1. What inguinal hernia operation and why?
Brian Jacob, MD FACS
Associate Clinical Prof Surgery
Laparoscopic Surgical Center of NY
Mount Sinai Medical Center
New York City, NY

2. TEP vs. TAPP More than 12,000 patients TEP TAPP
NO differences for recurrence rates, vascular injuries, and OR time
TEP
More conversions to another type of procedure
May be harder to learn
TAPP
Slightly higher
Intraabdominal adhesions
Trocar site hernias
Visceral injuries
Wake BL, McCormack K, Fraser C, Vale L, Perez, Grant A The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd

3. TEP vs. TAPP: Only one RCT
1 RCT (n=52)
Length of stay was shorter in the TEP group
(mean difference: ‐0.70 days, 95% CI ‐1.33 to ‐0.07; p=0.03)
No differences in OR time, LOS, recurrence, return to activity
Schrenk, British Journal of Surgery 1996

4. 10 year experience with laparoscopic hernias
N=1388 (1903 hernias)
1561 (82%) TEP
Minor complications 6%
Urinary retention (2.7%)
Conversion to a different technique (3.0%)
Major complications 1.3%
Enterotomy* (0.2%)
Bladder injury* (0.3%)
* All had lower midline incisions, TAPP
Schwab etal Surg Endosc

5. TEP has proven the test of time

6. Laparoscopic TEP: Retrospective Review
2,356 patients with 3,100 hernias
97% TEP and 3% TAPP
Dulucq JL, Wintringer P, Mahajna A, Surg Endosc (2009) 23:482–486

7. Laparoscopic TEP: Retrospective Review
2,356 patients with 3,100 hernias
97% TEP and 3% TAPP
Dulucq JL, Wintringer P, Mahajna A, Surg Endosc (2009) 23:482–486

8. Laparoscopic TEP: Retrospective Review
2,356 patients with 3,100 hernias
97% TEP and 3% TAPP
Dulucq JL, Wintringer P, Mahajna A, Surg Endosc (2009) 23:482–486

9. TEP vs. TAPP

10. TEP: Trocars

11. TEP: great for direct hernia
Left groin

12. TEP: great for femoral hernia
Right groin

13. TEP: great for indirect hernia
Left groin

14. TEP: no peritoneum to close!
Right groin

15. TEP: Outcomes Quicker return to daily activities
Better Quality of Life outcomes
Less acute and chronic pain complaints
Less intraabdominal morbidities
Overall no difference in recurrence rates*
*when performed by experienced groups

16. TEP: Quality of Life 1999 – 2006 N = 180 (90 Lichtenstein and 90 TEP)
Matched
Recurrence Rates (3% vs 2%)
SF-36
Physical function, bodily pain, general health
Myers E, Browne KM, Kavanagh DO, Hurley M World J Surg (ireland)

17. TEP vs. Lichtenstein: QoL
Myers E, Browne KM, Kavanagh DO, Hurley M World J Surg (ireland)

18. TEP: Minimal Chronic Pain
RCT
N=1370
665 TEP
705 Open
94% follow-up
5 years
5 years
Eklund A, Montgomery A, Bergkvist L, Rudberg C. Swedish Multicenter Trial of Inguinal Hernia Repair by Laparoscopy (SMIL). Brit J Surg

19. TEP vs. Lichtenstein: Chronic Pain
Eklund A, Montgomery A, Bergkvist L, Rudberg C. Swedish Multicenter Trial of Inguinal Hernia Repair by Laparoscopy (SMIL). Brit J Surg

20. Randomized, Prospective Trial
365 unilateral inguinal hernias randomly assigned
Shouldice repair (n = 74)
Bassini operation (n = 93)
Lichtenstein repair (n = 69)
TEP (n = 36)
TAPP (n = 93)
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

21. Randomized, Prospective Trial
365 unilateral inguinal hernias randomly assigned
Shouldice repair (n = 74)
Bassini operation (n = 93)
Lichtenstein repair (n = 69)
TEP (n = 36)
TAPP (n = 93)
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

22. Randomized, Prospective Trial
365 unilateral inguinal hernias randomly assigned
Shouldice repair (n = 74)
Bassini operation (n = 93)
Lichtenstein repair (n = 69)
TEP (n = 36)
TAPP (n = 93)
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

