Laparoscopic Intraperitoneal Onlay Mesh (IPOM) and IPOM Plus

Abstract

Minimally Invasive Surgery has revolutionized the surgical practice by imparting its ability to avoid major abdominal wall incisions [1]. It is expected that laparoscopic surgery might reduce the burden of incisional hernias which is the most common complication after abdominal surgery and despite ongoing research in wound closure and reparative techniques, abdominal incisional hernia remains an unresolved problem [1]. The outcome of incisional hernia may have major social and economic implications and worldwide 10–30% of patients undergoing laparotomy will develop an incisional hernia and subsequent conventional open repair often fails to adequately address this substantial problem [2]. The recurrence rate for primary tissue repairs may approach the 35% range, which is higher than the primary occurrence rate; when repaired for recurrence, rates have been reported greater than 50%. Although the advent of prosthetic repair has significantly reduced the recurrence rate compared with that of primary suture repair, it remains in the ranges of 10–24% [3].

Introduction

The field of minimally invasive surgery has revolutionized the surgical practice by imparting its ability to avoid major abdominal wall incisions [1]. It is expected that laparoscopic surgery might reduce the burden of incisional hernias which is the most common complication after abdominal surgery and despite ongoing research in wound closure and reparative techniques, abdominal incisional hernia remains an unresolved problem [1]. The outcome of incisional hernia may have major social and economic implications and worldwide 10–30% of patients undergoing laparotomy will develop an incisional hernia and subsequent conventional open repair often fails to adequately address this substantial problem [2]. The recurrence rate for primary tissue repairs may approach the 35% range, which is higher than the primary occurrence rate; when repaired for recurrence, rates have been reported greater than 50%. Although the advent of prosthetic repair has significantly reduced the recurrence rate compared with that of primary suture repair, it remains in the ranges of 10–24% [3].

Gradual decreases in recurrence rates have been realized over the last decade as minimally invasive techniques have been increasingly utilized. For example, in some series, the recurrence rate of initial incisional hernias has been reduced to 2–9% [4,5,6].

Moreover, multiple studies demonstrate that laparoscopic repair of ventral hernia results in a short length of stay and a quick return to normal activities [6]. The recurrence rate after laparoscopic repair of a recurrent hernia ranges between 9% and 12%, which is an improvement when compared with recurrence rates of 20% after conventional repair with prosthetic material [6, 7]. Clearly, the laparoscopic approach to repair ventral hernia has significantly improved the management of this problem. This technique involves either an intraperitoneal onlay mesh (IPOM) with or without defect closure (IPOM+) or preperitoneal mesh-placement (PPOM) as in the open sublay repair [8, 9].

This chapter will review the risk factors, indications, contraindications, preoperative preparation, and postoperative care after laparoscopic ventral hernia repair. Additionally, it will discuss the complications and steps to avoid these complications for safe practice.

Risk Factors for Primary and Recurrent Ventral Hernia

Risk factors for the development of incisional hernia formation are not well defined and prevention strategies are still a long way to know. Some well-established systemic and local factors being reported in many studies are enlisted as follows [10, 11].

Systemic Factors

• obesity

• diabetes

• steroid use

• benign prostatic hypertrophy

• pulmonary disease

• advancwed age

• Male gender

• Chronic coughing

• Pregnancy

• Weight lifting

Local Factors

• size of fascial defect

• type of incision

• method of fascial closure

• postoperative hematoma

• postoperative wound infection

Indications

• symptomatic ventral/incisional hernia larger than 3 cm

• recurrent hernia

Contraindications

• Loss of domain (ventral larger 20 cm)

• Strangulated hernia

• Gangrenous bowl

• Peritonitis

• Intra-abdominal Sepsis

• Infection

• Eventration

• Systemic condition like cirrhosis with caput medusae

Preoperative Preparation

• Routine blood investigations

• Bowel Preparation (optional)

• Antibiotic prophylaxis

• CT-Scan (selected cases: recurrent, incarcerated, etc.) (Fig. 1)

• Pulmonary function (obese)

• Informed Consent (risk for enterotomy, conversion, seroma, etc.)

