TEPP AND TAPP
LAWRENCE C. BISKIN, MD
With the remarkable success of laparoscopic cholecystectomy, a new approach for hernia repair has become forever embedded in the surgeon’s armamentarium.
To accept laparoscopic inguinal hernioplasty, first the posterior approach must be accepted. In 1920, Cheatle  developed the preperitoneal approach to groin herniorrhaphy. Henry  reintroduced the repair in 1935, but it was not until 1960 that Nyhus popularized the posterior approach . The next step for surgeons was to alleviate the fear of prosthetic infection. Synthetic mesh was used in France in 1949 by Acquaviva  and not until 1959 in the United States by Usher .
The value of a tension-free prosthetic posterior repair was first demonstrated by Stoppa  in 1965. In the 1980s, Lichtenstein  demonstrated the value of a tension-free prosthetic anterior repair. In the prelaparoscopic era, the majority of inguinal hernias were repaired by a nonprosthetic anterior approach; and with Lichtenstein’s excellent results, the use of a prosthesis for anterior repairs gained universal acceptance.
In 1982, Ger  closed the neck of inguinal hernia sacs with intraabdominal placement of Michele clips, then in 1989 demonstrated a laparoscopic technique for hernia sac closure . Around the same time, Schultz et al  presented the laparoscopic plug and patch technique. This marked the beginning of the laparoscopic hernia learning curve.
McKennan and Laws  then presented a totally extraperitoneal approach. Mesh was initially secured with sutures, and balloon dissectors were not available, making preperitoneal dissection tedious and timely with an average operative time of 76 minutes. Nevertheless, the results were excellent noting few complications and a recurrence rate of 0.3% . This was comparable to recurrence rates in the open preperitoneal approaches of Nyhus  (1.7%) and Stoppa  (1.4%).
During the developmental phase of laparoscopic hernioplasty, basic surgical principles were often overlooked, resulting in high recurrence rates and complications only rarely seen with open techniques. Skepticism was high until technical improvements and operative experience helped decrease recurrence rates to 0.3% for the TAPP and TEPP repairs [14,15]. Leibl  analyzed phases of the repair; and by keeping the technique and surgeons constant, he demonstrated the importance of the learning curve. If cost is based partially on time, the reduction of operating room time will reduce the overall cost. The only way to reduce operation time is for the surgeon to operate through the learning curve in order to improve his or her performance (Figure 1) [14,16,17,18,19,20].
Reluctance to perform laparoscopic hernioplasties is proportional to the learning curve and inversely proportional to reimbursement rates. Hospital costs were initially high due to long operating times . With unilateral repairs now less than 30 minutes, costs have decreased substantially. Conclusions have been made using a decision analytic approach that from a societal perspective, laparoscopic hernia repair is a cost-effective operation associated with higher quality of life benefits . Studies comparing open and laparoscopic hernia repair are problematic due to patient and investigator bias, surgeon and technical inconsistencies, and various social influences .
Utilization of the laparoscopic technique for only bilateral and recurrent hernias would minimize the surgeon’s experience because this group represents a small percentage of total hernia patients. Appropriate patient selection is important because a primary unilateral hernia is usually without scar tissue, providing a truss was not used and the anatomy is not displaced or distorted. By first performing 25 to 50 unilateral primary endoscopic hernioplasties, confidence and proficiency will improve rapidly .
Surgical training programs are now integrating into their teaching facilities’ inanimate labs with specialized trainers, cadaver dissection , virtual reality, telemedicine, and experienced surgeons to instruct the residents. Didactic and hands-on skills have become an integral part of the curriculum so that graduating surgeons clear the learning curve before entering private practice. Over the past decade, practicing surgeons had to rely on weekend courses, individual proctorships, and self-teaching. Now, fellowships are available for advanced laparoscopic training. The use of a simulator combined with didactic sessions improves operative performance, technical knowledge, and comfort in performing the operation. A valuable learning method for residents and practicing surgeons is to review their own performance by taping the operation and then reviewing it later in the day in a relaxed atmosphere. This method will eliminate inefficient and potentially dangerous maneuvering in future procedures.
