In a medically stable adult with a 2–10 cm primary or incisional ventral hernia, no contamination, and able to tolerate general anesthesia and laparoscopy, what is the recommended operative technique (intraperitoneal on‑lay mesh), mesh type, fixation method, peri‑operative antibiotic prophylaxis, and postoperative pain and activity management?

Laparoscopic IPOM for Primary and Incisional Ventral Hernia Repair

Operative Technique: IPOM is Recommended

For medically stable adults with 2-10 cm primary or incisional ventral hernias in clean surgical fields, laparoscopic intraperitoneal onlay mesh (IPOM) is the preferred technique, offering superior outcomes compared to open repair with reduced wound infections, shorter hospital stays, and equivalent long-term recurrence rates. 1, 2, 3

Key Technical Steps

• Defect closure is mandatory prior to mesh placement to reduce seroma formation and maintain abdominal wall functionality 4
• Close the fascial defect using transfascial sutures placed laparoscopically or intraperitoneally 1, 4
• For suprapubic hernias, mobilize the urinary bladder from the rectus abdominis muscle to create a compartment for mesh placement, then anchor mesh to the pubic bone before suturing the bladder back to its anatomical position 5, 6
• Use pre-marking of mesh fixation positions ("contraposition and alignment" technique) to ensure proper mesh placement and reduce operative time 7

Advantages of Laparoscopic IPOM Over Open Repair

• Significantly reduced operation time (median 120 vs 180 minutes) 3
• Shorter hospital stays (6 vs 8 days) 3
• Lower complication rates (10% vs 23%) 3
• Dramatically fewer surgical site infections (1% vs 21%) 3
• Equivalent recurrence rates at 5.5 years (20% laparoscopic vs 19% open) 3

Mesh Type Selection

Synthetic mesh is the gold standard for clean surgical fields and should be used even for small defects, as it provides superior long-term outcomes with significantly lower recurrence rates. 1, 2

Mesh Selection Algorithm

• Clean or clean-contaminated fields (no bowel resection or gross spillage): Use synthetic mesh 1, 2
• Clean-contaminated with bowel resection but no gross spillage: Synthetic mesh remains safe 1
• Contaminated/dirty fields with defects <3 cm: Primary tissue repair without mesh 1, 2
• Contaminated/dirty fields with defects ≥3 cm: Biological mesh preferred if available; otherwise polyglactin mesh or delayed repair 1, 2

Biological Mesh Performance (When Indicated)

When biological meshes are necessary in contaminated fields:

• Permacol (cross-linked porcine): 13.8-29% infection rate, 5.8-18.3% recurrence at 12-24 months 8, 2
• Strattice (non-cross-linked porcine): 4.9-29.9% infection rate, 0-43% recurrence 8, 2
• Cross-linked biological meshes provide better resistance to mechanical stress and longer durability 8

Mesh Fixation Method

Use a combination of transfascial sutures for defect closure plus tack or suture fixation of the mesh to the abdominal wall, ensuring at least 5 cm overlap beyond the defect edges. 4, 7

Fixation Technique Details

• Transfascial sutures are associated with lower seroma incidence and recurrence rates 1, 4
• Pre-mark fixation positions on the mesh before insertion to ensure proper alignment and minimize fixation points needed 7
• Short-term postoperative pain may be slightly higher with suture fixation compared to tacks, but no difference exists at 6 months 4
• Ensure mesh is completely flat on the peritoneum with no edge curling and remains firmly adhered after pneumoperitoneum removal 7

Perioperative Antibiotic Prophylaxis

Administer standard surgical prophylaxis with a first-generation cephalosporin (or appropriate alternative based on local antibiogram) within 60 minutes before incision. 1, 2

Key Considerations

• Single-dose prophylaxis is typically sufficient for clean cases 1
• Active local infection is an absolute contraindication to mesh placement 2
• Synthetic mesh in clean-contaminated fields shows no significant increase in 30-day wound-related morbidity when appropriate prophylaxis is used 1

Postoperative Pain Management

Implement multimodal analgesia with scheduled NSAIDs and acetaminophen, reserving opioids for breakthrough pain only.

• Laparoscopic approach inherently reduces postoperative pain compared to open repair 3
• Pain from mesh fixation (sutures vs tacks) equalizes by 6 months postoperatively 4

Activity Management

Restrict heavy lifting (>10-15 lbs) and strenuous activity for 4-6 weeks postoperatively to allow adequate tissue incorporation and healing.

• Gradual return to normal activities based on patient comfort and wound healing
• Early mobilization and ambulation should begin on postoperative day 1 to prevent complications

Common Pitfalls to Avoid

• Inadequate mesh overlap: Ensure minimum 5 cm overlap beyond defect edges in all directions 4, 7
• Failure to close fascial defect: This increases seroma formation and compromises abdominal wall function 4
• Using synthetic mesh in contaminated fields: High infection rates (up to 21%) occur with polypropylene in CDC class III wounds 8, 1
• Improper mesh placement: Can lead to intestinal obstruction, mesh infection, and increased recurrence 7