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Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
increased risk of injury (BMI, previous surgery,
position of scars, suspicion of adhesions, etc.).
Implementation of the available evidence should
Recommendations
5 Grade B: Lipomas of spermatic cord/
optimize the decision-making process in choosing a particular technique to enter the abdomen
during laparoscopy [14].
Aer an unsuccessful attempt in the umbilical region preferably with safety tests or having a
high intraperitoneal pressure when starting gas
insuations [15], “Palmer’s” point in le hypochondrium can be chosen [14]. If in any doubt,
the Hasson approach is recommended [17].
Quite oen, substantial funicular lipomas or preor retroperitoneal fat prolapse into the enlarged
hernia orices ring [26–29]. ey should be
retracted and eventually resected, as they may
become symptomatic or mimic a recurrent hernia
[30]. An overlooked lipoma is one of the known
9.2.3 Trocar Choice, Placement,
andPositioning
reasons of “recurrence” [31]. Although the published data provides low evidence, the search for
and exclusion of such masses is an integral part of
What Kind ofTrocars Should BeUsed?
Is There Any Relation Between Trocar
Type andRisk ofInjury and/or Trocar
Hernias?
the endoscopic hernia repair [32, 33].
Large Direct Hernia Sac andIncidence
ofSeromas
93
round ligament and the preperitoneal
lipomas of direct and femoral sacs
should be removed
9
Statements
5 Level 1B: The radially dilating trocars
cause less acute injuries (bleeding at trocar site) and less chronic tissue damage
(trocar hernias)
Recommendations
5 Grade A: The cutting trocars should be
avoided
e design of dilating instead of cutting trocars
contributed signicantly to decrease the risk of
port-site bleeding and development of port-site
hernias [7, 14, 22–25].
9.2.4 Special Technical Remarks
Cord Lipoma
Statements
5 Level 2C: Cord lipomas or lipomas in
the femoral canal may imitate primary
hernia and hernia recurrence or become
symptomatic in later course
Statements
5 Level 2B: The incidence of seromas
in direct hernias can be significantly
reduced when the lax transversalis fascia
is inverted
5 Level 2C: Seroma is a common early
postoperative minor complication in
endoscopic preperitoneal hernia repair
Recommendations
5 Grade B: In voluminous direct hernias,
the extended transversalis fascia should
be inverted and fixed to Cooper’s ligament
A prospective nonrandomized study demonstrates signicantly lower incidence of postoperative seromas in the group of patients with direct
hernias and transversalis fascia inversion, without
increase of postoperative pain despite the use of
invasive xation with tacks to the Cooper’s ligament [34]. In some expert reports, xation with
sutures is recommended as a less expensive alternative. A cautious use of supercial electrocoagulation to obliterate blood and lymphatic vessels
has also been suggested to reduce seroma formation [7, 22].
94
R. Bittner et al.
9.2.5 Mesh Choice, Mesh Size, Mesh
Slit, andMesh Fixation
mesh size of 7×12cm [40]; the other compared
TEP with Lichtenstein with 5-year clinical examination of 1370 patients when using a mesh size
Does theUse ofaLarger Mesh
Prevent Recurrence After
Laparoscopic Inguinal Hernia Repair?
of 12× 15 cm and showed a recurrence rate of
3–5% [41].
Animal data have suggested that a minimum
of 3cm mesh overlap is essential to prevent mesh
protrusion through the hernia defect resulting in
Statements
5 Level 2A: A small mesh may be a risk
factor for recurrence after laparoscopic
inguinal hernia repair
5 Level 5: Insufficient dissection of the
preperitoneal space makes it difficult to
place a large mesh properly and avoid
folds and wrinkles
5 Fixation does not compensate for inad-
equate mesh size
recurrence [42].
It should be emphasized that dissection of the
preperitoneal space has to be adequate for the size
of mesh to ensure that the mesh lies at against
the abdominal wall [37, 43, 44].
Some surgeons routinely cut the mesh making
it curved, i.e., rounding o the edges. is is not
necessary, but may diminish the mesh size signicantly. Instead, the dissection should be thorough
with a complete parietalization and a wide exposure of the entire preperitoneal space to ensure a
at positioning of the mesh.
