Professor Dr Ferdinand Köckerling talking about IPOM and the use of titanised mesh implants

What exactly is the laparoscopic IPOM technique? For which types of hernias is this method used?

The laparoscopic intraperitoneal onlay mesh technique is a minimally invasive procedure for the treatment of primary abdominal wall hernias (umbilical hernia, epigastric hernia) and incisional hernias. This procedure involves spreading a mesh implant over the affected area from the inside in order to close the abdominal wall defect and then fixing it with transfascial sutures and staples. Good outcomes can be achieved using the laparoscopic IPOM method – with a low risk of postoperative complications.

What other techniques are there for treating these types of hernias?

Aside from the laparoscopic IPOM method, the open sublay technique can be used to treat both primary and secondary abdominal wall hernias. This technique delivers the best outcomes compared to all other open surgical techniques. These open surgical techniques can also be optimised through the mini/less open sublay technique (MILOS) due to the smaller access port.

What are the advantages of the laparoscopic IPOM technique compared to other surgical techniques? When selecting the technique to use, should particular criteria be considered, based on the classification of the hernia?

Large registry studies and meta-analyses have shown that laparoscopic IPOM provides significant advantages compared to the open sublay technique 1. The risk of postoperative wound complications is markedly reduced thanks to the minimally invasive procedure 1. Thus, the laparoscopic IPOM technique is currently the evidence-based gold standard for the treatment of incisional hernias with a defect size of up to 8 - 10 cm. The advantage of laparoscopic IPOM lies in its very low wound and mesh complication rate of approximately 1% - 3%. In open incisional hernia surgery, a wound or mesh infection can be expected in around 10% of cases. A five year follow-up in the Danish hernia registry also found that the mesh complication rate was no higher for laparoscopic IPOM than for open incisional hernia surgery 2. However, the latest registry data prove that these advantages of the IPOM technique only exist for defects up to 10 cm 3. Similarly, the guidelines of the International Endohernia Society recommend that the laparoscopic IPOM technique should only be used for defect widths up to 8 - 10 cm and that the hernia site should be closed if possible 4.

Which mesh implants are used with the IPOM technique? How should the ideal mesh for intraperitoneal care be designed?

The ideal mesh implant for intraperitoneal use must have optimal ingrowth onto the abdominal wall and should minimise the risk of adhesions to the abdomen. Thus, pure polypropylene or polyester meshes are not an option – with these meshes, the side facing the abdomen has to be additionally covered with absorbable or permanent materials that have high tissue compatibility. Therefore, the meshes used for intraperitoneal hernia treatment are covered on one side with a permanent or absorbable protective layer, or they are completely titanised. It is known that these materials can reduce the extent of adhesions 5.

What postoperative complications can occur after using a mesh implant? What specific consequences can this have for patients?

Adhesions between the mesh implant and the intestinal wall may lead to a serious complication following insertion of the implant. Postoperatively, hernia treatment can also lead to infections at the surgical site as well as seromas or bleeding, which require revision surgery.

You use titanised polypropylene meshes in your everyday practice. What are the advantages of these meshes for laparoscopic IPOM?

Titanised meshes exhibit considerable advantages in everyday surgical practice. During laparoscopic IPOM, they are easy to insert into the abdomen via the trocar. Since the mesh is completely titanised, there is no risk of confusing the different sides. The titanised meshes are hydrophilic, so they are easily moulded to the abdominal wall and adhere well. The subsequent fixation can be carried out without any problems. The hydrophilic surface also means that the mesh implant is better accepted by the body’s own cells, which facilitates its ingrowth into the abdominal wall. The titanised meshes can be fixed to the abdominal wall with any [medical - note: pfm medical] stapler. Transfascial sutures at the four corners of the mesh are only required for optimal positioning of the mesh over the defect. Even after the defect has been closed, the anatomy behind the mesh implant can still be easily identified due to the large-pore structure of the mesh. Titanised meshes thus offer optimal handling properties for laparoscopic IPOM.

Are there any scientific investigations that document the high patient benefit of titanised mesh implants using the IPOM technique?

On the basis of several registry studies and a randomised controlled trial, it has been documented that titanised mesh implants fully meet the high expectations for patient benefit 6.

(June 2019)

  1. Köckerling F., Simon T., Adolf D., Köckerling D., Mayer F., Reinpold W., Weyhe D., Bittner R., Laparoscopic IPOM versus open sublay technique for elective incisional hernia repair: a registry-based, propensity score-matched comparison of 9907 patients., SurgEndosc. 2019, 33(10):3361-3369.
  2. Kokotovic D, Bisgaard T, Helgstrand F, Long-term recurrence and complications associated with elective incisional hernia repair. JAMA 2016, 316: 1575-1582
  3. Köckerling F, Simon T, Hukauf M et al., The Importance of Registries in the Postmarketing Surveillance of Surgical Meshes. Ann Surg 2018, 268: 1097-1104
  4. Bittner, R., Bingener-Casey, J., Dietz, U. et al., Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society [IEHS]) - Part I. Surg Endosc. 2014, 28(1): 2-29.
  5. Schug-Paß C., Tamme C., Tannapfel A., Köckerling F., A lightweight polypropylene mesh (TiMesh) for laparoscopic intraperitoneal repair of abdominal wall hernias: : comparison of biocompatibility with the DualMesh in an experimental study using the porcine model., Surg Endosc. 2006, 20(3): 402-409.
  6. Moreno-Egea A., Carrillo-Alcaraz A., Soria-Aledo V., Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh. Surg Endosc, 2013. 27(1): p. 231-239