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Page 2 of 9 Jani. Mini-invasive Surg 2018;2:14 I http://dx.doi.org/10.20517/2574-1225.2018.08

Keywords: Laparoscopic ventral hernia repair, intra-peritoneal onlay mesh plus repair, closure of defect in the fascia,
abdominal wall hernia, incisional hernia repair, para-umbilical hernia repair

INTRODUCTION
Ventral abdominal wall hernia surgery is a common procedure in the armamentarium of surgeons.
The commonest forms of these surgical procedures in adults are repair of incisional hernias and surgery
for paraumbilical hernia. Incisional hernias after previous abdominal surgeries occur in a varying range,
reported from 11% to 20% . Laparoscopic repair of such hernias has an advantage of shorter hospital
[1-3]
stay, lower wound infection, earlier recovery and recurrence rates less than 5% . Paraumbilical hernias
[4-6]
compromise 10%-12% of abdominal wall hernias . As compared to open repair, laparoscopic repair of adult
[7]
paraumbilical hernias has also shown favorable outcomes . Since its first description in 1993, laparoscopic
[8]
repair of ventral hernias is gaining acceptance and becoming more popular by the day worldwide . However,
[9]
the standard laparoscopic repair of ventral hernias consisted of bridging the defect from the peritoneal side
with a composite mesh, known as the intra-peritoneal onlay mesh (IPOM) repair, which is placement of the
mesh in the underlay position through the laparoscopic intraperitoneal approach. Such repair is associated
with a significant incidence of post-operative bulging or eventration of mesh, seromas, recurrences and non-
restoration of abdominal muscle function [10-12] . To circumvent these problems, sutured closure of the defect in
the fascia with intra-peritoneal mesh reinforcement has been described, termed the IPOM plus repair . This
[13]
repair is now the recommended procedure in the guideline of International Endohernia Society .
[14]
In this paper, we summarize our experience of the IPOM plus repair over a period of 10 years, beginning
from January 2007 to January 2017.

METHODS
All patients posted for laparoscopic repair of midline lower abdominal ventral hernia on an intention to treat
basis were included in the study. Patients unfit for general anesthesia, patients posted for open repair or a
hybrid approach (open reduction and closure of defect followed by laparoscopic IPOM repair) were excluded.
This approach removed patients with incarcerated, obstructed or strangulated hernias from this study as
these patients were managed either by open repair or a hybrid approach. This also excluded patients with
domain loss (width of the gap in fascia in resting supine position) of more than 8 cm. as these patients were
electively posted for open repair prior to 2015 or given a choice of open/laparoscopic component separation
reconstruction of abdominal wall after 2015.

The width of the defect was measured as the maximum distance between the medial edges of the defect in the
fascia when the patient is in a resting supine position. The average defect width was 1.2 cm (range: 0.8-2.4 cm, SD
0.29 cm) for paraumbilical hernias and 2.2 cm (range: 1.0-7.5 cm, SD 0.49 cm) for incisional hernias.

The operating time was calculated from the insertion of the first trocar to exsufflation. The technical details
of the surgery are briefly described. The patient was placed supine with both upper limbs by the side. The
monitor was at the foot end of the operation table. The surgeon stands near the head of the patient with the
camera surgeon to his left.

Ryle’s tube is inserted to ensure a deflated stomach. Pneumoperitoneum is achieved by insufflating through
a Veress needle inserted either below the xiphisternum, slightly to the left of the midline or at Palmer’s point.
Three ports are inserted [Figure 1]. Port A is optional, required only if there is adhesiolysis to be done. In
such a situation, port B serves as the camera port, while port A and C are the right and left hand working
ports. For suturing the defect and mesh placement, port C is the camera port while port B and D are the
working ports.