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199
17. TAPP vs. TEP
particularly prior mesh repairs, may have a higher conversion rate, and
consideration should be given to performing the hernia repair in a TAPP
fashion from the outset. In historical prospective randomized trials, TEP
has been associated with a higher conversion rate [ 7– 9 ] . A more recent
randomized trial showed no conversions in any of their TAPP or TEP
cases [ 5 ] . Conversion is clearly a matter of experience and likely decreases
as a surgeon becomes more facile with one or both techniques.
Cost
Argument: TEP is associated with higher supplies costs
since it requires an expensive pneumatic balloon dissector
to create the preperitoneal space.
The interpretation of cost data is unreliable, as the fi gures are country-
speci fi c and unique to each institution performing the surgery. The need
for a balloon dissector is not absolute with TEP, and the dissection can be
performed manually. In one single randomized trial, balloon dissection
was compared to CO
2
-supported trocar dissection, and there appeared to
be no difference in morbidity or recurrence rate, although balloon
dissection was associated with a lower need for conversion to TAPP and
a mean 8-min time advantage [ 10 ] . With reusable trocars and balloon-
less manual dissection, the cost of a TEP repair can be signi fi cantly
reduced. Another factor to consider is the use of a fi xation construct such
as a stapler, tacking device (metallic or absorbable), or fi brin sealant. At
least one of these products is often used in laparoscopic inguinal hernia
repair and is associated with a signi fi cant cost regardless of TAPP or TEP
approach. Two recent randomized trials of TAPP versus TEP failed to
demonstrate a cost difference between the techniques [ 5, 6 ] .
Intraoperative Complications
Argument: TAPP is associated with higher rates of vascular
and visceral injuries and port-site hernias.
To date, three studies have reported vascular injuries, one actually
demonstrated a higher injury rate in TEP [ 11 ] while the other two showed no
difference [ 12, 13 ] . Two comparative trials reported a higher rate of visceral
injury with TAPP compared to TEP, albeit the incidence was less than 1% in
both series [ 7, 8 ] . Several studies have reported on port-site hernia rate, and
it appears that TAPP has a higher incidence, upward of 3.7% [ 7 ] .
In a large study on bowel obstruction after inguinal hernia repair,
multivariate analysis demonstrated that TAPP had a relative risk of 2.79
compared to 0.57 with TEP [ 14 ] . Although the study was unable to
200
A.M. Carbonell II
determine the etiology of the bowel obstruction (hernia vs. adhesive), the
data is compelling, nevertheless. Knowledge of adhesions of the omentum
or bowel to metallic tacks or staples, as well as sutures is well-known. It
is more likely that patients undergoing TAPP repair have their peritoneal
fl ap closed with a fi xation construct, predisposing TAPP patients to the
potential sequelae of adhesions, such as bowel obstruction, or worse,
construct-bowel erosion. Newer absorbable fi xation constructs have
become available, yet it is too early to determine whether there is an
adhesion advantage to their use and the associated cost may make them
prohibitive for routine use.
TEP is associated with peritoneal tears which collapse the preperitoneal
space, making the operation lengthier, more laborious, and possibly
requiring conversion to TAPP for completion. Peritoneal tears during
TEP are commonplace, particularly with reoperative inguinal hernia
repair. Although they are related to surgeon experience, they are easily
managed by ligation of the tear or placement of an intraperitoneal Veress
needle to decompress the pneumoperitoneum. This complication does in
fact increase operative time by a mean of 20 min and is associated with
an eightfold increase in the rate of conversion to TAPP [ 15 ] . Whether the
tear should be closed at all due to the potential for bowel obstruction or
mesh adhesion bears mention. To that effect, two studies have reported
no complications after 16-month [ 16 ] and 4-year [ 15 ] follow-up in
patients in whom peritoneal tears were not closed.
Pain
Argument: TAPP is associated with higher rates of vascular
and visceral injuries and port-site hernias. TEP is associ-
ated with less pain since no peritoneal fl ap is opened and
hence the only fi xation constructs needed are the ones
placed into the mesh if any are used at all.
Fixation constructs may or may not have an impact on symptoms of
pain after the repair, as the data are con fl icting. One recent prospective
randomized trial found no difference in pain between TAPP and TEP.
