TAPP Repair Research Articles

Current status of laparoscopic inguinal hernia repair in Denmark

Laparoscopic inguinal hernia repair is becoming more common in many countries, but the quality of care, experience of the operating surgeon, and details of the surgical technique are not known in detail on a national level in Denmark. In a period of expanding surgical volume for laparoscopic inguinal hernia repair, it is important to know the typical indications for surgery, re-operation rates, details of surgical technique, and status of surgical training on a national level in order to rationalize interventions to improve outcome. Data from the National Hernia Database for the last 8 years regarding laparoscopic inguinal hernia repair were used in combination with questionnaire data obtained from all surgical units in Denmark. The questionnaire included issues such as the number of operating surgeons in the department, number of residents training in the laparoscopic technique, and the experience level of the most experienced surgeon in the department regarding laparoscopic inguinal hernia repair. The questionnaire also included details of the surgical technique. The frequency of laparoscopic repair has been increasing over the last 8 years and now accounts for about 16% of the total number of inguinal herniorrhaphies with the main indication nationwide being bilateral hernias and recurrent hernias. We found slight variations in surgical technique although all departments used the TAPP repair. The majority used adequate mesh sizes at or above 10 x 15 cm, and most departments used coils or tacks for mesh fixation and peritoneal closure. Fifteen of 25 departments had only one or two surgeons performing laparoscopic inguinal hernia repair and 12 of 25 departments did not have any young surgeons in training for laparoscopic inguinal hernia repair. Ten departments had one surgeon in training, and three departments had two surgeons in training. Laparoscopic inguinal hernia repair in Denmark is increasing in prevalence. Indications for surgery as well as operative techniques differ although all departments use the TAPP technique. Few surgeons are currently learning the laparoscopic technique, and it is therefore important to initiate meetings and courses to ensure uniform indications for surgery and operative techniques throughout the country.

Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group

In recent years long-term discomfort after inguinal hernia surgery has become an issue of great concern to hernia surgeons. Long-term results on discomfort from large randomised studies are sparse. One-thousand one-hundred and eighty-three patients were randomised in a multicentre trial with the primary aim of comparing recurrence rates after laparoscopic TAPP and Shouldice repair. Evaluating late discomfort and its possible risk factors were secondary objectives, and are reported here. The patients were clinically examined after 1 and 5 years, and answered questionnaires 2 and 3 years postoperation. Of 1,068 operated patients, 867 were eligible for analysis after 5 years (81.2%). The percentage of patients experiencing discomfort of any kind were 8.5% in the TAPP group and 11.4% (p = 0.156) in the Shouldice group. Although discomfort was usually mild it was severe for 0.2 and 0.7%, respectively. Severe pain the first postoperative week was a risk factor for late discomfort in the Shouldice group (OR 2.25, P = 0.022) but not in the TAPP group. No other risk factor for late discomfort was found. There was no difference between late discomfort at five-year follow-up after laparoscopic TAPP and Shouldice repair. Discomfort was mostly mild and pain during the first postoperative week was a prognostic variable for late discomfort in Shouldice patients.

The economic impact of laparoscopic inguinal hernia repair: results of a double-blinded, prospective, randomized trial

For this study, 66 patients with a preoperative diagnosis of unilateral primary inguinal hernia were randomized to undergo laparoscopic totally extra peritoneal (TEP), laparoscopic transabdominal (TAPP), or open inguinal hernia repair with polypropylene mesh (Lichtenstein type). Both the operative team caring for the patient postoperatively and the patient were blinded to the operative approach by placement of a large dressing covering the abdomen, which was not removed until postoperative day 3. The patients recorded their pain level on a visual analog pain scale daily. Medication usage also was recorded. All patients were seen at 7-day intervals until they returned to work. The patients were interviewed during their postoperative visits by an investigator blinded to the operative approach and questioned regarding their ability to return to work and their pain levels. The average number of lost work days in all the groups was 12, and there was no significant difference between the three groups (p = 0.074). The average operating time for the TAPP procedure was 59 min, less than the time required to complete either the TEP or the Lichtenstein approach, which had equivalent operative times (p = 0.027). The material cost was significantly lower for the Lichtenstein repair (1,200 dollars less) than for either of the laparoscopic approaches, a saving primarily related to consumable operating room supplies. The TEP repair costs were minimally higher than those for the TAPP repair (125 dollars more). No significant differences were noted in the postoperative pain scales, and the use of postoperative oral analgesics was equivalent. The higher operative costs noted for the laparoscopic hernia repairs were not offset by a shortened convalescence. Postoperative pain appears to be equivalent regardless of the operative approach chosen and is easily managed with oral analgesics.

