Inguinal hernia repair is one of the most frequently performed operations in general surgery. With the advancement of minimally invasive techniques, laparoscopic procedures have increasingly replaced conventional open surgery due to reduced pain, faster recovery, and better cosmetic outcomes. Among laparoscopic techniques, the Intraperitoneal Onlay Mesh (IPOM) repair is an effective option for certain types of hernias. Although more commonly used in ventral hernia repair, IPOM has been adapted for inguinal hernias in specific situations. It involves placing a mesh directly inside the peritoneal cavity, overlying the hernia defect, with the peritoneum left intact.

Principles of IPOM Repair

The IPOM technique is based on the principle of tension-free repair, where the hernia defect is covered with a prosthetic mesh rather than being closed with sutures. The mesh is placed intraperitoneally and fixed securely so that it reinforces the weak abdominal wall and prevents recurrence.

Because the mesh comes into contact with intra-abdominal organs, a composite mesh with an anti-adhesive barrier is mandatory. This prevents complications such as adhesions, bowel obstruction, and fistula formation.

Patient Preparation

Patients undergo routine preoperative evaluation including history, physical examination, and laboratory workup.

Imaging studies like ultrasound or CT scan may be performed for recurrent or complicated hernias.

Prophylactic antibiotics are administered.

Bowel preparation is usually not required, but the bladder must be emptied before surgery.

Anesthesia and Positioning

The surgery is performed under general anesthesia. The patient is placed in the supine position, with arms tucked by the sides. A slight Trendelenburg tilt helps move the bowel away from the pelvis, giving better visualization of the inguinal area.

The surgeon typically stands on the side opposite the hernia, while the assistant and monitor are positioned appropriately for ergonomic access.

Port Placement and Access

Pneumoperitoneum is established using a Veress needle or open (Hasson) technique at the umbilicus.

A 10 mm trocar is inserted for the laparoscope.

Two additional 5 mm trocars are placed under vision in the lower abdomen for working instruments.

Diagnostic Laparoscopy

The initial step after gaining access is a diagnostic survey of the abdominal cavity. The hernia defect is identified, and the type of inguinal hernia (direct, indirect, or femoral) is confirmed. Any contralateral hernia is also evaluated.

Hernia Reduction

The hernia sac is carefully dissected, and its contents (omentum, bowel, or bladder) are reduced into the abdominal cavity. Gentle traction with atraumatic instruments ensures that no injury is caused during reduction. Adhesions, if present, are divided to completely free the sac.

Mesh Selection and Preparation

For IPOM repair, the choice of mesh is crucial. A dual-layer or composite mesh is used, which has:

A parietal side that encourages tissue ingrowth.

A visceral side with an anti-adhesive barrier to prevent bowel contact.

The mesh must be large enough to cover the defect with at least 3–4 cm overlap on all sides to prevent recurrence.

Mesh Placement and Fixation

The prepared mesh is rolled and introduced through the 10 mm port. Once inside, it is unrolled and positioned over the hernia defect.

Fixation methods include:

Tackers (spiral or absorbable),

Transfascial sutures, or

A combination of both.

Tackers are applied circumferentially to secure the mesh. Care must be taken to avoid injury to the inferior epigastric vessels, iliac vessels, or nerves in the “triangle of pain.”

Final Steps

The operative field is inspected to ensure complete coverage of the defect and proper fixation.

Hemostasis is confirmed.

Pneumoperitoneum is released slowly under vision to check mesh stability.

Port sites are closed, with fascial closure for the 10 mm port to prevent port-site hernia.

Skin is closed with absorbable sutures or adhesive.

Postoperative Care

Patients typically recover quickly after laparoscopic IPOM repair. Postoperative pain is minimal compared to open techniques. Oral intake is resumed within hours, and mobilization is encouraged on the same day.

Discharge is usually possible within 24–48 hours. Patients are advised to avoid strenuous activity for several weeks but can return to light work early.

Advantages of IPOM for Inguinal Hernia

Minimally invasive approach with faster recovery.

Wide mesh coverage ensures a low recurrence rate.

Diagnostic capability to assess bilateral or occult hernias.

Short hospital stay and improved patient comfort.

Limitations and Concerns

Risk of adhesions if improper mesh is used.

Higher cost due to the requirement of composite mesh.

Potential for nerve or vessel injury during fixation.

IPOM is less commonly used than TEP (totally extraperitoneal) or TAPP (transabdominal preperitoneal) repair for inguinal hernias, which are often preferred.

Conclusion

Laparoscopic IPOM hernia repair for inguinal hernia is a safe and effective technique in selected cases, offering the benefits of minimally invasive surgery such as reduced pain, faster recovery, and minimal scarring. While TAPP and TEP remain the standard laparoscopic methods, IPOM provides an alternative option when preperitoneal access is not feasible or in cases of recurrent and complex hernias.

The key to success lies in the use of a suitable composite mesh, meticulous surgical technique, and secure fixation. With these principles, laparoscopic IPOM repair can provide excellent outcomes and durable hernia repair.