Ventral hernias are defined as defects in the abdominal wall fascia that are neither inguinal nor hiatal. 

With approximately 350,000 repair surgeries performed annually¹ various techniques have been developed, particularly laparoscopic methods like laparoscopic intraperitoneal on-lay mesh repair (lap. IPOM), which has gained popularity for its simplicity and safety ^2,3,4,5. However, concerns about postoperative complications, including abdominal adhesions and chronic pain ^6,7, have led to ongoing discussions regarding alternative approaches, such as laparoscopic hernia repair with preperitoneal mesh placement ^8,9. Despite advancements, potential complications remain significant, including small bowel obstruction, mesh infection, erosion, and entero-cutaneous fistula, highlighting the complexities associated with mesh interaction and postoperative outcomes¹⁰.An essential reference for hernia repair techniques is the International Endo Hernia Society (IEHS) guidelines, which outline the adequacy of both pre-peritoneal and intraperitoneal repair methods for small to medium-sized ventral and incisional hernias (classified as EHS W1 and W2). The guidelines address the feasibility of laparoscopic preperitoneal ventral and incisional hernia repair ^11,12. prompting further investigation into its potential benefits and applicability in clinical practice.The general opinion seems to be that TAPP for ventral hernia repair, while technically demanding and requiring elevated expertise on the part of the surgeon, also seems to have some advantages in terms of cost-effectiveness and location of the mesh¹¹.

AIM

To compare surgical outcomes of TAPP and IPOM PLUS in small and mid-sized ventral hernia cases.

The study population comprised patients diagnosed with ventral hernias at SMS Medical College and Hospital in Jaipur, utilising both clinical and radiological assessments. This hospital-based comparative study spanned from the approval of the Review Board and Ethical Committee until the desired sample size was reached. The sample size was determined to ensure 80% study power and an alpha error of 0.05, with a standard deviation of 1.67 in the ventral TAPP group for postoperative pain, as indicated in a relevant article. To detect a minimum mean difference of 1.04 in pain during movement, a total of 44 patients per group was initially calculated

This number was rounded up to 50 patients per group to account for an anticipated 10% loss to follow-up. The sample size calculation utilised the formula:

 n = [(za/2 + zb)² x σ²] / d²,

       where σ² represents population variance,

       d is the detectable difference,

       za/2 is 1.96 for a 95% confidence interval,

       and zb is 0.84 for a power of 80%.

Inclusion criteria for the study included all patients with non-inguinal, non-hiatal defects in the abdominal wall fascia, specifically small and mid-sized ventral hernias (5 cm or less in size), aged between 18 and 60 years, and presenting with uncomplicated hernias. Exclusion criteria encompassed patients unfit for general anaesthesia (ASA grade 4) and those requiring intraoperative conversion from TAPP to IPOM PLUS             

Table 1: Age distribution

The table shows that the IPOM Plus group had a mean age of 42.72 years, while the Ventral TAPP group had a mean age of 49.92 years, with a significant age difference (p < 0.05), suggesting age may influence the selection or outcomes of these surgical procedures.

Graph: Diagnosis types

The graph shows that the IPOM Plus group primarily had incisional hernias (46%) and umbilical hernias (18%), while the Ventral TAPP group had a higher incidence of primary umbilical (34%) and epigastric hernias (24%), indicating that these diagnosis differences may affect surgical approaches and outcomes.

Table 2: Distribution according to EHS Classification

The table shows that the IPOM Plus group had a higher percentage of M3 (32%) and M5 (30%) hernias, while the Ventral TAPP group had more M2 (32%) and M3 (30%) classifications, indicating varying complexity levels of hernias treated by each surgical technique.

Table 3:Comparison of VAS Score for Pain at rest and on movement

This table compares the mean VAS scores at rest and during movement for both groups on POD 1, 10, 30, and 90. It highlights the significant differences in pain levels, with the Ventral TAPP group consistently reporting lower pain scores, suggesting more effective pain relief and potentially faster recovery.

Table 4: Paired t test between VAS Scores at rest and movement for IPOM Plus

Group and  Ventral TAPP Group

The table shows paired t-test results for VAS scores in both the IPOM Plus and Ventral TAPP groups, highlighting significant differences where movement led to higher pain scores in the IPOM Plus group and lower overall pain levels in the Ventral TAPP group, indicating a better postoperative pain experience.

Table 5:Analysis of Variance for Average VAS Score by group

There are significant differences in the combined dependent variables over time, with varying patterns of change across groups, indicating that group membership moderates the effect of time.

