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

Totally Extraperitoneal (TEP) Repair for Inguinal Hernia

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

Key Benefits of TEP Repair

Postoperative Recovery Advantages

• TEP results in significantly less postoperative pain compared to open repair, with fewer patients requiring postoperative analgesics 2, 3
• Patients return to normal activities approximately 4 days earlier (7 days for TEP vs 11 days for open Lichtenstein repair) 2
• Hospital stay is significantly shorter with TEP compared to open extraperitoneal approaches 3

Complication Profile

• TEP demonstrates significantly lower total postoperative complication rates (OR 0.544,95% CI 0.369-0.803) compared to open extraperitoneal repair 3
• Wound infection rates are significantly lower with TEP (6.66%) compared to open repair (7.14%), with statistical significance (P<0.018) 1, 2
• Skin numbness occurs in only 2.8% of TEP patients versus 35.8% in open repair patients (P<0.01) 4
• Prolonged groin discomfort is less common with TEP (1.4%) compared to open repair (5.3%) 4

Diagnostic and Bilateral Hernia Advantages

• TEP allows visualization of the contralateral side to identify occult hernias, which are present in 11.2-50% of cases, preventing future operations 1
• For bilateral hernias, TEP operative time is significantly shorter (78 minutes) compared to open bilateral repair (102 minutes) 4

Operative Efficiency

• In mature surgical practices, TEP operative times are shorter than open repair for both unilateral (63 vs 70 minutes) and bilateral repairs, even when including the learning curve 4
• Operative times decrease significantly over time as surgeon experience increases 4

Important Considerations and Limitations

Higher Risk of Specific Complications

• Urinary retention occurs more frequently with TEP (7.9%) compared to open repair (1.1%), though this is generally self-limiting 4, 3
• Peritoneal tears are significantly more common with TEP, particularly with lateral approaches (36.7%) versus midline approaches (12%) 5, 3

Technical Considerations

• TEP requires general anesthesia, unlike open repair which can be performed under local anesthesia in select cases 1
• The midline approach between the peritoneum and posterior rectus sheath (MP approach) is optimal, as it minimizes peritoneal tears and provides adequate mesh positioning 5
• Both TEP and TAPP demonstrate comparable outcomes with low complication rates, with TAPP potentially easier in recurrent cases or when TEP proves technically difficult 1

Contraindications to TEP

• TEP is contraindicated when bowel resection is anticipated in emergency settings 1
• Active strangulation with bowel compromise requires open preperitoneal approach when bowel resection may be needed 1
• Inability to tolerate general anesthesia is an absolute contraindication 1

Clinical Application Algorithm

For Elective Inguinal Hernia Repair

• TEP should be the preferred approach for bilateral hernias, given significantly shorter operative times and ability to address both sides simultaneously 1, 4
• TEP is particularly beneficial for recurrent hernias (31% of TEP cases in mature practices) 4
• Consider TEP for younger, active patients who would benefit most from faster return to activities 2

For Emergency/Incarcerated Hernias

• For incarcerated hernias without strangulation and no suspicion of bowel necrosis, TEP is appropriate and can assess bowel viability 1
• Diagnostic laparoscopy can assess bowel viability after spontaneous reduction of strangulated groin hernias, decreasing hospital stay 1
• If strangulation is suspected or bowel resection may be needed, open preperitoneal approach is preferable 1

Recurrence and Long-Term Outcomes

• Recurrence rates are equivalent between TEP and open mesh repair (P<0.815), with both demonstrating excellent long-term results 1, 3
• Synthetic mesh is standard in clean surgical fields, associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 1
• Mesh fixation may not be necessary in TEP, as studies demonstrate successful outcomes without fixation 5

Common Pitfalls to Avoid

• Do not overlook contralateral hernias—the laparoscopic approach allows examination of the opposite side to identify occult hernias present in up to 50% of cases 1
• Avoid attempting TEP when bowel compromise is suspected—this requires open approach for potential bowel resection 1
• Do not underestimate the learning curve—operative times improve significantly with experience, but initial cases may take longer 4
• Recognize that peritoneal tears during TEP do not require routine closure and do not significantly impact outcomes 5