Steps of Transabdominal Preperitoneal (TAPP) Repair for Inguinal Hernia
The Transabdominal Preperitoneal (TAPP) technique is a standardized laparoscopic approach for inguinal hernia repair that involves entering the abdominal cavity to place mesh in the preperitoneal space, with a typical operative time of approximately 40-101 minutes and excellent outcomes when performed by well-trained surgeons. 1, 2
Preoperative Preparation
- Position patient supine with arms tucked
- General anesthesia is required
- Prepare and drape abdomen in standard fashion
- Empty bladder before procedure (reduces risk of bladder injury)
Step-by-Step TAPP Technique
1. Port Placement and Initial Access
- Create pneumoperitoneum using Veress needle or open Hasson technique
- Place 10mm umbilical port for camera
- Place two 5mm working ports at right and left lower quadrants at the level of umbilicus
2. Diagnostic Laparoscopy
- Inspect abdomen to confirm hernia type (direct, indirect, femoral)
- Advantage of TAPP: allows diagnosis of occult contralateral hernias 2
- Identify key anatomical landmarks:
- Inferior epigastric vessels
- Cooper's ligament
- Iliopubic tract
- Femoral canal
3. Peritoneal Incision and Flap Creation
- Make peritoneal incision 2-3cm above hernia defect
- Extend incision from medial umbilical ligament to anterior superior iliac spine
- Create peritoneal flap by dissecting peritoneum from underlying structures
4. Preperitoneal Space Dissection
- Identify and preserve key structures:
- Inferior epigastric vessels
- Iliopubic tract
- Cooper's ligament
- Vas deferens and testicular vessels (in males)
- Femoral and external iliac vessels
- Reduce hernia sac completely
- For indirect hernias: separate sac from cord structures
- For direct hernias: reduce protruding preperitoneal fat
5. Mesh Placement
- Use large polypropylene mesh (15 × 10 cm recommended over smaller sizes) 1, 3
- Position mesh to cover:
- Medial: pubic tubercle and midline
- Lateral: anterior superior iliac spine
- Superior: at least 2cm above defect
- Inferior: Cooper's ligament and femoral canal
- Secure mesh with tacks or sutures to:
- Cooper's ligament
- Anterior abdominal wall above arcuate line
- Avoid tacking below iliopubic tract (risk of nerve injury)
6. Peritoneal Closure
- Close peritoneum completely over mesh using continuous suture
- Ensure no gaps in peritoneal closure to prevent bowel herniation 1, 3
- Sutured peritoneal closure is preferred over stapling to reduce complications 1
7. Port Closure
- Release pneumoperitoneum under direct visualization
- Close fascial defects at port sites ≥10mm
- Close skin incisions
Postoperative Care
- Typically performed as outpatient or 23-hour stay procedure 3
- Acetaminophen 500-1000mg every 6 hours as first-line pain management 4
- Avoid NSAIDs due to increased bleeding risk 4
- Monitor for complications:
Advantages of TAPP vs TEP
- TAPP may be associated with less postoperative pain at 6 hours, 24 hours, and 7 days compared to TEP 5
- Lower conversion rate to open surgery compared to TEP (0.7% vs 2.5%) 6
- Easier learning curve for surgeons 6
- Allows inspection of contralateral side and intra-abdominal organs 2, 6
Technical Tips for Success
- Use large mesh (15 × 10 cm) to reduce recurrence rate (0.16% with larger mesh vs 5% with smaller mesh) 1
- Complete peritoneal closure with suture rather than staples to prevent bowel herniation 1, 3
- Careful identification of anatomical landmarks to prevent nerve injury
- Adequate dissection of preperitoneal space to ensure proper mesh placement
TAPP repair is associated with quick recovery (median return to normal activities in 7 days) and high patient satisfaction when performed by experienced surgeons 1.