2-Laparoscopic DynaMesh®-IPOM in 7 steps

	Primary access in an upper, unaffected quadrant with presumably no adhesions. As the scientific evidence is unclear, the choice of method depends on the surgeon’s preference*	Animation	OP-Video
2.01	Veress needle (preferred)
2.02	Optical trocar
2.03	Minilaparotomy
	Expert advice by Prof. Dieter Berger

* Ahmad G et al (2019) Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2019. https://doi.org/10.1002/14651858.CD006583.pub5

	Primary access in an upper, unaffected quadrant with presumably no adhesions. As the scientific evidence is unclear, the choice of method depends on the surgeon’s preference*
2.01	Veress needle (preferred)
2.02	Optical trocar
2.03	Minilaparotomy
	Expert advice by Prof. Dieter Berger

* Ahmad G et al (2019) Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2019. https://doi.org/10.1002/14651858.CD006583.pub5

	Points to consider:	Animation	OP-Video
6.01	Always close each trocar access with trocars ≥ 10 mm *
	Expert advice by Prof. Dieter Berger

1. Ciscar Belles A et al (2022) Umbilical incisional hernias (M3): are trocar-site hernias different? Comparative analysis of the EVEREG registry. Cir Esp (Engl Ed) 100:336–344. https://doi.org/10.1016/j.cireng.2022.05.023
2. Liot E et al (2017) Evaluation of port site hernias, chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study. Hernia 21:917–923. https://doi.org/10.1007/s10029-017-1663-2
3. Yamamoto M et al (2011) Laparoscopic 5-mm Trocar Site Herniation and Literature Review. JSLS 15:122–126. https://doi.org/10.4293/108680811X13022985131697
4. Helgstrand F et al (2011) Low risk of trocar site hernia repair 12 years after primary laparoscopic surgery. Surg Endosc 25:3678–3682. https://doi.org/10.1007/s00464-011-1776-0
5. Helgstrand F et al (2011) Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 15:113–121. https://doi.org/10.1007/s10029-010-0757-x

	Points to consider:
6.01	Always close each trocar access with trocars ≥ 10 mm *
	Expert advice by Prof. Dieter Berger

* Literature on trocar hernias:

1. Ciscar Belles A et al (2022) Umbilical incisional hernias (M3): are trocar-site hernias different? Comparative analysis of the EVEREG registry. Cir Esp (Engl Ed) 100:336–344. https://doi.org/10.1016/j.cireng.2022.05.023
2. Liot E et al (2017) Evaluation of port site hernias, chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study. Hernia 21:917–923. https://doi.org/10.1007/s10029-017-1663-2
3. Yamamoto M et al (2011) Laparoscopic 5-mm Trocar Site Herniation and Literature Review. JSLS 15:122–126. https://doi.org/10.4293/108680811X13022985131697
4. Helgstrand F et al (2011) Low risk of trocar site hernia repair 12 years after primary laparoscopic surgery. Surg Endosc 25:3678–3682. https://doi.org/10.1007/s00464-011-1776-0
5. Helgstrand F et al (2011) Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia 15:113–121. https://doi.org/10.1007/s10029-010-0757-x

The following literature is important for the laparoscopic IPOM technique:

