Laparoscopic Incisional Hernia Repair By Ipom Plus Technique And Titanized Mesh
Incisional hernia is a common complication following abdominal surgery, with an incidence of 10–20% after midline laparotomies. Laparoscopic repair has become the preferred approach due to minimally invasive access, reduced postoperative pain, faster recovery, and lower infection rates.
The Intraperitoneal Onlay Mesh (IPOM) Plus technique represents an advanced method of laparoscopic hernia repair. Unlike standard IPOM, the IPOM Plus technique involves closure of the hernia defect before mesh placement, combining the benefits of tension-free mesh reinforcement with restoration of abdominal wall integrity. Using titanized mesh enhances tissue integration, reduces foreign body reaction, and minimizes adhesions, making it particularly suitable for laparoscopic intraperitoneal repair.
Patient Evaluation and Selection
Preoperative assessment is critical for success:
History: Previous surgeries, comorbidities, complications, and recurrence history.
Physical examination: Size, reducibility, and location of hernia.
Imaging: CT scan is preferred for evaluating defect size, adhesion severity, and intra-abdominal organ involvement.
Laboratory tests: Complete blood count, coagulation profile, and metabolic evaluation.
Ideal candidates for laparoscopic IPOM Plus with titanized mesh:
Primary or recurrent incisional hernias.
Defect size up to 10 cm (larger defects may require component separation).
Patients at high risk of wound infection, where open repair may be problematic.
Patients must be counseled regarding potential conversion to open surgery, risks of organ injury, and postoperative expectations.
Anesthesia and Patient Positioning
The procedure is performed under general anesthesia with muscle relaxation.
The patient is placed supine, arms tucked, with a slight Trendelenburg tilt for lower abdominal hernias.
Surgeon stands on the side opposite the hernia; assistant on the other side; monitor positioned at the foot.
Port Placement
Pneumoperitoneum is established at the umbilicus using Veress or open technique, typically at 12–14 mmHg.
A 10 mm camera port is inserted away from previous scars.
Two 5 mm working ports are triangulated in the lower or lateral abdomen for instrument manipulation.
This setup allows safe access for adhesiolysis, defect closure, and mesh placement.
Adhesiolysis and Hernia Sac Management
Adhesiolysis is performed carefully to free the bowel, omentum, and other organs from the hernia sac.
Sharp and blunt dissection, along with energy devices (bipolar cautery or ultrasonic scalpel), reduce the risk of bowel injury.
Hernia sac contents are reduced into the abdominal cavity.
The peritoneal surface and fascia around the defect are cleared to allow effective closure and mesh fixation.
IPOM Plus Defect Closure
The IPOM Plus technique involves closure of the hernia defect prior to mesh placement, which provides several advantages:
Restores abdominal wall function and continuity.
Reduces seroma formation by eliminating dead space.
Enhances mesh-tissue integration and lowers recurrence risk.
Closure method:
Use a barbed or non-absorbable suture for intracorporeal defect closure.
Sutures are placed transversely or in a running fashion to achieve tension-free approximation.
Proper closure ensures the mesh will reinforce rather than replace the abdominal wall.
Mesh Selection and Placement
Titanized mesh is a lightweight, titanium-coated polypropylene mesh with the following advantages:
Biocompatible with reduced foreign body reaction.
Minimizes adhesions on the visceral side.
Strong and flexible, conforms to the abdominal wall.
Placement steps:
Roll the mesh and introduce through the 10 mm port.
Unroll over the closed defect with the titanium-coated surface facing the bowel.
Mesh fixation using tackers, transfascial sutures, or fibrin glue.
Ensure at least 3–5 cm overlap beyond defect margins.
Final Inspection and Closure
Confirm flat, secure mesh placement with complete coverage of the defect.
Check hemostasis and ensure no entrapment of viscera.
Gradually release pneumoperitoneum while observing mesh stability.
Remove ports and close the 10 mm fascial incision to prevent port-site hernia.
Skin closure with subcuticular sutures or adhesive ensures good cosmetic outcome.
Postoperative Care
Early ambulation and oral intake are encouraged.
Pain is managed primarily with NSAIDs.
Discharge typically occurs within 24–48 hours.
Patients should avoid heavy lifting for 4–6 weeks.
Follow-up is essential to monitor for complications such as seroma, hematoma, infection, or recurrence.
Advantages of IPOM Plus with Titanized Mesh
Restoration of abdominal wall integrity through defect closure.
Tension-free reinforcement with intraperitoneal mesh.
Reduced adhesions and foreign body reaction due to titanized coating.
Minimally invasive approach with smaller incisions and faster recovery.
Reduced seroma formation due to elimination of dead space.
Safe and effective for primary and recurrent hernias.
Limitations
Technically more demanding than standard IPOM; requires laparoscopic suturing skills.
Cost is higher due to titanized mesh.
Larger defects (>10 cm) may require component separation.
Rare risk of chronic pain or tack-related complications.
Conclusion
Laparoscopic IPOM Plus repair using titanized mesh combines the benefits of defect closure with tension-free mesh reinforcement. It restores abdominal wall function, minimizes seroma and adhesion formation, and provides durable, cosmetically favorable results.