The choice of TEPP (totally extraperitoneal) or TAPP (transabdominal preperitoneal) endoscopic hernioplasty is ultimately made by the surgeon, but it is important that the type of operation conforms to the patient and not the reverse. Random techniques and random searches for anatomic structures must be avoided. Consistency will minimize anatomic surprises and potential complications.
An advantage of the TAPP approach is a shorter learning curve because the landmarks are easier to identify. With TAPP, a hernia on the contralateral side can easily be seen without tissue dissection; however, cord lipomas will be missed unless the cord is properly manipulated in the preperitoneal space, which is best done with the TEPP approach. Incarcerated large scrotal hernias (Figure 2), recurrent hernias previously repaired via the posterior approach, and patients with prior prostate or bladder operations are best approached with TAPP . A complication that seems to be unique to the TAPP repair is postoperative bowel obstruction secondary to incarceration between defects in the improperly closed peritoneum. To prevent this problem, the peritoneum should be closed with a continuous running suture. With TEPP, the peritoneum is not opened, which not only saves time, but also diminishes the possibility of adhesions and possible bowel obstruction. If the peritoneum cannot be completely closed, then it can be left open and specialized mesh [Parietex (polyester/gel)/Composix (poly-propylene/PTFE)/Sepramesh (polypropylene/Seprafilm)/Bard-Dulex/Dualmesh (PTFE-Corduroy)] is utilized to minimize bowel adherence and possible fistulization. Other potential drawbacks of the TAPP approach are port-site hernias , injuries to the inferior epigastric vessels secondary to lateral trocar placement, and bowel injuries from intraabdominal manipulation and adhesiolysis.
General anesthesia is utilized for the majority of cases; however, TEPP can be done successfully with local [14,27] and spinal anesthesia . The TEPP repair is better tolerated in patients with minimal cardiac reserve because the CO2 is contained within the pelvic preperitoneal space.
In addition to good video equipment, proper graspers and S-retractors are instrumental in facilitating a smooth operation. The use of scissors and thermal energy is usually unnecessary and should be minimized to avoid vascular and visceral injuries [28,29]. Equipment that should be available for certain situations includes 5- and 10-mm clip appliers or hemolocks, suturing equipment, and 5-mm camera lenses. Foley catheters are not necessary, as they will generate more complaints from the postoperative patient than the actual operation.
The dissecting balloon rapidly develops the preperitoneal space without significant bleeding and the structural balloon keeps the space open to allow safe instrument handling. Innovative techniques to replace these balloons may be cheaper but are less effective and ultimately may increase operating time and subsequent cost.
The choice of mesh must meet the surgeon’s as well as the patient’s needs. It must be soft and pliable not only to conform to the patient’s anatomy and minimize postoperative stiffness, but also to permit easy insertion through the trocar. Mesh transparency and adhesiveness are also important qualities because wide interstices minimize displacement and help identify structures beneath the mesh. Placement of the mesh behind the epigastric vessels is unnecessary and time-consuming. Spiral tacks have replaced staples to fix the mesh in position, and the placement and number of tacks should be consistent. No more than 6 tacks total should be used with 2 in Cooper’s ligament, 2 in the rectus muscle, and 2 in the lateral wall, well above the ileopubic (IP) tract. The placement of staples or tacks too close to or below the IP tract has led to injuries of the lateral femoral cutaneous nerve (meralgia paraesthetica) [30,31] (Figure 3). Careful external abdominal wall pressure will prevent skin penetration by the tack during deployment. Fibrin glue fixation or no mesh fixation at all will minimize potential nerve and vascular injuries but the long-term success rate of these techniques has not been proven [32,33].
For high-riding cords or large hernia defects, wrapping the cord with the mesh and then buttressing with a second piece is an effective technique. If the mesh is wrapped too tightly, it can erode through the cord [34,35]. However, if done carefully no significant difference occurs in postoperative complaints or problems as confirmed by duplex flow studies of the testicular vessels .
