Why/When/How to do TEP and TAPP Archana Ramaswamy MD

Open Inguinal hernia repair 1920 Cheatle Preperitoneal inguinal hernia repair in recurrent hernias 1980s Nyhus, Stoppa Preperitoneal repair with prosthetic material 1987 Lichenstein Anterior approach Tension free repair with prosthetic material

Laparoscopic Inguinal Hernia Repair Transabdominal preperitoneal (TAPP) Totally Extraperitoneal (TEP)

Fixation in Inguinal Hernia Repair Fixation or no fixation When Tacking, Where to Tack Alternatives to Tacking

Fixation Options Sutures Permanent tacks (5mm) Absorbable tacks (5mm) Staples (5/10mm) Glues (5mm) No fixation

Fixation Fixation No fixation Decrease recurrence Decrease pain Rolling up of mesh No fixation Decrease pain Decrease cost

Mesh placement Size: 4x6 Material Polypropylene Polyester Slit

Fixation When Tacking, Where to Tack Trend toward limited tacks Coopers ligament (inferior-medial) Rectus Sheath (superior-medial) Above Iliopubic tract (lateral)

Fixation Alternative to Tacking N-butyl-2-cyanoacrylate glue Fibrin sealant application Good: Temporary mesh stabilization Bad: may increase cost, cumbersome application device (though improving) Bioabsorbable Tacks Good: Temporary Fixation (about 3 to 6 months depending on the product) Bad: Recently on the market, may increase cost

Mesh fixation No fixation Fixation Bilateral Medially- Cooper’s Laterally- anterior iliopubic tract Anteromedial Bilateral Overlap mesh medially

Lap vs Open Meta-analysis Forty-one studies 7161 participants Longer OR times (14 mins, 95% CI: 13.98-15.64) Less hematomas (OR: 0.72, 95% CI: 0.60-0.87, only TEP vs open) Less wound infection (OR: 0.45, 95% CI: 0.32-0.65) Higher risk of visceral injury (OR: 5.76, 95% CI:1.53- 21.68) 7 vs 1, 6 in TAPP group Return to usual activities was faster by 7 days (p<0.001) Less persisting pain at 1 yr (OR: 0.54, 95% CI: 0.46-0.64) Less numbness at 1 yr (OR 0.38, 95% CI 0.28-0.49) McCormack, K. Scott, Cochran database, 2007

TEP vs Open Systematic review 4231 patients Longer OR time Shorter hospital stay Earlier return to work Higher hospital costs, overall similar total expenses Similar or lower recurrence rates

TAPP vs TEP 1 RCT Length of stay was shorter in the TEP group (mean difference: -0.70 days, 95% CI -1.33 to -0.07; p=0.03) Schrenk, British Journal of Surgery 1996

TAPP vs TEP Systematic review 13000 patients Higher trocar site hernia: 0.8-3.7% Higher visceral injury: 0.4-0.9% vs 0-0.23% Wake BL, Cochran database, 2007

TAPP vs TEP 1 RCT Systematic review No differences in OR time, LOS, recurrence, return to activity Systematic review TAPP Higher port site hernias Higher visceral injuries TEP More conversions

Special Situations Primary Hernia Recurrent hernia Scrotal hernia Following previous appendectomy, lower midline surgery, retropubic prostatectomy, c-section Recurrent hernia Following open hernia repair Following TEP Indirect >direct Missed hernia, inadequate dissection Mesh failure: too small, inadequate positioning,?fixation Following TAPP Mesh size, mesh migration, recurrence along mesh slit Scrotal hernia Inguinodynia

Primary Inguinal Hernia Following Previous Lower Abdominal Surgery Operative approach TAPP TEP Lower midline surgery Limited balloon dissection on ipsilateral side Appendectomy Place balloon on contralateral side with limited lateral dissection

Primary Inguinal Hernia Following Previous Lower Abdominal Surgery Outcomes- TEP 1388 patients/10 years 171 previous lower midline incision Enterotomy: 3 All in early experience Cystotomy: 4 Schwab JR. et al. Surg Endosc. 2002

Primary Inguinal Hernia Following Previous Lower Abdominal Surgery Outcomes- TEP 150 patients comparative study Operative time: No previous surgery = lower midline non prostate surgery Previous prostatectomy > others Conversion to TAPP Greater in previous prostatectomy group Complications No enterotomies or cystotomies Dulucq et al. Surg Endosc. 2006

Recurrent Hernia/Preperitoneal Mesh TEP after TEP No balloon dissection Stay anterior to old mesh Ligate epigastrics as necessary Sharp dissection Insert foley if necessary Outcomes 1526 hernias/14 years 21 TEP after TEP 5 conversions to open No complications Ferzli et al, Hernia 2006 Ferzli et al, Surg Endosc 2004

Recurrent Hernia/Preperitoneal Mesh TAPP Peritoneal visualization Adhesions Open peritoneum 2-3 centimeters above mesh If plane is not accessible between mesh and peritoneum, dissect between mesh and transversalis Outcomes 5005 TAPP 46 recurrent follow LHR No enterotomies 2 cystotomies 1 testicular atrophy Leibl, BJ et al. JACS, 2000

Scrotal Hernia Relative contraindication for laparoscopic approach? TAPP probably easier than TEP

Scrotal Hernia TAPP 191 scrotal hernias two recurrences (30 mo f/u) 42 (22%) recurrent median of 65 min ( vs 45 mins) Major complications: 1.6% (vs. 0.6%) Minor complications: seroma, 10.5% needing evacuation two recurrences (30 mo f/u) Bittner et al Surg Endosc ,2000