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104
R. Bittner et al.
10
10.1.4 Ad 4. Urinary Bladder Injury
In literature, damages to the urinary bladder are
described between 0.07% [2] and 0.1% [1] of the
cases with laparo-endoscopic hernia repair. In our
own setting, we saw this complication in 0.1% of
TAPP patients [34], nearly exclusively aer previous
surgery in the preperitoneal pelvic space (e.g., transabdominal prostate resection, preperitoneal mesh)
presenting with severe adhesions (. Fig.10.5). Cave,
sometimes the urinary bladder, may be part of the
hernia sac and can be injured when the surgeon is
not aware of this (. Fig.10.5 le). Dissection of the
preperitoneal space (Retzius) is quite easy in patients
having had no previous surgery (. Fig.10.5, right,
above), but may be extremely dicult in patients
aer previous prostate resection (open and laparoscopically which makes no dierence) or aer previous TAPP or TEP (. Fig.10.5 right, low).
Preventive strategies are Gently performed
blunt dissection of the space of Retzius. In cases in
which severe adhesions are to be expected, choose
an open repair except great experience in such difcult cases is provided [5].
common complications; in so far the real occurrence is not exactly known. According to the
literature aer laparo-endoscopic hernia repair,
hematomas are observed in between 4.4% [2]
and 13.1% [1] of the cases and seromas between
4.4% [2] and 12.2% [1] of the cases. In our own
large series, we saw bleeding complications in
0.3% and seromas in 0.1% (reoperated) of our
patients [34]. e diagnosis is made by ultrasound (. Fig.10.6a, b).
Prevention strategies Anticoagulation with cou-
marin derivatives should be stopped and replaced
by low-molecular heparin (Quick >60%). Other
anticoagulation drugs like aspirin, Plavix, and
Xarelto should be nished about 8days before the
operation. Dissection in the anatomical layers and
meticulous bleeding control. Furthermore, it is recommended that in large direct hernia the pseudosac
should be inverted and xed to Cooper’s ligament
in order to reduce the dead space (. Fig.10.7).
10.1.6 Ad 6. Urinary Retention/
Infection
10.1.5 Ad 5. Hematoma/Seroma
In some clinical reports, it is not dierentiated
between hematoma and seroma. Moreover,
there are no clear denitions of these relatively
According to the literature aer laparo- endoscopic
hernia repair, urinary retention is reported about
3.5% [1] and 3.8% [2] of the cases, in one singlecenter study even up to 22.2% (10). In our own
large series, we saw urinary retention in 0.5% of
our patients and an infection in 0.1% only [34].
Rektus
Symphyse
Blase
. Fig.10.5 Laparoscopic view of the groin in a patient
after transabdominal prostate resection. Right supe-
rior: Spatium of Retzius in a patient without previous
operation. Right below: Completely scarred preperitoneal
space after previous mesh implantation
TAPP: Complications, Prevention, Education, andPreferences
105
10
. Fig.10.6 a Hematoma
along the cord. b Seroma
within the scrotum after
repair of a scrotal hernia
Preventive strategies are Gentle dissection in the
a
b
space of Retzius to minimize the trauma to the wall
of the urinary bladder. Emptying the urinary bladder immediately before the patients leave for the
operating theater. Restriction of liquid infusion
during anesthesia to a maximum of 500ml. Routine
use of urinary catheters is not recommended.
Hematoma
Seroma
10.1.8 Ad 8: Bowel Obstruction
Bowel obstruction is very rare and reported anec-
dotically. We saw this complication in three cases
(0.03%), who needed a reoperation [34]. e
cause was in all cases a reopening of the perito-
neal closure.
10.1.7 Ad 7. Wound/Mesh Infection
According to the literature aer laparo- endoscopic
hernia repair, the occurrence of wound infection is
reported between 0.5% [2] and 1.0% [1] of the cases;
in our large series, we saw a wound infection in
about 0.04% (47). But all of these patients received
“one-shot” antibiotic prophylaxis. A mesh infection
was seen in 0.1% of the cases. In most of these cases,
the infection occurred aer a puncture of a seroma.
Preventive strategies are Aspiration of seromas
should be avoided. Sometimes absorption of a large
seroma needs several months. Adequate guidance
of the patients and control by ultrasound are important. Any contact between the mesh and the skin
must be avoided. e value of antibiotic prophylaxis
is debatable; however, antibiotic prophylaxis should
be considered in the presence of risk factors like
advanced age, corticosteroid usage, immunosuppressive conditions, and obesity [35–37].
