort, or cosmetic concerns
Incarcerated or strangulated umbilical hernia
Hernias greater than 2-3 cm in diameter due to increased risk of complications.
Relative Indications:
Asymptomatic umbilical hernias in patients at high risk of future incarceration
Presence of other abdominal wall defects amenable to laparoscopic repair
Patient preference for minimally invasive surgery.
Contraindications:
Uncontrolled coagulopathy
Severe cardiopulmonary disease precluding pneumoperitoneum
Previous extensive abdominal surgery with dense adhesions
Inability to tolerate general anesthesia
Active infection at the surgical site.
Preoperative Preparation
Patient Evaluation:
Thorough medical history to identify risk factors (obesity, ascites, COPD, smoking)
Physical examination to assess hernia size, reducibility, and presence of any incarcerated contents
Assessment of nutritional status and comorbidities.
Anesthesia Considerations:
General anesthesia is typically required for laparoscopic procedures
Careful anesthetic management is needed for patients with respiratory compromise or ascites to manage pneumoperitoneum pressures.
Imaging Studies:
Ultrasound of the abdominal wall can confirm the diagnosis and assess hernia contents
CT scan may be useful for large or complex hernias, or to evaluate for associated intra-abdominal pathology.
Patient Counseling:
Discuss the procedure, benefits, risks (infection, bleeding, recurrence, mesh-related issues), alternatives, and expected recovery
Obtain informed consent
Advise on bowel preparation and preoperative fasting.
Procedure Steps Ipom
Port Placement:
Typically, three ports are used: a primary trocar for the camera and two working trocars
A supraumbilical incision is often made for initial entry and visualization, followed by pneumoperitoneum insufflation to 12-15 mmHg.
Hernia Sac Mobilization:
The hernia sac is identified and dissected free from the surrounding abdominal wall
The sac may be reduced back into the abdomen or excised if necessary
Care is taken to avoid injury to underlying bowel or omentum.
Mesh Selection And Placement:
A synthetic, non-absorbable mesh (e.g., polypropylene, composite mesh) is chosen based on hernia size and patient factors
The mesh is typically larger than the defect (at least 3-5 cm overlap) and is placed in an onlay fashion over the defect, covering the peritoneum
Various fixation methods exist, including tackers, sutures, or fibrin glue, to secure the mesh edges.
Fascial Closure:
The anterior fascial defect (if present and widened) is closed with sutures to prevent prolapse of preperitoneal fat and reduce tension on the mesh
The umbilical incision is closed in layers, and skin is approximated.
Postoperative Care
Pain Management:
Analgesics are provided, often including NSAIDs and opioids for breakthrough pain
Multimodal pain strategies are encouraged to minimize opioid use.
Ambulation And Diet:
Early ambulation is encouraged to prevent DVT and aid recovery
Patients can typically resume a regular diet as tolerated once bowel function returns.
Activity Restrictions:
Avoid strenuous activity, heavy lifting (typically >10 kg), and vigorous exercise for 4-6 weeks to allow for mesh integration and healing.
Wound Care:
Keep incisions clean and dry
Monitor for signs of infection (redness, swelling, discharge).
Discharge Criteria:
Patient should be pain-controlled, able to tolerate oral intake, ambulate independently, and void
No significant complications should be present.
Complications
Early Complications:
Bleeding at port sites or from mesh fixation
Seroma formation
Mesh infection
Injury to bowel or other intra-abdominal structures
Persistent incisional pain
Urinary retention.
Late Complications:
Mesh migration or displacement
Mesh erosion into adjacent organs (e.g., bowel, bladder)
Chronic pain syndrome
Recurrence of hernia
Adhesions leading to bowel obstruction
Granuloma formation.
Prevention Strategies:
Meticulous surgical technique to avoid tissue injury
Appropriate mesh selection and secure fixation
Strict sterile technique during surgery
Judicious use of mesh size and type
Adequate postoperative pain control and activity modification to prevent excessive strain.
Prognosis
Recurrence Rates:
Recurrence rates for laparoscopic IPOM are generally low, typically reported between 1-5% in experienced hands, especially for properly selected patients and adequately sized mesh placement.
Functional Recovery:
Most patients experience a significant improvement in quality of life with resolution of symptoms and a faster return to daily activities compared to open repairs.
Long Term Outcomes:
Long-term outcomes are generally excellent with high patient satisfaction
However, rare late complications related to the mesh can occur and require monitoring.
Key Points
Exam Focus:
Understanding the indications for IPOM versus other laparoscopic techniques (e.g., TAPP, TEP)
Knowledge of mesh types and fixation methods
Differentiating between IPOM and other IPOM variations (e.g., dual mesh)
Recognizing potential complications and their management is crucial for DNB and NEET SS exams.
Clinical Pearls:
Ensure adequate overlap of the mesh to cover the entire defect and beyond
Secure fixation is critical to prevent migration, especially in obese patients or those with ascites
Careful dissection is key to avoid injury to abdominal contents
Consider composite meshes for contaminated cases.
Common Mistakes:
Using a mesh that is too small
Inadequate fixation of the mesh
Failure to identify and close fascial defects
Excessive dissection leading to bleeding
Not considering the patient's comorbidities that may affect mesh healing or increase recurrence risk.