Page 24 - International guidelines for groin hernia management

Hernia

Recurrence rates in German hospitals found a significantly shorter hospital
In 23 comparisons, TAPP recurrence rates varied between stay in TAPP compared to TEP. 208 However, a similar
0 and 25% (median 2.3%) and TEP recurrence rates study from Switzerland reported an advantage for TEP (2.3
between 0 and 16.7% (median 0.6%). 67, 211–213, vs. 2.9 days, p = 0.002). 207 A randomized controlled study
216–219, 222, 223, 225, 227–229, 232–238, 240
Interestingly, an from India recently published could not demonstrate any
analysis of the 1990–1998 literature (TAPP and TEP, 13 significant difference between both techniques. 234
studies each) showed a TAPP recurrence rate of 1.33% and Guidelines
a TEP recurrence rate of 0.6%. In the 1999–2008 period The 2009 EHS Guidelines describe that no hard con-
(seven TAPP and eight TEP studies), recurrence rates clusions concerning the difference in results between
3
dropped to 0.77% for TAPP and 0.54% for TEP, possibly TEP and TAPP can be offered. The only conclusion
reflecting improved technical performance over time. 5, 241 (level 2A) was that TAPP seemed to be associated with
Pain a higher risk of port site and visceral injuries and TEP a
A qualitative systematic review of 71 TAPP and TEP higher conversion rate. Both other guidelines (IEHS and
studies showed no difference in acute pain intensity or EAES) reported similar results to those described
duration. 201 The same is generally true for chronic pain, above. 3, 5, 6
with six studies showing no differ-
ence 212, 214, 219, 229, 232, 234 and two 213, 230 slightly better Discussion, consensus and clarification of grading
outcomes after TAPP (1.15 vs. 3.03%;. 230 5 vs. 9%. 213 ).
Costs Only three of 29 RCTs and observational studies focused
A large population-based study in German hospitals found on primary, unilateral hernias in men. 215, 237, 240 In spite of
208
no differences in TAPP and TEP costs. all variations and limitations of most of the comparative
Access-related complications and conversion studies, all eight meta-analyses and systematic reviews
The frequency of visceral access-related complications inclusive of these studies concluded that insufficient evi-
varied. 5, 202–204, 206, 207, 209, 212 An early systematic review dence exists to recommend the use of one technique over
analyzing the results of 6 comparative studies and 3 case the other. 199–206 Each technique has different, very rare,
series showed that when using TAPP, visceral lesions but serious complications associated with it. One registry
occurred in 0.6% (54/9141) versus 0.2% (12/5803) in study reported a lower TAPP complication rate, 207 while
TEP. 206 On the other hand, after TEP vascular lesions another reported a lower TEP complication rate. 209 Oper-
occurred more often compared to TAPP (0.41 vs. 0.28%). ative team ease and experience are important factors in the
236
Port-site hernias were more common after TAPP (0.4 vs. decision to use one technique preferentially. Her-
0.026%). 5, 202–204, 206, 207, 209, 212 The conversion rate in niaSurge recommends that both techniques are suited for
TEP was higher than in TAPP (0.47 vs. 0.26%). A recently treatment of inguinal hernia(s).
published systematic review 5 analyzed 8 comparative
KQ06.f When considering recurrence, pain, learning
studies and 7 case series and found similar results: visceral
curve, postoperative recovery and costs which is preferred
injuries TAPP 0.21% vs. TEP 0.11%; vascular injuries
technique for primary unilateral inguinal hernias: best open
TAPP 0.25% vs. TEP 0.42%; port-site hernias TAPP 0.6%
mesh (Lichtenstein) or a laparo-endoscopic (TEP and
vs. TEP 0.05% and conversion rate TAPP 0.16% vs. TEP
0.66%. 5, 202–204, 206, 207, 209, 212 TAPP) technique?
In a large German hernia registry (Herniamed) 209 TAPP- F. Ko ¨ckerling, H. Tran and D. Chen
related visceral injuries (bowel, urinary bladder) were seen in
Introduction
0.27% cases (29/10,887) versus 0.1% in TEP (7/6700), the
difference was not statistically significant. Correspondingly In the EHS guidelines, open Lichtenstein and laparo-en-
to the literature, vascular complications were seen in 1.39% doscopic IH techniques (TEP/TAPP) are recommended as
cases after TEP and in 1.13% after TAPP. This difference the best evidence-based options for repair of primary uni-
was significant (p = 0.03). Reoperation rates were not sig- lateral hernias provided the surgeon is sufficiently experi-
3, 4
nificantly different (TAPP 0.9% and TEP 0.2%). Interest- enced in the specific procedure.
ingly, the overall complication rate as reported by the Swiss The HerniaSurge committee thought it prudent to
hernia registry 207 after TAPP was lower than after TEP (1.7 account for all important factors when considering rec-
vs. 4.2%), whereas the German registry 209 showed more ommendations on Lichtenstein and laparo-endoscopic
complications after TAPP (5.37 vs. 2.89%). techniques. It seems clear that when considering postop-
Length of hospital stay erative pain, recovery speed and chronic pain, the laparo-
In the update of the IEHS guidelines TAPP had a longer endoscopic techniques are superior. In TEP and TAPP
hospital stay than TEP. 241 A large population-based study expert hands, especially when performing high-volume

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