The TAPP group had tack mesh fi xation and sutured peritoneal closure,
while the TEP group had no mesh fi xation [ 6 ] . Another randomized
trial avoided the use of mesh fi xation in both groups, and the TAPP
group’s peritoneal fl ap was sutured closed. This study found TAPP to
be more painful at 1 h, 24 h, and 3 months postoperative [ 5 ] . If there is
a slight pain difference, it may be transient, as one prospective study
demonstrated a higher incidence of postoperative pain with TAPP
201
17. TAPP vs. TEP
compared to TEP at 1 month, but not at 6 months or 1 year. In that
study, 18.1% of TAPP patients had >10 tacks placed, while 2.3% of the
TEP patients had >10 tacks placed. Additionally, a subgroup analysis
demonstrated less pain at all time points in TAPP patients with <10
tacks compared to those with >10 tacks [ 17 ] .
If number of tacks used is proportional to the degree of pain then
perhaps avoiding tacks or staples altogether can help eliminate pain. The
current data suggest that nonmesh fi xation in TEP, although not associated
with a decrease in pain, is safe, cheaper, and does not result in an
increased rate of recurrence [ 18 ] . Nonmesh fi xation studies in TAPP are
lacking; however, one randomized trial compared fi brin sealant versus
staples for mesh fi xation during TAPP while the peritoneal fl ap was
sutured closed. No difference in recurrence rate or postoperative pain
was noted between the two fi xation methods [ 19 ] .
Summary
In summary, the TAPP technique is easier to learn, yet is associated
with an overall low but higher risk of visceral injury and port-site hernia
compared to TEP. Surgeon preference will always drive technique choice,
as both are equally effective at treating hernia disease.
References
1. Voitk AJ. The learning curve in laparoscopic inguinal hernia repair for the community
general surgeon. Can J Surg. 1998;41(6):446–50.
2. Feliu-Pala X, Martín-Gómez M, Morales-Conde S, Fernández-Sallent E. The impact
of the surgeon’s experience on the results of laparoscopic hernia repair. Surg Endosc.
2001;15(12):1467–70.
3. Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) vs
totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.
Cochrane Database Syst Rev. 2005;(1):CD004703
4. McCormack K, Wake BL, Fraser C, et al. Transabdominal pre-peritoneal (TAPP)
versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair:
a systematic review. Hernia. 2005;9(2):109–14.
5. Krishna A, Misra MC, Bansal VK, et al. Laparoscopic inguinal hernia repair:
transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a
prospective randomized controlled trial. Surg Endosc. 2012;26(3):639–49.
6. Gong K, Zhang N, Lu Y, et al. Comparison of the open tension-free mesh-plug,
202
A.M. Carbonell II
transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic
techniques for primary unilateral inguinal hernia repair: a prospective randomized
controlled trial. Surg Endosc. 2011;25(1):234–9.
7. Cohen RV, Alvarez G, Roll S, et al. Transabdominal or totally extraperitoneal
laparoscopic hernia repair? Surg Laparosc Endosc. 1998;8(4):264–8.
8. Felix EL, Michas CA, Gonzalez MH. Laparoscopic hernioplasty. TAPP vs TEP. Surg
Endosc. 1995;9(9):984–9.
9. Van Hee R, Goverde P, Hendrickx L, Van der Schelling G, Totté E. Laparoscopic
transperitoneal versus extraperitoneal inguinal hernia repair: a prospective clinical
trial. Acta Chir Belg. 1998;98(3):132–5.
10. Bringman S, Ek A, Haglind E, et al. Is a dissection balloon bene fi cial in totally
extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter
study. Surg Endosc. 2001;15(3):266–70.
11. Khoury N. A comparative study of laparoscopic extraperitoneal and transabdominal
preperitoneal herniorrhaphy. J Laparoendosc Surg. 1995;5(6):349–55.
12. Tamme C, Scheidbach H, Hampe C, Schneider C, Köckerling F. Totally extraperitoneal
endoscopic inguinal hernia repair (TEP). Surg Endosc. 2003;17(2):190–5.
13. Lepere M, Benchetrit S, Debaert M, et al. A multicentric comparison of transabdominal
versus totally extraperitoneal laparoscopic hernia repair using PARIETEX meshes.
JSLS. 2000;4(2):147–53.
14. Bringman S, Blomqvist P. Intestinal obstruction after inguinal and femoral hernia
repair: a study of 33,275 operations during 1992–2000 in Sweden. Hernia.
2005;9(2):178–83.
15. Muzio G, Bernard K, Polliand C, Rizk N, Champault G. Impact of peritoneal tears on
the outcome and late results (4 years) of endoscopic totally extra-peritoneal inguinal
hernioplasty. Hernia. 2006;10(5):426–9.
