Why is Transabdominal Preperitoneal (TAPP) repair preferred over Totally Extraperitoneal (TEP) repair for hernia repair in certain patients?

Why TAPP is Preferred Over TEP in Certain Clinical Scenarios

TAPP is preferred over TEP primarily in recurrent hernias, cases with previous lower abdominal surgery, when there is suspected bowel compromise requiring assessment, and when the surgeon has less laparoscopic experience—though both techniques show equivalent outcomes in most clinical scenarios. 1, 2

Clinical Situations Favoring TAPP

Recurrent Hernias

• TAPP offers superior visualization of distorted anatomy in recurrent hernia cases, making it technically easier to navigate the altered surgical field compared to TEP 2
• In recurrent cases, TAPP may be the preferred approach when anatomical landmarks are obscured from previous repairs 1

Previous Lower Abdominal Surgery

• TAPP is less technically challenging than TEP when patients have undergone previous lower abdominal operations, as the extraperitoneal space may be obliterated or scarred 2
• The transabdominal approach allows direct visualization and navigation around adhesions that would complicate the extraperitoneal dissection required for TEP 2

Emergency/Complicated Hernias Requiring Bowel Assessment

• In incarcerated hernias without strangulation, TAPP allows direct assessment of bowel viability while maintaining minimally invasive benefits 1, 2
• TAPP permits better evaluation of intestinal compromise in emergency settings for complicated hernias 2
• Both techniques can assess bowel viability, but TAPP provides more direct visualization of the bowel through the peritoneal cavity 1

Learning Curve Considerations

• TAPP has a shorter learning curve compared to TEP, making it more accessible for surgeons developing laparoscopic hernia repair skills 3
• The technical demands of TEP are steeper, requiring more advanced laparoscopic skills to safely create and maintain the extraperitoneal working space 4

Equivalent Outcomes Between Techniques

No Superiority in Key Clinical Outcomes

• The evidence shows no significant difference between TAPP and TEP for serious adverse events (0.4% vs 0.7%), hernia recurrence (1.2% vs 1.1%), or chronic pain 4
• Both techniques demonstrate comparable recurrence rates of 0-3.4% in large series, with equivalent postoperative morbidity 5, 3
• Quality of life improvements are similar between both approaches in the late postoperative period 4

Perioperative Outcomes

• Operative time, postoperative complications, pain scores, and time to return to work show no clinically meaningful differences between TAPP and TEP 4, 5
• Hospital stay may be slightly longer with TAPP compared to TEP, though this difference is minimal 5

TEP Advantages (When TAPP is NOT Preferred)

Avoiding Peritoneal Cavity Entry

• TEP avoids entering the abdominal cavity entirely, theoretically reducing the risk of visceral injury, though actual rates of perioperative visceral and vascular injury show no significant difference 4
• The extraperitoneal approach eliminates risks associated with trocar placement through the peritoneum 4

Conversion Risk

• TEP carries a higher risk of conversion to another repair method (2.5% vs 0.7%), either to TAPP or open surgery, compared to TAPP 4
• Surgeons choosing TEP as their standard approach should have proficiency in TAPP or be prepared to convert to open surgery 4

Common Pitfalls to Avoid

• Do not attempt TEP in recurrent hernias or previous lower abdominal surgery without advanced laparoscopic skills, as the distorted anatomy significantly increases technical difficulty 2
• Avoid TEP when bowel resection is anticipated or active strangulation with bowel compromise is present—open preperitoneal approach is preferable in these situations 1
• Do not overlook the higher conversion rate with TEP—have a clear strategy for managing conversions, including TAPP proficiency or patient counseling about open surgery risk 4
• Recognize that TAPP requires general anesthesia and peritoneal entry, which may not be suitable for patients unable to tolerate pneumoperitoneum 1

Practical Algorithm for Technique Selection

Choose TAPP when:

• Recurrent hernia with distorted anatomy 2
• Previous lower abdominal surgery 2
• Incarcerated hernia requiring bowel viability assessment 1, 2
• Surgeon has limited TEP experience 3
• Need to identify occult contralateral hernias (both techniques allow this, but TAPP provides direct visualization) 1

Choose TEP when:

• Primary hernia in virgin abdomen 2
• Surgeon has advanced laparoscopic skills and TEP proficiency 3
• Patient preference for avoiding peritoneal cavity entry 4
• No concern for bowel compromise requiring direct assessment 1

Avoid laparoscopic approach entirely (use open) when:

• Active strangulation with suspected bowel necrosis 1
• Bowel resection anticipated 1
• Patient cannot tolerate general anesthesia 1
• Peritonitis present 1