Inguinal hernia remains one of the most frequently performed surgical procedures worldwide. The evolution of laparoscopic surgery has provided minimally invasive alternatives to traditional open repair. While TAPP (Transabdominal Preperitoneal) and TEP (Totally Extraperitoneal) approaches are commonly used, the Intraperitoneal Onlay Mesh (IPOM) technique can be a practical alternative in selected cases, particularly in recurrent, complex, or technically challenging hernias.

The personal technique of laparoscopic IPOM repair involves systematic planning, careful dissection, and meticulous mesh placement to ensure durability and safety. The following description outlines a step-by-step, skin-to-skin approach with emphasis on critical points of execution.

Patient Selection and Preparation

Not every patient is an ideal candidate for IPOM repair. My approach is to select:

Patients with recurrent inguinal hernia where preperitoneal dissection is difficult.

Patients with dense scarring in the groin due to previous surgery.

Patients unsuitable for TEP due to anatomic limitations.

Preoperative preparation includes:

Routine investigations and anesthetic clearance.

Prophylactic antibiotics.

Emptying the urinary bladder.

Counseling the patient regarding mesh type and the possibility of recurrence.

Anesthesia and Positioning

The procedure is performed under general anesthesia. The patient is positioned supine, with arms tucked and legs apart. A mild Trendelenburg tilt is applied to allow small bowel loops to fall away from the pelvis, enhancing visualization of the inguinal region.

The surgeon stands on the contralateral side of the hernia, with the assistant on the opposite side and the monitor positioned at the foot end.

Creation of Pneumoperitoneum and Port Placement

A 10 mm infra-umbilical port is introduced using an open (Hasson) or Veress technique, and pneumoperitoneum is established at 12–14 mmHg. Two 5 mm working ports are inserted in the lower abdomen under vision, one in the midclavicular line on the ipsilateral side and another on the contralateral side.

This triangulation provides ergonomic access for dissection and mesh handling.

Diagnostic Laparoscopy

The first step is careful inspection of the inguinal regions. The hernia type (direct, indirect, or femoral) is confirmed, and contralateral pathology is ruled out. Any incarcerated contents are identified.

Hernia Reduction and Defect Preparation

The hernia sac is carefully dissected and reduced. Omentum or bowel loops, if present, are gently returned to the abdominal cavity. If adhesions are encountered, blunt and sharp dissection is used to ensure complete reduction.

The peritoneal area surrounding the defect is cleared of fat and adhesions to provide a clean surface for mesh placement. This preparation is essential for proper mesh adherence and to minimize the risk of recurrence.

Mesh Selection and Handling

In my technique, I use a composite mesh with two surfaces:

The parietal side promotes tissue ingrowth and fixation.

The visceral side has an anti-adhesive coating (e.g., ePTFE, collagen barrier, or absorbable layer) to prevent bowel adhesions.

The mesh size is selected to provide at least 3–4 cm overlap beyond the defect margins. The mesh is rolled and introduced through the 10 mm port.

Mesh Placement and Fixation

Once inside the abdominal cavity, the mesh is unrolled and placed over the hernia defect. The orientation of the anti-adhesive surface facing the bowel is carefully checked.

Fixation technique (personal preference):

Primary fixation with tacks: Absorbable or non-absorbable tacks are applied circumferentially around the defect. Care is taken to avoid the “triangle of pain” (containing nerves) and “triangle of doom” (containing major vessels).

Supplementary transfascial sutures: In larger defects, one or two transfascial sutures are placed at the center to prevent mesh migration and folding.

Hemostatic sealant: Occasionally, fibrin glue is applied for additional fixation and reduced postoperative pain.

The goal is secure fixation without excessive trauma or risk of neurovascular injury.

Final Inspection and Closure

After mesh placement, the operative site is carefully inspected for:

Proper mesh overlap.

Absence of folding or displacement.

Adequate hemostasis.

The pneumoperitoneum is gradually released under direct vision to ensure the mesh remains flat and stable. Ports are removed, and the 10 mm fascial incision is closed with absorbable sutures to prevent port-site hernia. Skin is closed cosmetically with subcuticular sutures or adhesive.

Postoperative Care

Patients are mobilized on the same day of surgery and given adequate analgesia. Oral feeding is initiated within hours. Most patients are discharged within 24–48 hours.

Patients are advised to avoid strenuous activities and heavy lifting for at least 4–6 weeks. Follow-up is scheduled to monitor wound healing, mesh integration, and detect early complications such as seroma, infection, or recurrence.

Advantages of the Personal Technique

Minimally invasive with faster recovery and less pain compared to open repair.

Reliable mesh coverage with secure fixation.

Useful in recurrent or complex hernias where preperitoneal dissection is difficult.

Ability to evaluate contralateral hernia during diagnostic laparoscopy.

Limitations

Requires a composite mesh, which increases cost.

Potential risk of adhesions if improper mesh is used.

Not the standard approach for primary inguinal hernias; TEP and TAPP are generally preferred.

Higher technical demand in mesh placement and fixation.

Conclusion

The laparoscopic IPOM repair for inguinal hernia represents a valuable option in selected patients, particularly those with recurrences or complex anatomy where preperitoneal approaches are not feasible. Using a structured personal technique—from patient selection to secure mesh fixation—ensures optimal outcomes.

With proper execution, composite mesh selection, and careful handling, IPOM provides a safe, effective, and durable repair, combining the benefits of minimally invasive surgery with reliable hernia control.