What is the Transabdominal Preperitoneal (TAPP) procedure for hernia repair?

Transabdominal Preperitoneal (TAPP) Procedure for Hernia Repair

The Transabdominal Preperitoneal (TAPP) procedure is a minimally invasive laparoscopic technique for hernia repair that involves entering the peritoneal cavity to place mesh in the preperitoneal space, offering excellent visualization of anatomy and allowing for treatment of bilateral, recurrent, and incarcerated hernias with lower postoperative pain and faster recovery compared to open techniques.

Overview of TAPP Procedure

TAPP is a laparoscopic approach for inguinal hernia repair that has gained popularity due to its effectiveness and benefits for patients. The procedure involves:

1. Initial Access and Setup:

   • Creation of pneumoperitoneum (usually at umbilicus)
   • Placement of three trocars (one 10mm umbilical port, two 5mm working ports)
   • Exploration of abdominal cavity

2. Key Anatomical Landmarks Identification:

   • Medial umbilical ligament
   • Inferior epigastric vessels
   • Cooper's ligament
   • Iliopubic tract
   • Femoral and internal rings

3. Peritoneal Incision and Flap Creation:

   • Incision of peritoneum 3-4cm above hernia defect
   • Creation of peritoneal flap to expose preperitoneal space
   • Careful dissection to avoid injury to vessels and nerves

4. Hernia Sac Management:

   • Complete reduction of hernia contents
   • Dissection and reduction of hernia sac
   • Identification of "occult" hernias (direct, indirect, femoral)

5. Mesh Placement:

   • Placement of large mesh (15 x 10 cm recommended) in preperitoneal space 1
   • Proper positioning to cover all potential hernia sites
   • Fixation with tacks or sutures (avoiding nerve injury)

6. Peritoneal Closure:

   • Complete closure of peritoneal flap with sutures or tacks
   • Ensuring no mesh exposure to peritoneal cavity to prevent adhesions

7. Completion:

   • Release of pneumoperitoneum
   • Closure of trocar sites

Advantages of TAPP

• Allows excellent visualization of anatomy
• Enables diagnosis and treatment of bilateral and "occult" hernias
• Permits evaluation of hernia contents in incarcerated cases 2
• Associated with less postoperative pain compared to TEP technique 3
• Facilitates faster return to normal activities (median 7 days) 1

Technical Considerations

• Proper mesh size is critical - larger mesh (15 x 10 cm) has been associated with significantly lower recurrence rates (0.16% vs 5% with smaller mesh) 1
• Sutured peritoneal closure reduces the risk of small bowel obstruction compared to stapled closure 1
• Median operation time is approximately 40 minutes with experienced surgeons 1
• The technique requires adequate laparoscopic training but has a less steep learning curve than TEP 4

Complications and Management

• Potential complications include:
  • Seroma formation (5.9-8%)
  • Mesh infection (rare)
  • Visceral injury (bladder, bowel)
  • Small bowel obstruction through peritoneal closure defect
  • Vascular injury
  • Recurrence (0.16-1.2% with proper technique) 1, 4

TAPP for Complicated Hernias

• TAPP can be used for incarcerated/strangulated hernias in stable patients 2
• Advantages in complicated cases include:
  • Direct visualization of hernia contents
  • Assessment of bowel viability
  • Ability to perform bowel resection if necessary
  • Reduced risk of wound complications compared to open surgery 5

TAPP vs TEP Comparison

• TAPP may be associated with less postoperative pain at 6 hours, 24 hours, and 7 days post-surgery 3
• TEP has a higher risk of conversion to another repair method (2.5% vs 0.7%) 4
• Both techniques have similar rates of serious adverse events and hernia recurrence 4
• TAPP allows inspection of the contralateral side and abdominal cavity

Postoperative Care

• Most patients require minimal or no postoperative analgesia 1
• Approximately 60% of patients can be treated as day surgery cases 1
• Acetaminophen is recommended as first-line pain management 5
• Patients should avoid NSAIDs due to increased bleeding risk 5
• Patients should be monitored for complications including seroma, hematoma, and infection

The TAPP procedure represents an effective minimally invasive approach for inguinal hernia repair with excellent outcomes when performed by appropriately trained surgeons.