• DVT prophylaxis

Fig. 1

Axial contrast-enhanced reformatted CT image of the abdomen shows herniation of gut and omental fat through a large abdominal defect

OT Setup, Patient’s Position, and Trocars Placement

• Monitor position (Fig. 2)

  • Position of the monitor should be opposite to the trocars

  • Height and distance should follow standard principles

• Instrumentation required (Fig. 3)

  • Veress Needle (Optional)

  • Trocars

  • Laparoscopic camera unit with 30° telescope 10 mm and 5 mm

  • Atraumatic Graspers (2) 5 mm

  • Curved Scissors (1) 5 mm

  • Bowel Clamp (2) 5 mm

  • Suction/irrigation device

  • Energy source preferably LigaSure (1) 5 mm

  • Suture passer/14 G IV Cannula and nonabsorbable suture

  • Tackers; absorbable or nonabsorbable (for mesh fixation)

  • Clip applier (1) 5 mm (optional)

  • Hook diathermy (1) 5 mm (optional)

• Patient Position and preparation

  • Standard supine position with both arms tucked at the side or on the arm board depending on the size and site of hernia

  • Surgeon and Assistant stand on the side of the patient

  • Foleys catheter for large, recurrent, incisional, or partially or irreducible hernia

• Trocars size and position

  • 12 mm Optical trocar (1)

  • 5 mm trocars (2)

  • 12 mm port inserted laterally between the costal margin and the Anterior superior iliac spine (ASIS)

  • 5 mm ports (2) inserted on either side of the optical trocar

  • an additional 5 mm port may be required in an approachable position for the mesh fixation.

Fig. 2

OT setup

Fig. 3

Common instruments for IPOM/IPOM+ repair

Surgical Technique

The hernia defect should be marked before the abdominal cavity is entered (Fig. 4).

Fig. 4

Marking of defect

First Trocar Insertion

Pneumoperitoneum can be established using either a Veress needle or a Hasson trocar. The “open technique” using Hasson’s trocar should be preferred. In our experience, we establish the pneumoperitoneum using open Hasson’s technique which is quite safe entry. Optical trocar entry should be preferred in obese male with thick anterior abdominal wall where open technique would be difficult to achieve (i.e., Opti-View) (Fig. 5a, b).

Fig. 5

(a) Endoscopic view of Opti-view. (b) Hasson’s technique

The direct view trocar with 0° scope is very useful to avoid bowel injury accessing the abdomen. The first trocar is inserted laterally between the anterior iliac spine and the subcostal margin (anterior axillary line). An angled [30° or 45°] laparoscope, inserted through the 10–12 mm trocar, must be utilized to facilitate the visualization of the anterior abdominal wall.

Working Trocars

Working Trocars placed too close to the edge of the defect may not allow adequate working space. Trocars placed too laterally may limit the downward displacement of the instrument handle. Once the first trocar is inserted, usually two, 5 mm trocars are placed under vision and well lateral to the defect, on either side of the 10–12 mm port.

Preparing the Defect: Adhesiolysis

If necessary, adhesiolysis is first performed to clear the margins of the defect and to avoid bowel injury, the use of diathermy or the ultrasonic dissector should be very careful. Any thermal injury to intestine could result in catastrophic peritonitis and result in delayed repair. Despite the fact that there are plenty of video material available on social media for using Ultrascission®, LigaSure®, or Thunderbeat®, authors are confident in using these devices, but with caution, being aware of the inherent risk. After adhesiolysis is performed a reduction of hernia contents is started with the steady hand-over-hand withdrawal of the sac contents (Figs. 6 and 7).

Fig. 6

Abdominal wall defect with adhesions

Fig. 7

Adhesiolysis to delineate defect margins

External countertraction applied by the assistant may facilitate the reduction of the hernia sac contents and can lower the abdominal “ceiling” to provide better working space. Care must be taken to avoid excessive tension with grasper to minimize the risk of intestinal injury at this step. In rare cases, when incarceration is not possible to reduce then sharp dissection of the fascial edge of the defect will facilitate the reduction.

