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

• 1990s– 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 – Decrease recurrence• Rolling up of mesh

• No fixation– Decrease pain– Decrease cost

Mesh placement

• Size:– 4x6

• Material– Polypropylene– Polyester

• Slit

FixationWhen Tacking, Where to Tack

• Trend toward limited tacks• Coopers ligament (inferior-

medial)• Rectus Sheath (superior-

medial)• Above Iliopubic tract

(lateral)

• 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

FixationAlternative to Tacking

Mesh fixation

• No fixation• Fixation– 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– 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

– 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 2006Ferzli 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 HerniaTAPP

• 191 scrotal hernias– 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