Importance and experiences with mesh material PVDF

1. Baker JJ et al (2023)
   Reoperation for Recurrence is Affected by Type of Mesh in Laparoscopic Ventral Hernia Repair: A Nationwide Cohort Study.
   Annals of Surgery 277:335–342. https://doi.org/10.1097/SLA.0000000000005206
2. Sánchez-Arteaga A et al (2021) Use of polyvinylidene fluoride (PVDF) meshes for ventral hernia repair in emergency surgery. Hernia 25:99–106. https://doi.org/10.1007/s10029-020-02209-3
3. Bertoglio C et al (2021) From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre. Surg Endosc 35:1863–1871. https://doi.org/10.1007/s00464-020-07589-2
4. Muysoms F et al (2018) Prospective cohort study on mesh shrinkage measured with MRI after laparoscopic ventral hernia repair with an intraperitoneal iron oxide-loaded PVDF mesh. Surg Endosc 32:2822–2830. https://doi.org/10.1007/s00464-017-5987-x
5. Zhou Z et al (2017) The use of a composite synthetic mesh in the vicinity of bowel – For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective  complications? Int J Surg 45:67–71. https://doi.org/10.1016/j.ijsu.2017.07.077
6. Verbo A et al (2016) Polyvinylidene Fluoride Mesh (PVDF, DynaMesh®-IPOM) in The Laparoscopic Treatment of Incisional Hernia: A Prospective Comparative Trial versus Gore® ePTFE DUALMESH®  Plus. Surg Technol Int 28:147–151
7. Roberts DG (2012) Laparoscopic Intraperitoneal Onlay Repair of Abdominal Incisional and Ventral Hernias wth Polyvinylidene Fluoride-Coated Polypropylene Mesh; A Retrospective Study with Short to Medium Term Results. Science Journal of Clinical Medicine 1:10. https://doi.org/10.11648/j.sjcm.20120101.13
8. Berger D, Bientzle M (2009) Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair! A prospective, observational study with 344 patients. Hernia 13:167–172. https://doi.org/10.1007/s10029-008-0435-4

Prologue – intraperitoneal vs. extraperitoneal mesh position

Based on the current level of evidence, there is no reason to doubt the performance of the IPOM technique. Large registry studies with long follow-up periods even show clear advantages of the IPOM technique compared to surgical techniques with extraperitoneal mesh: lower rates of infections and reoperations [1–3]. The IPOM technique is also preferred to open repair in relevant guidelines due to its lower infection rates (GRADE A or strong recommendation) [4–6].

Subject of the memo

Despite the evidence mentioned above, the intraperitoneal placement of mesh implants is increasingly being critically scrutinised. The main argument of the critics is the risk of intestinal adhesion to the mesh implant. Large-scale intestinal adhesions can impair the mobility and thus the functionality of the intestine. If the mobility of the intestine is restricted by adhesions, this can ultimately lead to an intestinal obstruction (mechanical ileus). In the case of a mechanical ileus, surgical intervention is unavoidable in most cases. The aim is therefore to avoid/reduce adhesions as much as possible. Fortin et al. have analysed the predisposing factors for adhesion formation in a systematic review [7]. Several factors have been shown to directly increase the risk of postoperative adhesion formation, namely, certain genetic polymorphisms, increased oestrogen exposure, and endometriosis. In addition, a number of factors are known to increase the risk of fibrosis and thus probably also indirectly increase the risk of adhesion development. The most severe complication associated with postoperative adhesions is small bowel obstruction (SBO). In their systematic review and meta-analysis, ten Broek et al. report that the incidence of SBO of any cause after abdominal surgery is 9%, while the incidence of adhesive SBO is 2% [8]. Besides patient-specific factors, there are essentially three factors that influence the extent and severity of adhesions: (1) operation, (2) mesh implant, (3) postoperative management. These factors form a triad – the best outcome can only be achieved if all three factors are taken into account. The memo aims to shed light on the three factors.

(1) Operation

The type of operation is a major influencing factor. For example, colorectal surgery has the longest length of stay in hospital as well as longest operating times and the highest operation costs due to postoperative adhesion-related SBOs [7]. However, in any type of operation, the risk of adhesions can be minimised by the correct surgical procedure. Professor Dieter Berger, as one of the most experienced DynaMesh^®-IPOM users and renowned laparoscopy expert, explains below the most important steps in the surgical procedure for the treatment of ventral hernias that can have an influence on the development of adhesions:

1. Mark the fascial defect and the planned mesh and measure the defect and mesh size
2. If the upper quadrant is free, puncture the abdominal cavity with a Veress needle, otherwise perform a minilaparotomy
3. Use of a 5 mm optic, 30°, in principle 4 trocars
4. Adhesiolysis without energy carrier with fine scissors along the entire anterior abdominal wall, dissection of the round ligament of the liver (ligamentum teres hepatis) and the falciform ligament as well as the medial umbilical ligament, opening of the prevesicular space in lower abdominal hernias
5. Haemostasis preferably selective with bipolar coagulation
6. Cover the entire defect/scar with appropriate overlap (> 5 cm)
7. Use of an elastic mesh with transfascial sutures to place the mesh under tension under the conditions of the pneumoperitoneum; reduction of intraperitoneal pressure (hardly possible with large meshes!)
8. Final fixation with absorbable tacks placed every 3-5 cm at a distance of at least 1 cm from the edges of the mesh

Fixing the mesh under pre-tension reduces/prevents wrinkling of the mesh during desufflation. This is best achieved with elastic mesh implants.