9
Recommendations
5 Grade A: A mesh size of at least
10×15cm is recommended
5 Grade D: Use a bigger mesh (i.e.,
12×17cm or greater) for large hernias
(direct >3–4cm, indirect >4–5cm)
Mesh size may have a greater impact on recurrence than surgical technique [35, 36]. A small
mesh has been shown to be an independent risk
factor for recurrence compared with a large one,
irrespective of the type of mesh, i.e., light- or
heavyweight [37].
Data extracted from a recent meta-analysis of
open versus laparoscopic hernia repairs provide
some information about this issue [38]. A signicant trend toward reduced recurrence rates with
increasing mesh size was noted (a “large” mesh
was most oen of 10× 15 cm size). Indeed, use
of a small mesh almost doubled the risk for recurrence [38]. A large retrospective series which
included 3017 patients undergoing TAPP inguinal herniorrhaphies showed a 5% recurrence rate
using an 11 × 6 cm mesh in 325 repairs and a
0.16% recurrence rate using a 15×10cm mesh in
3205 repairs [39].
ere are two large randomized studies from
Sweden: one compared TAPP with Shouldice
with a 5-year follow-up of 920 patients and
showed a recurrence rate of 6.6% when using a
Should theMesh Have aSlit or Not
toSurround theSpermatic Cord?
Current Statements
5 Level 1: Cutting a slit in the mesh to
allow the structures of the funicle to pass
through does not compromise testicular
perfusion and testicular volume
5 Level 3: There are no important differ-
ences between slitting and no slitting
for complications or recurrences (except
one study (Bittner)),but the incidence of
chronic pain and neuralgia is higher
Current Recommendations
5 Grade B: In most of the cases, cutting
a slit in the mesh to create a new inner
inguinal ring should be avoided
9.2.6 Comments
We identied one randomized trial [45]. In this
three-armed study including 360 patients, a TAPP
procedure was performed. In group A, the mesh
was implanted through a central incision, creating a deep inguinal ring by overlapping the two
incised sides. In groups B and C, a non-incised
mesh was used which was xed with staples in
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
group B and with nonabsorbable sutures in group
C.e authors reported no signicant dierences
between the groups regarding operation times,
Recommendations
5 Grade B: A thorough closure of perito-
postoperative complaints, and need for pain killers. Furthermore, they found only one recurrence
in group C (no recurrences in group A and B).
5 When suturing the peritoneum, reduc-
Moreover, we found one comparative study
with historical controls [46] including 2700
TAPP procedures from a single institution. Aer
a median follow-up time of 26 months, there
were 28 recurrences, 9 (0.3%) of which were due
to insucient closure of the mesh slit. From the
same institution, a later prospective study involving 8050 procedures without slit in the mesh
reported an overall recurrence rate of 0.4% [47].
We identied one new randomized trial [48].
In this trial [1] 40 patients undergoing TEPP were
randomized to a slit or no slit. Doppler ultrasound was performed preoperatively, day 5 and
aer 6months. ere were no signicant dierences in testicular perfusion and volume.
Finally, one case-control study [49] with a
retrospective design compared 78 patients undergoing TEP with a slit mesh with 300 patients
undergoing TEP with a no-slit mesh. Number
e bowel obstruction can develop due to adhesions between omentum or epiploic appendices
and suture line, between the mesh and the intestines, e.g., by inadequate closure of a peritoneal
lesion [50–54]. e peritoneal opening must be
thoroughly closed in order to prevent contact of
viscera with the prosthetic mesh material and to
reduce the risk of bowel obstruction. e closure can be achieved with staples, tacks, running
suture, or glue. e last two methods mentioned
are more time-consuming but less painful [7, 22].
e reduction of intra-abdominal pressure
(e.g., 8mmHg or even less) facilitates the peritoneal closure during the running suture especially
in dicult cases [7, 22].
of patients included was not based on a power
analysis. Patients had a 12 ×15cm polypropylene mesh. Clinical recurrences were seen in 0.6%
9.2.8 Port-Site Closure
in the slit group and in 6% in the no-slit group
(P<0.01), but chronic testicular pain and neuralgia were more oen aer slit mesh implantation
(p<0,009). Moreover follow-up aer 3years was
Statements
5 Level 2A: Use of 10mm trocars or larger
either with telephone interview or clinical examination; however, the study quality was questionable since signicant bias may have been involved
in patient selection for slit versus no slit, e.g.,
mean follow-up in the non-slit group was nearly
double compared to the slit group.
us, there is no convincing evidence to sup-
port use of a slit in the mesh for laparoscopic
Recommendations
5 Grade B: Trocar sites with fascial defects
inguinal hernia repair.