Large indirect hernias can be repaired with minimal complications by adhering to certain technical principles. Use a bowel preparation preoperatively and be prepared to convert to or commence with the TAPP approach. If incarcerated, attempt to reduce the hernia after induction of general anesthesia before prepping. If unsuccessful, prep the penis and scrotum into the field because intraoperative external manipulation may be required. Use a Foley catheter to keep the bladder decompressed. Open the sac if necessary to reduce the hernia, but do not dissect the sac off the cord because this increases potential injury to the cord structures. Divide the sac, leave the distal sac in place, and close the proximal sac. This does not increase hydrocele formation .
Excess manipulation of the cord may rarely cause testicular atrophy or hypoazoospermia by increasing serum antibody levels. Damage to the retroparietal sheath beneath the cord increases the contact between the mesh and external iliac vessels, which may limit access for future vascular and lymphatic procedures. If it is possible that vascular reconstruction, lymph node dissection, or prostate surgery will be needed, then hernia repair is best done at the same time to avoid future tedious and dangerous dissection through fibrotic tissue .
Patients with lower abdominal incisions may have an insignificantly higher incidence of complications and recurrence from laparoscopic hernia repairs . Prior operations with lower midline/paramedian and even transverse scars (Pfannenstiel) are only relative contraindications to the TEPP repair because balloon dissection can usually proceed away from the incisions.
Postoperative hematomas and seromas are common after repair of direct hernias. They can be prevented by tacking the pseudosac to the rectus muscle or Cooper’s ligament to eliminate the dead space (Figure 4). If a fluid collection does occur, it will usually resolve spontaneously after 6 weeks. If it does not resolve or is symptomatic, then sterile aspiration is appropriate. Postoperative groin swelling with a fluid wave can easily be misinterpreted as a recurrence. Hasty reoperation should be avoided. Scrotal swelling, subcutaneous (SQ) emphysema, even pneumomediastinum are not uncommon and will resolve spontaneously after several days.
A distinct advantage of the laparoscopic repair is that bilateral inguinal hernias can be repaired simultaneously through the same incisions by adding only a few minutes to the operative time. Not only is this very cost-effective, but the morbidity and recurrence rates are unchanged [40,41]. Other operations performed simultaneously without additional incisions are umbilical herniorrhaphies and vasectomies. Infection rates are extremely low, probably because the mesh is placed through the trocar and never touches the skin.
Many good hernia operations are available, and the optimal operation should be decided by several factors, including age, operative history, sex, size of the patient and hernia, unilateral or bilateral, primary or recurrent, incarcerated or reducible, general medical condition, and the patient’s expectations. The establishment of a comprehensive national hernia register will not only improve overall quality of care, but patient satisfaction will be optimized. Tremendous variation exists in the time when a patient returns to work, and factors other than operative technique must be considered .
When patients are selected properly and surgeons are well trained and experienced, laparoscopic hernioplasty is performed with excellent results. Because overall outcomes are improved with the surgeon’s experience, some studies advocate the move toward hernia specialists . Prospective outcome evaluation will determine whether the performance of specialized groups of surgeons can be reproduced .
Figure 1. TEPP average operating time.
Figure 2. Large incarcerated indirect hernia.
Figure 3. Lateral femoral cutaneous nerve.
Figure 4. Tack direct hernia pseudosac.
Address reprint requests to: Lawrence C. Biskin, MD, 100 Delafield Rd, Ste 213, Pittsburgh, PA 15215, USA. Tel: 412 784 5100, Fax: 412 784 5102, E-mail: firstname.lastname@example.org
Lawrence C. Biskin, MD, McGill University in Montreal, Quebec. He completed a 2-year fellowship in Surgical Nutrition in Houston, Texas in the mid-1980s. His surgical residency was completed at Western Pennsylvania Hospital and he is now actively operating in solo surgical practice at UPMC St. Margaret Hospital in Pittsburgh, Pennsylvania.
Dr Biskin is actively involved in developing new laparoscopic techniques and instruments. He began teaching courses and preceptoring laparoscopic hernioplasties over a decade ago. Now with several thousand hernia repairs, he has accumulated significant data for journal and conference presentations.
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