Preventive strategies are Careful tight closure of
the peritoneal incision by an absorbable running
suture (see
10.1.9 Ad 9. Orchitis/Testicular
7 Chap. 9).
Atrophy
Orchitis and atrophy of the testis are rare compli-
cations aer laparo-endoscopic hernia repair; in
literature, a frequency of between 0.15% [2] and
0.6% [1] is reported. In our total experience of
more than 15,000 TAPPs, we saw an atrophy of
the testis in six patients (0.04%), but the last was
20years back. Four of these six patients suered
from a complex hernia (three recurrent scrotal
hernias, one recurrence aer TAPP). In all these
patients, the hernia sac was very close to the
testicle. When trying to completely remove the
hernia sac, the blood circulation must have been
destroyed near the testicle.
10
R. Bittner et al.
106
Faszia transversalis
Pseudo-sac
. Fig.10.7 Direct hernia. The enlarged transversalis
fascia (hernia pseudosac) is inverted and xed to Cooper’s
ligament with suture or tacks
between the frequency of trocar hernias and the
diameter of the trocar, the shape of the tip of the
perforator, and the place the trocar is inserted.
Montz FJ etal. [7] could show that in nearly 90%
of these patients a trocar with a diameter equal or
larger than 10mm was used in the patients who
developed a trocar hernia in the later course.
Ridings P and Evans DS [6] reported a frequency
of 7.7% trocar hernias when using cutting trocars,
but they observed not any hernia when using blunt
trocars with a conical tip which is working expanding. Similar results were observed by us: Using
sharp trocars the frequency of trocar hernias was
1.27%, but using blunt trocars the frequency was
0.01% only. Furthermore, the risk is signicantly
increased when the midline is used for inserting
the trocars [8]. In our long-term study 5years aer
TAPP, we saw in 3.2% of the patients a trocar hernia at the umbilicus and not any at other positions.
Preventive strategies are (1) Use trocars as small
as possible. As now 5mm optics are available; there is
no longer a need for 10mm trocars at the umbilicus.
In order to bring in a standard mesh, a 7mm working trocar (see above) is sucient. In special cases
when using an extra-light mesh, it is possible to insert
it through a 5mm trocar. For the second working
trocar, a 3mm or 5mm trocar can be used. (2) Insert
only trocars with a blunt expanding working tip. (3)
For cosmetic reasons the umbilicus is an ideal place
for trocar placement, but it should looked for if at the
umbilicus some weak tissue is present. In these cases
aer removal of the trocar, the opening should be
closed like it is performed in an umbilical hernia.
Preventive strategies are Don’t dissect too close
to the testicle. In case of a long hernia sac showing
dense adhesions to the cord, cutting of the hernia sac
is recommended (see 7 Chap. 9). e distal part of
the sac should be le open; the proximal part of the
sac must be closed by suture. Furthermore, in unclear
hernia pathology it is recommended rstly to identify the vessels lateral/caudal near the kidney and
then use the vessels as guiding structures to dissect
the hernia sac up to the top (see 7 Chap. 9).
10.1.10 Ad 10. Trocar Hernias
Trocar site hernias (. Fig. 10.8) can occur in up
to 7.7% [6]. ere seems to be a clear relationship
10.2 Pitfalls andPrevention
As complications aer TAPP can occur with any
surgeons, pitfalls are as a rule caused by lack of
knowledge of the anatomy or of proper operative
technique. Pitfalls are rare and only anecdotally
described, however, from such unpleasant mishaps we can learn and better understand the principles of the operative procedure. e following
reports some events which actually happened.
10.2.1 Ad 1. Mismatch ofAnatomy
First case e surgeon mistook the femoral vein
with a femoral hernia sac (. Fig.10.9a). He tried to
TAPP: Complications, Prevention, Education, andPreferences
107
10
. Fig.10.8 Trocar hernia
ab
Pubic bone
Femoral vein
D. deferense
N. obturatorius
. Fig.10.9 a Mismatch of the femoral vein with a femoral hernia sac. b Mismatch of the N. obturatorius with the
ilioinguinal nerve
reduce the hernia sac, but this was impossible;
therefore he decided to cut the sac, and not before
doing this he became aware that he had cut the vein.
hernia repair; therefore he decided to perform a
neurectomy of the ilioinguinal nerve. It is unclear
why, but he resected the obturator nerve
Os pubis
Vena fem.
