Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.

 

Abstract

Background

The choice of approach to the laparoscopic repair of inguinal hernia is controversial. There is a scarcity of data comparing the laparoscopic transabdominal preperitoneal (TAPP) approach with the laparoscopic totally extraperitoneal (TEP) approach and questions remain about their relative merits and risks.

Objectives

To compare the clinical effectiveness and relative efficiency of laparoscopic TAPP and laparoscopic TEP for inguinal hernia repair.

Search methods

We searched Medline Extra, Embase, Biosis, Science Citation Index, Cochrane Central Register of Controlled Trials (CENTRAL), Journals@ Ovid Full Text and the electronic version of the journal, Surgical Endscopy. Recent conference proceedings by the following organisations were hand searched: Association of Endoscopic Surgeons of Great Britain & Ireland; International Congress of the European Association for Endoscopic Surgery; Scientific Session of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES); and the Italian Society of Endoscopic Surgery. In addition, specialists involved in research on the repair of inguinal hernia were contacted to ask for information about any further completed and ongoing trials, relevant websites were searched and reference lists of the all included studies were checked for additional reports.

Selection criteria

All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic TAPP with laparoscopic TEP for inguinal hernia repair were eligible for inclusion. Non-randomised prospective studies were also eligible for inclusion to provide further comparative evidence of complications and adverse events.

Data collection and analysis

Statistical analyses were performed using the fixed effects model and the results expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI).

Main results

The search identified one RCT which reported no statistical difference between TAPP and TEP when considering duration of operation, haemotoma, length of stay, time to return to usual activity and recurrence. The eight non-randomised studies suggest that TAPP is associated with higher rates of port-site hernias and visceral injuries whilst there appear to be more conversions with TEP. Vascular injuries and deep/mesh infections were rare and there was no obvious difference between the groups. No studies reporting economic evidence were identified. Very limited data were available on learning effects but these data suggest that operators become experienced at between 30 and 100 procedures.

Authors' conclusions

There is insufficient data to allow conclusions to be drawn about the relative effectiveness of TEP compared with TAPP. Efforts should be made to start and complete adequately powered RCTs, which compare the different methods of laparoscopic repair.

 

Plain language summary

Two different laparoscopic techniques for repairing a hernia in the groin

An inguinal hernia is a weakness in the wall of the abdominal cavity that is large enough to allow escape of soft body tissue or internal organ, especially a part of the intestine. It usually appears as a lump and for some peoples can cause pain and discomfort, limit daily activities and the ability to work. If the bowel strangulates or becomes obstructed it can be life-threatening. A hernia is repaired generally using a synthetic mesh either with open surgery or increasingly using less invasive laparoscopic procedures. The most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. In TAPP the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites. TEP is different in that the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum (the thin membrane covering the organs in the abdomen). This approach is considered to be more difficult than TAPP but may have fewer complications. Laparoscopic repair is technically more difficult than open repair.
The review authors searched the medical literature and found one controlled trial in which 52 mainly male adults were randomised to the two different laparoscopic techniques, carried out by an experienced surgeon. The trial reported that there was no clear difference between TAPP and TEP when considering duration of operation, haemotoma, length of stay, time to return to usual activity or in recurrence of a hernia in the follow-up time of only three months. The authors also looked at non-randomised prospective studies that included more than 500 participants and large prospective case series with greater than 1000 participants for complications and adverse events. From nine studies, a small increase in the number of hernias developing close by and injuries to internal organs were apparent with TAPP and conversions to another type of surgery were more frequent with TEP. These results were broadly consistent. Vascular injuries and deep and mesh infections were rare and there was no obvious difference between the two techniques.

 

摘要

背景

經腹腔腹膜前疝氣腹腔鏡修補手術(Transabdominal preperitoneal approach, TAPP)和全腹膜外疝氣腹腔鏡修補手術(Total Extraperitoneal Herniorrhaphy, TEP)對於治療腹股溝疝氣的效果

選擇是用腹腔鏡來治療腹股溝疝氣仍存在有很多爭議，目前缺乏針對經腹腔腹膜前疝氣腹腔鏡修補手術(Transabdominal preperitoneal approach，TAPP)和全腹膜外疝氣腹腔鏡修補手術(Total Extraperitoneal Herniorrhaphy，TEP)進行比較的有效數據，並且對於這些治療效果的相對效益及風險仍具有許多疑問

