What are the benefits and considerations of Totally Extraperitoneal (TEP) repair for hernia?

Totally Extraperitoneal (TEP) Repair for Inguinal Hernia

Primary Recommendation

TEP repair is a highly effective laparoscopic technique for inguinal hernia that offers significant advantages over open repair, including reduced postoperative pain, lower wound infection rates, faster return to normal activities, and the ability to identify and repair occult contralateral hernias present in 11-50% of cases. 1

Key Benefits of TEP Repair

Clinical Outcomes

• Reduced postoperative complications: TEP demonstrates significantly lower total postoperative complication rates (OR 0.544) compared to open extraperitoneal approaches 2
• Lower infection risk: Wound infection rates are significantly reduced with laparoscopic approaches, particularly important in emergency settings 3
• Decreased urinary problems: TEP shows an 80% reduction in urinary complications (OR 0.206) compared to open extraperitoneal repair 2
• Less chronic pain: TEP results in significantly less skin numbness (2.8% vs 35.8%) and prolonged groin discomfort (1.4% vs 5.3%) compared to open mesh repair 4

Recovery Advantages

• Faster return to activities: Patients undergoing TEP return to normal activities significantly earlier (mean difference -1.798 days) than those with open extraperitoneal repair 2
• Shorter hospital stay: TEP is associated with significantly reduced length of hospitalization (mean difference -1.995 days) 2
• Equivalent recurrence rates: No difference in hernia recurrence between TEP and open approaches, maintaining the low recurrence benefit of mesh repair 2

Operative Efficiency

• Shorter operative times: In mature surgical practices, TEP requires less operative time than open repair for both unilateral (63 vs 70 minutes) and bilateral hernias (78 vs 102 minutes) 4
• Learning curve considerations: Operative times decrease significantly over time as surgeon experience increases, even when including the learning curve 4

Special Advantages in Specific Scenarios

Bilateral and Recurrent Hernias

• Bilateral repair efficiency: TEP is particularly advantageous for bilateral hernias, with significantly shorter operative times (78 minutes) compared to bilateral open repair (102 minutes) 4
• Occult hernia detection: The laparoscopic approach allows assessment of the contralateral side to identify occult hernias in 11.2-50% of cases, preventing future operations 1, 3
• Recurrent hernia management: TEP is well-suited for recurrent hernias (31% of TEP cases in mature practices) 4

Emergency Settings

• Incarcerated hernias: TEP is feasible for incarcerated inguinal hernias without strangulation, with 328 cases reported showing acceptable results 3
• Bowel assessment: Laparoscopy allows evaluation of bowel viability and can facilitate bowel resection if necessary 3
• Lower infection risk: In emergency repair of strangulated groin hernias, laparoscopic approach shows significantly lower wound infection rates without higher recurrence 3

Important Considerations and Limitations

Technical Factors

• Peritoneal tears: TEP has a higher incidence of peritoneal tears compared to open extraperitoneal approaches (OR 46.5), though these typically do not require routine closure 2
• Urinary retention: TEP shows higher rates of urinary retention (7.9% vs 1.1%) compared to open repair, though this is typically transient 4
• Surgical approach selection: The midline approach between peritoneum and posterior rectus sheath (MP) is optimal, minimizing peritoneal tears (12% vs 36.7% with lateral approaches) 5

Anesthesia Options

• General anesthesia standard: TEP is typically performed under general anesthesia 6
• Regional anesthesia feasibility: TEP can be performed under epidural anesthesia with 68% success rate when sensory level T6 or above is achieved, though pneumoperitoneum and shoulder-tip pain may necessitate conversion to general anesthesia 6
• Emergency considerations: Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene, though general anesthesia should be preferred when bowel resection is anticipated 7

Contraindications and Cautions

• Strangulation with bowel resection: Open preperitoneal approach is preferable when bowel resection is suspected or needed 3
• Unstable patients: In emergency settings with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 1
• Contaminated fields: For contaminated or dirty surgical fields, primary tissue repair or biological mesh may be more appropriate than laparoscopic approaches 7

Mesh Considerations

• Mesh fixation: TEP can be safely performed without mesh fixation when adequate mesh size (15 x 10 cm) and positioning are achieved 5
• Clean fields: Prosthetic repair with synthetic mesh via TEP is recommended for intestinal incarceration without signs of strangulation (grade 1A recommendation) 3
• Mesh positioning: The arcuate line may impede mesh positioning in certain anatomical approaches, favoring the midline posterior approach 5