Laparoscopic, Endoscopic and Robotic Surgery 4 (2021) 116e120

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Laparoscopic, Endoscopic and Robotic Surgery

journal homepage: www.keaipublishing.com/en/journals/
laparoscopic-endoscopic-and-robotic-surgery

Laparoscopic management of ventral hernia repair using

intraperitoneal synthetic mesh: A 10-year retrospective observational
study
Bramhavar Shamburao Ramesh, Hosni Mubarak Khan*, Yashshwini B. Kareti
Department of General Surgery, Dr B R Ambedkar Medical College and Hospital, Kadugondanahalli, Bangalore, India

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Ventral hernia is an anterior abdominal wall hernia, with an incidence of 2%e13%. Laparo-
Received 17 October 2021 scopic ventral hernia repair is the preferred method worldwide with all the advantages of the laparo-
Received in revised form scopic technique proven to be an effective treatment option. This study aims to assess the long-term
22 November 2021
outcomes of laparoscopic management of ventral hernia repair using intraperitoneal onlay mesh (IPOM)
Accepted 24 November 2021
or intraperitoneal onlay mesh with defect closure (IPOM PLUS) technique with the usage of variety of
Available online 6 December 2021
synthetic meshes intraperitoneally.
Edited by Qingjie Zeng Methods: A retrospective study of 821 patients of a single institution for a decade was conducted. Long-
term outcomes such as pain, mesh infections, enterocutaneous fistula, bowel adhesions and recurrence
Keywords: were assessed.
Ventral hernia Results: There were 801 primary, 12 incisional, and 8 recurrent hernia cases, including 532 females and
Intraperitoneal onlay mesh 289 males with a mean age of 45.62±9.37 years. IPOM PLUS were underwent in 674 (82.10%) cases.
Intraperitoneal onlay mesh with defect Polypropylene, dual, titanium, composite meshes were applied in 473 (57.61%), 208 (25.33%), 82 (9.99%),
closure
and 58 (7.06%) cases respectively. Intraoperative bleeding occurred in 3 (0.37%) cases, seroma in 8
Synthetic intraperitoneal mesh
(0.97%), wound infection in 4 (0.49%), stitch abscess in 2 (0.24%). Recurrence was found in 8 (0.97%) cases,
with 5 used polypropylene mesh and 3 used dual mesh. Mesh infections were discovered in 6 (2.88%)
cases used dual, and foreign body sensation in 4 (0.85%) cases used polypropylene. Three (0.37%) patients
had suture site hernia, and 3 (0.37%) had chronic sinus.
Conclusion: IPOM or IPOM PLUS holds good in small or medium sized ventral hernias. The safety and
efficacy of intraperitoneal polypropylene mesh is comparable to that of other synthetic meshes. A mesh
overlap of minimum 5 cm beyond defect edge is must to minimise hernia recurrence. Absorbable suture
can be considered as alternative to tackers.
© 2021 Zhejiang University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co.
Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

1. Introduction
Ventral hernia is an anterior abdominal wall hernia (excluding
groin hernia). Ventral hernias, whether naturally occurring or the
result of previous surgery, comprise one of the most common
problems confronting general surgeons, with overall incidence
between 2% and 13%.1,2 Ventral hernia repair has seen a progressive
development. It was initially performed by the open technique to
* Corresponding author: Department of General Surgery, Dr B R Ambedkar
Medical College and Hospital, Kadugondanahalli, Bangalore, India.
E-mail address: drhosnimubarakkhan@gmail.com (H.M. Khan).
restore the anatomical layers without mesh insertion, and the
recurrence rate could range from 31% to 54%.3
Laparoscopic ventral hernia repair was described first by
LeBlanc et al, in 1993 for all types of hernia.4 This surgical technique
has improved over the last decade and has been proven to be an
effective treatment option. With fewer wound complications, faster
functional recovery and improved cosmesis, it has become a solu-
tion of choice in the treatment of small ventral hernia. However,
there are still some unresolved issues, including a certain number
of relapses, problems of fixation of the mesh, the choice of the
mesh, and the incidence of seromas. Primary closure of the hernial
defect is desirable, although technically complex, as shown by
previous experience. The goals of ventral hernia repair are relief of

