Dr Pravin John & Dr John Thanakumar, Anurag Hospital, Coimbatore present on ventral hernia laparoscopy

1. LAPAROSCOPIC IPOM PLUS
DR.PRAVIN HECTOR JOHN, MS, FIAGES, FALS, FIBC
DR.JOHN AC THANAKUMAR MS, MNAMS, FRCS, FRCS, FICS,
Dip MIS (FR), FALS

2. IPOM-INTRA PERITONEAL ONLAY MESH
• IPOM Plus = Defect closure with suture + IPOM

3. INDICATIONS:
• Ventral hernia
• Incisional hernia
• Recurrent hernia
• Defects up to 5cm

4. CONTRAINDICATIONS:
To laparoscopy in general
• Shock
• Cardiorespiratory
compromise
• Pregnancy
Specific to IPOM plus
• Fecal peritonitis
• Gangrene bowel
• Intra-abdominal sepsis
• Large defects with LOD
• Pediatric age group
• Cirrhosis with caput
medusae

5. POSITION & OPERATION THEATRE SETUP
• Ergonomics
• Supine
• Arms tucked
• Empty bladder

6. ERGONOMICS:
• Straight line (Surgeon, operating organ and
monitor to be in straight line)
• Azimuth angle
• Manipulation angle
• Elevation angle

7. OT SETUP

8. Mesh
• Coated (Dual) mesh 10*15cm, 15*15cm or
larger
– Visceral side: repels adhesions and ingrowth
– Parietal side: integrates into abdominal wall
7-14 days for neo-peritoneum formation
• No polypropylene mesh!!

9. INSTRUMENTS:
Laparoscopic set and open surgery set
• Laparoscopic camera unit with 30 degree scope
• Dual mesh of adequate sizes
• Trocar, Verres needle
• Suture passer
• Thick non absorbable suture (1-prolene, loop Ethilon)
• Suture for fixing mesh (non absorbable)
• Trackers (absorbable/non-absorbable)
• Bowel grasper
• Medium grasper
• Curved Maryland
• Needle holder
• Energy source

10. PORTS:
• 3 or 4 ports:
1. Camera 10-12mm
2. Working 5mm ports
3. Triangulation for ergonomics

11. PROCEDURE: PART 1
• Verres needle or Hassan open entry or direct view
trocar entry
• Diagnostic laparoscopy
• Adhesiolysis and reduction of contents
• Measure defect with low IAP
• Choose dual mesh size
• Suture defect-non absorbable suture
• Sac bite to prevent seroma
• Defect closure at low pneumoperitoneum
• Re-insufflate

12. • Mesh deployment and fixation
• Centering stitch
• 3 to 5cm overlap of mesh with normal tissue all
around defect
• 4 corner transfascial sutures
• Sutures to fix mesh-intracorporeal suturing
• Tacks: Double crowing-1 to 2 cm apart
• Omentum between mesh and bowel
• Correction of divarication when large
• Skin closure with steristrip/subcuticular
PROCEDURE: PART 2

13. FOR / AGAINST
IPOM PLUS
FOR: RESTORES FUNCTIONALITY OF ABDOMINAL
WALL
AGAINST: REPAIR UNDER TENSION
LARGE DEFECTS SUTURE CUT THROUGH
CENTERING STITCH ON MESH
FOR: HELPS ADEQUATE POSITIONING
AGAINST: CAN GET INFECTED AS IT IS SUBCUTANEOUS
TACKERS
FOR: NON ABSORBABLE – LESS PAIN, ADHESIONS
AGAINST: ONLY 2 MM PENETRATION GLUE
FOR: PAINLESS
AGAINST: EXPENSIVE

14. POST OP CARE:
• Oral fluids 4 hours---normal diet
• Ambulate
• Chest physiotherapy
• Adequate analgesia
• Antibiotics for 24 hours
• Discharge 48 to 72 hours
• Pressure dressing over hernia site or
abdominal support if necessary

15. COMPLICATIONS:
• Trocar injury (vascular, hollow viscus)
• Seroma
• Recurrence
• Wound infection
• Intestinal obstruction
• Port site hernia

16. To minimize complications
ENTRY
OPEN HASSON
DIRECT VIEW
CARE IN SCARRED
ABDOMEN
CHECK FOR INJURY
DIAGNOSTIC LAPAROSCOPY
RULE OUT OTHER DISEASE
INSPECT BOWEL
INJURY CHECK
AHDESIOLYSIS
PATIENCE
SCISSORS
NO CAUTERY
HEMOSTASIS - BIPOLAR
PREVENT BOWEL TRAUMA
GENTLE MANIPULATION
HOLD MESENTERY
ATRAUMATIC GRASPER
AVOID ENERGY NEAR BOWEL
VISUALLY INSPECT BOWEL
RE-LAPAROSCOPE IF DOUBTFUL

17. To minimize complications
ENTEROTOMY – WHAT NEXT?
DEFER REPAIR?
GROSS SPILLAGE OUTSIDE
LUMEN?
SURGEON’S WISDOM
PAIN
GLUE
LIBERAL LOCAL ANALGESIA
ADEQUATE IV ANALGESIA
SEROMA
COMPRESSION DRESSING
CLOSE DEFECT
BITE ON SAC DURING CLOSURE
CAUTERY – INCREASED INFECTION!
MESH INFECTION
PROPHYLACTIC & PERIOPERATIVE
ANBIOTICS
STERILITY OF INSTRUMENTS
CHANGE GLOVES
MINIMUM HANDLING OF MESH
POST AS FIRST CASE
NEW FIXATION DEVICE
LARGER PORE MESH

18. To minimize complications
INTESTINAL OBSTRUCTION
TISSUE SEPARATING MESH
LARGER MESH MORE SUTURES
TACKERS AT PERIPHERY OF MESH
INTERPOSE OMENTUM BETWEEN MESH AND BOWEL
PREVENT RECURRENCE
PRE-OP OPTIMISATION
APPROPRIATE TECHNIQUE
5CM OVERLAP OF MESH
COVER INCISION SITE IF NECESSARY
LARGE MESH
TRANSFASCIAL SUTURES
ANCHOR MESH EDGES WITHOUT GAP
CENTRE MESH WELL

19. LVHR

20. ANURAG HOSPITAL
NO.8, KRISHNA NAGAR, SOWRIPALAYAM MAIN ROAD,
COIMBATORE -641028
PH: 8015087871 ; 0422-4341486
EMAIL: anuraghospitalcoimbatore@gmail.com
Web: www.anuraghospital.com