TAPP / Transabdominal Preperitoneal Hernioplasty – a surgical procedure involving mesh implantation

An inguinal hernia is a gap in the abdominal wall in the groin area, accompanied by a hernial sac. It most commonly affects men.

Normally, the inguinal canal—which carries the spermatic cord and supplies the testicles—is located in the groin. If this canal widens, the peritoneum protrudes (forming the hernial sac), and an inguinal hernia develops.

The hernial sac contains abdominal contents and, in extreme cases, portions of the intestine. This can result in a swelling that is visible and palpable from the outside. This leads to pain or a feeling of pressure or instability, especially during movement.

If parts of the intestine enter the hernia sac, it can become incarcerated in the worst-case scenario. This constitutes a medical emergency requiring immediate surgery.

In most cases, an inguinal hernia develops in adulthood (acquired inguinal hernia). The inguinal canal is a natural weak spot in the abdominal wall of the human body.

Illustration of an inguinal hernia © designua | AdobeStock

Possible causes of a hernia in the groin region over the course of a person’s life include:

• a decrease in the strength of connective tissue and
• increased intra-abdominal pressure (e.g., due to obesity)

This results in a hernial opening, which is the cause of the symptoms.

However, inguinal hernias are also found in children. These are associated with an inguinal canal (processus vaginalis testis) that has remained open during the growth phase. In this case, they are therefore referred to as congenital inguinal hernias.

The diagnosis of “inguinal hernia” is made through a physical examination by a doctor and usually requires no additional diagnostic tools.

In rare cases where the diagnosis is uncertain, an ultrasound examination may provide further clarification. In most cases, however, the examiner’s clinical experience is sufficient.

If inguinal hernias cause symptoms, surgery is necessary, as they never resolve spontaneously.

There are various surgical procedures for treating an inguinal hernia, which must be tailored to the individual patient.

In general, physicians distinguish between:

• the classic “open,” conventional technique and
• the “closed,” minimally invasive technique

Open Inguinal Hernia Repair

In open surgery, doctors make an incision to separate the hernial sac from the spermatic cord in order to push it back into the abdomen.

The surgeon then closes the hernial orifice and the supporting layer of the abdominal wall with a continuous suture. One example is the open Shouldice repair.

Doctors primarily use this technique for the following patients:

• young people with strong connective tissue
• women of childbearing age
• in emergency situations, such as with an incarcerated bowel

The Minimally Invasive Surgical Technique

Minimally invasive hernia repair, which has been widely used since the mid-1990s, is a very elegant and largely atraumatic surgical technique. Like the classic open method, it has now become a standard procedure in nearly every hospital.

The keyhole surgery technique involves the minimally invasive insertion of a synthetic mesh to reinforce the abdominal wall. There are generally two equivalent procedures: the TEP and TAPP techniques.

The TEP Technique

In the TEP technique (Total Transperitoneal Plasty), surgeons first make a small incision at the navel between the peritoneum and the abdominal wall. They then introduce CO₂ gas into the abdominal cavity to create a larger working space. CO₂ is a gas naturally produced by the body and is therefore completely safe for humans.

Using a special camera, the surgeon can then examine the area under high magnification. In addition, the doctor creates two further, smaller incisions through which he detaches the hernia from the spermatic cord structure from the inside. In the next step, he inserts the hypoallergenic, biocompatible synthetic mesh into the hernia orifice, which has been thoroughly prepared and cleared.

This serves to reinforce the abdominal wall, which is weakened and unstable in this area. The doctor can perform all steps of the procedure with the aid of a monitor providing high-definition magnification.

The TAPP technique (Transabdominal Preperitoneal Patch Technique) is based on a slightly different principle. Here, too, the surgeon selects a small incision site near the navel. This time, however, he infuses the necessary CO₂ gas into the entire abdominal cavity. 

This significantly enlarges the surgeon’s field of view. Consequently, once the camera is inside the body, the surgeon can begin the procedure while viewing the monitor. Two additional tubular access points (each via a pinpoint-sized skin incision 0.5–1 cm long) are then created.

In the first step, the surgeon can assess the entire abdominal cavity and get an initial impression of the size of the hernia.

Dissection begins with a semicircular incision in the peritoneum just above the hernial orifice. To do this, the surgeon uses rod-shaped instruments (scissors, forceps) as surgical tools. After extracting the hernial sac from the inguinal canal, the surgeon thoroughly dissects the entire inguinal region. He can then insert a plastic mesh (polypropylene), typically measuring 10 × 15 cm, ensuring it is wrinkle-free.

Finally, the doctor closes the peritoneum with a continuous absorbable suture. The operation is then complete.

Thanks to the atraumatic, gentle surgical technique, pain is rarely an issue. Furthermore, the tension-free mesh placement allows for a quick return to normal activities once the wound has healed. TAPP is a cosmetically superior procedure, as it leaves virtually no visible scars.

If necessary, the surgeon can treat both inguinal regions in a single operation. Since the surgeon thoroughly examines the abdominal region and abdominal organs, he can also assess any other potential issues. 

The recurrence rate is lower compared to open surgical techniques without mesh stabilization. 

After the surgery, the patient is immediately mobile and able to walk. Short-term pain is generally quite manageable in most cases and can be treated with mild pain relievers.

Discharge is possible the following day, and full weight-bearing is permitted again after one to two weeks (tension-free procedure). 

Therefore, this method is ideal for:

• athletes (see “Athlete’s Groin”)
• highly active individuals, and 
• patients with physically demanding jobs

Thanks to the minimally invasive approach, wound healing is usually uncomplicated, and scarring is minimal. It is important to avoid physical overexertion during the first few days after the procedure to allow the implanted mesh to integrate optimally with the surrounding tissue.

Regular follow-up visits with the treating hernia surgeon ensure that abdominal wall stability is maintained and that no new hernias develop. As a rule, patients are able to resume full physical activity shortly after TAPP surgery.

The TAPP technique is a minimally invasive and safe procedure for repairing inguinal hernias. 

It has become a highly regarded method in hernia surgery in recent years.

When the indication is correctly determined, treatment is individually planned, and the surgeon is experienced, it is a safe and effective procedure with few side effects.

What is the TAPP technique, and when is it used?
TAPP (transabdominal preperitoneal hernioplasty) is a minimally invasive surgical procedure for treating inguinal hernias. During the procedure, a synthetic mesh is inserted through small incisions in the abdominal wall to permanently stabilize the weakened abdominal wall.

What is the difference between TAPP and other surgical procedures?
Unlike open surgery, the TAPP technique involves opening the peritoneum through small incisions, allowing for gentle access to the hernia site. The procedure is considered particularly gentle on the tissues and enables patients to resume physical activity quickly after surgery.

How is the synthetic mesh inserted?
After mapping the anatomy of the inguinal region, the mesh is placed preperitoneally—that is, between the peritoneum and the abdominal muscles. It serves as a barrier and reinforcement to prevent the hernia from recurring.

What are the advantages of the minimally invasive TAPP technique?
TAPP is considered a modern and safe preperitoneal patch repair with a low risk of complications. Advantages include less pain, shorter healing times, and barely visible scars. In addition, hernias on both sides can be treated in a single operation.

When will I be able to resume physical activity after TAPP surgery?
Patients are usually mobile again after just a few days. Full physical activity is possible after about one to two weeks, as the synthetic mesh stabilizes the abdominal wall and reduces the risk of a recurrent hernia.