laparoscopicipomplusvvjbvhbbkj-181127165606.pdf

1. LAPAROSCOPIC IPOM PLUS
DR.PRAVIN HECTOR JOHN, MS, FIAGES, FALS, FIBC
DR.JOHN AC THANAKUMAR MS, MNAMS, FRCS, FRCS, FICS,
Dip MIS (FR), FALS

2. IPOM-INTRA PERITONEAL ONLAY MESH
• IPOM Plus = Defect closure with suture + IPOM

3. INDICATIONS:
• Ventral hernia
• Incisional hernia
• Recurrent hernia
• Defects up to 5cm

4. CONTRAINDICATIONS:
To laparoscopy in general
• Shock
• Cardiorespiratory
compromise
• Pregnancy
Specific to IPOM plus
• Fecal peritonitis
• Gangrene bowel
• Intra-abdominal sepsis
• Large defects with LOD
• Pediatric age group
• Cirrhosis with caput
medusae

5. POSITION & OPERATION THEATRE SETUP
• Ergonomics
• Supine
• Arms tucked
• Empty bladder

6. ERGONOMICS:
• Straight line (Surgeon, operating organ and
monitor to be in straight line)
• Azimuth angle
• Manipulation angle
• Elevation angle

7. OT SETUP

8. Mesh
• Coated (Dual) mesh 10*15cm, 15*15cm or
larger
– Visceral side: repels adhesions and ingrowth
– Parietal side: integrates into abdominal wall
7-14 days for neo-peritoneum formation
• No polypropylene mesh!!

9. INSTRUMENTS:
Laparoscopic set and open surgery set
• Laparoscopic camera unit with 30 degree scope
• Dual mesh of adequate sizes
• Trocar, Verres needle
• Suture passer
• Thick non absorbable suture (1-prolene, loop Ethilon)
• Suture for fixing mesh (non absorbable)
• Trackers (absorbable/non-absorbable)
• Bowel grasper
• Medium grasper
• Curved Maryland
• Needle holder
• Energy source

10. PORTS:
• 3 or 4 ports:
1. Camera 10-12mm
2. Working 5mm ports
3. Triangulation for ergonomics

11. PROCEDURE: PART 1
• Verres needle or Hassan open entry or direct view
trocar entry
• Diagnostic laparoscopy
• Adhesiolysis and reduction of contents
• Measure defect with low IAP
• Choose dual mesh size
• Suture defect-non absorbable suture
• Sac bite to prevent seroma
• Defect closure at low pneumoperitoneum
• Re-insufflate

12. • Mesh deployment and fixation
• Centering stitch
• 3 to 5cm overlap of mesh with normal tissue all
around defect
• 4 corner transfascial sutures
• Sutures to fix mesh-intracorporeal suturing
• Tacks: Double crowing-1 to 2 cm apart
• Omentum between mesh and bowel
• Correction of divarication when large
• Skin closure with steristrip/subcuticular
PROCEDURE: PART 2

13. FOR / AGAINST
IPOM PLUS
FOR: RESTORES FUNCTIONALITY OF ABDOMINAL
WALL
AGAINST: REPAIR UNDER TENSION
LARGE DEFECTS SUTURE CUT THROUGH
CENTERING STITCH ON MESH
FOR: HELPS ADEQUATE POSITIONING
AGAINST: CAN GET INFECTED AS IT IS SUBCUTANEOUS
TACKERS
FOR: NON ABSORBABLE – LESS PAIN, ADHESIONS
AGAINST: ONLY 2 MM PENETRATION GLUE
FOR: PAINLESS
AGAINST: EXPENSIVE

14. POST OP CARE:
• Oral fluids 4 hours---normal diet
• Ambulate
• Chest physiotherapy
• Adequate analgesia
• Antibiotics for 24 hours
• Discharge 48 to 72 hours
• Pressure dressing over hernia site or
abdominal support if necessary

15. COMPLICATIONS:
• Trocar injury (vascular, hollow viscus)
• Seroma
• Recurrence
• Wound infection
• Intestinal obstruction
• Port site hernia

16. To minimize complications
ENTRY
OPEN HASSON
DIRECT VIEW
CARE IN SCARRED
ABDOMEN
CHECK FOR INJURY
DIAGNOSTIC LAPAROSCOPY
RULE OUT OTHER DISEASE
INSPECT BOWEL
INJURY CHECK
AHDESIOLYSIS
PATIENCE
SCISSORS
NO CAUTERY
HEMOSTASIS - BIPOLAR
PREVENT BOWEL TRAUMA
GENTLE MANIPULATION
HOLD MESENTERY
ATRAUMATIC GRASPER
AVOID ENERGY NEAR BOWEL
VISUALLY INSPECT BOWEL
RE-LAPAROSCOPE IF DOUBTFUL

17. To minimize complications
ENTEROTOMY – WHAT NEXT?
DEFER REPAIR?
GROSS SPILLAGE OUTSIDE
LUMEN?
SURGEON’S WISDOM
PAIN
GLUE
LIBERAL LOCAL ANALGESIA
ADEQUATE IV ANALGESIA
SEROMA
COMPRESSION DRESSING
CLOSE DEFECT
BITE ON SAC DURING CLOSURE
CAUTERY – INCREASED INFECTION!
MESH INFECTION
PROPHYLACTIC & PERIOPERATIVE
ANBIOTICS
STERILITY OF INSTRUMENTS
CHANGE GLOVES
MINIMUM HANDLING OF MESH
POST AS FIRST CASE
NEW FIXATION DEVICE
LARGER PORE MESH

18. To minimize complications
INTESTINAL OBSTRUCTION
TISSUE SEPARATING MESH
LARGER MESH MORE SUTURES
TACKERS AT PERIPHERY OF MESH
INTERPOSE OMENTUM BETWEEN MESH AND BOWEL
PREVENT RECURRENCE
PRE-OP OPTIMISATION
APPROPRIATE TECHNIQUE
5CM OVERLAP OF MESH
COVER INCISION SITE IF NECESSARY
LARGE MESH
TRANSFASCIAL SUTURES
ANCHOR MESH EDGES WITHOUT GAP
CENTRE MESH WELL

19. LVHR

20. ANURAG HOSPITAL
NO.8, KRISHNA NAGAR, SOWRIPALAYAM MAIN ROAD,
COIMBATORE -641028
PH: 8015087871 ; 0422-4341486
EMAIL: anuraghospitalcoimbatore@gmail.com
Web: www.anuraghospital.com