Continuous Laparoscopic Closure of the Linea Alba with Barbed Sutures Combined with Laparoscopic Mesh Implantation (IPOM Plus Repair) As a New Technique for Treatment of Abdominal Hernias

Abstract

Despite extensive experience and significant reduction of complications in recent years, laparoscopic treatment of complex abdominal hernias is a challenge even for the experienced endoscopic surgeon. Patients with severe incisional hernias or symptomatic rectus diastasis benefit from the closure of the linea alba as a morphological and physiological reconstruction of the abdominal wall followed by mesh implantation. Occasionally, an additional component separation is necessary. In open surgery, this is associated with very large wound areas, postoperative seromas, poor wound healing and, in the worst case, mesh infections. To avoid these complications, we operate these complex reconstructions completely endoscopically. Our concept is based on a laparoscopic closure of the linea alba through an ongoing, barbed non-resorbable 1–0 suture (polybutester) and final reinforcement by an intraperitoneal-onlay mesh (IPOM-Plus). For the treatment of complex abdominal hernias with a width of more than 10 cm, we performed an endoscopic anterior bilateral component separation. This allows the surgeon to combine the advantages of the open abdominal wall reconstruction with those of laparoscopic hernia repair. Between May 2015 and June 2017, we treated 42 patients with abdominal hernias by laparoscopic continuous hernia defect closure and complementary mesh implantation, whereby a complex reconstruction with additional endoscopic anterior component separation was performed in five patients. In this article, we will present this innovative technique of endoscopic/laparoscopic hernia repair in complex abdominal hernias.

Complete intracorporeal defect closure using unidirectional barbed suture in laparoscopic incisional hernia repair: Preliminary experience with short‐term follow‐up

“…The defect was then closed by a running suture in a caudal to cranial direction, with tissue bites and inter-suture spacing of 1 cm each. The suture intervals were comparable to those described in previous reports (2,4,12). As the BS was 45 cm in length, this maneuver was facilitated by pulling the needle holder out of the trocar at Palmer's point ( Figure 2).…”

“…We limited the maximum diameter of the defect to 6 cm to avoid excessive tension after the fascial closure. In recent studies, intracorporeal defect closure was preferably indicated for defects less than or equal to 10 cm, whereas extracorporeal closure, with relaxing incision or the endoscopic anterior component separation, was performed for larger defects (greater than 10 cm) . Accordingly, we may be able to extend the application of our technique to defects up to 10 cm.…”

“…Using barbed suture (BS) is considered beneficial because of improved tissue approximation, even distribution of tissue length, and reduced strangulating force . The widespread use of BS has enabled novel intracorporeal defect closure in LIHR with excellent surgical outcome .…”

Treatment Options for Abdominal Rectus Diastasis

“…Several different placements of trocars are used, most commonly suprapubic and periumbilical (26, 29, 32–34) or suprapubic and in both iliac fossae (28, 30, 35, 36). Four studies included patients with ventral hernia, specified as umbilical, epigastric, supraumbilical, or incisional hernia (28, 33, 35, 36). As during open approach, the repair of the rectus fascia can be performed with or without mesh reinforcement.…”

Two-stage laparoscopic surgery for incarcerated umbilical Littre’s hernia in severely obese patient: a case report

“…In laparoscopic incisional hernia repair, IPOM plus repair involves the performance of IPOM repair after suture the abdominal wall defect. Comparing the two approaches, some investigations have suggested that IPOM plus repair reduces recurrence rate, the risk of seroma, and mesh bulge [ 23 – 26 ]. We acknowledge that IPOM plus repair may reduce the recurrence rate of umbilical hernia.…”