Inguinal hernia repair is one of the most commonly performed procedures in general surgery. Traditional open approaches, while effective, are associated with postoperative pain, longer recovery, and wound complications. Minimally invasive techniques, particularly laparoscopic approaches, have revolutionized inguinal hernia management. Among these, Intraperitoneal Onlay Mesh (IPOM) repair has emerged as a reliable method, particularly for recurrent, bilateral, or complex hernias.

IPOM repair involves placing a synthetic mesh inside the peritoneal cavity, covering the hernia defect and reinforcing the abdominal wall. The technique allows tension-free repair, minimizing recurrence rates while maintaining patient comfort and rapid postoperative recovery.

Indications

IPOM inguinal hernia repair is indicated in:

Primary inguinal hernias, especially when laparoscopic approach is preferred

Recurrent hernias after failed open repair

Bilateral hernias, allowing simultaneous repair without additional incisions

Large or complex hernias, where anterior or preperitoneal approaches are challenging

Patients with previous abdominal surgery where preperitoneal dissection is difficult

Contraindications include severe intra-abdominal adhesions, active infection, or inability to tolerate general anesthesia.

Preoperative Preparation

Patient Evaluation: Complete history and examination, including hernia size, reducibility, and history of previous repairs.

Imaging: Ultrasound or CT scan may be used in complex or recurrent cases to delineate anatomy.

Anesthesia: General anesthesia is preferred to ensure muscle relaxation and optimal laparoscopic access.

Bowel Preparation: Optional, depending on surgeon preference.

Informed Consent: Patients should be counseled about procedure benefits, risks, and postoperative expectations.

Surgical Technique
Laparoscopic Access

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

Standard port placement includes:

Umbilical port (10 mm) for camera

Two or three accessory 5 mm ports for working instruments

Exploration of Hernia and Pelvis

The peritoneal cavity is inspected for:

Hernia defect(s)

Adhesions from previous surgeries

Associated pathologies such as hydrocele, cord lipoma, or organ adhesions

Reduction of Hernia Sac

Indirect hernias: Hernia sac is carefully reduced into the peritoneal cavity.

Direct hernias: Protruding sac and preperitoneal fat are reduced.

Careful dissection ensures avoidance of bladder, bowel, or major vessels.

Mesh Placement

A dual-sided or composite synthetic mesh is chosen to prevent adhesion to intra-abdominal organs.

The mesh is placed intraperitoneally over the defect, covering the myopectineal orifice with at least 3–5 cm overlap beyond the hernia margin.

Fixation methods:

Tacks or sutures

Fibrin glue or self-fixating meshes may be used

Proper positioning is verified under direct laparoscopic vision.

Closure and Final Inspection

Pneumoperitoneum is released slowly to ensure mesh remains in place.

All ports are removed, and skin incisions are closed with absorbable sutures or skin adhesive.

Advantages of IPOM Repair

Minimally Invasive: Smaller incisions reduce pain and improve cosmetic outcomes.

Tension-Free Repair: Mesh reinforces the abdominal wall without stress on tissues.

Simultaneous Bilateral Repair: Both sides can be repaired in one session.

Effective for Recurrences: Ideal for patients with prior failed open repair.

Faster Recovery: Shorter hospital stay and early return to normal activity.

Reduced Wound Complications: Lower risk of infection compared to open surgery.

Safety and Complications

Although generally safe, IPOM repair carries some risks:

Injury to intra-abdominal organs: Bowel or bladder injury during dissection or mesh placement

Vascular injury: Particularly from epigastric or iliac vessels

Chronic pain: May occur due to nerve irritation or fixation methods

Mesh-related complications: Adhesions, migration, or infection, minimized by using composite or coated meshes

Adherence to meticulous laparoscopic technique significantly reduces these risks.

Postoperative Care

Early ambulation and resumption of oral intake

Pain managed with oral analgesics

Discharge typically within 24 hours for uncomplicated cases

Follow-up includes monitoring for seroma, hematoma, infection, or recurrence

Patients can usually return to routine activities within 1–2 weeks

Outcomes

IPOM laparoscopic inguinal hernia repair has shown:

Low recurrence rates when mesh placement and fixation are adequate

Reduced postoperative pain compared to open repair

Short hospital stay and faster return to work

Safe and effective management of bilateral and recurrent hernias

Conclusion

Intraperitoneal Onlay Mesh repair is a safe, effective, and minimally invasive approach for inguinal hernia repair, particularly suited for recurrent, bilateral, or complex cases. Proper mesh selection, secure placement, and careful laparoscopic technique ensure low recurrence rates and minimal complications.

IPOM repair offers patients faster recovery, less postoperative pain, and superior cosmetic results, making it an important option in the armamentarium of modern hernia surgery. Surgeons skilled in laparoscopic techniques can achieve excellent long-term outcomes and high patient satisfaction with this approach.