Home » Laparoscopic IPOM technique for DynaMesh® IPOM in 7 steps

Laparoscopic IPOM technique for DynaMesh® IPOM in 7 steps

Vorabtext zu den 7 Steps:

Step 1. Preparation of the patient
Points to consider when preparing of the patient/procedure:

[The following points should be considered during the preparation of the patient:]

Animation OP-Video
1.01. Epidural catheter for large hernias (optional)

[Possible epidural catheter for large hernias]
1.02. Gastric tube to reduce the risk of gastric injury during insufflation
[Gastric tube – to avoid puncture of the stomach during air filling]
1.03. Bladder catheter for preperitoneal preparation in the lower abdomen (optional)

[Bladder catheter – safer pre-peritoneal preparation in the lower abdomen]

1.04. Positioning of the patient

[Positioning of the patient – limited space with extended arm]

gruene_punkte
1.05. Port placement

[Sufficient coverage – Adequate placement of trocars (up into the flank), especially if large meshes are required.]

S1_5_OP_coverrage_01

S1_05_06-OP-Coverage-Marking

1.06. Marking of the hernia and mesh position on the abdomen

[Marking of the hernia and the mesh (overlap of the defect and the original scar by at least 5 cm, better 7 cm) (in case of asymmetric hernias move the mesh and overlap far beyond the bones)]

gruene_punkte

S1_6_OP_markingS1_6_OP_marking

S1_05_06-OP-Coverage-Marking

Expert Advice (Prof. Dieter Berger) gruene_punkte
please ignore this COPY
The following points should be considered during the preparation of the patient: Animation OP-Video
1.01. Possible epidural catheter for large hernias
1.02. Gastric tube – to avoid puncture of the stomach during air filling
1.03. Bladder catheter – safer pre-peritoneal preparation in the lower abdomen
1.04. Positioning of the patient – limited space with extended arm gruene_punkte
1.05. Sufficient coverage – Adequate placement of trocars (up into the flank), especially if large meshes are required.
1.06. Marking of the hernia and the mesh (overlap of the defect and the original scar by at least 5 cm, better 7 cm) (in case of asymmetric hernias move the mesh and overlap far beyond the bones) gruene_punkte
Expert Advice gruene_punkte

 

Step 2. Access to the abdominal cavity
Selection of method according to surgeon‘s preference as the scientific evidence is not clear * Animation OP-Video
2.01. Veress needle in unaffected quadrant

-> Possible risk: puncture of hollow or solid organs in case of adhesions

gruene_punkte op+ani
2.02. Optical trocar

-> Possible risk: injury of hollow organs in case of adhesions

2.03. Minilaparotomy

-> Possible risk: injury to hollow organs in adherent intestines caused by sharp clamps when grabbing the peritoneum

Expert Advice gruene_punkte

* Ahmad G, Baker J, Finnerty J, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2019; 1: CD006583.

 

Step 3. Placement of the trocars
The following points should be considered for the placement of the trocars: Animation OP-Video
3.01. With today’s optical quality 5mm optical trocar is enough gruene_punkte 3.01.-3.03.
3.02. Minimum 10mm trocar for mesh gruene_punkte 3.01.-3.03.
3.03. For large meshes (> 20x30cm) minimum 12mm trocar gruene_punkte 3.01.-3.03.
gruene_punkte All in one: Animationen
3.01.-3.03.
Expert Advice gruene_punkte

 

Step 4. Adhesiolysis
The following points should be considered during adhesiolysis being the most dangerous and complicated part of the operation: Animation OP-Video
4.01. If possible in cranio-caudal direction gruene_punkte All in one: OP-Video
4.01.-4.05.
4.02. Usage of sharp adhesiolysis without the use of energy devices

-> Risk: Intestinal lesion with energy devices

-> Risk: Overlooking intestinal loops hidden behind omentum majus

gruene_punkte
4.03. Leaving parietal peritoneum on intestinal loops in case of intensive adhesions gruene_punkte
4.04. Not leaving the visceral peritoneum on the abdominal wall

-> Risk: intestinal lesion

4.05. Sufficient preparation of mesh landing zone gruene_punkte
Expert Advice gruene_punkte

 

Step 5. Preparation and placement of the mesh
The following points should be considered during the preparation of the mesh: Animation OP-Video
5.01. Making sure which is the visceral and parietal mesh side

-> Risk: adhesions by reverse placement

gruene_punkte OP-Video
5.01.-5.02.
5.02. Use of stay sutures: Suture material is preference of the surgeon. As an alternative, the sutures can also be tied. gruene_punkte
5.03. Making sure the following points are clear:

  • What is the ideal placement and centring of the mesh?
  • How to prevent mesh displacement due to incorrect fixation with tacks?
  • How to correctly fixate the mesh under tension? Reduction of intra-abdominal pressure with reduced visibility is not necessary with large meshes when using elastic material.
gruene_punkte
The following points should be considered during the placement of the mesh:
5.04. Mesh insertion in folded form through 10 or 12 mm trocars according to the mesh size gruene_punkte
5.05. Placing the mesh inside of the abdominal cavity
5.06. Grasping the midline sutures first, then the corner sutures in order to be able to exert adequate tension on the mesh

