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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 144-147

Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus) in 429 patients – Our experience


Department of General Surgery, Artemis Hospital, Gurugram, Haryana, India

Date of Submission19-May-2020
Date of Decision12-Jun-2020
Date of Acceptance25-Aug-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Kanu Kapoor
27-B Mig Flats Sheikh Sarai Phase-1, New Delhi - 110 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_19_20

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  Abstract 


INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) was first described in 1992 by Karl Leblanc and has increasingly gained popularity in this current era of minimal access surgery, hereby establishing itself as a well-accepted option for the treatment of these hernias.
OBJECTIVE: To assess; if the repair of Symptomatic Ventral hernia using Laparoscopic IPOM-PLUS is an effective modality in the treatment of such hernias or not.
AIM: The study reviews our experience in Laparoscopic Intraperitoneal Onlay Mesh repair (IPOM- PLUS) of symptomatic ventral hernia in a single surgical unit at Artemis Hospital, Gurgaon.
METHODS: A Prospective observational study was conducted where in we analysed the electronic medical records of 429 patients who underwent Laparoscopic Ventral Hernia Repair between July 2012 to January 2020 at Artemis Hospital, Gurgaon, Haryana. A Follow up period of 24 months was undertaken .
RESULTS: Four hundred and twenty nine patients underwent Laparoscopic IPOM in a span of 8 years. All patient's with a defect size of more than 2 cm were included in the study. Average BMI of the cohort was between 28.42 ± 4.8 kg/m2. Primary closure of all hernias greater than 2 cm was done (Trans-fascial sutures taken using Prolene No.1). Dual mesh was used as prosthesis and it was fixed using non absorbable tacking device. Hernia recurrence was found to occur in 2 of the 429 patient's (0.4%) where in one had chronic cough on account of COPD and the other showed excessive weight gain of 12 kg during the follow up period of 24 Months.
CONCLUSION: Laparoscopic IPOM- PLUS is a safe, highly efficacious and accepted method for ventral hernia repair with a very low recurrence rate.

Keywords: Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus), laparoscopic ventral hernia repair, Ventral Hernia Repair, Laparoscopic IPOM PLUS, IPOM- PLUS.


How to cite this article:
Gupta P, Kapoor K, Kundra D, Khanna AP, Arora C, Agarwal A. Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus) in 429 patients – Our experience. Int J Abdom Wall Hernia Surg 2020;3:144-7

How to cite this URL:
Gupta P, Kapoor K, Kundra D, Khanna AP, Arora C, Agarwal A. Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus) in 429 patients – Our experience. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2021 Mar 8];3:144-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/4/144/302020




  Introduction Top


Ventral hernia repair forms the most common procedure in the armamentarium of a surgeon.[1]

Laparoscopic ventral hernia repair (LVHR) was first described in 1992 by Karl Leblanc and has increasingly gained popularity in this current era of minimal access surgery, hereby establishing itself as a well-accepted option for the treatment of both primary ventral and incisional hernias with the advantage of shorter hospital stay, lower wound infection, earlier recovery, and low recurrence rates <5%.[2],[3],[4]

Standard LVHR involves bridging the defect from the peritoneal side followed by placement of a composite mesh, known as the “intraperitoneal onlay mesh (IPOM) repair,” wherein the mesh is placed in an “underlay” position via the laparoscopic intraperitoneal approach. These repairs are associated with a significant incidence of eventration of mesh, recurrence, and seroma formation and also cause incomplete restoration of abdominal muscle function [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].[5],[6],[7]
Table 1: Patient Demographics

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Table 2: Hernia incidence

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Table 3: Associated co-morbidities

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Table 4: Indication for IPOM plus

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Table 5: Operative and Immediate post operative findings

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Table 6: Outcomes on follow up

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To circumvent these problems, sutured closure of the defect in the fascia followed by intraperitoneal placement of a mesh, termed as the “IPOM plus repair,”[8] is now the recommended procedure in the guideline of the International Endohernia Society.[9]

This study summarizes our experience of the IPOM plus repair over a period of 8 years, beginning from July 2012 to January 2020 in a single surgical unit, at Artemis Hospital, Gurgaon, Haryana, India.


  Methods Top


A prospective observational study was conducted wherein we analyzed the electronic medical records of 429 patients who underwent laparoscopic IPOM plus. These were then followed up for a period of a minimum of 6 months and a maximum of 5 years, with a median follow-up period of 28.5 months between July 2012 to January 2020 at Artemis Hospital, Gurgaon, Haryana [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: (a and b) A laparoscopic view of the defect to be repaired and the size of which was measured using a paper scale intraoperatively. (c and d) Transfascial closure of the defect using Prolene No. 1. (e and f) Overlap of the closed defect using a composite mesh and fixation with tackers in a double-crowning fashion

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Figure 2: Type of hernia encountered for repair

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Figure 3: Incidence of Ventral hernia( According to site)

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Figure 4: Post operative pain as per Visual analogue score( VAS) at the end of 1st hour

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Four hundred and twenty-nine patients were operated from July 2012 till June 2019. It implies that all the patients included in the study group were spread over a period of 7 years and were followed up for a maximum of 5 years to the last group for a period of 6 months duration.

Patients operated from July 2012 to June 2014 were followed up for a maximum of 5 years till January 2020.

Patient consent and ethical clearance

The procedure (laparoscopic IPOM plus) is the standard surgical procedure for ventral hernia, and the same is a recognized and permitted technique by the credentialing committee to be used for the repair of ventral hernia patient at our institute.

The patients included in the study were explained in detail about the procedure and all other options available, and they were informed that their case would be included in a prospective study for which they would be requested for a follow-up and review in the coming years for which they gave written consent.

Prior institutional ethics committee clearance was taken for the study.

Inclusion criterion

  • All patients with anterior abdominal wall hernia with defect size >2 cm and <10 cm. Defect size was measured using a Vernier caliper/computed tomography scan imaging preoperatively, and a paper scale was used intraoperatively
  • Incarcerated/obstructed hernias in their early presentation phase


Exclusion criterion

  • Patients unfit for general anesthesia
  • Patients posted for open hernia or hybrid approach based on a surgeon's expertise
  • Patients with loss of domain


Information recorded for data analysis

  • Age
  • Gender
  • Body mass index (kg/m2)
  • Hernia type
  • Location
  • Associated comorbidities
  • Size of the defect
  • Operative time
  • Intraoperative Bowel injury
  • Conversion to open
  • Postoperative pain score
  • Length of postoperative stay


Follow-up was done by outpatient department visits, E-mail, and telephone at 1-week, 2-week, 3-month, and 6-month duration, respectively.

Technique

  1. Operative technique adopted was that of a standard laparoscopic intraperitoneal onlay mesh repair with extracorporeal primary transfascial closure of the defect using Prolene No. 1 via a port closure needle
  2. Empty peritoneal hernial sac was left in situ
  3. “Landing zone” was prepared after dissecting down the preperitoneal fat from the posterior rectus sheath, especially in the epigastric region, ligamentum teres was also separated so that crumpling could be avoided, and mesh was placed. In case of hypogastric/ incisional hernias arising following uterine/gynecological procedures, the preperitoneal fat and median umbilical ligament were brought down till the space of Retzius was reached, mesh was placed in a manner that the lower edge was in the preperitoneal space and tackers were applied on the pubic symphysis and pectineal line
  4. Composite mesh of size sufficient to ensure a minimal overlap of 5 cm over the edges of the defect was introduced for intraperitoneal placement and fixed using CapSure™ tackers in “double-crowning fashion”
  5. Transversus abdominis block was administered in all the 429 patients
  6. Abdominal binders were given as anterior abdominal wall supports in all postoperative patients



  Results Top


Four hundred and twenty nine patients underwent Laparoscopic IPOM in a span of 8 years. All patient's with a defect size of more than 2 cm were included in the study. Average BMI of the cohort was between 28.42 ± 4.8 kg/m2. Primary closure of all hernias greater than 2 cm was done (Trans-fascial sutures taken using Prolene No.1). Dual mesh was used as prosthesis and it was fixed using non absorbable tacking device.

Hernia recurrence was found to occur in 2 of the 429 patient's (0.4%) where in one had chronic cough on account of COPD and the other showed excessive weight gain of 12 kg during the follow up period of 24 Months.


