port insertion in a laparoscopic hernia repair procedure

IPOMp and Circumstance: Fixing a Hernia with an Intraperitoneal Onlay Mesh

by Amanda Derhy and Yiu Luke, Digital Surgery

In a previous blog post, we introduced ventral incisional hernias and how to repair these using an open approach. Our earlier simulation on Touch Surgery™, Open Retromuscular Repair of a Ventral Incisional Hernia, focused on the open surgical approach to mending a midline ventral hernia.

Touch Surgery™ is proud to present a new hernia simulation, Laparoscopic IPOM Repair of a Recurrent Ventral Incisional Hernia, illustrating ventral hernia repair using the intraperitoneal onlay mesh (IPOM) method. This educational simulation is available for free now on the Touch Surgery™ mobile app.

Touch Surgery™ thanks Ben Griffiths, M.D., consultant colorectal surgeon at Newcastle Upon Tyne NHS Foundation Trust, for his authorship of this simulation. The surgical video featured in this simulation was provided thanks to Filip Muysoms, M.D., abdominal wall surgeon at Hernia Centrum Gent.

What is a ventral incisional hernia?

Surgical incisions can become a weak point on the abdomen after healing. Strenuous activity or weight gain can worsen the weak point, allowing internal tissues to protrude. This is called a ventral incisional hernia. Ventral incisional hernias are fairly common, developing after 15% to 20% of laparotomies.2

Ventral incisional hernias may start as a painless, reducible abdominal bulge. They always require surgery to treat definitively. If left untreated, the hernia may grow larger, and may lead to bowel incarceration, obstruction or strangulation.

What is intraperitoneal onlay?

Intraperitoneal onlay mesh, or IPOM, is a technique used for hernia repair. The mesh is introduced into the abdomen and fixed in place to mend the defect from inside the peritoneal cavity.

This Touch Surgery™ simulation presents a case of recurrent supraumbilical hernia with multiple defects after a failed mesh repair. After removing the failed mesh and suturing the defect closed, the IPOM method is used to apply the new mesh. This results in the mesh lying in close contact with the contents of the abdominal cavity.

Our simulation features Medtronic’s Symbotex™ composite mesh, which has two surfaces—a porous three-dimensional monofilament polyester textile surface for abdominal wall adherence, and an absorbable hydrophilic film surface, designed to minimize visceral adhesions when placed in the intraperitoneal space.4

onlay mesh

Placing of the mesh, ensuring correct centering and orientation.

When might you choose or not choose an IPOM repair?

IPOM repair is typically indicated for primary and recurrent ventral hernias, and for ventral incisional hernias3—as demonstrated in this simulation.

Previous surgeries may leave dense adhesions, which are a relative contraindication to IPOM repair, as they make laparoscopic operations more difficult. The use of a mesh may not be indicated in periods of growth, pregnancy, or infection or contamination at or around the surgical site.3

measurement for hernia mesh placement

Measuring the size of the entire area with multiple defects.

What if the patient has multiple hernia defects?

The case demonstrated in the Touch Surgery™ simulation, Laparoscopic IPOM Repair of a Recurrent Ventral Incisional Hernia, presents a recurrent supraumbilical hernia with multiple defects. This is occasionally referred to as a “Swiss cheese” hernia. To repair this type of hernia, the author recommends measuring the outer limits of all the defects both vertically and horizontally, and treating the entire area as one large defect. The mesh is then cut to a size and shape that covers the area wholly.

What happens in an IPOM hernia repair?

1. Patient preparation

The surgical team prepares the patient preoperatively by placing them supine, disinfecting, and draping. A patient return electrode is placed, and intravenous antibiotics are administered.

2. Trocar insertion

In this simulation, an incision is made for the optical trocar at Palmer’s point, located 3 cm below the left subcostal margin on the midclavicular line. The abdomen is insufflated before two more trocars are inserted: one at the left flank on the anterior axillary line 2–3 cm above the iliac crest, and one at the level of the hernia defect.

3. Adhesiolysis

Adhesions to the bowel and the previous failed mesh are removed. Any bleeding from injured vessels is controlled mechanically.

port insertion vertical

4. Preparing the ‘landing zone’

The ‘landing zone’ refers to the perimeter of the hernia defect, where the mesh is to be secured. The preperitoneal fat in this area is dissected to improve integration of the mesh with the abdominal wall. At this stage, the surgeon also takes the vertical and horizontal measurements of the defect. Multiple defects are considered as a single large defect.

5. Defect closure

The surgeon sutures the hernia defect closed under direct visualization. For larger defects, it may be necessary to perform a transabdominal suture through a stab incision.

dissection of adhesions

Dissecting adhesions from previous surgery.

6. Mesh preparation

Our simulation features Medtronic’s Symbotex™ composite mesh. In preparation for usage, the mesh can be marked and cut  to size. Next, it is hydrated in sterile saline, then rolled, before being inserted through the trocar. Rolling protects the film side, which faces the abdominal cavity and is intended to limit adhesions to the mesh.4

7. Mesh fixation

After positioning the mesh and ensuring it is correctly centered and oriented, fixation tacks are applied to secure the mesh in place. In this simulation, we demonstrate a ‘double crowning’ technique, where the tacks are placed in two concentric ovals, using Medtronic’s AbsorbaTack™ fixation device.5

8. Closure

To complete the surgery, the dissected specimens are removed using specimen bags. Following this, all instruments and swabs are removed from the abdomen, and then the trocars are removed. The subcutaneous tissues and skin at the trocar sites are closed.

Ready for more? Dive into a detailed step-by-step guide through laparoscopic IPOM ventral hernia repair in the Touch Surgery™ app now.

Launch in App

or scan the QR code below.

A QR code that links to the simulation on Touch Surgery

How to cite this simulation: Griffiths B. Laparoscopic IPOM Repair of a Recurrent Ventral Incisional Hernia. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0184. Published May 21, 2021.

References

1. Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas A. Current Trends in Laparoscopic Ventral Hernia Repair. JSLS. 2015;19(3) doi:10.4293/JSLS.2015.00048.

2. Hope WW, Tuma F. Incisional Hernia. https://www.ncbi.nlm.nih.gov/books/NBK435995/. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Updated 26 Jun. 2020. Accessed 19 Jan. 2021.

3. Earle D, Roth JS, Saber A. SAGES Guidelines Committee. SAGES Guidelines for Laparoscopic Ventral Hernia Repair. Surg Endosc. 2016;30(8):3163-3183.

4. Symbotex™ Composite Mesh [instructions for use]. Trevoux: Medtronic; 2014.

5. AbsorbaTack™ Fixation Device [instructions for use]. Covidien: Medtronic; 2009.