https://doi.org/10.1016/j.lers.2021.11.003
2468-9009/© 2021 Zhejiang University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
B.S. Ramesh, H.M. Khan and Y.B. Kareti
patient symptoms and/or cure of the hernia with minimization of
recurrence rates. While laparoscopic ventral hernia repair has
gained popularity in recent years, there is still significant contro-
versy about the optimal approach to ventral hernia repair. This
study aims to assess the long-term outcomes of laparoscopic
management of ventral hernia repair using intraperitoneal onlay
mesh (IPOM) and intraperitoneal onlay mesh with defect closure
(IPOM PLUS) technique retrospectively, with the usage of variety of
synthetic meshes.
2. Materials and methods
2.1. Patient selection
A retrospective observational study was conducted, including
821 patients admitted with clinical diagnosis of ventral hernia in
Dr B R Ambedkar medical college and Hospital Bangalore India
from January 2010 to December 2020. The inclusion criteria were:
(1) patient's age above 18 years; (2) symptomatic patients with
primary, incisional and recurrent ventral hernias; (3) defect size
ranged from 2 cm to 6 cm. And the exclusion criteria were: (1)
patient younger than 18 years; (2) strangulated ventral hernia; (3)
patients unfit for laparoscopic surgeries under general anesthesia;
(4) defect size <2 cm or >6 cm and those who needed abdominal
wall reconstruction; (5) BMI >30 kg/m2. The following parameters
were assessed: pain, mesh infection, enterocutaneous fistula,
significant bowel adhesions and recurrence.
2.2. Pre-operative workup
All patients underwent thorough clinical examination, routine
blood investigations, ultrasound of abdomen. CT abdomen was
done when indicated for patients who had previous abdominal
surgery, recurrent hernia, or with multiple defects. Patients were
advised to stop smoking and alcohol consumption 1 month prior to
surgery. Correction of cardiac and pulmonary issues were done.
Weight loss was also advised.
Fig. 1 Laparoscopic images of hernia diagnosis and covering defect
A, umbilical hernia with working port. B, defect in the anterior abdominal wall. C, defect is covered by polypropylene mesh, which is secured with transfascial sutures.
117
Laparoscopic, Endoscopic and Robotic Surgery 4 (2021) 116e120
2.3. Technique
Laparoscopic placement of IPOM or IPOM PLUS were applied. All
patients were under general anesthesia. Defect closure was done in
IPOM PLUS technique. Intraperitoneal synthetic meshes were used,
including polypropylene (lotus), dual, composite (covidien), tita-
nium meshes. Mesh was fixed using transfascial sutures and tackers
(covidien and bard).
Pneumoperitoneum (12e14 mmHg) was created using closed
Veress needle technique, inserted at palmar's point (reduces the
incidence of inadvertent bowel injury). In majority of the cases, 2
ports were used (a 10 mm port at palmar's point and another 5 mm
port in left lumbar region) and an additional third port (5 mm) was
added when required. The port positions varied for a few cases
depending on the area of defect while adhering to the principle of
triangulation. Diagnostic laparoscopy and reduction of contents
(with or without adhesiolysis) was done, and the defect was defined
(Fig. 1). Synthetic intraperitoneal mesh (tailored to get an overlap of
minimum 5 cm from the edge of the defect) was introduced through
a 10 mm port under vision. Mesh anchoring was done by transfascial
sutures or tackers (depending on the size of the mesh). Defect was
closed in IPOM PLUS (Fig. 2) with shoelace technique, or using su-
ture passer needle or intracorporeal suturing when required. Ports
were removed under vision. Pneumoperitoneum was reduced and
ports were retrieved under vision. Pressure dressing was placed.
Patients were discharged on the day after meeting the parame-
ters for discharge. Skin sutures and the pressure dressings were
removed on the first follow up period (7e10 days) in the out-patient
department. Post-operatively patients were advised to avoid lifting
heavy weights for 3 months, use abdominal binders post operatively
for a period of 2e 3 months and follow strict balanced diet to prevent
obesity and hence to prevent future recurrence.
2.4. Follow up
Follow up was done in out-patient department visits and tele-
phonically. Patients were required to do regular follow-up evalua-
tions, physical examinations in the out-patient department. While
B.S. Ramesh, H.M. Khan and Y.B. Kareti Laparoscopic, Endoscopic and Robotic Surgery 4 (2021) 116e120

Fig. 2 Laparoscopic images of defect closure with IPOM PLUS

A, omental adhesions in the defect. B, defect in the anterior abdominal wall after reducing the contents. C, primary defect closed with non-absorbable suture (IPOM PLUS). D, defect
is covered by polypropylene mesh, which is secured with transfascial sutures and tackers.