(. Fig.10.9b). Aer the operation, the patient not
Second case A female patient complained about
intractable pain in the groin aer open inguinal
only continued to have pain but also diculties
when walking.
10
ab
108
R. Bittner et al.
. Fig.10.10 a Clear visible large hernia defects on both sides. b No defect is visible, but clinically and by ultrasound
seen a large lipoma in the inguinal canal mimicking a hernia
10.2.2 Ad 2. Mismatch oftheSide
oftheHernia
Not always the hernia defect is clearly visible at
laparoscopy (. Fig.10.10a). In many cases, despite
unequivocal clinical diagnosis no hernia opening
can be seen (. Fig. 10.10b). In the rule the reason for this may be a large lipoma representing
the hernia pathology without any deep hernia sac
(. Fig.10.10b). Unfortunately, it can happen that
on the contralateral side, some excavation may be
visible and then the surgeon operates on that side.
erefore, it is recommended that preoperatively
the location of the hernia should be marked.
10.2.3 Ad 3. Adhesions Between
Omentum andBowel
withtheHernia Sac
Case report: Male, 49 years, scrotal hernia.
Laparoscopy: Adhesions between parts of the
omentum and of the bowel with the hernia sac.
Procedure: Firstly sharp adhesiolysis of the hernia content from the hernia sac with scissor,
then TAPP. Dicult closure of the peritoneum
because of multiple defects due to the adhesiolysis. Postoperative course: Pain right lower abdomen and right ank. At third postoperative day
urologic consultation – in CT scan – suspected
abscess formation. At h PO day reoperation:
Severe peritonitis and abscess due to some lesions
in the wall of the small bowel. Next day: Septic
shock and death of the patient. Conclusion: Two
severe mistakes, (1) unnecessary adhesiolysis and
injury to the bowel and (2) too late reintervention.
. Fig.10.11 Indirect hernias, omentum, and sigmoid
bowel are adherent to the hernia sac
Preventive strategy It is not necessary but dan-
gerous to release adhesions between the hernia sac
and the hernia content intraoperatively found
(. Fig. 10.11). Hernia sac and hernia content
should be reduced “en bloc” without touching the
content.
TAPP: Complications, Prevention, Education, andPreferences
109
10
10.2.4 Ad 4. Pitfalls Due to Fixation
Errors
Case 1
Male, 49years, 25 clips/tacks for xation of the
mesh and closure of the peritoneum (. Fig.10.12).
Postoperatively severe pain in the groin, not possible to walk for 7days. With painkiller improvement, but under physical stress intensity of pain
increased again. Furthermore, suering of pain
when emptying the urinary bladder, with bowel
movements, and during sexuality.
a
b
Case 2
Female, 43years, BMI 20,3: Bilateral TAPP.Twenty-ve
spiral tacks for xation of the mesh and closure of the
peritoneum. Postoperatively severe pain VAS 7. After
3month’s pain and defense right lower abdominal
quadrant, thickening of the wall of the ascending
colon. Reoperation: Fistula between one spiral tack
and the coecum. Removal of 12 tacks and closure of
the stula. Because of persisting pain 2months later
removal of 13 tacks from the other side and removal of
both meshes. Result: Still persisting severe foreign body
feeling not being able to do any physical activities.
Case 3
Male, 52years. Unilateral TAPP.Fixation of the
mesh and closure of the peritoneum with staples.
Postoperatively intractable pain (Meralgia paresthetica) in the groin and numbness proximal lateral skin
of the thigh. Fifteen days later laparoscopic reoperation: Removal of a piece of mesh (2×2cm) lateral/
cranial in the region of the spina iliaca anterior superior and removal of six clips. Postoperatively pain and
numbness persisted. Seventeen months later open
removal by a neurosurgeon of an additional clip
which was sticking in the femoral cutaneous nerve.
As the neurosurgeon didn’t see any mesh in this
region, it must be assumed that this clip was placed
not to x the mesh but to close the peritoneum.
N. femoralis
N. cutaneous
A
B
femoris
lateralis
N. genitofemoralis
. Fig.10.12 X-ray of the groin after tack-xation
Case 4
Male, years. Bilateral TAPP.Fixation of the mesh with
glue. Early recurrence on one side. Reoperation
after 10days: Direct recurrence, no mesh medially (dislocation?). Implantation of a second mesh
but now xation with clips. Postoperative course:
Urinary retention and hematuria, treated by Foley
catheter for 24h. Three months later while jogging
occurrence of hematuria. Cystoscopy veried mesh
within the urinary bladder (. Fig.10.13). Open
reoperation by a urologist and resection of this part
of the wall of the urinary bladder. The pathologist
found mesh and clips sticking into the wall of the
urinary bladder.
