We have come a full circle, we started with open evolved to lap and recent guidelines again advocate open approach. Members from European and American hernia societies sat together and formulated the guidelines which were accepted in 2019 and published in 2020 in the famous British journal of surgery. IEHS guidelines are more elaborate and focus on each and every aspect of hernia repair and there guidelines mainly focus on use of IPOM (intraperitoneal teechnique), while they investigated the newer extraperitoneal techniques but kept them open to further studies The slightly more latest guideline which is the most recent and is published in British journal surgery 2020 mainly focus on placement of mesh in extraperitoneal compartment by lap or an open method. They discourages use of intraperitoneal mesh or IPOM The challenge with 2020 guidelines is that most of recommendations are weak and especially they still need further studies to see whether for size 1-4cms- open or lap approach is the best Introduced by Le Blanc in 1993, IPOM technique is Straightforward, Easy and Quick. It is most commonly used technique to manage ventral hernia. Clearing the hernia of its contents and placing a suitable size intraperitoneally by fixating it Drawback of intraperitoneal mesh placement: regardless of the material and coating used coupled with great progress in mesh technology, nearly all types of meshes- a varying level of tissue reaction to produce: Mesh adhesion fistula formation mesh migration into hollow organs including the small bowel, large bowel, and oesophagus Long term pain Hence Retrorectus and preperitoneal placement is the currently favoured method. However, laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. Why? IPOM is a robust method of repair Especially useful when comorbidities present Obesity Diabetes steroid use No study has shown absolute superiority over laparoscopic IPOM Since 1993 it has shown good results in terms of at recurrence and complication rate Easy to perform and does not require specialized equipment New emerging techniques are lagging widespread implementation due to technical difficulties According to study published in Hernia 2022- meta-analysis for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence, comparing intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP): Based on short-term results: extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient The conclusions hence are: Be well versed with various newer and established techniques Tailoring the approach Level of evidence: strong Repair technique is tailored based on patient characteristics hernia characteristics local resources

1. IPOM & Introduction to
Extraperitoneal ventral hernia
repair techniques
Jagpreet Singh Deed
FRCS, FACS, MS, DNB (General Surgery)
Specialist General Surgery, Zulekha hospital, Sharjah
Adjunct Clinical Tutor, College of Medicine, University of Sharjah
Honorary Clinical Tutor for University of Edinburgh

2. Types of ventral hernia repair
Pic Source: Surgical clinics North America 2021

3. Laparoscopic IPOM
intraperitoneal onlay mesh
 Clearing the hernia of its contents and placing a suitable
size intraperitoneally by fixating it
 Straightforward, Easy
 Quick
 Most commonly used technique to manage ventral
hernia

4. IPOM steps
 Contents reduced, adhesions managed, hernial orifice is examined
 Size of mesh is decided based on the size and number of hernia defects, overlap
more than 4cms
 Mesh inserted
 orientated- coated surface is placed against the viscera
 centered over the hernial orifice
 Fixation
 tackers
 Trans-fascial suture

5. IPOM video
With closure of defect, also
known as:
 IPOM plus
 Defect closure
 Hybrid repair
 Linea alba reconstruction

6. Drawback of intraperitoneal mesh
placement
 regardless of the material and coating used coupled with great progress in mesh
technology, nearly all types of meshes- a varying level of tissue reaction to produce:
 Mesh adhesion
 fistula formation
 mesh migration into hollow organs including the small bowel, large bowel, and
oesophagus
 Long term pain

7. Current guidelines (latest)
 Guidelines for treatment of umbilical and epigastric hernias from the
European Hernia Society and Americas Hernia Society
 As an intraperitoneal mesh may cause adhesions, placement of the mesh
in the preperitoneal or retromuscular position is suggested, when
possible.
 BJS 2020; 107: 171–190

8. Retro-rectus (extraperitoneal)
approach
 retro-rectus space is limited by its fascial compartment
 Linea alba needs to be disconnected, incised and repaired to allow the
mesh to place across the right and left retro-rectus space
 Each right or left retro-rectus compartment limits the size of the mesh to
be placed.
 For larger mesh lateral extension puts important neurovascular bundle
running posterior to the internal oblique muscle at risk
 the muscle should be freely gliding within this space- mesh causes
adhesion between the muscle and fascia compartment

9. Preperitoneal mesh placement:
advantages
 least or no structural disruption of our abdominal wall architecture
 Mesh placement in preperitoneal space induces adhesions between the
peritoneum and posterior fascia
 Peritoneum flap keeps mesh away from abdominal viscera
 Replicates the natural abdominal wall anatomy closely

 Also known as PPOM

10. Drawback of preperitoneal techniques
 Technically demanding, longer operative time
 Longer learning curve
 Holes in peritoneum, especially near the hernial defect
 Skin injury possibility over hernia sac

11. Other extraperitoneal techniques
 MILOS (mini and less open sublay) and
 EMILOS Approaches (endoscopic mini/less open sublay) by Reinpold
 Subcutaneous Onlay Laparoscopic Approach (SCOLA)
 Endoscopic-Assisted Linea Alba Reconstruction (ELAR)

12. 2020 Guidelines for treatment of umbilical and epigastric hernias
from the European Hernia Society and Americas Hernia Society
BJS 2020

13. Thanks for kind attention
Being ignorant is not so much a shame
as being unwilling to learn
Benjamin Franklin