I think a lot depends on how one was trained. I was trained at a center where majority of cases are managed with TEP repair. And I am a fan of TEP. I do TAPP repair for selected cases (irreducible content, rec. hernias, accidental intra-peritoneal entry of trocar). I have seen few surgeons who started with TAPP and then shifted to TEP, once they are more confident with the technique.     

I think both approaches are acceptable as long as one is familiar with the anatomy however do not discount the open method which can easily be done using lite weight dual meshes such as ultrapro ( ethicon) thru relatively small incisions as day cases. Also see the interesting responses I received on this forum when I posed to doctors which procedure they would prefer for themselves. Over 50 % opted for the open procedure ! 

Hello. In the hospital where I do 90% TAPP. also depends as much formed one. PE to boot seems a bit more complex to navigate in the anatomy. It would be good that the surgeon is trained first and then start TAPP with TEP.

Cheers

TEP procedure start to get more and more popularity but in general it depend on the surgeon preference .

i have been trained to do both , i found TEP is more convienent  for the pt and surgeon as well but the learning curve is needed .

TAPP has the extra dimension of exploration so I use it in case of doubt. Normally I prefer TEPP. Less pain, less intra-abdominal scarification and faster, especially in bilateral hernias where I use a tailored 30X15 cm mesh. Even in accidental entry of the peritoneum I prefer to convert back to TEPP approach.

Lap hernia repair is a industry driven propaganda. Both TAPP and TEPP have their limitations. They are best suited for lolly-pop cases only. Open surgery is still the safest and best option for hernia repair. The proponents of lap hernia repair usually cite the same advantages of small incision , less pain and early return to work but do not state the true recurrence rates.

Mostly surgeon preference whether you do one or the other. TAPP probably easier to start with. No real advantage or disadvantage of either. Results equivalent.

i feel TAPP is a more physiological procedure as an inlay mesh secures well with a rise in intraabd pressure.further all the three potential defects are covered. third the dissection and the laying of mesh as well as its fixation is better achieved in TAPP

Dear Prassana,

To comment your question fills a book. To answer it maybe two books (wrote 4 chapters on this issue last month). Comments like "industry driven propaganda" are not the level of discussion of modern herniology. I hope this is not our future as potential patients, although I had a TAPP repair on my recurrent hernia in 1993 and am stil OK.

European Hernia Society Guidelines on groin hernia repair, International Endohernia Society Guidelines , their respective updates in 2014 and The Consensus development conference of 2013 can give you a little more differentiated insight than mentioning lolly-pop cases.  

Be carefull with 3D, some of them are too narrow in their lateral third, which allows the fat pad lateral of spermatic vessels to under-crawl the mesh. 15x10cm and larger is the best recurrence prevention. The rest is not Know-how, but Do-how ...

Correctly performed TAPP and TEP must have the same quality of outcome. But TAPP teaches more minimal invasive technical elements (e.g. suturing, true dissection) than separating tissue with two graspers,  besides being more versatile in indication range and easier to taech and learn. In Germany TAPP is more popular, Penetration of endo is 52%, in Switzerland TEP is more offen taught, although it causes more intra- and postoperative complications than TAPP.

There are several bigger Hernia - Collective Works on their way to all of you.

Dear Prassana,

I totally agree with Jan K, that there is no known difference in the outcomes of TEP vs TAPP, when performed by similarly skilled surgeons.

However, your question was which procedure is most popular. It seems as if this is more a matter of geography (eminence based) rather than science (evidence based)...

Sweden:

Due to the national Swedish Hernia Registry, we have an almost 100% overview of which methods are used in my country. TEP and TAPP are both increasing, but with a very strong dominance for TEP.

 I do think it is a matter of where one is trained and also one's work set-up. In the UK, for instance, perhaps due to the high volume requirements of the public system, most general surgeons are trained initially in TAPP with laparoscopic surgeons reserving TEP for selected cases - often when they hold training courses! In Australasia, it seems more people are trained primarily in TEP. Personally, I like the advantages of TAPP, as one is able to consent patients for bilateral repairs and repair of other incidentally found groin hernias, if required. And yes, it appears more intuitive due the anatomical familiarity, allowing one to tackle even large hernias. Rural New Zealand and remote Australia see patients presenting with large hernias, as one finds in India. I've no idea about the USA, but our impression in the UK of Europe in general was as above, I.e. a predominance of TEP. 

I mostly agree with Jan Kukleta and Bengt Novik. However, the TEP is by far the most popular procedure in Norway and I am not sure Jan Kukleta is right when stating that TEP has more intra- and post-operative complication compared to TAPP. TAPP is in skilled hands and in established TEP-centers in Norway mostly reserved for recurrence after a TEP or other posterior repairs. For the Lollipop argument: almost all hernias, primary or recurrence after an anterior procedure are suited for the TEP procedure - including incarcerated and large scrotal hernia - and the interponate easily assessed and dealt with by a concluding laparoscopy through the optical port-site if there is any doubt of tissue viability or damage. The tedious opening and closure of the peritoneum is avoided by TEP. It is not a candy-game: skilled surgeons with the opportunity to actually learn and compare the methods often transgress from TAPP to TEP, as it is easier, faster and no less effective. In a country where the single patient does not impact the gross domestic product the added cost of an endoscopic procedure is problematic as the advantage of less complications and economic benefit of shorter absence from work will not be harvested.

In our departement almost all hernias are treated by TEP.

In our hands it gives a shorter operatingtime than other techniques.  There are almost no recurrences and patients have almost no dyscomfort.  We use a light weight mesh with large pores (3Dmax Xlarge Bard).

Learning curve is longer then open repair, but in my experience as long as for TAP.  1ste year resident is able to perform this procedure safely after one year.

Tapp give the advantage of the extra dimention of the intraperitoneal view, if requiered.  We perform TAPP sometimes after previous midline incision.  Closing the peritoneum by suturing adds an extra operating time of 10 min. We use in TEP and Tapp the same mesh (the repair is the same, the mesh also).

Open repair only in scrotal hernias if TEP is not/seems not possile or if the preperitoneal cavity is not accesable (prostatectomy, previous herniasurgery, ......).

It seems Marc Van Cleemput has the same experience as we have - also regarding training of the residents (in primary hernia).

In low midline laparotomy incisions e.g. after open prostatectomy we also prefer TEP, but often do an initial laparoscopy to check that no intestine or bladder is adherent to the scar. If not (mostly so), then we can proceed speedily with preperitoneal midline trocar insertions and sharp dissection of the scar tissue to recreate the embryological plane. But this is not a training exercise for residents...

It’s really Commendable if your resident can pick up TEP/TAAP tech.

I prefer TEP , TAPP is more time consuming, for larger irreducible I use hybrid tech, many a time requires opening the sac and reduction of contents by minimal open incision , close the incision and resume back TEP.

Both are excellent techniques when performed by surgeons adequately trained to do them. I am not convinced any trial would ever show any significant differences between the two. Personally I marginally prefer TAPP as I like the familiarity and options that the laparoscopy gives you and I think it is slightly easier to train more junior surgeons in this technique.

TAPP is easier and most appropriate for beginners.

technically easier

I prefer TEP but TAPP is easier however it is time consuming

In Sweden 2018 (official nation-wide data from the Swedish Hernia Registry):

• TEP 30 %
• TAPP 6 %
• The other repairs are open, predominantly Lichtenstein.