110
R. Bittner et al.
Average is smooth
Learning
Experience
. Fig.10.14 A learning curve averaged over many
trials is smooth and can be expressed as a mathematical
function
10
Inside urinary bladder
. Fig.10.13 Cystoscopy: Mesh inside of the
urinary bladder
Preventive strategies Laparo-endoscopic hernia
repair works according to the principle of Pascal. In
so far in the vast majority of the cases, a xation of
the mesh is not necessary if the mesh has an adequate size (at least 10×15cm) and an overlapping
of about 5cm is guaranteed (3,4,9). Fixation is rec-
defect with a diameter larger than 3–4cm. In these
rather rare cases, an atraumatic xation with glue
should be applied; only in very large direct defects
(>4cm) absorbable tacks may be used. But tacks
should only be applied to the rectus muscle and to
Cooper’s ligament which must be clearly anatomically identied. A mesh xed by glue or tacks cannot move or migrate but may penetrate if xed to
the urinary bladder or near the bowel.
e peritoneal incision should never be closed
by clips or tacks but by an absorbable running
suture. Suture closure is less expensive and safer
and causes less pain.
10.3 Education andLearning Curve
Laparo-endoscopic hernia repair is considered
to be a dicult operation with a long “learning curve” and not suitable as an operation for
trainees. e learning curve is dened as the
number of TAPPs that is needed to acquire the
necessary skills. A learning curve is a graphical representation of the increase of learning
(vertical axis) with experience (horizontal axis)
(Wikipedia) (
. Fig.10.14).
e goals in hernia surgery that must be
achieved are low morbidity, low recurrence
rate, and low rate of acute and chronic pain.
Accordingly, duration of learning curve in laparoendoscopic hernia surgery means number of
procedures needed to achieve the average plateau
in the rate of complications and undesired side
eects which is reported in literature.
e familiar expression “a steep learning
curve” is intended to mean that the activity is difcult to learn, although a learning curve with a
steep start actually represents rapid progress. In
order to avoid this rather confusing terminology,
it seems to be better the term learning curve with
meanings of easy and dicult should be described
with adjectives like short and long rather than
steep and shallow (Wikipedia).
However, the data published that described
education and how to overcome the learning
curve in inguinal hernia repair are extremely
contradictory. Some studies evaluated the learning curve by studying the operation time [9–14],
conversion rate [9, 10, 12, 15, 16], or number
of recurrences [36, 9, 10, 15–18]. According to
these studies, between 20 and 240 procedures are
required for the learning curve to reduce operation time, morbidity, and recurrence rate to a
stable level in line with experienced surgeons. e
TAPP: Complications, Prevention, Education, andPreferences
111
10
cause for the large dierences in the number of
operations necessary to become familiar with the
new technique lies in the remarkable heterogeneity of these studies. Many factors may inuence
the learning curve, including previous individual
and institutional experiences in hernia surgery,
and specically in the laparo-endoscopic technique. Furthermore, the number of hernia repairs
in the respective institution performed per year
may be important, as may be the selection of
patients for laparoscopy, the details of the technique and their standardization, and the structure of the training. In addition individual skill
preexisting experience of the trainee with other
laparoscopic procedures like cholecystectomy,
the number of prestudy camera guiding, and
the strictness and duration of supervision by an
experienced surgeon may play a role when dening the learning curve. In analyzing the literature,
you will not nd any study in which all these factors are included when estimating the duration
of the learning curve. In this context, it is important to dierentiate between the learning curve
of surgeons establishing this new technique and
the learning curve of young surgeons working
in a hospital where TAPP already has been fully
standardized and is performed as a daily routine
procedure. Our large study [19] about more than
15,000 cases clearly demonstrates that senior surgeons well experienced in open surgery who had
started laparoscopic inguinal hernia repair had
needed signicantly more operations to decrease
morbidity and recurrence rate down to today’s
standard level than did trainees who started not
before TAPP was a well-standardized procedure
in the hospital. Moreover, the total morbidity in
the patients operated on by the trainees was signicantly lower than those operated on by the
pioneers, which amounted to a level of 3–4%
already in their rst lot of operations (operations
1–50). Even more strikingly, in the patients operated on by the trainees, we observed a recurrence
rate that was less than 1% even from the beginning. Accordingly, our overall results achieved
by the 23 individual surgeons included in the
hernia program demonstrate that it is just the
operation time that demonstrates a signicant
learning curve. erefore according to our large
experience, TAPP is not just a surgery for specialists but also for young surgeons in training, who
can achieve excellent results [19]. Without any
doubts, operation time is longer when performed
by less experienced surgeons or trainees, but this
does not inuence long-term results, and the
trainees demonstrated a continuous improvement
in terms of the operation time. ese results are
in sharp contrast to the reports in the literature.
