Page 22 - International guidelines for groin hernia management

Hernia

Discussion, consensus and grading clarification and posterior anatomical planes which has a theoretical
From the available evidence, it can be concluded that open disadvantage when a recurrence needs repair. There
pre-peritoneal repairs seem as effective as the Lichtenstein remains a need for learning curve studies, RCTs and reg-
repair in terms of recurrence and may possibly result in less istry studies, with long-term follow-up, to permit firmer
postoperative pain and faster recovery. However, the conclusions.
caveat is that it is predominantly the anterior trans-inguinal
KQ06.e Is TEP or TAPP the preferred laparo-endoscopic
pre-peritoneal technique (TIPP) and the posterior pre-
technique?
peritoneal technique, as described by Kugel, which have
R. Bittner, F. Ko ¨ckerling, J. Kukleta, S. Tumtavitikul and
been compared to the Lichtenstein repair. This caution is
M. Misra
reinforced in the 2009 European Guidelines and the 2014
update. 3, 4 The various other open pre-peritoneal tech-
Introduction
niques have not been sufficiently studied to differentiate
one from another.
Trans-abdominal pre-peritoneal (TAPP) and total extra-
Concerns about these surgical techniques may exist
peritoneal (TEP) differ although both techniques are in
regarding both cost and long-term safety for some of these
widespread use. In both, mesh is inserted in the pre-peri-
mesh devices. For the Kugel mesh there is an abundant
toneal plane but use a different access to that plane. In
amount of foreign material present. Problems with the
TEP, a totally pre-peritoneal approach is used with or
initial recoil ring resulted in pain and even bowel perfo- without the help of a dissection balloon. In TAPP a
ration. 197 The recent version of this mesh type now con-
laparoscopy is performed. The approach difference confers
tains a resorbable memory ring. This being said, whether it
a theoretical advantage favoring TAPP. The anatomy is
is TIPP, Kugel, TREPP or others, the mesh choice is not
easier to identify when starting with a laparoscopy and the
strictly connected to the applied technique.
presence and type of hernia on the contralateral side can be
Mesh devices are more costly than flat meshes. How-
identified before starting dissection. In TEP it is not nec-
ever, a 2013 study found no differences in hospital costs
essary to open and close the peritoneum. Studies compar-
between TIPP and Lichtenstein repairs. When productivity
ing TAPP and TEP show similar complication rates for
gains were included in the analysis, significant differences
seroma, scrotal edema, cord swelling, testicular atrophy,
in cost favoring the TIPP modality were noted urinary bladder injury, inguinal nerve lesions, chronic pain
(p = 0.037). 198 Individual surgeons and healthcare systems
and recurrence. Access-related complications can differ:
may wish to consider this point, depending on practice
there is increased risk of visceral injuries during trans-ab-
setting and reimbursement systems.
dominal entry with TAPP while there is increased risk of
HerniaSurge acknowledges the potential value of open
vascular injuries during extra-peritoneal entry and dissec-
pre-peritoneal mesh techniques. The committee expressed
tion during TEP.
concerns that some of these approaches use both anterior

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