(2) Mesh implant

Adhesiolysis is a standard procedure in IPOM surgery. Therefore, one can say: adhesions are not a mesh-induced phenomenon! Adhesions of the intestine with the abdominal wall are present in the majority of patients with previous surgery without a mesh implant. There is therefore no reason to assume that no new adhesions will develop after an operation. Nevertheless, many surgeons expect intraperitoneal mesh implants to prevent adhesions. In fact, there is no adhesion barrier and no mesh implant on the market that completely prevents adhesions [9, 10]. Using the National Inpatient Sample, Lee et al. sought to identify risk factors associated with postoperative ileus following ventral (open or laparoscopic) hernia repair. They included 30,900 patients, of whom 2,660 (8.6%) had a postoperative ileus during their hospital stay. Interestingly, univariate analysis and logistic regression accounting for all risk variables showed that mesh implant use was not associated with the development of ileus. [11]

Individual animal studies with sheep and rats show a higher adhesion tendency after implantation of DynaMesh^®-IPOM compared to coated competitor products [12, 13]. Conversely, there are also animal studies on adhesions where DynaMesh®-IPOM provides good or the best results [14, 15]. The translation of results from animal experiments to humans is generally difficult and, in the case of mesh implants, only possible to a limited extend. There are several reasons for this. Amongst others, animals either lack a naturally occurring abdominal wall defect or an artificial defect is created in an otherwise intact abdominal wall, there are inherent differences in the anatomy between species, and mesh implants are not adapted to the animals’ physiology.

Published human clinical data show that there are large series (344 cases) in which not a single mesh-related reoperation was performed after the use of DynaMesh^®-IPOM [16, 17]. Some journal publications describe reoperations due to adhesions after implantation of DynaMesh^®‑IPOM [18, 19]. However, according to current data from the clinical evaluation, these events are rare. In more than 4,400 documented cases (~64% incisional hernia, ~36% primary ventral hernia) after treatment with DynaMesh^®-IPOM, the overall incidence of ileus/intestinal obstruction was 1.35%, with large variations between different studies/centres. The key question is therefore: What do centres where adhesions are not a problem after DynaMesh^®‑IPOM implantation do differently/better? In addition to the aforementioned influences of the surgical procedure, the answer can also be found in perioperative management, as explained in more detail below.

(3) Perioperative management

If a patient complains of abdominal pain and distension, nausea or vomiting in the first five days after surgery, the reason is most likely a paralytic ileus, i.e. a postoperative intestinal atony, and not a mechanical ileus due to adhesions. However, as both the symptoms and appearance are similar in paralytic and mechanical ileus, they are often confused. Postoperative intestinal atony is a phenomenon that has been known for a long time. Haug et al. have addressed this in a curriculum; paralytic ileus often occurs due to the reaction of the gastrointestinal tract to surgical trauma, anaesthetics, opioid use and medication in general [20]. The duration of paralysis varies in the different sections of the gastrointestinal tract: 1 day for the small intestine, 1‑2 days for the stomach, and 3-5 days for the colon, with colonic motility being decisive. The symptoms of paralytic ileus do not disappear until the colonic paralysis has passed. Studies on this topic suggest that a multimodal perioperative treatment concept that promotes intestinal motility can shorten the postoperative intestinal atony. Professor Dieter Berger has prepared a brief summary below of the most important points for perioperative management in the context of the laparoscopic IPOM technique:

