This video demonstrates Intraperitoneal Onlay Mesh Repair of Inguinal Hernia. Our study at World Laparoscopy hospital as well as the meta-analysis of the series presented in the Literature, indicate that the IPOM may be a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias or when a hernia repair is performed during other laparoscopic procedures. The IPOM has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (TAPP and TEP). These data may also suggest utilizing this technique in particular cases of primitive hernia such as very active young males or heavy duty workers. However, the limited series and the short follow-up ask for randomized prospective long term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.

Intraperitoneal Onlay Mesh (IPOM) repair is a minimally invasive laparoscopic technique used in the surgical management of inguinal hernias. In this approach, a prosthetic mesh is placed on the inner surface of the abdominal wall within the peritoneal cavity to reinforce the hernia defect. Although newer preperitoneal techniques such as TAPP and TEP are more commonly preferred today, IPOM repair still holds historical and selective clinical relevance.

Principle of IPOM Repair

The fundamental concept of IPOM repair is based on the tension-free reinforcement of the myopectineal orifice. By placing a mesh intraperitoneally over the hernia defect, the technique utilizes intra-abdominal pressure to keep the mesh in position, thereby preventing hernia recurrence. To avoid adhesion formation between the mesh and intra-abdominal viscera, composite or barrier-coated meshes are used.

Surgical Technique

The procedure is performed under general anesthesia. After creating pneumoperitoneum, laparoscopic ports are inserted. The peritoneal cavity is inspected, and the hernia defect—direct, indirect, or femoral—is clearly identified. Unlike TAPP or TEP, extensive preperitoneal dissection is not required. A composite mesh is introduced into the abdomen and positioned to adequately cover the hernia defect with sufficient overlap. The mesh is then fixed to the abdominal wall using tacks, sutures, or a combination of both. Care is taken to avoid nerve injury and vascular structures. The peritoneum is not closed over the mesh, as it lies intraperitoneally.

Advantages of IPOM Repair

IPOM repair is technically simpler and requires less dissection compared to preperitoneal approaches. This makes it easier to learn for surgeons in the early phase of laparoscopic hernia surgery. Operative time may be shorter, and the procedure provides good visualization of bilateral hernias through the same port placement. It is also useful in selected cases where preperitoneal dissection is difficult due to previous surgeries or scarring.

Limitations and Concerns

Despite its simplicity, IPOM repair has certain drawbacks. The intraperitoneal placement of mesh carries a risk of adhesion formation, bowel obstruction, and fistula formation, even with barrier-coated meshes. Fixation-related complications such as chronic pain may occur. Additionally, long-term outcomes and recurrence rates have been less favorable when compared to TAPP and TEP repairs, leading to a decline in its routine use for inguinal hernia repair.

Current Role in Clinical Practice

With advancements in laparoscopic techniques and mesh technology, IPOM repair for inguinal hernia has largely been replaced by preperitoneal mesh repairs. However, it may still be considered in highly selected patients, complex redo cases, or in settings where preperitoneal access is not feasible. A thorough understanding of anatomy and careful patient selection are essential to minimize complications.

Conclusion

Intraperitoneal Onlay Mesh Repair of inguinal hernia represents an important step in the evolution of laparoscopic hernia surgery. While it is no longer the preferred standard technique, knowledge of IPOM repair remains valuable for surgeons to understand alternative approaches and manage complex clinical scenarios. Proper mesh selection, meticulous fixation, and adherence to surgical principles are key to achieving safe and effective outcomes.