Inguinal hernia is one of the most common surgical conditions worldwide. With the advent of minimally invasive surgery, laparoscopic approaches have become increasingly popular due to their advantages of reduced postoperative pain, faster recovery, smaller scars, and ability to assess both groins. Among the laparoscopic techniques, Intraperitoneal Onlay Mesh (IPOM) repair using dual-mesh has emerged as a reliable option, particularly for recurrent, large, or complex inguinal hernias, or in situations where preperitoneal dissection is challenging.

IPOM involves placing a prosthetic mesh directly inside the peritoneal cavity over the hernia defect. The use of dual-mesh, also known as composite mesh, minimizes the risk of adhesions between intra-abdominal organs and the mesh, while providing strong reinforcement to prevent recurrence.

Patient Selection

IPOM with dual-mesh is preferred in:

Patients with recurrent inguinal hernias after open or laparoscopic repair.

Large direct or indirect hernias with difficult preperitoneal access.

Cases with previous lower abdominal surgeries causing scarring or adhesions.

Patients in whom TEP (Totally Extraperitoneal) or TAPP (Transabdominal Preperitoneal) repair may be technically difficult.

Preoperative evaluation includes clinical examination, routine blood tests, and imaging (ultrasound or CT scan) for complex or recurrent cases. Patients are counseled regarding mesh type, fixation method, and postoperative expectations.

Anesthesia and Positioning

The procedure is performed under general anesthesia with the patient in a supine position. A mild Trendelenburg tilt helps the small bowel move away from the inguinal region, improving visibility. The surgeon stands opposite the hernia, with the assistant on the other side and the monitor positioned at the foot end.

Port Placement

Pneumoperitoneum is established using a Veress needle or open technique at the umbilicus.

A 10 mm umbilical port is inserted for the laparoscope.

Two 5 mm working ports are placed under direct vision, usually in the lower abdomen along the midclavicular lines, forming a triangulation for ergonomic instrument handling.

Port placement should allow access to both the inguinal region and contralateral groin if required.

Diagnostic Laparoscopy

Initial inspection identifies the hernia type—direct, indirect, or femoral—and allows assessment of hernia size and contents. Reduction of any hernia contents such as bowel, omentum, or bladder is performed carefully to avoid injury. Contralateral hernias can also be identified and treated during the same procedure.

Preparation of Hernia Defect

The hernia sac is dissected and reduced into the abdominal cavity. The peritoneal surface around the defect is cleared of fat and adhesions to create a clean and flat surface for mesh placement. This ensures proper mesh adherence and reduces the risk of folding or displacement.

Mesh Selection: Dual-Mesh

Dual-mesh is a composite mesh designed for intraperitoneal placement. It has:

A visceral side with anti-adhesive coating (e.g., ePTFE, collagen barrier) to prevent bowel adhesions.

A parietal side that encourages tissue ingrowth for secure fixation.

Mesh size is critical: it should provide at least 3–4 cm overlap beyond the defect margins to prevent recurrence. Typical dimensions for inguinal hernia repair are 10×15 cm or larger depending on defect size.

Mesh Placement and Fixation

The dual-mesh is rolled and introduced through the 10 mm port.

Once inside, the mesh is unrolled and oriented correctly so the anti-adhesive side faces the viscera.

Fixation is achieved using tackers, transfascial sutures, or a combination, ensuring stable placement.

Fixation must avoid critical anatomical zones:

Triangle of doom: Contains major vessels.

Triangle of pain: Contains nerves; improper fixation can cause chronic pain.

The goal is secure mesh placement without excessive tension, ensuring a flat and stable coverage over the myopectineal orifice.

Final Inspection and Closure

The operative field is inspected for:

Adequate mesh coverage.

Proper fixation with no folds or displacement.

Complete hemostasis.

Pneumoperitoneum is released gradually to verify mesh stability. Ports are removed, the 10 mm fascial defect is closed to prevent port-site hernia, and skin incisions are closed with subcuticular sutures or adhesive.

Postoperative Care

Early ambulation and oral intake are encouraged.

Pain is typically mild and managed with NSAIDs.

Discharge is usually within 24–48 hours.

Patients should avoid heavy lifting for 4–6 weeks.

Follow-up ensures proper healing and monitors for complications such as seroma, infection, or recurrence.

Advantages of IPOM with Dual-Mesh

Minimally invasive—smaller incisions, less pain, faster recovery.

Tension-free repair reduces recurrence rates.

Dual-mesh prevents bowel adhesions while allowing tissue ingrowth.

Ability to inspect contralateral groin during laparoscopy.

Useful in recurrent or complex hernias where preperitoneal access is challenging.

Limitations

Higher cost due to dual-mesh.

Not usually first-line for primary inguinal hernias; TEP or TAPP are often preferred.

Risk of chronic pain if tackers are improperly placed.

Requires expertise in laparoscopic dissection and mesh fixation.

Conclusion

Laparoscopic IPOM repair of inguinal hernia using dual-mesh is a safe, effective, and durable technique, particularly suitable for recurrent, large, or complex hernias. Proper patient selection, meticulous defect preparation, and correct mesh orientation and fixation are crucial for optimal outcomes.

With modern composite meshes and careful surgical technique, patients benefit from minimally invasive surgery with low recurrence, minimal adhesions, and faster recovery, making IPOM with dual-mesh an important option in advanced laparoscopic hernia repair.