Page 16 - Journal of WALS

10.5005/jp-journals-10007-1153
Galal MM Abou El-Nagah
ORIGINAL RESEARCH
Combined TAPP and TEP: A New Modified Technique for

Laparoscopic Inguinal Hernia Repair

Galal MM Abou El-Nagah

ABSTRACT repair, dissection is initiated totally in the extraperitoneal
space. However, there is a crucial difference between the
Background: No other laparoscopic procedure has been the
source of controversy as much as the laparoscopic approach two techniques because TEP does not include the use of
to inguinal hernias. The two common laparoscopic techniques pneumoperitoneum as opposed to TAPP approach. The TEP
include the transabdominal preperitoneal repair (TAPP) and the
total extraperitoneal repair (TEP). We present our experience technique of laparoscopic inguinal hernia repair avoids entry
with a novel technique by combining the two ideas of TAPP and into the abdominal cavity, and thereby eliminates the risks
TEP to get benefit of both techniques. We compared the and complications inherent to the TAPP repair. Major blood
operative time and the need for mesh fixation of the new vessel, bowel and bladder injury are extremely rare and
technique with that of the standard TAPP technique.
mostly associated with TAPP technique. Recently, the TEP
Methods: From May 2009 to July 2011, a total of 335 patients technique has become more popular laparoscopic approach
complaining of indirect inguinal hernia were included in this
study. We have operated on 137 patients with new technique of to groin hernias.
combined TAPP and TEP (first group). The other 198 patients In our practice, we developed a novel technique by
were operated with the standard TAPP technique (second combining the two ideas of TAPP and TEP so as to get
group). All patients who had the new modified technique were
operated by a single surgeon in a university-affiliated hospital. benefit of both techniques. We noticed that creating a
‘pneumoperitoneum-like’ state in TEP technique facilitates
Results: All procedures have been finished laparoscopically
with no conversion. The average operative time was 39.8 minutes the dissection of the peritoneum and fascia transversalis off
for the first group and 44.3 minutes for the second group. Mesh anterior abdominal wall. We do this in TAPP by insufflation
was fixed in 30 patients (21.9%) of the first group and 81 patients of CO under vision in extraperitoneal space using Veress
(40.9%) of the second group. Postoperative port site infection 2
in the first group occurred in 3 patients (2.19%). No perioperative needle then withdraw the needle and continue the operation
morbidity or mortality occurred. as usual classical TAPP.
Conclusion: Combined TAPP and TEP is safe and feasible. It
simplifies the procedure; makes operative time significantly less METHODS
with lower rate of recurrence as well as decreases the need for From May 2009 to July 2011, a total of 235 patients were
mesh fixation.
scheduled for elective laparoscopic inguinal hernia repair
Keywords: TAPP, TEP, Laparoscopic hernia repair. and included in this study. All patients have signed an
How to cite this article: Abou EL-Nagah GMM. Combined informed consent to be enrolled in this study and protocol
TAPP and TEP: A New Modified Technique for Laparoscopic of the research has been approved by Alexandria Faculty
Inguinal Hernia Repair. World J Lap Surg 2012;5(2):72-75.
Medical Ethics Committee. All patients were operated under
Source of support: Nil general anesthesia in a university-affiliated hospital. The
Conflict of interest: None declared patients were randomly divided into two groups: The first
group included 137 patients who underwent the new
INTRODUCTION technique of combined TAPP and TEP while the second

A variety of laparoscopic techniques for hernia repair were group included 198 patients who underwent the standard
described. The two common laparoscopic techniques TAPP technique. All the patients had routine preoperative
include the transabdominal preperitoneal repair (TAPP) and evaluation. The patients were put in supine position which
the total extraperitoneal repair (TEP) which mimics the open had been changed to Trendelenburg position after
preperitoneal repair of Stoppa. Both the TAPP and TEP introduction of first umbilical trochar.
use the basic principle of placing a piece of mesh in the In the first group, who underwent combined TAPP and
1
preperitoneal space as described by Stoppa. The TAPP TEP, a Veress needle was inserted through a small supra-
repair is performed from within the abdomen with an umbilical incision and a pneumoperitoneum at a pressure
incision that is made in the peritoneum to access the of 15 mm Hg was performed. Removal of Veress needle
preperitoneal space. It is the most common laparoscopic and then a 10 mm camera trochar was inserted instead and
technique used because it allows the surgeon to have the the groins were assessed. The preperitoneal space was then
entire abdominal cavity as visual referral points. In the TEP entered through a small 2 mm infraumbilical incision,
72
JAYPEE