Laparoscopic IPOM and Cholecystectomy for Incisional Hernia and Gallstones in a 49 Y.O. Female

PACE Hospitals' expert Surgical Gastroenterology team successfully performed a Laparoscopic IPOM plus and Cholecystectomy on a 49-year-old woman with abdominal pain and two episodes of vomiting. The surgery was performed to relieve her symptoms and prevent further complications.

Chief Complaints

A 49-year-old woman with a body mass index (BMI) of 26 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with chief complaints of spreading, cramping (colicky) abdominal pain and two episodes of greenish (bilious) vomiting. She also had a history of intermittent pain and a ventral hernia that cannot be pushed back in, which had gradually increased in size over the past two years and progressively worsened, causing increased discomfort.

Past Medical History

The patient was a known case of hypertension (high blood pressure) and hypothyroidism, for which she has been taking medication regularly to control them. And has experienced intermittent pain in the past, along with an irreducible ventral hernia (a protrusion of abdominal contents through a weak or defect in the anterior abdominal wall) that slowly increased in size over the previous two years. These medical conditions were important considerations in the planning of her treatment and surgical care.

On Examination

Upon admission to PACE Hospitals, the patient's vital signs were stable. After a thorough physical examination, the doctors identified a bulge in the abdomen wall.



The respiratory system showed bilateral air entry, the abdomen was soft and non-tender, and the central nervous system examination indicated that the patient was alert, oriented, and conscious of time, person and place.

Diagnosis

After the initial examination, the patient underwent a comprehensive assessment by the surgical gastroenterology team, which included detailed clinical evaluation, laboratory investigations and imaging studies, including:

• A subsequent CT scan of the abdomen was conducted, providing detailed imaging that showed a defect in the anterior abdominal wall in the right lumbar region. Bowel loops were present within the defect. There was no evidence of intestinal obstruction.
• The CBC test showed normal haemoglobin levels, with no neutrophilic predominance, indicating the absence of active systemic infection.
• Abdominal ultrasonography demonstrated the presence of gallstones and a dilated common bile duct.

To support the clinical findings, laboratory examinations, ultrasound imaging, and CT scans later confirmed the diagnosis of an Irreducible incision hernia (a condition where a bulge at a past surgery site that cannot be pushed back in) with cholelithiasis (gallstones in the gallbladder). These radiographic findings correlated with the patient’s symptoms and confirmed the provisional diagnosis, guiding the team toward planning appropriate surgical intervention.

Based on the confirmed diagnosis, she was advised to undergo Incisional Hernia and Gallstone treatment in Hyderabad, India, under the care of the Surgical Gastroenterology Department, ensuring comprehensive management.

Medical Decision-Making (MDM)

Given the patient's symptoms, functional limits in day-to-day activities, and the confirmed diagnosis of an Irreducible incisional hernia with cholelithiasis, surgical intervention was considered essential.

Following a detailed discussion with the patient and her guardians, Dr CH Madhusudan, Senior Consultant Surgical Gastroenterologist and Liver Transplant Surgeon, in collaboration with Dr Seshi Vardhan Janjirala, a Cardiologist, recommended Laparoscopic Intraperitoneal Onlay Mesh (IPOM) plus and Cholecystectomy would be a most effective and appropriate treatment option to achieve optimal stability and promote recovery.

The patient and her family were thoroughly counselled regarding the nature of the condition, the surgical procedure, potential risks, and the necessity of IPOM Plus and Cholecystectomy to restore function and promote optimal recovery.

Surgical Procedure

Following the decision, the patient was scheduled to undergo Laparoscopic intraperitoneal onlay mesh (IPOM) Plus and Cholecystectomy Surgery in Hyderabad at PACE Hospitals, under the supervision of an expert in the Surgical Gastroenterology Department. 

The following steps were carried out during the procedure:

Preoperative Preparation

The patient was evaluated under general anaesthesia, and standard preoperative protocols were followed.

Initial Intraoperative Findings

The gallbladder was well distended. Calot's triangle appeared fatty, and the critical view of safety was achieved. A single cystic duct and a single cystic artery were identified.

Gallbladder Removal

The gallbladder was dissected from the liver bed using electrocautery and was retrieved through the umbilical port using an endo-bag.

Evaluation of Incisional Hernia and Adhesiolysis Technique

An incisional hernia was identified in the right lower quadrant, measuring approximately 4 cm, with omentum as the hernial content. Adhesiolysis was performed to free the omentum, which was reduced back into the abdominal cavity. The defect was primarily closed using a single continuous V-Loc suture.

Mesh Placement and Fixation

A 15 x 15 cm composite mesh (tymesh) was placed in an intraperitoneal onlay position (IPOM) and secured with tackers, ensuring full coverage and adequate fixation.

Haemostasis and closure

Haemostasis (bleeding control) was secured, and the wound was closed in layers, with a drain placed as needed to minimise postoperative complications and promote optimal recovery for the patient.

Postoperative Care

The procedure was completed without complications, and the patient remained stable throughout the surgery.



Postoperatively, she received intravenous fluids, antibiotics, and supportive care to promote healing and prevent infection. She showed steady improvement and was discharged in a hemodynamically stable condition, with proper follow-up plans.

Discharge Medications

Upon discharge, the patient was given a carefully selected set of medications to aid in recovery and minimise potential complications after surgery. The regimen included pain medication to control pain, antibiotics to help prevent infection at the surgical site, and antacids to protect the stomach from irritation that can occur with the use of pain medication.



In addition, Osmotic laxatives were prescribed to treat constipation and promote regular bowel movements and electrolyte supplements to treat potassium deficiency. She was advised to continue her regular antihypertensive medications to control blood pressure, along with her thyroid hormone replacement therapy.

Advice on Discharge

The patient was advised to maintain proper wound and drain care, continue the prescribed medications, and use the abdominal binder as instructed. Strenuous activities were to be avoided for six weeks for proper healing and to lower the risk of hernia recurrence.

Emergency Care

The patient was informed to contact the emergency ward at PACE Hospitals in the event of any emergency or the development of symptoms such as fever, abdominal pain, or vomiting.

Review and Follow-up

The patient was advised to return for a follow-up visit with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals, after one week for further evaluation.

Conclusion

This case highlighted the effectiveness of combined laparoscopic Intraperitoneal Onlay Mesh (IPOM) plus and Cholecystectomy Surgery in addressing both incisional hernia and gallstone condition. The minimally invasive approach enabled comprehensive management of the patient’s conditions with a focus on safety, mesh reinforcement, and rapid recovery, reflecting advanced expertise in laparoscopic surgery. The patient experienced a smooth postoperative recovery with minimal risk of complications.

Gastroenterology Department | Gastroenterology Hospital in Hyderabad