With careful patient selection, meticulous adhesiolysis, precise defect closure, and correct mesh handling, this technique represents a modern, effective solution for incisional hernias, offering patients faster recovery and long-term durability.
The Intraperitoneal Onlay Mesh (IPOM) Plus technique represents an advanced method of laparoscopic hernia repair. Unlike standard IPOM, the IPOM Plus technique involves closure of the hernia defect before mesh placement, combining the benefits of tension-free mesh reinforcement with restoration of abdominal wall integrity. Using titanized mesh enhances tissue integration, reduces foreign body reaction, and minimizes adhesions, making it particularly suitable for laparoscopic intraperitoneal repair.
Patient Evaluation and Selection
Preoperative assessment is critical for success:
History: Previous surgeries, comorbidities, complications, and recurrence history.
Physical examination: Size, reducibility, and location of hernia.
Imaging: CT scan is preferred for evaluating defect size, adhesion severity, and intra-abdominal organ involvement.
Laboratory tests: Complete blood count, coagulation profile, and metabolic evaluation.
Ideal candidates for laparoscopic IPOM Plus with titanized mesh:
Primary or recurrent incisional hernias.
Defect size up to 10 cm (larger defects may require component separation).
Patients at high risk of wound infection, where open repair may be problematic.
Patients must be counseled regarding potential conversion to open surgery, risks of organ injury, and postoperative expectations.
Anesthesia and Patient Positioning
The procedure is performed under general anesthesia with muscle relaxation.
The patient is placed supine, arms tucked, with a slight Trendelenburg tilt for lower abdominal hernias.
Surgeon stands on the side opposite the hernia; assistant on the other side; monitor positioned at the foot.
Port Placement
Pneumoperitoneum is established at the umbilicus using Veress or open technique, typically at 12–14 mmHg.
A 10 mm camera port is inserted away from previous scars.
Two 5 mm working ports are triangulated in the lower or lateral abdomen for instrument manipulation.
This setup allows safe access for adhesiolysis, defect closure, and mesh placement.
Adhesiolysis and Hernia Sac Management
Adhesiolysis is performed carefully to free the bowel, omentum, and other organs from the hernia sac.
Sharp and blunt dissection, along with energy devices (bipolar cautery or ultrasonic scalpel), reduce the risk of bowel injury.
Hernia sac contents are reduced into the abdominal cavity.
The peritoneal surface and fascia around the defect are cleared to allow effective closure and mesh fixation.
IPOM Plus Defect Closure
The IPOM Plus technique involves closure of the hernia defect prior to mesh placement, which provides several advantages:
Restores abdominal wall function and continuity.
Reduces seroma formation by eliminating dead space.
Enhances mesh-tissue integration and lowers recurrence risk.
Closure method:
Use a barbed or non-absorbable suture for intracorporeal defect closure.
Sutures are placed transversely or in a running fashion to achieve tension-free approximation.
Proper closure ensures the mesh will reinforce rather than replace the abdominal wall.
Mesh Selection and Placement
Titanized mesh is a lightweight, titanium-coated polypropylene mesh with the following advantages:
Biocompatible with reduced foreign body reaction.
Minimizes adhesions on the visceral side.
Strong and flexible, conforms to the abdominal wall.
Placement steps:
Roll the mesh and introduce through the 10 mm port.
Unroll over the closed defect with the titanium-coated surface facing the bowel.
Mesh fixation using tackers, transfascial sutures, or fibrin glue.
Ensure at least 3–5 cm overlap beyond defect margins.
Final Inspection and Closure
Confirm flat, secure mesh placement with complete coverage of the defect.
Check hemostasis and ensure no entrapment of viscera.
Gradually release pneumoperitoneum while observing mesh stability.
Remove ports and close the 10 mm fascial incision to prevent port-site hernia.
Skin closure with subcuticular sutures or adhesive ensures good cosmetic outcome.
Postoperative Care
Early ambulation and oral intake are encouraged.
Pain is managed primarily with NSAIDs.
Discharge typically occurs within 24–48 hours.
Patients should avoid heavy lifting for 4–6 weeks.
Follow-up is essential to monitor for complications such as seroma, hematoma, infection, or recurrence.
Advantages of IPOM Plus with Titanized Mesh
Restoration of abdominal wall integrity through defect closure.
Tension-free reinforcement with intraperitoneal mesh.
Reduced adhesions and foreign body reaction due to titanized coating.
Minimally invasive approach with smaller incisions and faster recovery.
Reduced seroma formation due to elimination of dead space.
Safe and effective for primary and recurrent hernias.
Limitations
Technically more demanding than standard IPOM; requires laparoscopic suturing skills.
Cost is higher due to titanized mesh.
Larger defects (>10 cm) may require component separation.
Rare risk of chronic pain or tack-related complications.
Conclusion
Laparoscopic IPOM Plus repair using titanized mesh combines the benefits of defect closure with tension-free mesh reinforcement. It restores abdominal wall function, minimizes seroma and adhesion formation, and provides durable, cosmetically favorable results.
With careful patient selection, meticulous adhesiolysis, precise defect closure, and correct mesh handling, this technique represents a modern, effective solution for incisional hernias, offering patients faster recovery and long-term durability.
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