Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) repair of inguinal hernia

Both the transabdominal preperitoneal and the totally extraperitoneal repair of inguinal hernia have gained wide popularity throughout the surgical community. Recent guidelines issued by the International Endohernia Society noticed the lack of high-quality comparative evidence between endoscopic and laparoscopic inguinal hernia repair. In view of the wide dissemination of minimally invasive techniques for inguinal hernia repair and the high prevalence of this surgical disease, evaluation of currently available high quality comparative evidence of contemporary modalities is essential. A systematic review and meta-analysis of randomized trials, quasi-randomized studies and prospective non-randomized studies comparing the transabdominal with the preperitoneal approach of inguinal hernia repair was undertaken, with the objective to evaluate the outcomes of the two techniques, as expressed by the incidence of recurrence, operative morbidity and chronic pain. The electronic databases of the National Library of Medicine, Excerpta Medica and the Cochrane Central Register of Controlled Trials were searched. No language restrictions were applied, and abstracts of articles in other than the English language were translated. The Medical Subject Headings (MeSH terms) “laparoscopy”, “endoscopy” and “inguinal hernia”, and the terms “TAPP”, “preperitoneal”, “properitoneal”, “TEP”, “totally extraperitoneal”, “total extraperitoneal” were used. A total number of 18 articles (10 randomized and 8 prospective case-control studies) were included in the analysis. The selected studies were published in the English language. The cumulative study population consisted of 1288 patients with a total of 1303 hernia defects. Our meta-analytical model demonstrated similar recurrence rates for the preperitoneal (1.4 %) and the transabdominal approach (3.5%), with a trend in favor of the TEP repair. The incidence of intraoperative complications was similar for the laparoscopic and the preperitoneal approach (3.6% vs. 2.0%, respectively). Postoperative in-hospital morbidity was similar for TAPP and TEP (11.2% vs. 7.3%), with no evidence of between-study heterogeneity and no evidence of publication bias. No significant differences between the TAPP and the TEP repair were demonstrated with regard to operative time (73.0 versus 70.9 minutes, respectively), whereas significant heterogeneity existed among studies. Postoperative pain as expressed by the visual analogue scoring system was similar between TAPP and TEP (2.4 vs. 2.2), although heterogeneity and publication bias were evident. Furthermore, no significant differences in terms of long-term pain or sensory deficits were found between the two treatment arms. A trend in favor of the transabdominal approach could not be statistically confirmed (6.1% vs. 9.1%). Current data suggest similar results for laparoscopic and endoscopic inguinal hernia repair with regard to patient-oriented outcomes. A trend toward higher recurrence rates with the TAPP repair must not be disregarded, and may suggest modification of technical details, in order to provide long-term outcomes to the patients. Discrete differences between the transabdominal and the preperitoneal repair render transition from one technique to another rather not justified according to current data. High-quality randomized trials with a longer-term follow-up are considered essential, in order to further assess the relative effectiveness of the two procedures in the prevention of hernia recurrence