One study reported a recurrence rate of 14.3% in
patients operated on by less experienced surgeons
(level 1, 10 procedures performed), but 2.4% for
experienced surgeons (level 3, 25 hernia repairs)
[20]. A large randomized clinical trial reporting
long-term results of 1183 patients operated on in
seven surgical centers by a total of 12 TAPP surgeons found the recurrence rate at the dierent
hospitals to range between 5% and 13% and for
the individual surgeons 0–23% [38]. A further
large randomized controlled trial [39] including
12 hospitals and 22 TEP surgeons demonstrated
a 5-year recurrence rate ranging from 0% to 32%
for the individual surgeons and 0 and 13.5% for
the dierent hospitals. ese extremely large differences in the quality of hernia surgery between
hospitals and individual surgeons who had taken
part in the abovementioned studies demonstrate
clearly that there is an urgent need for strictly
standardization of the technique worldwide and
a better structured education as well [36, 11, 14,
15, 17, 40]. Learning curve must only be a mat-
ter of duration of operating time but not a matter
of quality of performance. In our department, in
which TAPP is completely standardized, a gradually increasing number of younger surgeons and
trainees became familiar with the new technique,
but education must be well structured. e preconditions that the trainee will be included in the
operation program are: (1) Trainees should do
camera guiding for at least 50 times. (2) Trainees
should have some previous experience with laparoscopic operations (25 laparoscopic cholecystectomies). (3) e operations should be done under
the guidance of experienced surgeons until gaining sucient prociency; thus, many pitfalls and
intraoperative problems could be anticipated and
possible complications prevented. (4) TAPP must
be strictly standardized, which made it easier
for young trainees to become familiar with the
laparoscopic anatomy and the operative strategy.
In a similar study regarding the TEP technique,
Haidenberg etal. [17] came to the same conclusion. ey demonstrated that under structured
guidance by an experienced endoscopic surgeon,
young trainees benet from the knowledge of
the more senior surgeon. e experience and
112
R. Bittner et al.
10
knowledge that the more experienced surgeons
gained when establishing the new surgical technique can be passed on, thus avoiding typical
possible problems in operations performed by
the trainees.
In accordance with Miserez et al. [21], we
advocate a stepwise learning of TAPP.is saves
time and is more relaxing for both the trainer and
the trainee. In our experience, it is best to start
with intra-abdominal suture closure of the peritoneum because there is no danger to the patient.
e next step is the opening of the peritoneum,
then dissecting the medial compartment, mesh
placement and glue xation, and last, dissecting
the hernia sac (most dicult and dangerous). In
order to learn more easily and eectively, video
recordings of the trainee operation should be created and analyzed in the clinical rounds aerward.
In the discussion about making the operation
more acceptable, operating time is an important
issue, as is shortening the learning curve, e.g., a
trainee will need more than 30min solely to perform suturing the peritoneum for the rst time.
Considering the economic situation of most
hospitals, such long operation times are hard for
management to bear. Furthermore, as a result of
current restrictions on resident duty hours and
the huge increase in bureaucratic obligations,
trainees spend less and less time in the operating
theater. us, there is an urgent need to organize
training more eciently. In this context, training surgeons outside the operating room with
simulation-based strategies (computer, video,
model) is gaining increasingly more importance
[22–27]. Several studies have demonstrated that
trainees who practice laparoscopic skills in a
simulated environment demonstrate improvement of those skills when tested in the same environment, but Zendejas etal. [28] were the rst
to demonstrate that a simulation-based mastery
learning decreased operating time, improved
trainee performance, and decreased intra- and
postoperative complications aer laparoscopic
inguinal hernia repair. Skills training consisted of
supervised practice sessions using the Guildford
MATTU TEP hernia model [29] and standard
laparoscopic equipment. A similar model [19]
was developed in our department in cooperation
with the company Karl Storz, allowing model
simulation training of four steps of TAPP: opening the peritoneum, placing the mesh, and xing
and suturing closed the peritoneum.