Table 1
10% patients were missed follow-up. The period of follow up in this Patient demographic
study was 6 monthse10 years, with a mean of 5.72 ± 2.75 years.
n ¼ 821
Telephonic follow-ups were regularly implemented every 6
months. The latest follow-up date was June 20, 2020. Gender, F:M, n (%) 532 (64.80): 289 (35.20)
Age, mean ± SD, y 45.62 ± 9.37
Hernia type, n (%)
2.5. Statistical analysis Primary hernia 801 (97.56)
Incisional hernia 12 (1.46)
Recurrent hernia 8 (0.97)
The collected data was entered into Microsoft Excel Worksheet-
Defect size, mean ± SD, cm 2.41 ± 0.47
2010 and data was taken into IBM SPSS Statistic for windows, Technique, n (%)
version 24 (IBM Corp., Armonk, N.Y., USA) software to calculation of IPOM 147 (17.90)
frequency, percentage. Descriptive statistics were used to depict IPOM PLUS 674 (82.10)
demographic parameters of the patients. Measurement data were Mesh, n (%)
Polypropylene mesh 473 (57.61)
expressed as mean ± standard deviation for normal distributed Dual mesh 208 (25.33)
variable. Titanium mesh 82 (9.99)
Composite mesh 58 (7.06)
Transfacial fixation, n (%)
3. Results Prolene 203 (24.73)
Vicryl 610 (74.30)
3.1. Demographic data Tacker 8 (0.97)

