The TAPP technique (transabdominal preperitoneal patch technique) is a gentle and safe technique for repairing inguinal hernias. An inguinal hernia is a fully formed gap with a hernia sac in the inguinal area which mainly occurs in adult men. Mainly if there is discomfort, an inguinal hernia should be treated surgically.

Overview

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TAPP / Transabdominal preperitoneal mesh technique - Further information

Inguinal hernia: Definition and symptoms

An inguinal hernia, also known as an inguinal rupture, is a fully formed gap with a hernia sac in the inguinal area, generally in men. Normally, the inguinal canal is located at groin level. The inguinal canal contains the spermatic cord and the vessels that supply the testicles. If this canal broadens, this causes a protuberance of the peritoneum (hernia sac) and forms an inguinal hernia. This can contain abdominal content, in extreme cases parts of the bowel and it can develop into a swelling which is externally visible and palpable. This causes pain mainly when the person is moving or a feeling of pressure or instability. If the bowel prolapses externally, in the worst case it can become incarcerated, which is an emergency requiring immediate surgery.

Generally, an inguinal hernia forms in adulthood (acquired inguinal hernia) because, in relation to the inguinal canal, this is due to a natural weak point in the anatomy of the abdominal wall in the human body. Because the firmness of the connective tissue wanes and/or the internal abdominal pressure increases (e.g. with overweight), during the course of a lifetime the tissue at groin level slackens, resulting in a hernia gap, which is the cause of the discomfort.

However, inguinal hernias can also occur in children. These are associated with an inguinal canal which has remained open (processus vaginalis testis) during the growth stage and so they are also called acquired inguinal hernias.

The diagnosis of an inguinal hernia is reached after examination by a doctor and usually needs no further resources. Exceptionally, in doubtful cases, an ultrasound examination may shed light on the situation. Generally however, the clinical experience of the examining medic is enough.

Inguinal hernias should be treated surgically mainly in the case of discomfort because spontaneous retraction never happens.

Treatment of an inguinal hernia

There are many surgical techniques for treating an inguinal hernia, which should be adapted individually to each patient. Basically, a distinction is made between the classic, open and conventional technique and the closed, minimally invasive technique.

Open inguinal hernia treatment

In the open surgical technique, the hernia sac is separated from the spermatic cord by means of an incision made externally, then pushed back inside and the hernial ring and the supporting abdominal wall layer are closed again with continuous suturing (e.g. as an open Shouldice repair). This technique is applied predominantly with young people with strong connective tissue, with women of child-bearing age and in emergency situations where - for example - the bowel is incarcerated.

The minimally invasive surgical technique for an inguinal hernia

The minimally invasive technique for inguinal hernia repair, widely adopted since the mid 1990s, is a very elegant and extremely atraumatic surgical technique, which is now a standard procedure in practically every German medical center just as much as the classic open technique. This 'buttonhole' surgical technique is based on the minimally invasive introduction of a synthetic mesh to reinforce the abdominal wall. In general, two equivalent techniques are available, namely TEP and TAPP.

The TEP technique for an inguinal hernia

The TEP technique (total transperitoneal plastic) consists in making a small access point by the navel between the peritoneum and the abdominal wall layer to create a working space by introducing CO2 gas. CO2 is a gas present naturally in the human body and so is completely harmless for the body. With a special camera, with several degrees of magnification, the inguinal hernia situation can be appraised and the hernia can be detached from the spermatic cord structure from inside after creation of two more small access points. The next step in the procedure is to insinuate an anti-allergenic, biocompatible synthetic mesh on to the now well prepared and exposed hernial ring. This has the effect of reinforcing the abdominal wall, which is unstable and weakened in this area. All the steps in this technique are performed by observing them on a monitor (with several degrees of HD quality magnification).

The TAPP technique for treating an inguinal hernia

The TAPP technique (transabdominal preperitoneal patch technique) is based on a somewhat different principle. Here, too, a small access point is selected above the navel, but in this case the necessary CO2 gas is introduced into the whole abdominal cavity. This significantly increases the working area for the surgeon so that after insertion of the camera, surgery can begin by reference to the monitor (see above). Also in this case, two more sleeve-like work access points are created (via two dot-shaped skin incisions 0.5 - 1 cm in length). In the first step, the whole abdominal cavity can be assessed and an initial impression can be gained of the size of the inguinal hernia to be repaired and also of the other side. Preparation begins with a semicircular incision in the peritoneum just above the hernial ring. For this, rod-shaped instruments (scissors, tweezers) are used as tools. After removal of the hernia sac from the inguinal canal and thorough preparation of the whole inguinal area, a (polypropylene) synthetic mesh, generally measuring 10 x 15 cm, is insinuated without creases. Finally, the peritoneum is closed with a continuous resorbable suture, which concludes the surgery.

 

 

Advantages of the TAPP technique as treatment for inguinal hernias

Because the surgical technique is atraumatic and gentle, pain is very unlikely and the body can soon be exposed to strain after wound healing with the tension-free plastic mesh. From a cosmetic point of view, it is unobjectionable because it results in practically no visible scarring. Because both inguinal regions can be assessed, both sides can, if necessary, be treated surgically. The abdominal region and abdominal organs are inspected thoroughly and therefore any other potential problems can be assessed. In comparison with the open surgical technique without mesh stabilization, the recurrence rate seems to be lower.

Is any follow-up treatment necessary with the TAPP technique?

Post surgery, patients are immediately mobile once more and capable of walking. Short-term pain is very limited in most cases and can be treated easily with mild painkillers. Patients can be discharged on the following day and are capable of full weight bearing one to two weeks later (tension-free technique).  This makes the technique ideal for athletes, highly active people and patients with physically demanding work.

TAPP technique - Summary

The TAPP technique is a gentle and safe procedure for repairing inguinal hernias and has become very highly valued in hernia surgery in recent years. With the right indication, individual treatment planning and an experienced surgeon, it is a safe and successful technique with very minor side effects for patients.