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Why/When/How to do TEP and TAPP

Why/When/How to do TEP and TAPP

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Why/When/How to do TEP and TAPP

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  1. Why/When/How to do TEP and TAPP Archana Ramaswamy MD

  2. Open Inguinal hernia repair • 1920 • Cheatle • Preperitoneal inguinal hernia repair in recurrent hernias • 1980s • Nyhus, Stoppa • Preperitoneal repair with prosthetic material • 1987 • Lichenstein • Anterior approach • Tension free repair with prosthetic material

  3. Laparoscopic Inguinal Hernia Repair • 1990s • Transabdominal preperitoneal (TAPP) • Totally Extraperitoneal (TEP)

  4. Fixation in Inguinal Hernia Repair • Fixation or no fixation • When Tacking, Where to Tack • Alternatives to Tacking

  5. Fixation Options • Sutures • Permanent tacks (5mm) • Absorbable tacks (5mm) • Staples (5/10mm) • Glues (5mm) • No fixation

  6. Fixation Decrease recurrence Rolling up of mesh No fixation Decrease pain Decrease cost Fixation

  7. Mesh placement • Size: • 4x6 • Material • Polypropylene • Polyester • Slit

  8. FixationWhen Tacking, Where to Tack • Trend toward limited tacks • Coopers ligament (inferior-medial) • Rectus Sheath (superior-medial) • Above Iliopubic tract (lateral)

  9. FixationAlternative to Tacking • N-butyl-2-cyanoacrylate glue • Fibrin sealant application • Good: Temporary mesh stabilization • Bad: may increase cost, cumbersome application device (though improving) • Bioabsorbable Tacks • Good: Temporary Fixation (about 3 to 6 months depending on the product) • Bad: Recently on the market, may increase cost

  10. Mesh fixation • No fixation • Fixation • Medially- Cooper’s • Laterally- anterior iliopubic tract • Anteromedial • Bilateral • Overlap mesh medially

  11. Lap vs Open • Meta-analysis • Forty-one studies • 7161 participants • Longer OR times (14 mins, 95% CI: 13.98-15.64) • Less hematomas (OR: 0.72, 95% CI: 0.60-0.87, only TEP vs open) • Less wound infection (OR: 0.45, 95% CI: 0.32-0.65) • Higher risk of visceral injury (OR: 5.76, 95% CI:1.53- 21.68) • 7 vs 1, 6 in TAPP group • Return to usual activities was faster by 7 days (p<0.001) • Less persisting pain at 1 yr (OR: 0.54, 95% CI: 0.46-0.64) • Less numbness at 1 yr (OR 0.38, 95% CI 0.28-0.49) McCormack, K. Scott,Cochran database, 2007

  12. TEP vs Open • Systematic review • 4231 patients • Longer OR time • Shorter hospital stay • Earlier return to work • Higher hospital costs, overall similar total expenses • Similar or lower recurrence rates

  13. TAPP vs TEP • 1 RCT • Length of stay was shorter in the TEP group (mean difference: -0.70 days, 95% CI -1.33 to -0.07; p=0.03) Schrenk, British Journal of Surgery 1996

  14. TAPP vs TEP • Systematic review • 13000 patients • Higher trocar site hernia: 0.8-3.7% • Higher visceral injury: 0.4-0.9% vs 0-0.23% Wake BL, Cochran database, 2007

  15. TAPP vs TEP • 1 RCT • No differences in OR time, LOS, recurrence, return to activity • Systematic review • TAPP • Higher port site hernias • Higher visceral injuries • TEP • More conversions

  16. Special Situations • Primary Hernia • Following previous appendectomy, lower midline surgery, retropubic prostatectomy, c-section • Recurrent hernia • Following open hernia repair • Following TEP • Indirect >direct • Missed hernia, inadequate dissection • Mesh failure: too small, inadequate positioning,?fixation • Following TAPP • Mesh size, mesh migration, recurrence along mesh slit • Scrotal hernia • Inguinodynia

  17. Primary Inguinal Hernia Following Previous Lower Abdominal Surgery • Operative approach • TAPP • TEP • Lower midline surgery • Limited balloon dissection on ipsilateral side • Appendectomy • Place balloon on contralateral side with limited lateral dissection

  18. Primary Inguinal Hernia Following Previous 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

  19. Primary Inguinal Hernia Following Previous Lower Abdominal Surgery • Outcomes- TEP • 150 patients comparative study • Operative time: • No previous surgery = lower midline non prostate surgery • Previous prostatectomy > others • Conversion to TAPP • Greater in previous prostatectomy group • Complications • No enterotomies or cystotomies Dulucq et al. Surg Endosc. 2006

  20. TEP after TEP No balloon dissection Stay anterior to old mesh Ligate epigastrics as necessary Sharp dissection Insert foley if necessary Outcomes 1526 hernias/14 years 21 TEP after TEP 5 conversions to open No complications Recurrent Hernia/Preperitoneal Mesh Ferzli et al, Hernia 2006 Ferzli et al, Surg Endosc 2004

  21. TAPP Peritoneal visualization Adhesions Open peritoneum 2-3 centimeters above mesh If plane is not accessible between mesh and peritoneum, dissect between mesh and transversalis Outcomes 5005 TAPP 46 recurrent follow LHR No enterotomies 2 cystotomies 1 testicular atrophy Recurrent Hernia/Preperitoneal Mesh Leibl, BJ et al. JACS, 2000

  22. Scrotal Hernia • Relative contraindication for laparoscopic approach? • TAPP probably easier than TEP

  23. Scrotal HerniaTAPP • 191 scrotal hernias • 42 (22%) recurrent • median of 65 min ( vs 45 mins) • Major complications: 1.6% (vs. 0.6%) • Minor complications: seroma, 10.5% needing evacuation • two recurrences (30 mo f/u) Bittner et al Surg Endosc ,2000