why/when/how to do tep and tapp archana ramaswamy md
TRANSCRIPT
Why/When/How to do TEP and TAPP
Archana Ramaswamy MD
Open Inguinal hernia repair
• 1920– Cheatle
• Preperitoneal inguinal hernia repair in recurrent hernias
• 1980s– Nyhus, Stoppa
• Preperitoneal repair with prosthetic material
• 1987– Lichenstein
• Anterior approach• Tension free repair with prosthetic material
Laparoscopic Inguinal Hernia Repair
• 1990s– Transabdominal preperitoneal (TAPP)– Totally Extraperitoneal (TEP)
Fixation in Inguinal Hernia Repair
• Fixation or no fixation– When Tacking, Where to Tack– Alternatives to Tacking
Fixation Options
• Sutures• Permanent tacks (5mm)• Absorbable tacks (5mm)• Staples (5/10mm)• Glues (5mm)• No fixation
Fixation
• Fixation – Decrease recurrence• Rolling up of mesh
• No fixation– Decrease pain– Decrease cost
Mesh placement
• Size:– 4x6
• Material– Polypropylene– Polyester
• Slit
FixationWhen Tacking, Where to Tack
• Trend toward limited tacks• Coopers ligament (inferior-
medial)• Rectus Sheath (superior-
medial)• Above Iliopubic tract
(lateral)
• N-butyl-2-cyanoacrylate glue• Fibrin sealant application– Good: Temporary mesh stabilization– Bad: may increase cost, cumbersome
application device (though improving)• Bioabsorbable Tacks
• Good: Temporary Fixation (about 3 to 6 months depending on the product)
• Bad: Recently on the market, may increase cost
FixationAlternative to Tacking
Mesh fixation
• No fixation• Fixation– Medially- Cooper’s– Laterally- anterior iliopubic tract– Anteromedial
• Bilateral– Overlap mesh medially
Lap vs Open• Meta-analysis – Forty-one studies
• 7161 participants • Longer OR times (14 mins, 95% CI: 13.98-15.64)• Less hematomas (OR: 0.72, 95% CI: 0.60-0.87, only TEP vs open) • Less wound infection (OR: 0.45, 95% CI: 0.32-0.65)• Higher risk of visceral injury (OR: 5.76, 95% CI:1.53- 21.68)
– 7 vs 1, 6 in TAPP group• Return to usual activities was faster by 7 days (p<0.001)• Less persisting pain at 1 yr (OR: 0.54, 95% CI: 0.46-0.64)• Less numbness at 1 yr (OR 0.38, 95% CI 0.28-0.49)
McCormack, K. Scott, Cochran database, 2007
TEP vs Open
• Systematic review– 4231 patients• Longer OR time• Shorter hospital stay• Earlier return to work• Higher hospital costs, overall similar total expenses• Similar or lower recurrence rates
TAPP vs TEP
• 1 RCT– Length of stay was shorter in the TEP group (mean
difference: -0.70 days, 95% CI -1.33 to -0.07; p=0.03)
Schrenk, British Journal of Surgery 1996
TAPP vs TEP
• Systematic review– 13000 patients– Higher trocar site hernia: 0.8-3.7%– Higher visceral injury: 0.4-0.9% vs 0-0.23%
Wake BL, Cochran database, 2007
TAPP vs TEP
• 1 RCT– No differences in OR time, LOS, recurrence, return
to activity• Systematic review– TAPP• Higher port site hernias• Higher visceral injuries
– TEP• More conversions
Special Situations• Primary Hernia
– Following previous appendectomy, lower midline surgery, retropubic prostatectomy, c-section
• Recurrent hernia– Following open hernia repair– Following TEP
• Indirect >direct• Missed hernia, inadequate dissection• Mesh failure: too small, inadequate positioning,?fixation
– Following TAPP• Mesh size, mesh migration, recurrence along mesh slit
• Scrotal hernia• Inguinodynia
Primary Inguinal Hernia Following Previous Lower Abdominal Surgery
• Operative approach– TAPP– TEP• Lower midline surgery
– Limited balloon dissection on ipsilateral side
• Appendectomy– Place balloon on contralateral side with limited lateral
dissection
Primary Inguinal Hernia Following Previous Lower Abdominal Surgery
• Outcomes- TEP• 1388 patients/10 years
• 171 previous lower midline incision• Enterotomy: 3
– All in early experience
• Cystotomy: 4
Schwab JR. et al. Surg Endosc. 2002
Primary Inguinal Hernia Following Previous Lower Abdominal Surgery
• Outcomes- TEP– 150 patients comparative study – Operative time:• No previous surgery = lower midline non prostate
surgery• Previous prostatectomy > others
– Conversion to TAPP• Greater in previous prostatectomy group
– Complications• No enterotomies or cystotomies
Dulucq et al. Surg Endosc. 2006
Recurrent Hernia/Preperitoneal Mesh
• TEP after TEP– No balloon dissection– Stay anterior to old mesh– Ligate epigastrics as necessary– Sharp dissection– Insert foley if necessary
• Outcomes– 1526 hernias/14 years– 21 TEP after TEP– 5 conversions to open– No complications
Ferzli et al, Hernia 2006Ferzli et al, Surg Endosc 2004
Recurrent Hernia/Preperitoneal Mesh
• TAPP– Peritoneal visualization• Adhesions
– Open peritoneum 2-3 centimeters above mesh– If plane is not accessible between mesh and
peritoneum, dissect between mesh and transversalis
• Outcomes– 5005 TAPP– 46 recurrent follow LHR– No enterotomies– 2 cystotomies– 1 testicular atrophy
Leibl, BJ et al. JACS, 2000
Scrotal Hernia
• Relative contraindication for laparoscopic approach?
• TAPP probably easier than TEP
Scrotal HerniaTAPP
• 191 scrotal hernias– 42 (22%) recurrent – median of 65 min ( vs 45 mins)– Major complications: 1.6% (vs. 0.6%)– Minor complications: seroma, 10.5% needing
evacuation• two recurrences (30 mo f/u)
Bittner et al Surg Endosc ,2000