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

2. 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

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

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

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

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

7. Mesh placement
Size:
4x6
Material
Polypropylene
Polyester
Slit

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

9. 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

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

11. Lap vs Open Meta-analysis Forty-one studies 7161 participants
Longer OR times (14 mins, 95% CI: )
Less hematomas (OR: 0.72, 95% CI: , only TEP vs open)
Less wound infection (OR: 0.45, 95% CI: )
Higher risk of visceral injury (OR: 5.76, 95% CI: )
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: )
Less numbness at 1 yr (OR 0.38, 95% CI )
McCormack, K. Scott, Cochran database, 2007

12. 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

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

14. TAPP vs TEP Systematic review 13000 patients
Higher trocar site hernia: %
Higher visceral injury: % vs %
Wake BL, Cochran database, 2007

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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