23. Randomized, Prospective Trial
365 unilateral inguinal hernias randomly assigned
Shouldice repair (n = 74)
Bassini operation (n = 93)
Lichtenstein repair (n = 69)
TEP (n = 36)
TAPP (n = 93)
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

24. Randomized, Prospective Trial
365 unilateral inguinal hernias randomly assigned
Shouldice repair (n = 74)
Bassini operation (n = 93)
Lichtenstein repair (n = 69)
TEP (n = 36)
TAPP (n = 93)
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

25. TEP: Recurrences no significant difference between lap and open
Surgeons who specialized in one method of hernia repair appeared to have excellent outcomes whenever they operated
Pokorny H, Klingler A, Schmid T, etal. Hernia (2008) 12:385–389 (Vienna, Austria)

26. TAPP: early internal hernia through peritoneal defect

27. TAPP: early trocar site hernia

28. TAPP: late adhesions

29. TAPP vs TEP: bowel obstruction
TAPP repairs
Higher trocar site hernia
Higher occurrence of bowel obstruction
0.5% (6/1,157) versus 0.07% (1/1,357) for TEP
Adhesions to peritoneal closure site
Bringman S, Blomqvist P (2005) Intestinal obstruction after inguinal
and femoral hernia repair: a study of 33,275 operations during
1992–2000 in Sweden. Hernia 9:178–183

30. Indications / recommendations
TEP
TAPP
All Primary Hernia
(unilateral or bilateral)
All Recurrences
Following open hernia repair
Prior lower midline incisions and prostatectomy*

31. Primary Hernia with history of lower abdominal surgery
Outcomes‐ TEP
1388 patients/10 years
171 previous lower midline incision
Enterotomy: 3
All in early experience
Cystotomy: 4
Schwab JR. et al. Surg Endosc. 2002

32. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrences
Following open hernia repair
Prior abdominal surgical history, including lower midline and prostatectomy*

33. Incarcerations / strangulations

34. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrent hernia
Following open hernia repair
Prior abdominal surgical history, even involving lower midline
Incarcerations or strangulations

35. Scrotal Hernias

36. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrent hernia
Following open hernia repair
Prior abdominal surgical history, even involving lower midline
Incarcerations or strangulations
Scrotal hernias

37. Inguinodynia: tack

38. Inguinodynia: recurrence

39. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrent hernia
Following open hernia repair
Prior abdominal surgical history, even involving lower midline
Incarcerations or strangulations
Scrotal hernias
Inguinodynia

40. Recurrence after TEP or TAPP

41. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrent hernia
Following open hernia repair
Prior abdominal surgical history, even involving lower midline
Incarcerations or strangulations
Scrotal hernias
Inguinodynia
Recurrence
After TEP or TAPP

42. Female, palpable inguinal hernia, but also a history of Pfennensteil

43. Female, palpable inguinal hernia, but also a history of Pfennensteil

44. Indications / recommendations
TEP
TAPP
Primary Hernia
(unilateral or bilateral)
Recurrent hernia
Following open hernia repair
Prior abdominal surgical history, even involving lower midline
Incarcerations or strangulations
Scrotal hernias
Inguinodynia
Recurrence
After TEP or TAPP
Women with previous Pfenensteil

45. When not to do a TEP?
GIANT inguinal scrotal incarceration – TAPP

46. When not to do a TEP? GIANT inguinal scrotal incarceration – TAPP
Contraindication to laparoscopy (or general anesthesia)

47. When not to do a TEP? GIANT inguinal scrotal incarcerations
Contraindication to laparoscopy or general anesthesia
Morbid obesity – TAPP

48. Not all hernias need to be fixed
Evidence to support watchful waiting until symptoms worsen without adverse events
Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A randomized clinical trial. Fitzgibbons RJ etal. JAMA 2006.
Observation or Operation for Patients with an Asymptomatic Inguinal Hernia: A randomized clinical trial. O’dwyer PJ etal. Annals Surg. 2006
Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS etal. Am J Surg. 2008

49. Conclusions Establish and individualize goals
There is no “one BEST” approach
A hernia specialist should be familiar with all available options
Each method has its merits and its disadvantages
Utilize the technique you are most familiar with , but have back up plans for specific scenarios