Table 6:Repeated Measures ANOVA Results for the Effect of Post Op Days  and Group

There is a highly significant main effect of time on the dependent variable, indicating notable differences across time points (p < .001). Additionally, a significant interaction effect between time and group (p = .010) suggests that the response to time varies among different groups.

Table 7: Operating time in minutes

The table compares operating times, showing that the IPOM Plus group had a mean time of 67.09 minutes compared to 76.70 minutes for the Ventral TAPP group (p = 0.003), indicating greater complexity for TAPP, while the Ventral TAPP group also had a significantly shorter mean hospital stay of 2.22 days versus 2.8 days for IPOM Plus (p < 0.001), suggesting faster recovery and earlier discharge.  

The analysis of age distribution in this study revealed a significant difference between the two groups. The mean age in the IPOM PLUS group was 42.93 years (SD = 7.34), while in the TAPP group, it was 49.92 years (SD = 8.76), with a statistically significant P-value of < 0.05. This finding is in line with research conducted by Baucom et al. ¹³, which similarly reported that ventral hernias are more common in older populations, often due to weakening abdominal wall structures associated with ageing.

Our study revealed a varied distribution of hernia types in patients undergoing IPOM and ventral TAPP repairs, with incisional hernias most common in the IPOM group (46%) and umbilical hernias leading in the TAPP group (34%). Kaushik et al. ¹⁴ also observed a higher prevalence of incisional hernia in both groups, i.e. IPOM plus and v-TAPP (50%, 43.8%, respectively).This trend aligns with previous research, which highlights TAPP's effectiveness in addressing umbilical hernias and its advantages in visualizing lateral defects, as evidenced by the presence of epigastric (6% IPOM, 24% TAPP) and spigelian hernias (6% TAPP only).

In our study, the EHS classification showed that most patients fell into the M2 and M3 categories, indicating moderate complexity, while the M5 category, representing the most complex hernias, was higher in the IPOM group (30%) compared to TAPP (14%)¹⁴. Overall, our findings align with existing literature that highlights the predictive value of the EHS classification in assessing surgical outcomes and emphasises careful patient selection based on hernia complexity ^15,16,17.

The assessment of postoperative pain via VAS shows that on Postoperative Day 1, the IPOM group reported a mean score of 5.58, significantly higher than the TAPP group's 3.76 (p < 0.001), with both groups showing decreased scores by POD 10—IPOM at 3.87 and TAPP at 2.06—still significantly different (p < 0.001)¹⁸. Similarly, Kaushik et al.¹⁴, had observed a significant difference (p=0.045) after one week (7days) of operation between the two techniques.  This trend continues through POD 30 and POD 90, where the IPOM group (mean scores of 2.48 and 1.58 respectively) consistently reported higher pain levels than the TAPP group (mean scores of 0.793 and 0.408 respectively), both statistically significant (p < 0.001).

Our analysis shows significant differences in pain on movement between the IPOM and TAPP groups, with IPOM reporting a mean VAS score of 6.86 on POD 1 compared to TAPP's 4.53 (p < 0.001), consistent with prior studies linking higher early pain to laparoscopic techniques69. By POD 30, the IPOM group maintained a higher mean score of 3.55 versus TAPP's 1.84 (p < 0.001), underscoring the need for improved postoperative pain management strategies for IPOM, despite its viability for complex hernias.as suggested by Saber et al.¹⁹. While IPOM PLUS remains a viable option, especially in larger or more complex hernias, its higher pain scores at rest and during movement indicate a need for improved postoperative pain management strategies for this technique.

The correlation between VAS scores at rest and movement provides further insights into the pain experience of patients. In the IPOM group, significant correlations were observed on POD 1 (r = 0.305, p = 0.031) and POD 10 (r = 0.374, p = 0.007), indicating that higher pain at rest is associated with higher pain on movement²⁰. Conversely, the TAPP group exhibited no significant correlations in pain at these time points, suggesting a different recovery trajectory, likely due to the surgical techniques that minimize postoperative discomfort²¹. 

In terms of hospital stay, our findings indicate that the IPOM group had a longer mean stay of 2.8 days (SD 0.687) compared to the TAPP group, which had a mean stay of 2.22 days (SD 0.679), with a statistically significant difference (p < 0.001). In a study by Kaushik et al.¹⁴, the patients of the TAPP group stayed for 2.50 days, whereas the patients of the IPOM group stayed for 3.80 days, which was statistically significant (p=0.030).

