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114
R. Bittner et al.
. Fig.10.16 A 15years
of experience with TAPP
(1993–2007, Marienhospi-
tal Stuttgart)
Offen [Shoulddice, Lichtenstein] laparoskopisch [TAPP]
1200
[n]
1000
800
600
400
200
0
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
10
. Table10.1 Types of hernia in 15,000 TAPPs
II (indirect)
IIIa (direct)
IIIb (ind./komb.)
IIIc (femoral)
IV (Rec. Hernie)
Scrotal
Irreducible
Strangulated
4537
5594
3096
483
1965
807
477
161
32.2%
40.8%
22.9%
3.6%
13.0%
5.3%
3.2%
1.1%
7. In TAPP additional abdominal operations
arepossible, e.g., cholecystectomy
(. Fig.10.20).
8. TAPP is an excellent operation for strangulated
hernias.
For an expert surgeon in TEP, it might be possible
to repair a strangulated hernia but not without
doing laparoscopy. It makes more sense to do a
TAPP, because during the whole operation it is
possible to observe the perfusion of the strangulated bowel and its recovery (
. Fig. 10.21).
Following this concept, frequency of bowel resection in these cases is signicantly reduced compared to open surgery [31].
. Fig.10.17 Bilateral hernia, left side detected
Intraoperatively
9. In TAPP repair of scrotal hernias is easier.
In scrotal hernia (. Fig. 10.22), the complete
reduction of the hernia sac may be dicult and
time-consuming; however, in TAPP dissection is
easier due to more clear anatomy from the beginning and the possibility to see the hernia sac
not only from outside like in TEP but also from
inside. erefore, it is possible to detect any adhesions between the bowel and the omentum and
the hernia sac; accordingly, dissection and use of
heat for bleeding control can be adapted.
abc
TAPP: Complications, Prevention, Education, andPreferences
115
Mesh
. Fig.10.18 a Bilateral hernia. b Indirect recurrence due to lateral uprolling of the mesh. c Sigmoid sliding hernia
abc
10
. Fig.10.19 a Recurrent hernia after open repair: Two defects, medially and supravesically. b Recurrence after open
repair: indirect and direct defect. c Recurrence after TAPP due to insucient medial overlapping
Surgery in the space of Retzius or Bogros produces more or less scar tissue; therefore, sepa-
. Fig.10.20 Starting with TAPP, then after closure of
the peritoneum additional cholecystectomy
ration of the anatomical layers may be very
dicult. However, in contrast to TEP the pathologic characteristics of the hernia as well as the
10. In TAPP inguinal hernia repair in patients
aer previous preperitoneal groin surgery
(transabdominal prostate resection, hernia
mesh repair) is easier.
anatomical structures are very clear to identify in
laparoscopic repair. us, TAPP can successfully
be performed even in these dicult cases [32, 33]
(. Fig.10.23).
. Fig.10.21 TAPP in strangulated hernia
116
R. Bittner et al.
. Fig.10.22 Scrotal hernia
10
a
b
Scar tissue in
the space of
Retzius
Scar tissue+
mesh
. Fig.10.23 a Recurrence after preperitoneal mesh repair and b TAPP after previous transabdominal prostrate resection
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C. Teaching and training in laparoscopic inguinal
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LP, Weidema WF, Steyerberg EW, Lange JF, Bonjer HJ,
Jeekel J.Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a longterm follow-up study. Arch Surg. 2012;147(3):256–360.
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Cregan P, Scott D, Maddern GJ.Surgical simulation: a
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versus video for teaching laparoscopic knot tying in
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WF, Sarr MG, Farley DR. Simulation-based mastery
learning improves patient outcomes in laparoscopic
inguinal hernia repair: a randomized controlled trial.
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29. Slater GH, Jourdan I, Fölscher DJ, Snook AL, Cooper M, D’Allessandro P, Rangeley C, Bailey ME. The
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of a subperitoneal patch under pre-peritoneoscopy.
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31. Leibl BJ, Schmedt CG, Kraft K, Kraft B, Bittner R.Laparoscopic transperitoneal hernia repair of incarcerated
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Surg Endosc. 2001;15:1179–83.
32. Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R.Recurrence after endoscopic transperitoneal hernia repair
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the reoperation. J Am Coll Surg. 2000;190:651–5.
33. Wauschkuhn CA, Schwarz J, Bittner R. Laparoscopic
transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively
collected data of more than 200 cases. Surg Endosc.
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34. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ.
