What are the differences between Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) repair for inguinal hernia?

Differences Between TAPP and TEP Repair for Inguinal Hernia

Both TAPP (Transabdominal Preperitoneal) and TEP (Totally Extraperitoneal) are effective laparoscopic techniques for inguinal hernia repair, with TEP having an edge over TAPP due to significantly reduced postoperative pain and better patient satisfaction scores.1

Key Anatomical and Procedural Differences

• Access to Peritoneal Cavity: TAPP requires entry into the peritoneal cavity to place the mesh, while TEP is performed entirely in the preperitoneal space without entering the abdominal cavity 2
• Surgical Approach:
  • TAPP: Involves creating a peritoneal flap after entering the abdominal cavity, placing mesh in the preperitoneal space, and then closing the peritoneum 3
  • TEP: Creates a working space directly in the preperitoneal area without breaching the peritoneum 3, 4
• Learning Curve: TEP is considered technically more challenging with a steeper learning curve compared to TAPP due to the limited working space and peculiar anatomy 4, 2
• Visualization: TAPP offers better visualization of the inguinal anatomy and allows inspection of the contralateral side and intra-abdominal organs 2

Clinical Outcomes Comparison

• Serious Adverse Events: Little to no difference between TAPP and TEP (0.4% versus 0.7%) 2
• Hernia Recurrence: Similar rates between both techniques (1.2% versus 1.1%) 2
• Chronic Pain:
  • TEP demonstrates significantly reduced postoperative pain up to 3 months compared to TAPP 1
  • This leads to better patient satisfaction scores with TEP 1
• Conversion Rates: TEP carries a higher risk of conversion to another repair method (either TAPP or open surgery) compared to TAPP (2.5% versus 0.7%) 2
• Hospital Stay: TAPP is associated with a slightly longer hospital stay compared to TEP 5

Specific Complications

• Seroma Formation: Higher incidence in TEP (37.8%) compared to TAPP (18.3%) 1
• Scrotal Edema: More common with TAPP (16% vs 9% in TEP) 1
• Visceral Injury Risk: TAPP may have a higher risk of visceral injury due to entry into the peritoneal cavity 2
• Wound Infection: Similar rates between both techniques (2-3%) 1

Special Considerations

• Bilateral Hernias: TAPP may be advantageous as it allows easier access to both sides without creating additional working spaces 2
• Recurrent Hernias: Both techniques are suitable, but TAPP may offer better visualization of distorted anatomy 3
• Previous Lower Abdominal Surgery: TAPP may be preferred as previous surgery can make the TEP approach more difficult 3
• Incarcerated Hernias: Both techniques can be used for incarcerated hernias without strangulation, with laparoscopy allowing assessment of bowel viability 3

Practical Recommendations

• Mesh Fixation: Not needed in TEP repair, which can reduce potential for nerve injury and chronic pain 6
• Mesh Selection: Heavyweight meshes in TEP result in lower recurrence rates 6
• Surgeon Experience: For surgeons new to laparoscopic hernia repair, starting with TAPP may be easier before progressing to TEP 4
• Conversion Strategy: Surgeons opting for TEP should be proficient in TAPP as a backup approach in case conversion is needed 2

Both techniques have proven effective for inguinal hernia repair, with the choice often reflecting surgeon preference and specific patient factors. However, TEP appears to offer advantages in terms of postoperative pain and patient satisfaction when performed by experienced surgeons 1, 6.