In summary, laparoscopic hernia repair is
a well-accepted technique in inguinal hernia
repair that has signicant benets regarding all
pain- associated parameters when compared to
open surgery. Moreover, we demonstrated that
laparoscopic hernia repair is a safe and promising method even if performed by young trainees. Laparoscopic hernia repair should therefore
be an elementary part of the trainee program.
Under the precondition that TAPP is well established in the clinic, that the operative technique
is strictly standardized, and that there is a wellstructured educational program, learning curve
does not necessarily have to mean higher complication rates and recurrence rates. e depth of
experience presented in this study demonstrates
that the learning curve can be reduced to the
operating time. In order to shorten the operating time and thereby make the surgery more
ecient, model simulation training is strongly
recommended.
10.4 Aftercare andPain
Management
Immediately aer passing the recovery room,
the patient is allowed to drink and to have some
light meal. e mobilization starts when the
patient needs to empty his urinary bladder. It is
important that the patient gets up out of the bed,
and when doing this for the rst time that he is
guided to the toilet by the nurse. Aer successful
rst mobilization, the patient can do it by himself
next times. Moreover, he will be encouraged to
carry his own clothes and walk around as much
as possible.
All patients are advised to stay at least one
night in the hospital for safety reasons. e morning aer the operation, the patient is allowed to
have a shower. en, an ultrasound examination is performed and if there is no pathologicanatomic peculiarity to be seen, the patient can be
discharged home. All patients receive a standardized prophylactic pain medication with ibuprofen
600 mg three times daily plus stomach protection with 20 mg pantoprazole once per day. At
the evening and the morning aer the operation,
pain at rest and physical stress (VAS) is recorded.
All relevant patient data are documented in the
German hernia registry “Herniamed”. When
dismissed home, the patients are asked to fully
a b
TAPP: Complications, Prevention, Education, andPreferences
113
. Fig.10.15 a Maurice Arregui with the author of this chapter and b Jean L.Dulucq during the EHS meeting in
Cologne
10
mobilize according to their body feeling without
any special restrictions; regarding the pain medication the same advice is given. e patients are
requested to come back for outpatient visit aer
5days, 4weeks, and 1 and 5years. Return to work
is recommended about 1–2 weeks aer TAPP
according to the demands of their work.
10.5 Why do IPrefer TAPP
Maurice Arregui (. Fig.10.15a) was the rst who
described reliable principles of TAPP in 1992
[41]; Jean L.Dulucq (. Fig.10.15b) was the rst
who published the TEP technique later in the
same year [30]. In both techniques, identical dis-
section of the groin is done, but the access to the
groin is dierent.
Although I am well aware that with both techniques excellent results can be achieved, in my
experience there are 11 reasons to prefer TAPP:
1. TAPP is easier to learn.
e transabdominal approach is largely independent on the body conditions of the patient, the
course of the epigastric vessels and their branches,
and possible diculties to detach the posterior
sheath of the rectus muscle, respectively, the peritoneum from the muscle, e.g., in patients aer
previous lower abdominal surgery.
2. TAPP is better to standardize.
In TAPP from the beginning, the surgeon has
a complete and clear view to the anatomical
structures and a sucient large space for dissection of the hernia sac and the cord structures.
3. Applicability in virtually all types of hernia.
e analysis of more than 15,000 inguinal hernia repairs shows that in 98% of the
patients (. Fig.10.16) and in all types of hernia
(. Table10.1), TAPP can successfully be done [42].
4. In TAPP the dissection area is less.
Although in laparo-endoscopic hernia repair the
space in the groin dissected for placement of the
mesh is just the same for both techniques, but
in TEP due to the necessary extended access the
total wound area is much larger. erefore, this
larger wound area may result in more bleeding
complications.
5. In TAPP rapid assessment of the contralateral
side is possible.
One of the advantages of laparo-endoscopic hernia repair is that in bilateral hernias both sides
can be operated simultaneously through the same
three small incisions without increasing the rate
of complication, or pain, or time of disability of
work [5]. In open surgery as well as in TEP occult,
hernias may be missed; however, in TAPP these
hernias which were not detected in clinical examination are seen with the rst laparoscopic view
(. Fig.10.17; le side).
6. In TAPP type of hernia and cause of recurrence
immediately recognizable with the rst laparoscopic view (. Figs.10.18a–c and 10.19a–c).