95
neal incision or peritoneal tears larger
than 1cm should be done
tion of the intra-abdominal pressure
should be done
may predispose to hernias, especially in
the umbilical region or in the oblique
abdominal wall
of 10mm or larger should be closed
9
9.2.7 Peritoneal Closure
Statements
5 Level 3: Incomplete peritoneal closure
or its breakdown in endoscopic preperitoneal hernia repair increases the risk of
bowel obstruction
Port-site hernia is a late postoperative complication predominantly reported in TAPP repair.
Although, according to general opinion, only
10 mm and bigger trocar site defects should be
closed, the development of incisional hernia with
consequences was described even with 3–5mm
trocars [55–59].
A review of 63 reports (24 case reports, 27
original articles, 7 technical notes, and 5 review
96
R. Bittner et al.
articles) was published in 2004 [60]. e evi-
9.3 Specic Risks
dence level of these reports varies from 1 to 3.
Recommendation B concerns the closure of trocars of 10mm or bigger.
Specic risks of TAPP in comparison to open
inguinal hernia repair are (1) injuries to the bowel,
(2) injuries to the urinary bladder, (3) injuries to
the aorta and iliac vessels, (4) bowel obstruction,
9.2.9 Conclusion onTechnical Key
and (5) trocar hernias.
Points inTAPP Repair
Ad 1 Creating the pneumoperitoneum and place-
The multitude of data published on this subject
presents different levels of evidence, but particular technical key points are well investigated
[61, 62]. Some expert opinions lack supporting
data, but some steps of the TAPP technique are
clearly supported by strong levels of evidence.
The grade of recommendations varies from
A to D.
e proven technical key points should
become the pillars of the standardized TAPP
repair, transferred to the wide surgical commu-
9
nity and emphasized in the teaching and learning
environment to guarantee the best possible outcomes.
ment of the rst trocar are the most dangerous
parts of the operation, because both acts are blind
procedures. erefore, some authors recommend
an open access to the abdominal cavity (Hasson
technique). However, even when using this technique, lesions to the bowel are not completely
avoided (. Fig.9.30).
A systematic review of the literature could not
show any signicant dierence between the Veress
needle and the open techniques (Kukleta [3, 4]).
In our practice we use the Veress needle
but we always do the “safety tests” according to
K. Semm. When doing this it is important to
develop a specic feeling with your thumb and
. Fig.9.30 Access-related vascular complication
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
97
9
index nger which hold the needle when perforating the fascia or the peritoneum (snap test).
Furthermore it is essential to observe the insufator very carefully. In the case that when starting with the insuation the intra-abdominal
pressure is high (>2–3mmHg) and the gas ow
is low (<1ml/min), the needle has to be removed
because something may be wrong. In these cases
showing diculties when creating the pneumoperitoneum by the Veress needle, we have two
alternatives: (1) use the open technique (Hasson)
or (2) choose the “palm point” (below the le costal margin, medio-clavicular line) for the Veress
needle.
In patients with previous periumbilical sur-
gery, it should be started at the palm point.
In addition in TAPP injuries to the bowel are
possible in patients presenting with extensive
adhesions of the bowel to the inguinal region or
to the hernia sac. In these cases the indication
for TAPP must not be overstressed. e surgeon
being not familiar with adhesiolysis should better
do an open repair in these cases. But never take
down adhesions between the bowel and the hernia sac. is is not necessary and carries a high
risk for a bowel lesion. In TAPP the hernia sac
inclusive the adherent structures is reduced “en
bloc.”
e last possibility for an injury of the bowel
is accidentally by using monopolar electric for
bleeding control. erefore, when using heat
always the whole metallic tip of the instrument
must be under view control.
