Laparoscopic Pre-peritoneal Onlay Mesh (PPOM) Repair for Ventral and Incisional Hernia
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Leblanc described the laparoscopic mesh repair of incisional hernia in 1993 . It involves placing a PTFE the mesh with fixation by staples in the posterior abdominal wall in the peritoneal cavity covering the hernia orifice. This technique is known as intra-peritoneal onlay mesh repair (IPOM). The IPOM+  technique involves the addition of closing the hernia defect with suture before placement of the mesh in the intra-peritoneal cavity. Laparoscopic repair for ventral hernia has undisputed advantages. Being able to place a large mesh through just several small tiny 5–10 mm wounds minimized tissue dissection and hence lowers the risk of wound infection. With low rate of wound infection, the risk of mesh infection also reduced. Secondly it clearly identifies the site and size of all hernia defects and avoids missing out multiple defects in some patients. However, having the mesh placed in the peritoneal cavity creates one problem—mesh-induced visceral complications. This is a result of foreign body reaction to the synthetic materials and the tackers, or chemical degradation reaction to those re-absorbable components of the mesh like the coating barriers or absorbable tackers. This chronic foreign body tissue reaction, if persist long enough, will leads to bowel erosion and fistulation, and in some cases migration of the mesh into the internal lumen of the bowel causing distal obstruction. Some even reported spontaneous passage of the mesh through rectum . This is more than just usual post-operative adhesion. The severity of this reaction is difficult to predict. Some may exhibit extensive reaction leading to adhesion, fistulation and obstruction. On the other hand, others might have mild reaction only. It is impossible to predict who will have problem and who will not. Needless to say there is no clinical parameter allowing us to predict the future progress of the patient after IPOM repair. The true incident of mesh-induced visceral complications is not known. The complexity of such event and subsequent management can be a surgical nightmare. It is this mesh-induced visceral complication drives the search for alternative laparoscopic approach for ventral and incisional hernia repair.