Totally, 821 patients were enrolled, with 532 (64.80%) females Table 2
and 289 (35.20%) males at a mean age of 45.62 ± 9.37 years Complications
(Table 1). Most patients (801, 97.56%) had primary hernia. The mean n ¼ 821
defect size was 2.41 ± 0.47 cm. For the surgical technique, 674
Intraoperative complication, n (%)
(82.10%) patients underwent IPOM PLUS and 147 (17.90%) patients Bleeding 3 (0.37)
underwent IPOM. Polypropylene mesh was applied in 473 (57.61%) Bowel injury 0 (0.00)
patients, dual mesh in 208 (25.33%) patients, titanium mesh in 82 Immediate complication, n (%)
Seroma 8 (0.97)
(9.99%) patients, and composite mesh in 58 (7.06%) patients. For
Hematoma 0 (0.00)
transfascial fixation, 203 (24.73%) patients used prolene, 610 Stitch abscess 2 (0.24)
(74.30%) patients used Vicryl, and 8 (0.97%) patients used tackers. Wound infection 4 (0.49)
Delayed complication, n (%)
Recurrence 8 (0.97)
3.2. Postoperative complications Mesh infections 6 (0.73)
Chronic pain and foreign body sensation 4 (0.49)
The complications are depicted in Table 2. During the opera- Transfascial suture site hernia 3 (0.37)
tion, 3 (0.37%) patients had bleeding. For immediate complica- Chronic discharging sinus 3 (0.37)
Significant bowel obstruction 0 (0.00)
tion, seroma, stitch abscess and wound infection were most
Enterocutaneous fistula 0 (0.00)
118
B.S. Ramesh, H.M. Khan and Y.B. Kareti
Table 3
Mesh-related complication
Polypropylene (n ¼ 473)
Recurrence, n (%) 5 (1.05)
Mesh infections, n (%) 0 (0.00)
Foreign body sensation, n (%) 4 (0.85)
common, with 8 (0.97%), 2 (0.24%), and 4 (0.49%) cases respec-
tively. Recurrence was found in 8 (0.97%) cases. Mesh infections
were discovered in 6 (0.73%) cases, and foreign body sensation in
4 (0.49%) cases. Both suture site hernia and chronic sinus
occurred in 3 (0.37%) patients.
3.3. Mesh-related complication
Mesh-related complications are listed in Table 3. Recurrence
was found in 5 (1.05%) cases used polypropylene mesh and 3
(1.44%) cases used dual mesh. Mesh infections were discovered in 6
(2.88%) cases used dual mesh, and foreign body sensation in 4
(0.85%) cases used polypropylene mesh.
4. Discussion
The closure of the primary fascial defect during laparoscopic
approach of hernia repair (IPOM PLUS) has improved outcomes e
citing lower recurrence rates, lower rates of seroma formation and
improved patient satisfaction.5e7 Our approach in the laparoscopic
management of ventral hernia repair was through IPOM technique
(17.90%) in the earlier part of our study period. During which, seroma
formation was found in 8 cases, and the patient was not satisfied with
the defect found on imaging for other abdominal pathology during
the follow up period. Hence, IPOM PLUS techniques were employed,
which was incorporated in 82.10% of the cases following which
seroma formation was not recorded and the patient had a better
satisfaction.
Expanded polytetrafluoroethylene and polyester can erode as
well resulting in uncontrolled fistula and necrotizing fasciitis of the
abdominal wall.8,9 Out of 208 patients with dual mesh, 6 cases had
mesh infection. None of the other meshes reported such compli-
cation. The total mesh infection rate is 0.73% in this study which is
comparable to literature (<1%).10 Though polypropylene mesh was
used in highest numbers in the study, none of them had any
complications with regards to enterocutaneous fistula or bowel
obstruction which is comparable to other studies.11e16
There is a lack of randomized studies comparing the outcomes
of the variety of meshes. However, in a meta-analysis by Ram-
akrishna and Lakshman,17 they concluded that complications can
occur with both polypropylene mesh and newer mesh when used
intraperitoneally and there was no statistically significant differ-
ence in the incidence of complications among the various meshes.
The type of mesh used and the mesh location play an important
factor with regards to recurrence. Of which sublay and intraperi-
toneal repairs had the least recurrence rates.18,19 It is noted that a
5 cm mesh overlap overall from the defect generally accepted as an
ideal and also to prevent recurrence.20e22 Also Carbajo et al claimed
low recurrence rates of 1.4% and 4.4% for tacks and transfascial
sutures respectively.23
In this study, a total of 8 cases of recurrence (most common
complication) were noted with defect size in the range of 3e5 cm,
where all of them had undergone IPOM repair using poly-
propylene or dual mesh. In these cases, mesh fixation was done by
transfascial prolene suture. In the initial days of management,
3 cm overlap was used which had probably led to recurrence.
Apart from mesh overlap discrepancy, non-incorporation of
119
Laparoscopic, Endoscopic and Robotic Surgery 4 (2021) 116e120
Dual (n ¼ 208) Titanium (n ¼ 82) Composite (n ¼ 58)
3 (1.44) 0 (0.00) 0 (0.00)
6 (2.88) 0 (0.00) 0 (0.00)
0 (0.00) 0 (0.00) 0 (0.00)
tackers for mesh fixation (cost factor) was suspected to add the
recurrence rates. Hence, we incorporated a standard protocol of
mesh overlap of 5 cm beyond the defect edge depending on the
defect size and recorded a decreased recurrence rate. With
regards to recurrence related to fixation device, as per the litera-
ture, the recurrence rate is approximately 4% (0.97% in this study)
with the use of sutures and 1.8% (0% in this study) with the use of
tackers (used during the repair of 8 cases of recurrence) which is
comparable.24
When it comes to the severity of postoperative pain or fixation
site hernia, it is related to mesh fixation technique, be it the tacker,
or transfascial suture.25 In this study, we have fixed the mesh by
using prolene 1 suture material through a transfascial technique
placed in 6e8 sites of the mesh in some of the cases, which was
done in the initial days and found out that it was associated with
chronic pain and foreign body sensation (4 patients), chronic dis-
charging sinus (3 patients) and suture site hernia (3 patients) due to
over tightening of the suture knots causing tissue necrosis and
defect.26,27 Hence we evolved over, to use absorbable sutures
(Vicryl 1) for mesh fixation by a transfascial technique and also by
practising not to excessively tighten the suture knots which gave
satisfactory results by lowering the incidence of the previously
named complications when compared to other studies.
The major limitation of this study was that it was a retrospective
analysis with 90% of the patients completed the follow-up. The
main reason was due to a change in their contact numbers in the
subsequent years. While this is the case with most retrospective
studies where the follow-up ranges from 60% to 70% of the enrolled
population.26,28,29 Another limitation was that we excluded pa-
tients of BMI >30 kg/m2.
5. Conclusion
With the advent of newer laparoscopic technique for ventral
hernia, still the laparoscopic IPOM/IPOM PLUS holds good in small
and medium sized ventral hernias with least complications. The
safety and efficacy profile of intraperitoneal polypropylene mesh
using IPOM or IPOM PLUS technique is comparable to that of other
synthetic meshes. A mesh overlap of minimum 5 cm beyond the
defect edge can minimise hernia recurrence. Absorbable suture
material (Vicryl 1) can be used or considered as an alternative to
tackers to secure the mesh through a transfascial technique and to
make sure not to overtighten the knot over the tissue.
Conflict of interest
The authors declare no conflict of interest.
Ethics approval
The research protocol for this clinical study was approved by the
Ethics Committee of Dr B R Ambedkar Medical College and Hospital
Bangalore.
B.S. Ramesh, H.M. Khan and Y.B. Kareti
Patient consent for publication
Written informed consent was obtained from all patients for the
publication.
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