16. Shpitz B, Lansberg L, Bugayev N, Tiomkin V, Klein E. Should peritoneal tears be
routinely closed during laparoscopic total extraperitoneal repair of inguinal hernias? A
reappraisal. Surg Endosc. 2004;18(12):1771–3.
17. Belyansky I, Tsirline VB, Klima DA, et al. Prospective, comparative study of
postoperative quality of life in TEP, TAPP, and modi fi ed Lichtenstein repairs. Ann
Surg. 2011;254(5):709–15.
18. Tam K-W, Liang H-H, Chai C-Y. Outcomes of staple fi xation of mesh versus
non fi xation in laparoscopic total extraperitoneal inguinal repair: a meta-analysis of
randomized controlled trials. World J Surg. 2010;34(12):3065–74.
19. Fortelny RH, Petter-Puchner AH, May C, et al. The impact of atraumatic fi brin sealant
vs. staple mesh fi xation in TAPP hernia repair on chronic pain and quality of life:
results of a randomized controlled study. Surg Endosc. 2012;26(1):249–54.
203
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_18,
© Springer Science+Business Media New York 2013
18. Fixation Versus No Fixation
in Laparoscopic TEP and TAPP
Viney K. Mathavan and Maurice E. Arregui
Hernias have been a subject of interest since the dawn of surgical
history. The treatment has evolved through several stages. Bassini
revolutionized the treatment of inguinal hernia by the introduction of
the technique to restore the conditions which exist under normal
circumstances. The concept of the tension-free repair was introduced by
Lichtenstein. Nyhus and Stoppa have described the inguinal hernioplasty
through the posterior approach. Nyhus used small piece of mesh to
reinforce the primary repair, but Stoppa used giant prosthesis for the
repair. The mesh used by Nyhus was small and required suture fi xation.
The approach by Stoppa used a giant prosthesis (mesh) requiring single
suture fi xation in the midline. Laparoscopic inguinal hernia was fi rst
reported by Ger and Colleagues in 1990 [ 1 ] . They repaired the hernia in
dogs by stapling the abdominal opening of patent processus vaginalis.
The other minimally invasive techniques which have been described
include plug and patch repair and intraperitoneal onlay mesh repair.
These two techniques are not commonly used. Currently, laparoscopic
inguinal hernia repairs are performed mostly with placement of synthetic
mesh into the preperitoneal space. It can be done either by transabdominal
preperitoneal (TAPP) approach or the totally extraperitoneal (TEP)
approach. The TAPP approach was fi rst described by Arregui et al. [ 2 ] in
1992. It requires laparoscopic access into the peritoneal cavity and
placement of mesh in the preperitoneal space after reducing the hernia
sac. The fi rst TEP inguinal hernia repair was described by McKernan and
Laws [ 3 ] in 1993. This approach involves preperitoneal dissection and
placement of mesh in the preperitoneal space without entering into the
abdominal cavity. Laparoscopic approach has been re fi ned into an
attractive alternative to open hernia repair for many patients and surgeons.
There is abundant literature which supports that the laparoscopic inguinal
204
V.K. Mathavan and M.E. Arregui
hernia repair can be performed with excellent results. The results of open
mesh repairs are also good and the learning curve for laparoscopic
technique is long. In the United States, about 15–20% of all inguinal
hernias are repaired laparoscopically. With most laparoscopic approaches,
mesh is fi xed to the abdominal wall with spiral tacks, clips, or sutures.
The need for fi xation of mesh, however, is controversial. Some have
suggested that fi xation of the mesh is necessary to prevent hernia
recurrence. However, fi xation of mesh is thought to contribute to
increased postoperative pain and the risk of nerve injury. The purpose of
this chapter is to describe the TAPP and TEP repair and then discuss the
literature with and without fi xation of the mesh.
Indications and Contraindications
For the patients with a straightforward, unilateral, fi rst-time hernia,
both open mesh and laparoscopic mesh repairs offer excellent results and
the choice depends upon surgeon experience and patient preference.
A Cochrane meta-analysis found no signi fi cant difference in hernia
recurrence rates between laparoscopic and open mesh techniques [ 4 ] .
Laparoscopy offers advantages for recurrent inguinal hernias previously
repaired by open technique. It bypasses the need to dissect in scarred
tissue planes, thereby avoiding the risk of orchitis, testicular atrophy, and
chronic inguinodynia. Laparoscopy also makes it possible to see the
myopectineal ori fi ce and identify the femoral hernias. The mesh can be
placed over the entire myopectineal ori fi ce. It avoids the groin incision and
subsequent risk of wound complication [ 5– 8 ] . Laparoscopic approach is
a major bene fi t for patients who present with bilateral inguinal hernias.