Measurement of Defect Size

Once the margins of the hernia are well delineated and cleared, the defect can be measured by external palpation or with an intra-abdominal ruler/suture, or even with a laparoscopic instrument. It is best practice to reduce intra-abdominal pressure to 6 mmHg in order to get accurate size. Mesh overlap to defect according to mesh type should be selected appropriately.

Mesh Size and Choice of Mesh

At the moment, plenty of different types of mesh are available in the market: Gore-Tex and PTFE (dual mesh or dual mesh plus), polyester, or polypropylene coated with different antiadhesive agents. All the mesh comes in different sizes and dimensions. A prosthetic mesh is then tailored to ensure at least 5 cm overlap of all defect margins. Distinct “orienting” marks are placed on the mesh and on the skin (Fig. 6), respectively, to assist with intra-abdominal orientation. Individual needs and properties should be kept in mind for appropriate mesh size and choice.

Mesh Fixation

Suture, tacking devices, and glue fixation methods are common in practice while authors believe to use a tailor approach for devising a final method of mesh fixation based on previous repair, site, size, and other factors. Main idea of fixation is to keep the mesh in contact with the anterior abdominal wall in order to achieve fibrosis and to avoid landing of mesh in the peritoneal cavity to prevent complications. Authors recommend to practice absorbable spiral tack fixation over suture repair but a tailored approach should always be practiced before making any decision.

If suture fixation is decided then sutures should be placed at four cardinal points of the mesh (Fig. 8).

Fig. 8

Four cardinal sutures for mesh anchoring

For larger prosthesis, additional sutures may be placed between these four sutures. The mesh is then wrapped around a laparoscopic grasper and inserted through the 12 mm trocar. Once inserted, the mesh is unfurled and oriented correctly; the preplaced sutures are pulled transabdominally using a suture passer through the previously marked locations (Fig. 9).

Fig. 9

Transabdominal suture

Sutures should not be tied until all sutures are pulled, so that the mesh must be adjusted. If we need to readjust the mesh to better cover the hernia defect, the sutures can simply be pulled back into the abdomen and replaced.

Metallic or Absorbable tacks can be used for fixation but the latter is preferred for less pain, less seroma, and to prevent other long-term post complications. Larger meshes require more number of tacks but it is recommended to keep a safe distance of 1–1.5 cm between two tacks aiming for no gaps in between in order to prevent small bowel obstruction. Selection of length of tack depends on individual factors like abdominal wall fats, distance of solid layer (fascial layers) from mesh, and also type of mesh (prosthetic vs biological). Spiral tack is 3.9 mm long, AbsorbaTack^® 4.1 mm (functionally), Sorbafix^® 6.4 mm, and Securestrap^® 7.1 mm. These lengths are aimed for solid layers like fascia and not just peritoneal or preperitoneal fat. The most difficult part of tack fixation is the one which is the closest to the trocars. In order to fix properly, it is recommended to place a contralateral trocar or use different angels with a combination of camera and working ports to achieve solid fixation (Fig. 10).

Fig. 10

Spiral AbsorbaTack with safe distance and with one closest to trocar

IPOM+

In IPOM + additional transfascial sutures should be placed transabdominally to ensure defect closure after sutures passed every 3–5 cm. Suture passer or 14 G IV Cannula should be used in order to pass nonabsorbable sutures for this technique. One length of suture should not be used for more than two passes. Care must be taken to avoid underlying visceral injury (Fig. 11).

Fig. 11

Placement of Tranfascial suture with suture passer to close the defect before mesh placement

Intracorporeal continuous repair of defect site or divarication of recti repair by this technique gives an additional benefit to restore anatomy but at the cost of increased post-op complications like pain, seroma, and prolonged immobility (Fig. 12).