目標

本研究的主要目的在於比較腹腔鏡TAPP治療法和腹腔鏡TEP治療法對於腹股溝疝氣治療的臨床效益和相對效益

搜尋策略

我們檢索了Medline Extra、Embase、Biosis、Science Citation Index、Cochrane Central Register of Controlled Trials (CENTRAL)、Journals@ Ovid Full Text等資料庫，也檢索了Surgical Endscopy期刊的電子版，近期由下列組織主辦的研討會論文也會進行檢索：Association of Endoscopic Surgeons of Great Britain & Ireland、International Congress of the European Association for Endoscopic Surgery、Scientific Session of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES)和Italian Society of Endoscopic Surgery，此外，也聯繫參與腹股溝疝氣治療研究的專家，並且詢問相關更完整或是進行中試驗的資訊，同時檢索相關網站和被納入研究的試驗其參考文獻清單以確認其他可以被納入研究的試驗

選擇標準

所有已公開和未公開的隨機性對照試驗和類隨機性對照試驗，只要是針對使用腹腔鏡TAPP方法和腹腔鏡TEP方法治療腹股溝疝氣效果進行比較，即適合納入本研究中，非隨機性的前瞻性試驗也適合納入本研究中，藉此可以取得更多有關於併發症和不良事件的比較性證據

資料收集與分析

利用固定效應模型進行統計分析，而二元式試驗成果以相對風險(RR值)的形式表示，連續性試驗成果則以加權平均值(WMD值)和95％的信心區間進行表示

主要結論

有一個被確認的RCT試驗結果顯示TAPP和TEP治療，對於手術時間長短、出現血腫(haemotoma)、住院時間長短、恢復至一般活動能力和復發的影響並沒有統計學上的差異性，有8個非隨機性試驗推測TAPP治療方法似乎與插管處疝氣和內臟受傷的高發生率有關，但是對於TEP治療法來說卻具有較高的轉換率，血管的損傷和深層/網狀感染是較少出現的併發症，這些症狀出現的機率在2組之間也沒有顯著差異，沒有試驗提供明確的經濟證據，有非常有限的可用數據是說明學習效果，但是這些數據推測手術者在進行30至100個手術後會變的更有經驗

作者結論

有一些較不充分的數據可以讓我們對於TEP和TAPP的相對效用作出一些結論，應該要開始努力並且進行具有適當效力，以針對不同腹腔鏡治療方法的RCT試驗

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

兩種用來治療鼠蹊部疝氣的腹腔鏡技術。 腹股溝疝氣是一種因為腹腔壁薄弱而讓身體軟組織或是內部器官(特別是腸道)滑落在腹腔的一種症狀，通常出現疝氣時，腹腔會出現一個團塊，有些人會感覺疼痛不適、影響日常活動和影響工作能力，如果發生腸道絞死或是阻塞的現象便有可能危及生命安全，通常疝氣是使用人工網膜搭配開放性手術或是越來越多人使用且具低侵入性的腹腔鏡手術來進行治療，最常使用在治療腹股溝疝氣的腹腔鏡手術包括了TAPP和TEP治療法，進行TAPP治療法時，手術的操作部位在患者的腹腔膜並且由醫師透過腹膜切口在可能發生疝氣的部位置放一塊人工網膜，TEP治療法則與TAPP治療法的操作方式不一樣，因為TEP治療法不會在腹腔膜進行操作，而是使用人工網膜由腹膜外側來縫合發生疝氣的部位(薄膜會覆蓋腹部的器官)，TEP治療法被認為比TAPP治療法更不容易操作，但是卻具有較少的併發症，腹腔鏡治療使一種比開放性治療更難的操作技術，審閱作者搜尋了醫學文獻並且發現有一個對照試驗是將52位男性患者隨機分配進行這兩種腹腔鏡手術，所有手術都由同一位有經驗的醫師操刀，試驗結果說明使用TEP治療法和TAPP治療法對於手術時間、出現血腫、住院時間、恢復至正常活動所需時間、在治療後3個月在出現疝氣復發等治療成果上並沒有明確的差異，審閱作者也閱覽了納入超過500名患者的非隨機性前瞻試驗，以及利用超過1000名患者來研究相關併發症及不良事件的大型前瞻個案系列，由9個試驗結果顯示，使用TAPP來說有少數的疝氣和內臟受傷的情況，但是對於TEP治療法來說卻具有較高的轉換率，這些數據具有高度的一致性，血管的損傷和深層/網狀感染是較少出現的併發症，這些症狀出現的機率在2組之間也沒有顯著差異