1. Clinical diagnosis and, in individual cases, cross-sectional imaging (CT or MRI) in the case of large defects or possible denervation
2. Preparation for anaesthesia and surgery before admission
3. Inpatient admission on the day of the operation
4. Preoperative: enema (in all cases)
5. Always use a peridural catheter in pain-patients or in cases where difficult surgery is expected
6. Postoperative analgesia with Novaminsulfon and NSAIDs (preferably Parecoxib), and opioid admission (Piritramide preferably as a PCA) if the VAS is over 5 during movement
7. Routine administration of osmotically active laxatives [21] from the first day until liquefaction of the stool (sometimes more than 2-3 weeks), possibly an enema on day 3
8. Inpatient stay until stool activity is confirmed and the pain is under control (on average approx. 5 days)

According to a review by Venara et al., paralytic ileus develops in 10-30% of patients after abdominal surgery. Certain risk factors, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Perioperative nutrition is very important, as is limiting preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum are preventive. [22]

Epilogue – strengths and weaknesses of DynaMesh^®-IPOM

Recurrence
Recurrences in the early phase after the operation (up to 3 months) are either due to technical error(s) (inappropriate overlap and/or fixation) and/or poor biocompatibility of an implant. In the long term, mesh shrinkage may lead to recurrence due to inadequate foreign body reaction (FBR) with excessive formation of scar tissue (fibrosis). However, the extent of the FBR can be influenced by many factors such as the individual host response, contamination, the trauma created by the surgery, and not the least the mesh structure. In recent decades, many studies have been conducted that have analysed the impact of mesh structure on tissue response [23–25]. The pore size of the mesh has been shown to be of major importance in predicting the FBR and the risk of bridging scar tissue associated with local tissue contraction (mesh shrinkage). For this reason, the concept of “effective porosity” was developed in 2008 [26]. DynaMesh^®-IPOM are made of highly biocompatible PVDF [27–29] and have an open-porous mesh structure with high effective porosity, which allows good integration, reducing recurrences.

According to recent data from the HERNIAMED registry (Export date: AUG-2018), the recurrence rate of DynaMesh^®‑IPOM is 4.3% in 3,000 fully documented cases (2/3 incisional hernia, 1/3 primary ventral hernia) with 12 months follow-up. In their comparative study Tandon et al. compared the outcome after laparoscopic incisional hernia repair using Parietex^TM Composite with DynaMesh^®-IPOM [19]. After a median follow-up time of 53.6 months, the recurrence rate was over three times higher in the Parietex^TM Composite cohort (12.9% vs. 3.8%). Berger et al. treated 297 patients with DynaMesh^®-IPOM for ventral hernias [16]. After an average follow-up of 24 months, the recurrence rate was 0.6%. Particularly impressive are the data from the renowned Danish Ventral Hernia Database [30], which investigated the rate of reoperation rate for recurrence in relation to the brand of IPOM mesh used for laparoscopic ventral hernias. From a follow-up period of 4 to 10 years, DynaMesh^®-IPOM has the lowest rate of reoperation for recurrence of all IPOM mesh implants studied for both primary ventral hernias (6% reoperation rate for recurrence after a mean follow-up of 114 months [9.5 years]) and incisional ventral hernias (11% reoperation for recurrence after a mean follow-up of 110 months [9 years]).

With the DynaMesh^® visible technology, one has the possibility to directly observe and evaluate the position, conformation, and incorporation behaviour of our meshes in vivo. The results of studies on DynaMesh^® products using the DynaMesh^® visible technology are consistently positive [31, 32]. Filip Muysoms (AZ Maria Middlares, Gent, Belgium) presented for the first time at the EHS Congress in Vienna 2017 results from the IMAP study, which analysed shrinkage of DynaMesh^®-IPOM between 1 months and 13 months postoperatively after laparoscopic ventral hernia repair. The convincing results in this case series of 15 patients treated with DynaMesh^®-IPOM have been published [33]. No statistically significant shrinkage was observed at 13 months postoperatively. Furthermore, all previously published results from animal and human studies show that DynaMesh^®-IPOM is superior to the competitor products in terms of mesh shrinkage [12, 14].