Technical Notes and Tips: TAPP Repair for Inguinal Hernias – A New Composite Mesh Technique

Technical Notes and Tips: TAPP Repair for Inguinal Hernias – A New Composite Mesh Technique

Laparoscopic hernia repair?TAPP or/and TEP?

Of various endoscopic hernia repair procedures, TAPP and TEP have been selected for routine use. Results from Medline research were analysed. There is a similar risk for postoperative morbidity for both techniques. The recurrence rate in large single-centre series is between 0% and 3.4%. There were numerous indications for both procedures, whereby a transperitoneal TAPP can also be applied in cases of previous preperitoneal operations. Randomised trials comparing both methods of hernia repair are lacking. Seven non-randomised studies showed no differences in recurrence rate and morbidity. In general the learning curve for is shorter in favour of TAPP repair.

Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair.

Surgeons who favor the laparoscopic repair of groin hernias must limit the additional costs associated with this technique, which is not universally acknowledged to be superior to other less expensive open tension-free repairs. This retrospective study compared outcome and costs between laparoscopic and open tension-free hernia repair in 320 patients with inguinal hernias. Patients underwent either (a) transabdominal preperitoneal procedure (TAPP; 60 patients, 72 procedures), (b) totally extraperitoneal procedure (TEP; 174 patients, 202 procedures), or (c) open tension-free procedure (86 patients, 105 procedures). Regarding important postoperative complications there were two (3.3%) recurrences in the TAPP group and one (0.6%) in the TEP group, and six (9.9%) transient neuralgias in the TAPP group and one (1.2%) in the tension-free group. There were no deaths, no testicular atrophies, and no wound or mesh infections. The mean hospital postoperative stay was the same in the three groups (1 day). Mean operating time was shorter in the tension-free group concerning the unilateral cases and shorter in the TEP group concerning the bilateral cases. Fewer patients required analgesia during the first 6 h after the operative procedure in the TEP group than in the other two groups. The mean total costs were 483.90 euros in the open tension-free repair, 763.20 euros in the TAPP repair, and 572.50 euros in the TEP repair. The open procedure was the cheaper for the hospital. Laparoscopic hernia repair and tension-free repair as described by Gilbert are comparable in postoperative complications. TEP hernia repair is associated with less postoperative pain and earlier return to normal activities, but it is more expensive and continues to be a difficult procedure. Open tension-free repair is the least expensive method and is easier to learn than the other two procedures.

Developments in inguinal hernia based on newly introduced intervention techniques in the North Rhine district

In Germany inguinal hernia surgery has changed over the last decade from conventional repairs without alloplastic material to video-assisted minimal invasive techniques or Lichtenstein repair. Since 1991 every patient undergoing inguinal hernia repair has been documented in the North-Rhine area in a routine quality-surveillance study. A total of 173,923 patients with 192,718 groin hernias (85.26% male and 14.74% female) were operated on. In 1993 the Shouldice repair was performed in 54.2%, the Bassini operation in 26%, the transabdominal laparoscopic TAPP repair in only 3.2% of cases. In 1999 the TAPP repair was performed in 13%, the extraperitoneal video-assisted TEP repair in 14%, Lichtenstein repair in 18.5%, Shouldice repair in 35% and the Bassini operation in only 4.8%. The percentage of operations was 13.4% over the last 10 years. However, there was an increase from 12.8% in 1993 to 14.1% in 1997, and a rate of 13.5% in 1999. The following complications were observed: hematoma/seroma formation in 3.78%, wound infection in 1.15%, testicular edema in 0.37% and scrotal edema in 0.64%. The data document the introduction of three new methods for inguinal hernia repair (TAPP, TEP and Lichtenstein repair). A decrease in operations on recurrences is not observed.

