Inguinal hernia is one of the most common surgical problems worldwide. With the evolution of minimally invasive techniques, laparoscopic management has become the standard of care in many centers. Among the techniques used, Intraperitoneal Onlay Mesh (IPOM) repair is an effective method for the treatment of inguinal hernias, especially in selected patients. The term “skin to skin” describes the entire surgical process from the initial incision to final closure, highlighting each step in sequence. This approach is especially valuable in surgical teaching and training because it outlines the procedure in a logical, comprehensive manner.

Patient Preparation and Positioning

Before surgery, the patient undergoes thorough evaluation, including history, physical examination, and necessary imaging if required. Preoperative preparation includes fasting, prophylactic antibiotics, and bladder emptying.

The patient is positioned supine on the operating table with both arms tucked at the sides. A slight Trendelenburg tilt helps the small bowel fall away from the pelvis, providing a clearer view of the inguinal region. The surgeon stands on the side opposite the hernia, the assistant on the other side, and the monitor is placed at the foot end.

Creation of Pneumoperitoneum

A small infra-umbilical incision is made as the first step of “skin to skin.” Pneumoperitoneum is created either with a Veress needle or by open (Hasson’s) technique, depending on surgeon preference. Carbon dioxide is insufflated to a pressure of 12–14 mmHg, creating a working space inside the abdominal cavity.

Once pneumoperitoneum is achieved, a 10 mm trocar is inserted at the umbilicus for the laparoscope. Additional 5 mm working ports are placed in the lower abdomen, usually in the mid-clavicular lines, under direct vision.

Diagnostic Laparoscopy

The first visual inspection helps confirm the presence, type, and size of the inguinal hernia. Hernia contents such as omentum, small intestine, or bladder are identified. Any contralateral hernia can also be ruled out during this step. Dr. R. K. Mishra and other laparoscopic experts emphasize the importance of careful diagnostic evaluation to avoid missing occult hernias.

Hernia Reduction

The hernia sac is identified, and contents are gently reduced back into the abdominal cavity using atraumatic graspers. Adhesions, if present, are carefully dissected to free the sac. This step is critical to ensure complete reduction and avoid residual herniation.

Preparation of the Defect Area

Once the sac is reduced, the peritoneal defect is exposed. Surrounding tissue is cleared to create an adequate landing zone for mesh placement. Unlike totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) approaches, IPOM involves placement of the mesh directly over the defect within the peritoneal cavity. For this reason, a composite mesh with anti-adhesive properties is mandatory to prevent bowel adhesion and fistula formation.

Mesh Selection and Introduction

The size of the mesh is chosen to cover the defect with at least 3–4 cm overlap on all sides. Composite meshes such as dual-layer polypropylene with ePTFE or absorbable barriers are commonly used.

The mesh is rolled and introduced through the 10 mm port. Inside the abdomen, it is unrolled and positioned carefully over the defect.

Mesh Fixation

Fixation of the mesh is done using:

Tackers (absorbable or non-absorbable),

Transfascial sutures, or

A combination of both.

The key principle is to achieve secure fixation without excessive tension. Tackers are placed circumferentially, avoiding injury to underlying vessels like the inferior epigastric or iliac vessels. Some surgeons use fibrin sealant for atraumatic fixation in selected cases.

Final Inspection and Desufflation

After fixation, the surgeon inspects the operative field to ensure complete coverage of the defect and absence of folding or mesh displacement. Hemostasis is confirmed. The pneumoperitoneum is then gradually released under vision.

Port Closure and Skin Suturing

The 10 mm port site is closed with a fascial suture to prevent port-site hernia. Skin incisions are closed with absorbable sutures or skin adhesive, completing the “skin to skin” sequence.

Postoperative Care

Patients usually recover quickly after laparoscopic IPOM repair. Oral intake is resumed within hours, and ambulation is encouraged on the same day. Pain is typically less compared to open surgery, allowing early discharge, often within 24–48 hours.

Patients are advised to avoid heavy lifting for several weeks but can resume normal activities rapidly. Follow-up ensures proper healing and early identification of complications such as seroma, mesh infection, or recurrence.

Advantages of Laparoscopic IPOM Inguinal Hernia Repair

Minimally invasive – less pain, smaller scars, faster recovery.

Excellent visualization – allows assessment of contralateral hernia.

Reduced recurrence rates when mesh is placed correctly.

Short hospital stay and early return to work.

Limitations and Considerations

Cost of composite mesh is higher than standard polypropylene mesh.

Risk of adhesions or bowel complications if improper mesh is used.

Requires advanced laparoscopic skills and experience.

Not suitable for all patients, especially those with extensive adhesions or very large scrotal hernias.

Conclusion

Laparoscopic IPOM inguinal hernia repair – skin to skin is a safe, effective, and minimally invasive option for treating inguinal hernias. The structured step-by-step approach, from patient preparation to final skin closure, ensures a comprehensive understanding of the technique.

With proper patient selection, use of appropriate composite mesh, and meticulous surgical technique, IPOM provides excellent outcomes, rapid recovery, and minimal complications. Its role continues to expand in modern hernia surgery, making it an essential skill for laparoscopic surgeons.