Seromas
Seromas are accumulations of lymphatic exudate. The open-porous mesh structure of DynaMesh^®-IPOM allows fluids to easily permeate the mesh implant. Consequently, the likelihood of fluid accumulation between the mesh implant and the peritoneum is low. This is once again underlined by the clinical data from the studies of Tandon et al. [19], who found no seromas for DynaMesh^®-IPOM (vs. 6.4% for Parietex^TM Composite), and Berger at al.[16], who recorded a seroma rate of 1.2% in 297 cases.

Bibliography

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9. Rajab TK, Wallwiener M, Planck C, et al (2010) A Direct Comparison of Seprafilm, Adept, Intercoat, and Spraygel for Adhesion Prophylaxis. Journal of Surgical Research 161:246–249. https://doi.org/10.1016/j.jss.2008.11.839
10. Langbach O, Holmedal SH, Grandal OJ, Røkke O (2016) Adhesions to Mesh after Ventral Hernia Mesh Repair Are Detected by MRI but Are Not a Cause of Long Term Chronic Abdominal Pain. Gastroenterology Research and Practice 2016:1–7. https://doi.org/10.1155/2016/2631598
11. Lee MJ, Sugiyama G, Alfonso A, et al (2020) It’s not just an ileus: disparities associated with ileus following ventral hernia repair. Hernia. https://doi.org/10.1007/s10029-020-02339-8
12. Zinther NB, Wara P, Friis-Andersen H (2010) Shrinkage of intraperitoneal onlay mesh in sheep: coated polyester mesh versus covered polypropylene mesh. Hernia 14:611–615. https://doi.org/10.1007/s10029-010-0682-z
13. D’Amore L, Ceci F, Mattia S, et al (2016) Adhesion prevention in ventral hernia repair: an experimental study comparing three lightweight porous meshes recommended for intraperitoneal use. Hernia. https://doi.org/10.1007/s10029-016-1541-3
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15. Celik A, Altinli E, Koksal N, et al (2009) The shrinking rates of different meshes placed intraperitoneally: a long-term comparison of the TiMesh, VYPRO II, Sepramesh, and DynaMesh. Surg Laparosc Endosc Percutan Tech 19:e130-134. https://doi.org/10.1097/SLE.0b013e3181aa598d
16. Berger D, Bientzle M (2009) Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair!: A prospective, observational study with 344 patients. Hernia 13:167–172. https://doi.org/10.1007/s10029-008-0435-4
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28. Laroche G, Marois Y, Schwarz E, et al (1995) Polyvinylidene Fluoride Monofilament Sutures: Can They Be Used Safely for Long-Term Anastomoses in the Thoracic Aorta? Artificial Organs 19:1190–1199. https://doi.org/10.1111/j.1525-1594.1995.tb02282.x
29. Klink CD, Junge K, Binnebösel M, et al (2011) Comparison of long-term biocompability of PVDF and PP meshes. J Invest Surg 24:292–299. https://doi.org/10.3109/08941939.2011.589883
30. Baker JJ, Öberg S, Rosenberg J (2023) Reoperation for Recurrence is Affected by Type of Mesh in Laparoscopic Ventral Hernia Repair: A Nationwide Cohort Study. Annals of Surgery 277:335–342. https://doi.org/10.1097/SLA.0000000000005206
31. Hansen NL, Ciritsis A, Otto J, et al (2015) Utility of Magnetic Resonance Imaging to Monitor Surgical Meshes: Correlating Imaging and Clinical Outcome of Patients Undergoing Inguinal Hernia Repair. Invest Radiol 50:436–442. https://doi.org/10.1097/RLI.0000000000000148
32. Köhler G, Pallwein-Prettner L, Lechner M, et al (2015) First human magnetic resonance visualisation of prosthetics for laparoscopic large hiatal hernia repair. Hernia. https://doi.org/10.1007/s10029-015-1398-x
33. Muysoms F, Beckers R, Kyle-Leinhase I (2018) Prospective cohort study on mesh shrinkage measured with MRI after laparoscopic ventral hernia repair with an intraperitoneal iron oxide-loaded PVDF mesh. Surg Endosc 32:2822–2830. https://doi.org/10.1007/s00464-017-5987-x