Fig. 12

Intracorporeal continuous repair of defect and divarication as IPOM + repair

Closure

Once mesh fixation is done, abdominal cavity should be explored to look for any bleeding or injury. All CO₂ should allow to exit from the cavity, and 10 mm trocar site should be closed with either nonabsorbable suture or PDS. Care must be taken to avoid any injury or taking abdominal content in sutures. Finger inspection before closure ensures safety.

When to Convert

• dense bowel adhesion

• adhesion between the bowel and previous mesh repair

• Enterotomy with important spillage for enteric fluid

• Unidentified bleeding

Postoperative Care

• Standard Analgesia

• Compressive bandage for 5 post-op days

• Abdominal binder for 4–6 weeks

• Antibiotic therapy if needed

• Conservative management of the seroma, treat by aspiration only if symptomatic (pain) (Fig. 13)

Fig. 13

Postoperative large seroma after mesh repair

Difficult Hernia Location

• For lateral/flank hernias: mobilize the colon to get adequate space to place the mesh laterally.

• For hernia near the costal margin: sutures may be passed around the rib/costal cartilage to anchor.

• For Suprapubic hernia: it is a quite common defect and it is the most difficult and challenging location to repair either in open or laparoscopic repair. Actual experience shows that the best solution is to fix the mesh extraperitoneally at the Cooper’s ligament using a TAPP-like technique.

Complications and Management

• Trocar injury

  • Open Hasson’s technique

  • Direct visualization

  • Care in scarred abdomen

  • Check for injury

• Adhesiolysis leading to injury

  • Patience in adhesiolysis

  • Careful dissection

  • Use scissors instead of cautery

  • Bipolar hemostasis instead of monopolar

• Post-op ileus or intestinal obstruction

  • Larger mesh with more sutures

  • Composite mesh instead of simple polypropylene meshes

  • Tackering at periphery of mesh

  • Bring omentum at top of bowl after mesh placement

• Mesh infection

  • Consider for first case on list

  • Achieve complete sterilization

  • Antibiotic prophylaxis

  • Change gloves before putting in mesh

  • Minimum handling of mesh

  • Nontouch technique for mesh placement

  • New fixation device (absorbable)

  • Mesh with larger pore size

• Seroma/Bleeding

  • Avoid extensive adhesiolysis

  • Safe entry into the abdomen with injury to epigastric vessels

  • Invert sac before closing the defect

  • Less cautery—less infection

  • Compression dressing

• Recurrence

  • Pre-op optimization for systemic conditions as well as for defects

  • Apply appropriate technique

  • Transfascial sutures

  • Use larger mesh to overlap 5 cm from defect

  • Centralization of mesh

  • No gaps at mesh edges

• Suture site pain

  • Liberal but judicious use of local analgesia

  • Adequate post-op analgesia

  • Use glue where preferable to close skin

  • Adequate IV analgesia

  • Abdominal binder

• Missed or delayed bowel injury

  • Use atraumatic graspers

  • Careful inspection of bowel and other structures

  • Gentle manipulation of bowel, if needed then hold mesentery instead of bowel itself

  • Avoid energy devices in the vicinity of bowel

  • Careful inspection at end of the procedure

  • Re-laparoscope if in doubt

Clinical Results

Since its introduction in 1992, the laparoscopic approach has achieved better outcomes than the historical conventional open approach. Patients have also the benefits associated with MIS approach such as less pain, shorter length of hospital stay, and less blood loss [12, 13].

In several series, for laparoscopic ventral hernia repair the length of stay in the hospital ranges between 1 and 3 days, the operating time for laparoscopic repair is less than the conventional repair by as much as 30–40 min and the recurrence rate is significantly reduced around 2–8% [13, 14]. Intraoperative complications like enterotomies should be managed by immediate repair of the enterotomy and if there is important enteral spillage the mesh repair should be delayed for 1–2 months. Extensive adhesiolysis increases the risk of prolonged ileus, another possible complication that may lengthen the hospital stay.

Lastly, the laparoscopic approach provides additional benefit as a complete exploration of the abdominal cavity, the possibility to add another procedure if needed, an easier adhesiolysis due to the magnification of the view, and a lower chronic postoperative abdominal pain because no wide dissection is performed.