For a challenging trial of intraperitoneal onlay mesh‑plus (IPOM‑plus) in elective laparoscopic ventral or incisional hernia repair in adults aged 18‑75 with BMI < 40 kg/m², defect ≤10 cm, and no intra‑abdominal infection, what patient selection criteria, mesh type, fixation technique, and peri‑operative management should be used?

IPOM-Plus in Elective Laparoscopic Ventral/Incisional Hernia Repair

Overview of the IPOM-Plus Technique

The IPOM-plus technique—which combines intraperitoneal mesh placement with fascial defect closure—significantly reduces hernia recurrence (OR = 0.51), seroma formation (OR = 0.48), and mesh bulging (OR = 0.08) compared to standard IPOM without defect closure, making it the preferred laparoscopic approach for ventral and incisional hernias in appropriate candidates. 1

Patient Selection Criteria

Ideal Candidates

• Adults aged 18–75 years with BMI < 40 kg/m² are optimal candidates, as BMI significantly influences postoperative recurrence rates (OR = 0.43, p < 0.0001). 1
• Hernia defects ≤10 cm are most suitable for laparoscopic IPOM-plus repair. 1, 2
• Clean or clean-contaminated surgical fields (CDC Class I-II) without intra-abdominal infection are essential prerequisites. 3, 4

Exclusion Criteria

• Avoid IPOM-plus in contaminated/dirty fields (CDC Class III-IV) with gross enteric spillage, as polypropylene mesh infection rates reach 21% in these settings. 4, 5
• Active intra-abdominal infection is an absolute contraindication to synthetic mesh placement. 3

Mesh Selection Algorithm

For Clean/Clean-Contaminated Fields (CDC Class I-II)

• Use synthetic polypropylene mesh for all defect sizes in elective repairs without contamination. 3, 4, 5
• Synthetic mesh provides superior long-term outcomes with significantly lower recurrence rates (OR = 0.2) compared to non-mesh repair. 3, 4
• Dual-layer composite meshes designed for intraperitoneal placement should be selected to minimize adhesion formation. 2

For Contaminated Fields (CDC Class III)

• For defects <3 cm with bowel necrosis or gross spillage: Primary repair without mesh is recommended. 3, 4, 5
• For defects ≥3 cm in contaminated fields: Biological mesh is preferred when available. 3, 4, 5
• If biological mesh is unavailable: Consider polyglactin mesh or open wound management with delayed repair. 4, 5

Fixation Technique

Defect Closure Method

• Perform continuous laparoscopic closure of the linea alba using barbed non-resorbable 1-0 suture (polybutester) prior to mesh placement. 6
• Transfascial sutures for defect closure reduce seroma formation and recurrence rates, making them an essential component of the IPOM-plus technique. 2
• Complete fascial approximation restores abdominal wall anatomy and physiology before mesh reinforcement. 6

Mesh Fixation

• Anchor mesh with transfascial sutures to achieve secure fixation and reduce mesh migration. 2
• For suprapubic hernias: Mobilize the urinary bladder from the rectus abdominis muscle to create a compartment for mesh placement, anchor to the pubic bone, then reposition the bladder. 2
• Ensure adequate mesh overlap of at least 5 cm beyond the defect margins in all directions. 6

Peri-operative Management

Pre-operative Considerations

• Assess surgical field classification to determine appropriate mesh type and approach. 3, 4
• Optimize modifiable risk factors including smoking cessation, diabetes control, and nutritional status. 7
• Screen for chronic immunosuppression (OR = 2.41 for wound complications) and previous hernia repair (OR = 1.99 for wound complications). 7

Intra-operative Management

• Use laparoscopic approach to benefit from lower wound infection rates compared to open repair. 4, 8
• Evaluate hernia content viability and identify occult contralateral hernias during laparoscopy. 4
• For complex hernias >10 cm: Consider endoscopic anterior bilateral component separation in combination with IPOM-plus. 6

Post-operative Care

• Initiate early mobilization beginning on postoperative day 1 to reduce complications. 4
• Resume normal activities gradually guided by comfort and wound healing. 4
• Monitor for seroma formation, which occurs less frequently with IPOM-plus (OR = 0.48) compared to standard IPOM. 1

Critical Pitfalls to Avoid

Mesh-Related Complications

• Never use polypropylene mesh in grossly contaminated fields (CDC Class III-IV with spillage), as infection rates reach 21%. 4, 5
• Avoid absorbable prosthetic materials for permanent repair, as complete dissolution leads to inevitable hernia recurrence. 3, 5
• Do not automatically exclude mesh based solely on non-viable intestine presence when gross spillage is absent, as infection rates are similar between viable and non-viable bowel cases. 3, 5

Technical Considerations

• Ensure adequate fascial closure before mesh placement, as sublay extra-peritoneal bio-prosthesis placement without anterior fascia closure increases wound complications (OR = 0.33). 7
• In severely obese patients (BMI >50): Consider hybrid IPOM-plus combining open and laparoscopic approaches for safe trocar insertion and reduced wound strain. 9

Expected Outcomes

Efficacy

• Recurrence rates: IPOM-plus demonstrates significantly lower recurrence (OR = 0.51) with follow-up times significantly influencing outcomes (OR = 0.50, p = 0.0004). 1
• Seroma reduction: 52% reduction in seroma formation (OR = 0.48) compared to standard IPOM. 1
• Mesh bulging: 92% reduction in mesh bulging (OR = 0.08) with fascial closure. 1

Safety Profile

• Complication rate: 5.1% overall complication rate in laparoscopic ventral hernia repair. 8
• Infection rate: 1.7% infection rate in clean/clean-contaminated fields. 8
• Hospital stay: Reduced postoperative stay compared to open repair. 8