Ad 3 Injuries to the big vessels are exclusively
caused by inadequate rough introduction of the
trocars or applying a rough dissection technique.
When introducing the trocars, keep in mind that
the distance between the back of the abdominal
wall and the aorta is only about 3cm. It is strongly
recommended to use blunt trocars and develop a
feeling for the resistance strength of the abdominal
wall when introducing them and never lose the
view control.
Ad 4 Very rarely the postoperative course aer
TAPP may be complicated by bowel obstruction.
An insucient closure of the peritoneum or inadequate use of some suture material [63] is the cause
of this unpleasant sequela in the vast majority of the
cases. It must emphasized that a tight closure of the
peritoneal incision, best by an absorbable monolament suture, is an essential step of the operation,
because a gap of 1cm only le may lead to this
complication.
Ad 5 In contrast to TEP, more trocar hernias
occur in the later postoperative course. At the
umbilicus when using a 10mm optic trocar aer
5years, about 3.2% trocar hernias were seen [2],
despite closure of the opening intraoperatively.
erefore it may be helpful for prevention of
this late complication to reduce the diameter of
this trocar by using a 5mm optic. Furthermore
for introduction of the working trocars, a transmuscular (m. rectus abdominis) route is recommended.
Ad 2 Injuries to the urinary bladder may happen
not only in TAPP but also in TEP, as the operating
eld in the groin is identical. In patients without any
history of surgery in the preperitoneal space
between the urinary bladder and the pubic bone
(space of Retzius), the risk for a lesion of the bladder
is very low. A damage of the wall of the urinary
bladder may be caused by a rough dissection technique, by excessive use of electric coagulation, or
xing the mesh to the wall of the urinary bladder. In
order to avoid this complication, a gentle blunt dissection technique is recommended, and if there is
some bleeding, use rst a compression with a gauze
for some time, and last use bipolar electric but very
punctually. Indeed in patients aer transabdominal
prostate resection, the risk for a lesion of the urinary bladder is clearly increased, but in these
patients TAPP should be reserved for specialists.
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TAPP: Complications,
Prevention, Education,
andPreferences
ReinhardBittner, JanF.Kukleta, andDavidChen
10.1 Complications – 102
10.1.1 Ad 1: Bleeding/Lesions to the Vessels – 102
10.1.2 Ad 2. Lesions oftheInguinal Nerves – 102
10.1.3 Ad 3: Bowel Lesion – 103
10.1.4 Ad 4. Urinary Bladder Injury – 104
10.1.5 Ad 5. Hematoma/Seroma – 104
10.1.6 Ad 6. Urinary Retention/Infection – 104
10.1.7 Ad 7. Wound/Mesh Infection – 105
10.1.8 Ad 8: Bowel Obstruction – 105
10.1.9 Ad 9. Orchitis/Testicular Atrophy – 105
10.1.10 Ad 10. Trocar Hernias – 106
101
10
10.2 Pitfalls andPrevention – 106
10.2.1 Ad 1. Mismatch ofAnatomy – 106
10.2.2 Ad 2. Mismatch oftheSide oftheHernia – 108
10.2.3 Ad 3. Adhesions Between Omentum andBowel
withtheHernia Sac – 108
10.2.4 Ad 4. Pitfalls Due to Fixation Errors – 109
10.3 Education andLearning Curve – 110
10.4 Aftercare andPain Management – 112
10.5 Why do IPrefer TAPP – 113
References–116
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_10
102
R. Bittner et al.
10
TAPP is a complex technical procedure. ere are
many possibilities for complications which may
occur intraoperatively, early postoperatively, and
in the late postoperative course (. Fig.10.1).
10.1 Complications
10.1.1 Ad 1: Bleeding/Lesions
totheVessels
Injuries of the aorta, caval vein, or the iliac/
femoral vessels are very rare but life-threatening.
