TAPP or TEP – which method to trust?

Abstract

INTRODUCTION. TAPP (transabdominal preperitoneal) and TEP (totally extraperitoneal) laparoscopic techniques are modern mini-invasive approaches for inguinal hernia repair and tensionfree recovery. They are based on a preperitoneal approach during implantation of the prosthetic material (mesh). Both methods provide uni- or bilateral implantation of a sufficiently large prosthetic mesh covering the weak sites of direct, indirect, femoral and obturator hernia formation, using the natural forces of intra-abdominal pressure to fix and support the mesh. Advantages include better visualization of the anatomy, faster recovery, reduced postoperative pain and a lower risk of infection. Аnatomic indicators are used for dissection and implantation of the prosthetic material and certain „critical” structures are taken under consideration, which are potential for intraoperative (vascular and spermatic cord elements lesions etc.) and postoperative (mostly postoperative chronic pain) complications.
MATERIALS AND METHODS. A retrospective analysis of 126 laparoscopic hernioplasties performed over the last 3 years was conducted, with a follow-up period from 12 to 18 months for TAPP and from 18 to 36 months for TEP.
Indicators such as mean operating time, intra- and postoperative complications, hospitalization stay from the day of operation to the day of discharge, calculated cost of the operative procedure and hernia recurrence rate for the follow-up period are used for comparison between the two techniques. 
RESULTS. A total of 66 patients underwent TAPP laparoscopic hernioplasty and 60 – TEP.
A number of 26 TAPP and 36 TEP procedures were performed in cases with bilateral inguinal hernia. There were 4 patients with femoral hernia underwent TAPP hernioplasty. There were 8 cases of conversion from TEP to TAPP. The average operating time was 300 minutes in the first 10-15 surgical interventions and 90 minutes at the end of the period. No significant difference in the average operating time between the two techniques was found. No serious intraoperative complications were reported. In eight of the TEP interventions, a small peritoneal lesion with pneumoperitoneum was noted, requiring additional placement of a Veress needle around the optic trocar in the umbilical fossa for decompression with subsequent suture of the peritoneal defect. A number of 7 postoperative seroma was reported after a TAPP intervention and two recurrent hernias during the follow-up period – one in each group. There was no significant difference in the hospital stay. The cost of the TAPP method was significantly higher due to the use of a laparoscopic tacker to fix the mesh and a “V-loc™” suture to close the peritoneal incision.
DISCUSSION. Technical skills, longer operating time and the risk of recurrence (related in the beginning of the so-called “learning curve”), the need for general anesthesia and muscle relaxation, as well as the higher cost, are disadvantages common to both methods. The advantage of the laparoscopic method in reconstructing a recurrent hernia after anterior access (including Lichtenstein) is indisputable. Both methods have their advantages and disadvantages. In the TEP method the preperitoneal dissection is achieved faster and the potential risk of iatrogenic injury to intraperitoneal organs is lower at the cost of limited working space. The originally used balloon dissectors are expensive and if the integrity of the peritoneum is compromised, pneumopreperitoneum becomes insufficient, leading to conversion to the TAPP method. The transabdominal approach provides an adequately wide working space, allows better identification of the entire inguino-femoral anatomy before extensive dissection, and is particularly suitable in cases of incarceration to assess the vitality of the hernial contents and the entire intraperitoneal viscera. Both methods are an ideal option for a recurrence after previous conventional anterior hernioplasty (with/without mesh). There are no absolute contraindications for laparoscopic hernioplasty, other than the patient's inability to tolerate general anesthesia. Previous laparotomies and interventions in the lower half of the abdomen (especially radical retropubic prostatectomy) sometimes require special attention in securing access and thorough adhesiolysis. Both methods require caution to avoid iatrogenic lesions of the so-called "corona mortis". In TAPP the peritoneal sheet covers the prosthetic mesh and is fixed to the remaining peritoneum. Fibrin glue, unlike tackers, gives less postoperative pain, and in TEP the mesh may not be fixed, as stopping the CO2 insufflation self-fixes the mesh in the preperitoneal space.
CONCLUSION. Neither method has advantages or disadvantages over the other that strictly define its application. The personal preferences and intraoperative comfort of the surgeon, as well as the characteristics of the specific type and size of the hernia determine the choice of surgical technique.