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Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry
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Klinge U, Koeckerling F, Kuhry E, Kukleta J, Lomanto D,
Misra MC, Montgomery A, Morales-Conde S, Reinpold
W, Rosenberg J, Sauerland S, Schug-Paß C, Singh K,
Timoney M, Weyhe D, Chowbey P. Update of guidelines
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Technique Total
Extraperitoneal Patch
Plasty (TEP): Standard
Technique andSpecic
Risks
FerdinandKöckerling, PradeepChowbey, DavideLomanto,
andMauriceArregui
11.1 History–120
11.2 Standard Technique–120
11.2.1 Patient Preparation–120
11.2.2 Antibiotic Prophylaxis–120
11.2.3 Thromboembolic Prophylaxis–120
11.2.4 Patient Positioning–120
11.2.5 Anesthesia–121
11.2.6 Team Positioning–121
11.2.7 Instruments–122
11.2.8 Placement oftheTrocars–122
11.2.9 Dissection–125
11.2.10 Mesh Placement–131
119
11
11.3 Specic Risks–134
11.3.1 Bilateral Inguinal Hernias–134
11.3.2 Recurrent Inguinal Hernias–134
11.3.3 Scrotal Hernias–135
11.3.4 Incarcerated Hernias–135
11.3.5 Previous Lower Abdominal, Pelvic, andUrological
Surgery, Vascular Operations, andAscites–135
11.3.6 Patients withCoagulopathy or Antithrombotic
Therapy–136
11.3.7 Patients Older Than 65Years–136
References–137
© 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_11
120
F. Köckerling et al.
11
11.1 History
Following the rst laparoscopic transabdominal
inguinal hernia repair involving the implantation of polypropylene material in the form of a
mesh [1] or with plug and mesh [2, 3], the TAPP
approach using no additional plugs was established and is now in widespread use [4].
Initial experience with totally extraperitoneal
hernioplasty was reported in Europe in 1991 by
the French surgeon Dulucq [5] and in the USA by
McKernan [6] and Phillips [7]. In 1992 and 1993,
Ferzli [8, 9] also published a report on an “endoscopic extraperitoneal hernia repair” (EEPH)
technique.
11.2 Standard Technique [10–13]
11.2.1 Patient Preparation
On the day of the operation, the patient is shaved
from the costal arch to the pubis.
Immediately prior to being brought into the
operating room, the patient is asked to empty his
bladder. Routine transurethral catheterization is
not indicated on account of the not infrequent
complications such as urinary tract infection and
urethral stricture, and, anyway, a partially lled
bladder hardly impairs preperitoneal dissection.
In exceptional cases, a full bladder, however,
requires intraoperative insertion of a catheter,
which is removed again prior to anesthesia termination.
e guidelines for laparoscopic (TAPP) and
endoscopic (TEP) treatment of inguinal hernia of
the International Endohernia Society (IEHS) recommend that the patient empty his/her bladder
before the operation. Only if technical diculties
are expected (e.g., aer prostatic surgery, scrotal
hernia) or an extended operating time is the use
of a urinary catheter considered during the intervention [12].
11.2.2 Antibiotic Prophylaxis
Analysis of the Herniamed Registry patient group
with laparo-endoscopic inguinal hernia repair
(n=48.201) did not identify any signicant inuence of antibiotic prophylaxis on postoperative
impaired wound healing and deep infection [14].
In the Consensus Development Conference on
endoscopic repair of groin hernias of the European
Association for Endoscopic Surgery, a statement
is given that there is not enough evidence to support the routine use of prophylactic antibiotics in
elective endoscopic groin repair [15].
In the guidelines of the IEHS [12], antibiotic prophylaxis for elective laparo-endoscopic
inguinal hernia repair is not universally recommended. Antibiotic prophylaxis should be
considered in the presence of risk factors for
wound and mesh infection based on the patient
(advanced age, corticosteroid usage, immunosuppressive conditions and therapy, obesity, diabetes, and malignancy) or surgical complications
(contamination, long operation time, drainage,
urinary catheter) [12].
11.2.3 Thromboembolic Prophylaxis
Because thromboembolic complications have
been very rarely reported aer inguinal hernia
surgery, there has been a debate about whether
thromboembolic prophylaxis is needed at all in
the absence of risk factors [12]. Moreover, the
laparo-endoscopic techniques might involve risks
from altered venous ow due to CO2 insuation
and the reverse trendelberg position [12]. e
IEHS Guidelines recommend that thromboembolic prophylaxis be given according to the usual
routines in patients with risk factors [12].
11.2.4 Patient Positioning
e patient is placed supine on the operating
table. Depending on the intraoperative situation, adoption of a Trendelenburg position and
tilting of the table toward the surgeon may
be useful, since the resulting shi of abdominal contents enlarges the preperitoneal space
accordingly and facilitates the dissection. In the
event of a unilateral hernia, the patient’s arm on
the ipsilateral side can be placed at 90°, since
the surgeon and his assistant both stand on
the contralateral side to the hernia. For bilateral hernias, both of the patient’s arms must
be placed at his side to permit unobstructed
working (
. Figs.11.1, 11.2).