In one comprehensive literature overview [1], 3
out of a total of 3503 laparo-endoscopic hernia
repairs (0.09%) were observed, in another overview none out of 2997 patients [2], but there
may be a larger number unreported. In most
cases, the causes of these severe complications
were rough introduction of a trocar or a crude
operative technique. In our own experience with
more than 15,000 TAPPs, no injury of the great
vessels was seen. Injuries to the epigastric vessels which are caused when opening or closure
of the peritoneum in TAPP are more common
but rather harmless and easy to treat either with
Intra- and postoperative
complications after TAPP
1. Bleeding/lesion of vessels
2. Lesion of nerves
3. Bowel injuries
4. Urinary bladder injury
5. Hematoma/seroma
6. Urinary retention/infection
7. Wound-/mesh infection
8. lleus
9. Orchitis/atrophy testis
10. Trocar hernia
Intraoperative
Early
postoperative
Late
postoperative
electrocoagulation or by clipping. Some branches
of the inferior epigastric vessels may be injured
when introducing the working trocars especially
when using perforators with a sharp cutting tip
(. Fig.10.2a). Using this sharp three-edged perforator, we saw bleeding from the trocar site in
0.9%, but using a perforator with a conical tip
and expanding working mechanism, the occurrence of this kind of bleeding could be reduced
down to 0.067% (. Fig.10.2b).
Preventive strategies are Deep knowledge of
anatomy. Gentle blunt dissection technique and
carefully respecting the anatomical layers. Use of
blunt perforators with expanding working tips [3].
Removal of the trocars under view and observe the
trocar site for some seconds.
10.1.2 Ad 2. Lesions ofthe
Inguinal Nerves
In the literature, the information on violations
of the inguinal nerves varies between 0.8% [2]
and 3.8% [1]. Most commonly aected is the N.
cutaneous femoris lateralis in nearly 60% of the
cases (. Fig.10.3) [4]. Nerve injuries are caused
by direct trauma to the nerve either due to rough
dissection or use of electrocoagulation for bleeding control near to the nerve. Postoperatively,
these patients will complain about some numbness or complete loss of sensitivity in the corresponding skin area. Much more worse is the case
when a clip or tack for mesh xation was put to
the nerve, because this will result in intractable
pain. In our experience, we observed a lesion to
the nerves in 0.3% but exclusively a damage to
the N. cutaneous femoris lateralis, produced by
thermic application [34].
. Fig.10.1 Intra- and postoperative complications
after TAPP
ab
. Fig.10.2 a Sharp-edged cutting perforator. b Blunt expanding perforator
Preventive strategies are Deep knowledge of
anatomy. Gentle blunt dissection technique and
TAPP: Complications, Prevention, Education, andPreferences
Traktus iliopubicus
IP
103
10
R.genitalis
N. cutaneous femoris lateralis
Triangle
of pain
. Fig.10.3 Right inguinal region. Triangle of pain, caudally of the ileo-pubic tract and laterally to the testicular vessels
n.genitofem
R.femoralis
n.genitofem.
Triangle
of pain
N. cutaneous
femoris
lateralis
. Fig.10.4 Mechanism of bowel violation by Veress needle or electrocautery
carefully respecting the anatomical layers especially
the deep layer of the transversalis fascia. Avoid use
of monopolar electric in the region of the “triangle
keeping down adhesions aer surgery in the
lower abdominal cavity to gain access to the groin
(
. Fig.10.4).
of pain” (. Fig.10.3), and this is a law: Don’t put
clips or tacks in this region and up to 1–2cm above
of the ileo- pubic tract.
Preventive strategies are In patients aer previ-
ous periumbilical surgery, use open access (Hasson)
or the Palm point (see above). Be maximally careful when gaining rst access to the abdominal cav-
10.1.3 Ad 3: Bowel Lesion
ity. Adhesions to the groin or to the hernia sac must
not be taken down; in these cases the incision of the
According to the literature, lesions to the bowel
are described between 0% [2] and 0.1% [1]. In
our own experience, it happened in 0.1% (47).
e cause of this life-threatening complication
may be a direct violation by the Veress needle or
by electrocautery or during adhesiolysis when
peritoneum should atypically be carried slightly
above the adhesions. Always keep the whole metal-
lic tip of the instruments when using heat under
direct vision. In cases with excessive adhesions of
the bowel with the anterior abdominal wall, it may
be advisable to convert to open surgery.