Abstract
This cohort study examines changes in the proportion of laparoscopic intraperitoneal onlay mesh procedures performed for hernia repair in Denmark since initial description of the procedure.
The implementation of new surgical procedures and other technologies has peaks and valleys, which may be described by the theory of the Gartner hype cycle for innovation and adoption of new technology.1 This is characterized by 5 stages, beginning with the trigger of innovation with the first description of the procedure, followed by the peak of expectations, where the procedure gains popularity among surgeons. The trough of disillusionment comes when complications seem to be associated with the procedure; then, benefits and disadvantages become better understood with the slope of enlightenment. The cycle ends with the plateau of productivity.
Laparoscopic ventral hernia repair using intraperitoneal onlay mesh (IPOM) was initially described in 1993.2 A mesh was placed intraperitoneally and fixated to the abdominal wall. The procedure quickly became 1 of the most popular procedures for ventral hernia repair. In recent years, alternative minimally invasive ventral hernia repair procedures have emerged, and we hypothesized that the number of laparoscopic IPOM procedures is decreasing. This study evaluated the annual number of laparoscopic IPOM procedures performed in Denmark in light of the Gartner hype cycle.
Methods
This cohort study used the Danish Hernia Database, which contains data on all ventral and incisional hernia repairs performed in Denmark since 2007. Reporting to the database is mandatory and requires no patient consent, and data are prospectively registered by surgeons. We assessed the annual number of laparoscopic IPOM procedures and other ventral hernia repairs for both primary ventral and incisional hernias from January 1, 2007, through August 20, 2022. The study was approved by the regional data protection agency of the Capital Region of Denmark. Data were analyzed using R, version 4.0.2.
Results
A total of 66 257 ventral hernia repairs were performed (mean [SD] patient age, 54.1 [14.7] years; 38 746 patients [58.5%] were female and 27 511 [41.5%], male). Of these, 14 829 (22.4%) were laparoscopic IPOM procedures, 47 883 (72.3%) were open repairs, and 3545 (5.4%) were other minimally invasive procedures. Of the IPOM procedures, 7094 (47.8%) were incisional hernia repairs and 7735 (52.2%) were primary ventral hernia repairs.
At the height of its popularity in 2012, laparoscopic IPOM was performed in 28.8% of all ventral hernia repair procedures, compared with the lowest proportion (5.8%) in 2022 (Figure 1). For incisional hernia repair, laparoscopic IPOM was performed in 48.5% of all procedures in 2009 compared with 11.4% in 2022. Overall, use of the laparoscopic IPOM procedure peaked in 2012 and declined rapidly after 2016. This history of the surgical procedure matches the theory of the Gartner hype cycle1 (Figure 2).2,3,4,5
Figure 1. Laparoscopic Intraperitoneal Onlay Mesh (IPOM) vs Other Repair Procedures for Ventral and Incisional Hernia Repairs in Denmark, 2007-2022.
Figure 2. Gartner Hype Cycle of Laparoscopic Intraperitoneal Onlay Mesh (IPOM) Repair.
Circles indicate publication of studies with important findings.
Discussion
This study found that the trigger of innovation was the description of the laparoscopic IPOM procedure in 1993, followed by the peak of expectations in the 2000s. Meshes with antiadhesive barriers were developed, different fixation devices were tested, and there was industry competition to gain market interests.
The trough of disillusionment began around 2016, when a popular mesh for intraperitoneal use was withdrawn from the market due to high recurrence rates.3 Furthermore, need for defect closure and sufficient mesh overlap was emphasized, and a risk of chronic pain due to traumatic mesh fixation and adhesions to the intraperitoneal mesh was reported.4,5
A short slope of enlightenment possibly led to the plateau of productivity, where use of laparoscopic IPOM is now limited. In hospitals where newer minimally invasive approaches have yet to be implemented, there is still an indication for IPOM repair. The IPOM approach will probably also remain in use by experienced hernia surgeons in cases with a destroyed posterior rectus sheath and peritoneum. A study limitation was that trends in use of laparoscopic IPOM in Denmark may not reflect its use worldwide.
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
Data Sharing Statement