  • under consideration of the subcutaneous fat pad
  • under consideration of the osseous boundaries
  • Thanks to correct fixation under tension: Prevention of wrinkling and thus excessive adhesions
gruene_punkte
5.07. Fixation with absorbable tacks on mesh border every 2-4 cm alternating sides, possibly “double crown” (not on the diaphragm) gruene_punkte
Expert Advice gruene_punkte
Step 6. Closure of trocar access
The following points should be considered for the closure of trocar accesses: Animation OP-Video
6.01. Always close any trocar access with trocars ≥ 10 mm

prevention of trocar hernias

6.02. Literature on trocar hernias:

  1. Yamamoto M, Minikel L, Zaritsky Laparoscopic 5-mm trocar site herniation and literature review. JSLS 2011; 15(1):   122-6.
  2. Helgstrand F, Rosenberg J, Kehlet H, Bisgaard Low risk of trocar site hernia repair 12years after primary laparoscopic   surgery. Surg Endosc 2011; 25(11): 3678-82.
  3. Helgstrand F, Rosenberg J, Bisgaard Trocar site hernia after laparoscopic surgery: a qualitative systematic review.   Hernia 2011; 15(2): 113-21.
  4. Liot E, Breguet R, Piguet V, Ris F, Volonte F, Morel P. Evaluation of port site hernias, chronic pain and recurrence rates   after laparoscopic ventral hernia repair: a monocentric long-term study. Hernia 2017; 21(6): 917-23.
  5. Ciscar Belles A, Makhoukhi T, Lopez-Cano M, Hernandez Granados P, Pereira Rodriguez JA, members Eg. Umbilical   incisional hernias (M3): are trocar-site hernias different? Comparative analysis of the EVEREG registry small star, filled.   Cir Esp (Engl Ed) 2022; 100(6): 336-44.
Expert Advice gruene_punkte
Step 7. Postoperative rehabilitation
The following points should be considered for postoperative rehabilitation: Animation OP-Video
7.01. Feeding without restriction
7.02. In all cases, use of an osmotic laxative from the first day

  • prevention of postoperative paralysis
Please also read the “MEMO IPOM Adhesions” for further information
Expert Advice gruene_punkte
Literature

The following literature is important for the laparoscopic IPOM technique:

General overview of incisional hernia

  1. Henriksen NA, Mortensen JH, Lorentzen L, et al. Abdominal wall hernias-A local manifestation of systemically impaired quality of the extracellular matrix. Surgery 2016; 160(1): 220-7.
  2. Henriksen NA. Systemic and local collagen turnover in hernia patients. Dan Med J 2016; 63(7):B5265.
  3. Helgstrand F. National results after ventral hernia repair. Dan Med J 2016; 63(7):B5258.
Advantages of laparoscopic versus open

  1. Arita NA, Nguyen MT, Nguyen DH, et al. Laparoscopic repair reduces incidence of surgical site infections for all ventral hernias. Surg Endosc 2015; 29(7): 1769-80.
  2. Al Chalabi H, Larkin J, Mehigan B, McCormick P. A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-analysis of randomized controlled trials. Int J Surg 2015; 20: 65-74.
  3. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011; (3): CD007781.

Importance and experiences with mesh material PVDF

  1. Baker JJ et al (2021) Reoperation for Recurrence is Affected by Type of Mesh in Laparoscopic Ventral Hernia Repair: A Nationwide Cohort Study. Ann Surg. https://doi.org/10.1097/SLA.0000000000005206
    includes data on primary ventral hernia (n = 416, FU: median 114 months) and incisional ventral hernia (n = 610, FU: median 110 months)
  2. 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
    includes data on incisional ventral hernia (n = 297, FU: median 24 months) and parastomal hernia (n = 47, FU: median 20 months)
  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
    includes data on parastomal hernia (n = 13, FU: median 26 months)
  4. 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
    includes data on primary ventral hernia (n = 78, FU: 12 months) and incisional ventral hernia (n = 45, FU: 12 months)
  5. 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
    includes data on mesh shrinkage in primary ventral hernia (n = 14, FU: 13 months)
  6. 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
    includes data on primary and incisional ventral hernia (n = 40, FU: mean 15 months)
  7. 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
    includes data on incisional ventral hernia (n = 35, FU: > 6 months)
  8. Zhou Z, Bilkhu A, Anwar S (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 includes data on parastomal hernia (n = 20, FU: mean 27 months)

Allgemeingültiger Nachtext
Presented by the International IPOM Group (IIG) – in Zusammenarbeit mit “Namen” “Namen” “Namen”

Timezone Selection

Choose your preferred time zone. All times will then be converted to your time zone.

Selected Timezone:
Current time: