Inguinal hernia is one of the most common surgical conditions, characterized by the protrusion of abdominal contents through a weakened area in the inguinal canal. Traditional open repair methods have long been practiced, but with the rise of minimally invasive surgery, laparoscopic repair has become increasingly popular due to reduced postoperative pain, quicker recovery, and improved cosmetic outcomes. Among the laparoscopic techniques, the Intra-Peritoneal Onlay Mesh (IPOM) approach combined with fibrin glue fixation has emerged as a safe and effective alternative to conventional fixation methods.

Understanding the IPOM Technique

The IPOM technique involves placing a mesh intraperitoneally (inside the abdominal cavity) directly over the hernia defect, ensuring adequate overlap with healthy tissue. Unlike the transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) repairs, which involve dissecting the preperitoneal space, IPOM is technically simpler and faster. It avoids extensive dissection and is especially useful in recurrent or complex hernias where anatomical planes may be distorted.

The mesh used in IPOM is typically a dual-layer composite mesh designed to minimize adhesion formation on the visceral side while promoting tissue ingrowth on the parietal side.

Role of Fibrin Glue in Hernia Repair

Traditionally, meshes are fixed using sutures, tacks, or staples. However, these fixation methods are associated with certain drawbacks:

Chronic pain due to nerve injury or tension from fixation devices

Bleeding or vascular injury from staples or tacks

Increased operative time in suture fixation

Fibrin glue, a biological adhesive that mimics the final stages of the clotting cascade, has gained popularity as an alternative fixation method. It provides secure mesh adherence without the trauma of mechanical fixation.

Benefits of fibrin glue include:

Atraumatic fixation without nerve or vessel injury

Reduced postoperative pain

Faster application, shortening operative time

Secure fixation even in difficult anatomical areas

Surgical Technique: IPOM with Fibrin Glue

Patient Positioning and Anesthesia
The patient is placed supine under general anesthesia. Prophylactic antibiotics are administered, and pneumoperitoneum is created via a trocar.

Port Placement
Typically, three ports are used: one 10 mm port for the laparoscope and two 5 mm working ports for instruments.

Hernia Reduction
Herniated contents such as bowel or omentum are reduced back into the peritoneal cavity. Adhesiolysis may be required if the hernia sac is adherent.

Defect Assessment
The defect is carefully measured laparoscopically to determine the size of mesh required. Adequate overlap of at least 3–5 cm beyond the margins of the defect is recommended.

Mesh Placement
A composite mesh is rolled and introduced through the 10 mm trocar. It is then spread out intraperitoneally over the defect, ensuring smooth placement without folds.

Fixation with Fibrin Glue
Using a laparoscopic applicator, fibrin glue is applied along the mesh margins and at key central points to secure it firmly against the abdominal wall. The glue provides immediate tackiness and sets within minutes, offering stable fixation.

Closure
Ports are removed under vision, and skin incisions are closed with absorbable sutures.

Advantages of IPOM with Fibrin Glue

Minimally Invasive: Small incisions, less pain, and rapid recovery

Reduced Postoperative Pain: Absence of tacks or sutures prevents nerve entrapment and chronic pain syndromes

Lower Risk of Complications: No risk of vascular injury from staples or tacks

Secure Fixation: Fibrin glue provides even distribution of fixation forces across the mesh

Shorter Operative Time: Glue application is faster than suturing or stapling

Cosmetic Benefit: Minimal scarring with excellent patient satisfaction

Limitations and Considerations

Despite its advantages, certain challenges exist:

Cost: Fibrin glue and composite meshes are more expensive than traditional fixation methods.

Learning Curve: Surgeons must be trained in proper glue application to avoid inadequate fixation or mesh migration.

Case Selection: IPOM is generally better suited for small-to-medium inguinal hernias and certain recurrent cases. For large primary hernias, TAPP or TEP may be preferred.

Potential Adhesions: Although composite meshes reduce adhesions, intraperitoneal placement always carries some risk compared to preperitoneal repairs.

Clinical Outcomes

Clinical studies and experiences have demonstrated that IPOM repair with fibrin glue fixation yields excellent outcomes, with:

Comparable recurrence rates to other laparoscopic methods

Reduced postoperative pain scores

Faster return to normal activity and work

High patient satisfaction due to minimal invasiveness and low complication rates

Long-term follow-up indicates that recurrence is rare when the mesh is properly overlapped and securely fixed with fibrin glue.

Conclusion

Laparoscopic repair of inguinal hernia using Intra-Peritoneal Onlay Mesh (IPOM) with fibrin glue fixation is a safe, effective, and patient-friendly approach. It combines the advantages of minimally invasive surgery with atraumatic fixation, reducing pain and improving recovery. While cost considerations and case selection remain important, this technique is particularly useful in recurrent and complex hernias where traditional methods may be more challenging. As experience with fibrin glue fixation grows, IPOM repair is likely to become an increasingly accepted option in the armamentarium of hernia surgeons.