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
121
11
11.2.5 Anesthesia
As a rule, we carry out TEP under general anesthesia, since we consider spinal anesthesia to be
contraindicated for the following three reasons:
1. In patients in whom general anesthesia is
contraindicated for cardiopulmonary reasons,
the uncontrollable absorption of CO2 from
the preperitoneal space and from an inadvertent lesion-related pneumoperitoneum,
hypercapnia of varying degree is possible,
. Fig.11.1 Positioning of the patient on the operating
table for repair of a right-sided unilateral inguinal hernia
in TEP technique
which, in the presence of impaired pulmonary function, might not be compensated via
the respiration.
2. A Trendelenburg position necessary to ensure
appropriate dissection and mesh placement
may cause problems due to the possibility of
anesthetic rising within the spinal canal.
3. To maximize the preperitoneal space and
enable optimal mesh implantation, we consider muscular relaxation to be necessary.
11.2.6 Team Positioning
Aer disinfection of the skin and application of
sterile drapes, the surgeon takes up a position
on the contralateral side to the hernia, with his
assistant on the ipsilateral side. Once the working trocars have been placed, the assistant then
changes sides and takes up a position behind
the surgeon (. Fig.11.2), enabling unobstructed
camera work without coming into conict with
the surgeon’s arms. e monitor of the endoscopy
unit is positioned at the foot end of the patient on
the side of the hernia and in the case of bilateral
hernias can easily be moved to the contralateral
side. e instrument nurse is on the same side as
the surgeon with the instrument table in front of
. Fig.11.2 Position of
operating team in a unilateral right-sided inguinal
hernia
122
F. Köckerling et al.
11
her such that she has an unobstructed view of the
operating eld and the video monitor. e cables
for camera, light, diathermy, and the CO2 line
should be on the contralateral side to the hernia,
thus enabling unobstructed access to the working
trocars (. Fig.11.1). An irrigation-sucking device
is not routinely required. In the event of bilateral
hernias, the surgeon, on completion of the dissection of the rst side, moves over to the other side.
11.2.7 Instruments
e following laparoscopic instruments have
demonstrated their worth in TEP: an atraumatic
ne 5mm grasper, a 5mm Overholt forceps, and
a 5mm Metzenbaum scissors for dissection, electrocautery hook, a 10mm swab forceps for punctiform hemostasis and also dissection, a 5mm needle
holder with axial handle, a 10mm clip forceps for
endoclip sutures, and a knot pusher (. Fig.11.3).
For TEP, we almost always use a 30° optic.
11.2.8 Placement oftheTrocars
e IEHS Guidelines recommended direct access
with the Hasson trocar via a 1–2cm subumbilical incision on the side of the hernia and opening of the rectus sheath, enlargement of the space
between the rectus muscle and the posterior
rectus sheath [12]. Balloon dissection should be
considered for extraperitoneal space creation,
especially during the learning period, when it is
dicult to nd the correct plane in the preperitoneal space [12].
Via a roughly 1–2-cm-long, infraumbilical
curved transverse incision (. Fig.11.4) followed
by blunt dissection of the subcutaneous tissue
using three small Langenbeck hooks (. Fig.11.5),
the anterior rectus sheath is incised transversely
on the inguinal hernia side. To avoid bleeding from the abdominal rectus muscle, a primary short incision with a No. 11 blade is made
(. Fig.11.6) and extended medially and laterally
. Fig.11.4 1–2-cm-long, infraumbilical curved trans-
verse incision for a left-sided unilateral inguinal hernia
. Fig.11.3 Instruments and trocars for TEP procedure
. Fig.11.5 Blunt dissection of the subcutaneous tissue
using Langenbeck hooks (left side)
. Fig.11.6 Transverse incision of the anterior rectus
sheath in a left-sided unilateral inguinal hernia
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
using the dissection scissors (. Fig.11.7). Aer
adequate incision in the anterior rectus sheath,
the medial margin of the abdominal rectus muscle is displaced laterally using a small Langenbeck
hook (. Fig.11.8). Following digital dissection, a
dissection balloon trocar is advanced dorsal to the
muscle on the posterior rectus sheath (. Fig.11.9)
down to the pubis (. Fig.11.10) using a twisting
motion and elevation of the trocar tip during the
process. e trocar is inserted in the midline to
avoid tearing the epigastric vessels or their side
branches. Under video-endoscopic control the
. Fig.11.10 The dissection balloon trocar is pushed
down to the pubis using twisting motion and elevation of
the trocar tip during the process (left side)
a
123
11
. Fig.11.7 Extension of the incision in the anterior
rectus sheath by using a scissor (left side)
. Fig.11.8 The rectus muscle is displaced laterally
using a small Langenbeck hook, and the posterior rectus
sheath becomes visible (left side)
b
. Fig.11.11 Under video-endoscopic control a the bal-
loon is inated in the preperitoneal space b (left side)
. Fig.11.9 A dissection balloon trocar is advanced dor-
sal to the muscle on the posterior rectus sheath (left side)
balloon is inated within the preperitoneal space
(
. Fig. 11.11) while observing the landmark
structures (pubic bone with Cooper’s ligament,
inferior to the epigastric vessels, abdominal