Studies show a signi fi cant advantage over the open repair in terms of less
postoperative pain and an earlier return to work, without fi nding any
difference in recurrence rates or complications [ 9– 11 ] . When the
diagnosis of an inguinal hernia is uncertain, diagnostic laparoscopy
provides a de fi nitive diagnosis and an opportunity to repair the hernia at
the same time. Some surgeons also think that women should undergo
laparoscopic repair of all inguinal hernias as synchronous femoral hernias
are common and can be missed. Laparoscopy is also better in patients
who engage in intense physical activity as it avoids dividing the
aponeurosis of the external oblique and minimizes scar tissue between
muscle planes. Contraindications for laparoscopic hernia repair include
patients, for whom general anesthesia is risky due to their comorbidities.
205
18. Fixation Versus No Fixation in Laparoscopic TEP and TAPP
Patients with prior pelvic operations and irradiation, or who have had a
recurrence from a prior laparoscopic approach, should undergo an open
inguinal hernia repair.
Operative Technique
The operative steps to perform TEP and TAPP repairs are similar
[ 12, 13 ] and are described below.
Operative Steps for Transabdominal Preperitoneal
Repair
The operative steps are well standardized. After transperitoneal
incision, wide dissection is done laterally, across the midline, and
parietalization of the cord is necessary to prepare the inguinal space for
placement of a large mesh. Prosthetic mesh is used for repair. A 6 × 6-in.
or 6 × 5-in. sheet of nonabsorbable mesh is cut to fi t the preperitoneal
space. A larger mesh may be used but a smaller mesh is not advised. A
preformed, contoured mesh can also be used for coverage. Some surgeons
prefer to slit the mesh with the tails wrapped around the cord. We do not
recommend this. The mesh should cover the myopectineal ori fi ces,
including the direct, indirect, and femoral hernia spaces. When the mesh
is smoothed out, it overlaps the pubic bone and crosses the midline. It is
important to examine the mesh carefully to eliminate any wrinkles or
folds. Recently, some surgeons have reported using biological mesh that
becomes a scaffold for the patient’s own collagen and is eventually
absorbed. Long-term results of this are not yet known.
Operative Steps for Totally Extraperitoneal Repair
The initial creation of the preperitoneal space can be done bluntly or
with a balloon. We prefer to use blunt dissection [ 14 ] . It is important to
perform a wide dissection especially laterally and posteriorly with
parietalization of the cord and identi fi cation and removal of herniated
preperitoneal fat (lipoma of the cord). This is necessary for placement of
a large mesh in the method of Stoppa [ 15 ] . We use a piece of 6-in. by
5-in. (15 × 12.5 cm) polypropylene lightweight mesh or Mersilene mesh.
We do not slit it. We then use two blunt graspers to lay the mesh so that
206
V.K. Mathavan and M.E. Arregui
medially it crosses the midline and covers the direct, femoral, and indirect
inguinal spaces. Laterally, it covers the lateral inguinal space
(Fig. 18.1 ).
Fixation of the Mesh
The mesh is anchored to the posterior wall of the groin by the majority
of surgeons. Mesh fi xation theoretically ensures that it will remain where
it was placed long after the operation. Such fi xation is safe in most
patients. Since the nerves at risk for injury are below the iliopubic tract,
injury or entrapment of the nerves (genitofemoral nerve, lateral femoral
cutaneous nerve, and femoral nerve) can be avoided by placing all mesh
anchors into or above the iliopubic tract. The ilioinguinal and
iliohypogastric nerves are above the iliopubic tract and can be
compromised by fi xation in thin patients. The landmarks must be
identi fi ed when placing fi xation. To avoid nerve injury, some authors
suggest that the surgeon should be able to feel the stapler by pushing
against it from anteriorly with the opposite hand. No staples should be
placed unless the stapling device can be felt with the opposite hand. It
also helps in placing the staples more perpendicular. Fitzgibbons has
pointed out, however, that the ilioinguinal and iliohypogastric nerves
travel laterally and anteriorly and can be potentially injured with this
approach. The fi rst staples are placed into the Cooper’s ligament. This
stabilizes the mesh and allows the surgeon to fan the mesh out in a lateral
direction. The staples are then subsequently placed into the transversalis
fascia medial to the inferior epigastric vessels. The lateral staples are
placed by using the bimanual technique to prevent any damage to the
Fig. 18.1. Mesh without
staples.
