Inguinal hernia repair is one of the most commonly performed general surgical procedures worldwide. Traditionally, open hernia repair has been the mainstay, but laparoscopic techniques have revolutionized hernia surgery, offering reduced postoperative pain, faster recovery, and minimal scarring. Among laparoscopic approaches, Intraperitoneal Onlay Mesh (IPOM) repair has emerged as a valuable technique, particularly in complex or recurrent hernias.

IPOM laparoscopic inguinal hernia repair involves placing a synthetic mesh inside the peritoneal cavity over the hernia defect, reinforcing the abdominal wall and preventing recurrence. It is especially useful in patients with bilateral, recurrent, or difficult hernias and has gained popularity due to its minimally invasive nature and reliable outcomes.

Indications

IPOM laparoscopic inguinal hernia repair is indicated in:

Primary or recurrent inguinal hernias, especially after failed open repair

Bilateral hernias, allowing simultaneous repair

Patients at high risk for wound complications where open repair is less desirable

Hernias with large or multiple defects

Cases where preperitoneal dissection is difficult due to adhesions

Preoperative Considerations

Clinical Evaluation: Comprehensive history and physical examination, including hernia size, reducibility, and previous surgeries.

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

Anesthesia: General anesthesia is preferred for laparoscopic hernia repair.

Patient Positioning: Supine with arms tucked; Trendelenburg tilt helps displace bowel loops for better pelvic exposure.

Surgical Technique
Port Placement

Standard three-port laparoscopic setup:

Umbilical 10 mm port for camera

Two 5 mm working ports on either side of the abdomen

Ports are placed to allow optimal triangulation for instrument manipulation and mesh placement.

Creation of Pneumoperitoneum

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

Insufflation with CO₂ provides space for visualization and safe dissection.

Hernia Sac Identification and Reduction

The peritoneum overlying the hernia defect is identified.

Indirect hernias: Hernia sac is reduced into the abdominal cavity.

Direct hernias: Protruding sac is pushed back, and the defect is exposed.

Adhesions or scar tissue from previous surgery are carefully dissected to prevent injury to surrounding structures.

Mesh Placement

A composite or dual-sided synthetic mesh is selected to prevent adhesions to intra-abdominal organs.

The mesh is positioned over the hernia defect intraperitoneally, covering the entire myopectineal orifice with adequate overlap (at least 3–5 cm beyond the defect).

Fixation may be achieved using tacks, sutures, or fibrin sealant, depending on surgeon preference and hernia characteristics.

Closure and Verification

Proper mesh placement and fixation are confirmed visually.

Pneumoperitoneum is released gradually, ensuring mesh remains in position.

Ports are removed, and incisions are closed in layers.

Advantages of IPOM Laparoscopic Hernia Repair

Minimally Invasive: Small incisions result in reduced postoperative pain and better cosmetic outcomes.

Faster Recovery: Patients can typically resume normal activities within a few days.

Effective for Recurrent Hernias: Ideal for cases where the anterior approach is difficult.

Bilateral Repair: Both sides can be repaired in the same session without additional incisions.

Lower Risk of Wound Complications: Less risk of infection compared to open repair.

Safety Considerations

While IPOM repair is generally safe, careful attention is required to avoid complications:

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

Vascular injury: Careful dissection around epigastric vessels and iliac vessels

Chronic pain: Can occur due to nerve entrapment; careful mesh placement minimizes risk

Mesh-related complications: Adhesion formation or migration; using composite mesh reduces adhesion risk

Meticulous surgical technique and adherence to laparoscopic principles significantly reduce these risks.

Postoperative Care

Early ambulation and oral intake are encouraged.

Pain is usually managed with oral analgesics.

Most patients are discharged within 24 hours.

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

Outcomes

IPOM laparoscopic inguinal hernia repair has demonstrated:

Low recurrence rates when performed with proper mesh overlap and fixation

Reduced postoperative pain compared to open repair

Shorter hospital stay and faster return to daily activities

Effective management of recurrent and bilateral hernias with minimal complications

Conclusion

IPOM laparoscopic inguinal hernia repair is a safe, effective, and minimally invasive technique that offers excellent anatomical restoration, low recurrence rates, and rapid recovery. It is particularly valuable in recurrent, bilateral, or complex hernias, where traditional open approaches may be challenging.

With careful patient selection, meticulous technique, and proper mesh placement, IPOM laparoscopic repair provides durable results and improved quality of life for patients, establishing it as a key option in modern hernia surgery.