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TEP , TAPP, or What?

TEP , TAPP, or What?. Brian Jacob, MD FACS Associate Clinical Prof Surgery Laparoscopic Surgical Center of NY Mount Sinai Medical Center New York City, NY. Disclosures. Consultant / Teaching/Research Grant: Covidien Research Grant: Atrium Consultant: Ethicon. Recipe for Success.

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TEP , TAPP, or What?

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  1. TEP , TAPP, or What? Brian Jacob, MD FACS Associate Clinical Prof Surgery Laparoscopic Surgical Center of NY Mount Sinai Medical Center New York City, NY

  2. Disclosures • Consultant / Teaching/Research Grant: Covidien • Research Grant: Atrium • Consultant: Ethicon

  3. Recipe for Success

  4. TEP vs. TAPP • More than 12,000 patients • 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. 2008. The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd

  5. 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

  6. 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. 2002. SurgEndosc

  7. TEP has proven the test of time

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

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

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

  11. TEP vs. TAPP

  12. TEP: Trocars

  13. TEP: great for direct hernia Left groin

  14. TEP: great for femoral hernia Right groin

  15. TEP: great for indirect hernia Left groin

  16. TEP: no peritoneum to close! Right groin

  17. 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

  18. 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. 2010. World J Surg (ireland)

  19. TEP vs. Lichtenstein: QoL Myers E, Browne KM, Kavanagh DO, Hurley M. 2010. World J Surg (ireland)

  20. 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. 2010.

  21. TEP vs. Lichtenstein: Chronic Pain * P < 0.001 Eklund A, Montgomery A, Bergkvist L, Rudberg C. Swedish Multicenter Trial of Inguinal Hernia Repair by Laparoscopy (SMIL). Brit J Surg. 2010.

  22. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (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) • Bassinioperation (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) • Bassinioperation (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. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (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)

  26. Randomized, Prospective Trial • 365 unilateral inguinal hernias randomly assigned • Shouldice repair (n = 74) • Bassinioperation (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)

  27. 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)

  28. TAPP: early internal hernia through peritoneal defect

  29. TAPP: early trocar site hernia

  30. TAPP: late adhesions

  31. 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

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

  33. 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. SurgEndosc. 2002

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

  35. Incarcerations / strangulations

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

  37. Scrotal Hernias

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

  39. Inguinodynia: tack

  40. Inguinodynia: recurrence

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

  42. Recurrence after TEP or TAPP

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

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

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

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

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

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

  49. 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

  50. 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

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