207
18. Fixation Versus No Fixation in Laparoscopic TEP and TAPP
nerves below the iliopubic tract. The purpose of the staples is to hold the
mesh in place until the body’s own in fl ammatory response takes place
and not to provide any strength to the repair. Many surgeons, including
us, do not use the staples. There are various descriptions of where and
how to place staples or tacks and methods to avoid nerve injury. Some
only fi x medially.
Fixation Versus No Fixation
Several investigators have questioned the need for mesh fi xation,
which has been implicated as a source of chronic inguinodynia. Mesh
fi xation is believed to prevent hernia recurrence as it is an important
measurable outcome. The mechanisms of recurrence have been studied
by many investigators and are mostly related to technique [ 16– 19 ] . One
of the most common reasons for recurrence is incomplete dissection of
the myopectineal ori fi ce. Incomplete dissection is more often associated
with inadequate reduction of the hernia sac, missed hernias, missed
lipomas or preperitoneal fat, insuf fi cient exposure for adequate mesh
size, or rolling of the mesh edges. The mesh rolling usually occurs
laterally and inferiorly in an area where fi xation is contraindicated.
Another common reason for hernia recurrence is inadequate overlap of
the hernia defect from placement of a small mesh. The average mesh size
in patients who had a recurrence was 6.0 cm × 9.2 cm in the trial by
Fitzgibbons and colleagues [ 17 ] . It is now generally believed that the
mesh size should be at least 10 cm × 15 cm to cover all of the potential
hernia sites, to provide at least 4-cm overlap with the hernia, and to avoid
problems with mesh migration, shrinkage, and rolling.
Felix et al. [ 18 ] reported too small a mesh to be the cause of hernia
recurrence in 29% recurrences and 90% of these occurred in TAPP repairs.
Inadequate lateral fi xation was one of the major causes of failure in their
review—36% of TAPP and 22% of TEP repairs. In TEP repair, there may
be a tendency not to dissect far enough off the cord structures to allow the
mesh lay under the peritoneum. In TAPP repairs, as the peritoneum is
closed, the cord structures may be tented, lifting the mesh, and may lead
to lateral recurrence. To prevent lateral recurrences, some surgeons have
utilized a keyhole, but that may lead to recurrence itself. Phillips et al.
[ 19 ] in a multicenter review of recurrence following laparoscopic hernia
repair found too small a mesh in 60% cases and non fi xation of the mesh
in 20% cases. Avoiding mesh fi xation prevents nerve entrapment. Kraus
208
V.K. Mathavan and M.E. Arregui
fi rst reported [ 20 ] damage to the lateral femoral cutaneous nerve of the
thigh and subsequently noted injury to the femoral branch of the
genitofemoral nerve [ 21 ] . The cause of injury was misplacement of staples,
and he concluded that more accurate positioning would decrease the
incidence of nerve injuries. There are numerous anecdotal reports of new
groin pain that is well localized, corresponds with the location of a fi xation
tack, and is ameliorated by its removal (Fig. 18.2a, b ). There are several
prospective randomized studies comparing stapled versus unstapled mesh
in laparoscopic preperitoneal inguinal hernia repair. Ferzli et al. [ 22 ] in a
prospective randomized study reported no difference in the hernia
recurrence rate between the stapled and unstapled groups over 12-month
follow-up period in 92 patients. Taylor et al. [ 23 ] conducted a large
prospective multicenter double-blinded randomized trial for 500 hernias
repaired with TEP. They found no difference in recurrence between stapled
and unstapled group. They also looked at pain after hernia repair. Moderate
to severe pain was reported in 2% of fi xated repairs and none in patients
with un fi xated mesh. There are several other randomized studies comparing
fi xation versus non fi xation with similar results [ 24–27 , 28 ] . Most of these
studies involve TEP repair and with small hernias. TEP without fi xation
may not be appropriate for everyone. Whether larger defects can be
repaired without mesh fi xation has not been adequately answered. Some
suggest that mesh fi xation should be used in patients with large hernial
defects. Hollinsky et al. [ 29 ] did a cadaver experiment in non fi xed mesh.
They recommended minimum mesh overlap of 2 cm for small hernias.
For a hernia size 2 cm and larger, the distance between the margin of
the prosthesis and the hernial opening should be equal to the diameter of
the hernia. From 4 cm and larger, they recommended that the prosthesis
Fig. 18.2. ( a and b ) Fixation tack on the nerve.