  Discussion Top


As per the Updated International Endohernia Society guidelines, the advantages of IPOM plus over conventional approach are:[9],[10]

  1. Fewer surgical site infections
  2. Less blood loss
  3. Less postoperative pain
  4. Shorter hospital stay
  5. Less incidence of ileus.


(1) and (2) being Level 2B statements and (3), (4), and (5) are Level 3 statements.

As per the Level 3 statement given by IEHS, augmentation repair is considered stronger than bridging repair with reduced recurrence rate.

As per the Level 2C statements given by IEHS (updated guidelines), IPOM plus results in lesser recurrence, seroma formation, and bulging.

Another Level 4 statement given by IEHS states that defect closure is associated with decreased incidence of seroma formation and adverse hernia site events with decreased incidence of chronic pain.[10],[11]

Several comparison studies between IPOM and IPOM plus suggests that IPOM plus is associated with more favorable surgical outcomes.[10],[11]

The Grade C IEHS recommendation states that tack-only fixation is the technique of choice keeping into account pain and overlap of 5 cm.

Our technique was that of transfascial closure of the defect with the use of a composite mesh to overlap the closed defect over a margin of about 5 cm with CapSure™ tacker fixation in a double-crowning fashion and administration of TAP block, and this study summarizes the results of the same.

The recurrence rate observed in our study was 0.4%, and 2 of the 429 patients followed came back with recurrence. The first patient was a 56-year-old hypothyroid woman with a documented weight gain of 12 kg over a period of 6-month duration. The second was a 45-year-old man, a chronic smoker with chronic obstructive pulmonary disease.


  Conclusion Top


In our study of 429 patients who underwent laparoscopic IPOM plus repair, wherein all defects >2 cm were closed intracorporeally and reinforced using a dual mesh, a documented recurrence of 0.4% was found; hence, we can safely say that laparoscopic IPOM plus remains not only safe and feasible but is also a reliable surgical option for the repair of ventral hernias with faster recovery, very low recurrence rate, smaller surgical incisions, and fewer complications, and we recommend laparoscopic IPOM plus over laparoscopic IPOM for all anterior abdominal wall defects >2 cm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jani K. Laparoscopic intra-peritoneal onlay mesh plus repair for ventral abdominal wall hernias-is there substance to the hype? Mini-invasive Surg 2018;2:14.  Back to cited text no. 1
    
2.
Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias. Ann Surg 2003;238:391-9.  Back to cited text no. 2
    
3.
Carbajo MA, Martín del Olmo JC, Blanco JI, Toledano M, de la Cuesta C, Ferreras C, et al. Laparoscopic approach to incisional hernia lessons learned from 270 patients over 8 years. Surg Endosc 2003;17:118-22.  Back to cited text no. 3
    
4.
Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007781. doi: 10.1002/14651858.CD007781.pub2. PMID: 21412910.  Back to cited text no. 4
    
5.
Kurmann A, Visth E, Candinas D, Beldi G. Long-term follow-up of open and laparoscopic repair of large incisional hernias. World J Surg 2011;35:297-301.  Back to cited text no. 5
    
6.
Tse GH, Stutchfield BM, Duckworth AD, de Beaux AC, Tulloh B. Pseudo-recurrence following laparoscopic ventral and incisional hernia repair. Hernia 2010;14:583-7.  Back to cited text no. 6
    
7.
Tse GH, Stutchfield BM, Duckworth AD, de Beaux AC, Tulloh B. Pseudo-recurrence following laparoscopic ventral and incisional hernia repair. Hernia 2010;14:583-7.  Back to cited text no. 7
    
8.
Schoenmaeckers EJ, Wassenaar EB, Raymakers JT, Rakic S. Bulging of the mesh after laparoscopic repair of ventral and incisional hernias. JSLS 2010;14:541-6.  Back to cited text no. 8
    
9.
Palanivelu C, Jani KV, Senthilnathan P, Parthasarathi R, Madhankumar MV, Malladi VK. Laparoscopic sutured closure with mesh reinforcement of incisional hernias. Hernia 2007;11:223-8.  Back to cited text no. 9
    
10.
Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1. Surg Endosc 2014;28:2-9.  Back to cited text no. 10
    
11.
Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, et al. Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))–Part A. Surg Endosc 2019;33:3069-139.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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