Utility of a new soft non-woven polypropylene mesh for the transabdominal extraperitoneal laparoscopic hernia repair: preliminary results

Aims Tension-free mesh reinforcement is the mainstay of laparoscopic hernia repair. Problems with current prostheses include shrinkage, migration, patient discomfort and neuralgias. We prospectively analyzed the short-term utility of a soft, non-woven mesh (Biomesh W/NK®, Cousin Biotech) in the TAPP repair.

Postoperative pain and return to activity after five different types of inguinal herniorrhaphy

The purpose of this study was to determine postoperative pain following inguinal herniorrhaphy dependent of technical factors such as: minimal access surgery, open transinguinal and preperitoneal tension-free repair, reduced suture line tension, type of anesthesia. 240 consecutive unilateral groin hernia repairs were prospectively allocated to one of five groups: Lichtenstein patch under local anesthesia, and the following under general anesthesia, Lichtenstein patch, laparoscopic TAPP repair, a modified Shouldice technique with omission of the third and fourth row of sutures and open preperitoneal prosthethic repair [Wantz 1989]. Using a visual pain analogue score, no significant differences were found for pain intensity between the groups on days 0, 1, 2, 3, 21. There was also no significant difference for return to work. Analgesic requirements were lower than in previous studies and this is attributed to immediate resumption of physical activity on a home-trainer bicycle. The percentage of patients who did not require any pain medication after the first postoperative day was 85% for Wantz, 81% for Shouldice, 86% for TAPP, 77% for Lichtenstein under general anesthesia and 89% for Lichtenstein under local anesthesia. Local anesthesia was the only technical factor for significantly reducing analgesic requirements during the three perioperative days. With local anesthesia and immediate resumption of physical activity early postoperative pain becomes a limited outcome measure for comparing open versus laparoscopic groin hernia repair techniques.

Endoscopic hernia surgery (TAPP)--gold standard in management of recurrent hernias?

From April 1993 to December 1995 210 TAPP procedures were performed because of recurrent hernia. With the TAPP method there is no difference between primary and recurrent repair. All procedures in this study were done with general anaesthesia by senior surgeons. The learning curve shows a reduction of operation time (60 to 55 min) with increasing experience and a reduction in complications as well (total 4.3%). Recurrence was observed in two cases. The reasons for these recurrences were technical failures during the previous repair. In both cases a second TAPP repair was carried out successfully. The main advantage of TAPP in recurrent hernia is that this method gives possibilities to avoid anterior scar tissue. Secondly tension-free repair can be combined with the benefit of the minimal access technique. For this reason, the TAPP procedure must be considered the method of choice in recurrent hernia repair.

Laparoscopic herniorrhaphy: initial experience in 126 patients.

The initial experience in laparoscopic transabdominal preperitoneal mesh (TAPP) repairs is reviewed. In this study, consecutive TAPP repairs were performed in 126 patients. There were no intraoperative complications, and only 1 procedure had to be converted to open surgery. Forty-six patients had direct inguinal hernias, 56 had indirect inguinal hernias, and 24 had both, of which 21 were recurrent. Fifty-one hernias were right sided, 46 were left sided, and 29 were bilaterals. The male/female ratio was 116:10, and the mean age of the patients was 49.8 (range 17-76). Minor complications included parasthesia over the distribution of the lateral cutaneous nerve of the thigh in 2 patients, hydrocoeles in 2 patients, hematomata in 6 patients, and testicular pain in 4 patients, all of which resolved on conservative management. Incomplete bowel obstruction has been the only major postoperative complication to date, where an area of bowel herniated between two staples in the peritoneum. This was further complicated by an aspiration pneumonia and death of the patient. The mean hospital stay was 1.2 days (range 1-3), and the mean return to unrestricted activity was 8 days (range 3-12). There have been 2 true recurrences to date. One patient had a tender swelling after the repair, which was thought to be a recurrent strangulated hernia. On investigation, it was found to be a hematoma. The mean follow-up has been 7 months (range 1-18). Although early results of the TAPP repair are encouraging, we have had 1 significant complication that may have been avoided if an endoscopic extraperitoneal approach was employed.