Our study found a significant difference in operating times, with the IPOM Plus group averaging 67.09 minutes compared to 76.70 minutes for the Ventral TAPP group (p = 0.003), indicating that IPOM Plus is faster. While this aligns with previous research, including Kaushik et al.¹⁴which reported longer times for vTAPP, our findings highlight that despite the longer operating time for TAPP, postoperative outcomes, especially in pain management, often favor this approach

This study comparing IPOM Plus and Ventral TAPP techniques for hernia repair revealed that the Ventral TAPP group had a higher mean age, more epigastric hernias, and consistently lower VAS pain scores at rest and during movement across all postoperative days. Despite longer operative times, the Ventral TAPP group experienced shorter hospital stays and better survival rates, with quicker recovery reflected in reduced analgesia requirements. These findings indicate that, while more time-consuming, the Ventral TAPP approach offers significant advantages in pain management and recovery, informing clinical decisions in hernia repair surgeries.

1. Smith, J., & Parmely, J. D. (2023). Ventral Hernia. In StatPearls. StatPearls Publishing.
2. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M (2011) Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev [Internet] (3). https:// www. cochr aneli brary. com/ cdsr/ doi/ 10. 1002/ 14651 858.CD007781.pub2/full. Accessed 28 Sep 2020
3. Van Hoef S, Tollens T (2019) Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach? Hernia J Hernias Abdom Wall Surg 23(5):915–925
4. Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK (2009) Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg 197(1):64–72
5. Natarajan S, Meenaa S, Thimmaiah KA (2017) A randomised prospective study to evaluate preperitoneal mesh repair versus onlay mesh repair and laparoscopic IPOM in incisional hernia surgery. Indian J Surg 79(2):96–100
6. Liot E, Bréguet R, Piguet V, Ris F, Volonté F, Morel P (2017) Evaluation of port site hernias, chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study. Hernia J Hernias Abdom Wall Surg 21(6):917–923
7. Sharma A, Chowbey P, Kantharia NS, Baijal M, Soni V, Khullar R (2018) Previously implanted intra-peritoneal mesh increases morbidity during relaparoscopy: a retrospective, case-matched cohort study. Hernia J Hernias Abdom Wall Surg 22(2):343–351
8. Vorst AL, Kaoutzanis C, Carbonell AM, Franz MG (2015) Evo lution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg 7(11):293–305
9. 9)Reynvoet E, Deschepper E, Rogiers X, Troisi R, Berrevoet F (2014) Laparoscopic ventral hernia repair: is there an optimal mesh fixation technique? A systematic review. Langenbecks Arch Surg 399(1):55–63
10. Robinson TN, Clarke JH, Schoen J, Walsh MD (2005) Major mesh-related complications following hernia repair: events reported to the Food and Drug Administration. Surg Endosc 19(12):1556–1560
11. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G, Fortelny R, Köckerling F, Kukleta J, LeBlanc K, Lomanto D, Misra M, Morales-Conde S, Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser R, Simon Th, Smietanski M, Stechemesser B, Timoney M, Chowbey P (2014) Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (Inter national Endohernia Society [IEHS])—part III. Surg Endosc 28(2):380–404
12. Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, Chen J, Chowbey P, Dietz UA, de Beaux A, Ferzli G, Fortelny R, Hoffmann H, Iskander M, Ji Z, Jorgensen LN, Khullar R, Kirchhoff P, Köckerling F, Kukleta J, LeBlanc K, Li J, Lomanto D, Mayer F, Meytes V, Misra M, Morales-Conde S, Niebuhr H, Radvinsky D, Ramshaw B, Ranev D, Reinpold W, Sharma A, Schrittwieser R, Stechemesser B, Sutedja B, Tang J, Warren J, Weyhe D, Wiegering A, Woeste G, Yao Q (2019) Update of guide lines for laparoscopic treatment of ventral and incisional abdomi nal wall hernias (International Endohernia Society (IEHS))-part A. Surg Endosc 33(10):3069–3139
13. Baucom RB, Beck WC, Holzman MD, Sharp KW, Nealon WH, Poulose BK. Prospective evaluation of surgeon physical examination for detection of incisional hernias. J Am Coll Surg. 2014 Mar;218(3):363-6. doi: 10.1016/j.jamcollsurg.2013.12.007. Epub 2013 Dec 12. PMID: 24559951