Inguinal hernia repair is one of the most common surgical procedures performed worldwide. With the evolution of minimal access surgery, laparoscopic approaches have become increasingly popular, offering reduced postoperative pain, shorter recovery times, and excellent functional outcomes. Among the laparoscopic techniques, Transabdominal Preperitoneal (TAPP) repair is widely practiced due to its versatility and clear anatomical exposure. This article provides a comprehensive overview of laparoscopic TAPP inguinal hernia repair, including indications, surgical technique, advantages, and potential complications.

Introduction

An inguinal hernia occurs when intra-abdominal contents, typically bowel or omentum, protrude through a weakness in the inguinal canal. Traditional open repair has been the gold standard for decades, but laparoscopy has changed the paradigm. The TAPP approach involves entering the abdominal cavity, creating a peritoneal flap, and placing a mesh in the preperitoneal space to reinforce the myopectineal orifice. It is particularly advantageous in bilateral hernias, recurrent hernias after open repair, and in patients desiring early return to activity.

Indications

Dr. R. K. Mishra and other laparoscopic experts recommend TAPP repair in the following cases:

Primary unilateral or bilateral inguinal hernias.

Recurrent hernias following open surgery.

Femoral hernias, which can be addressed through the same approach.

Patients with physically demanding jobs, who benefit from faster recovery.

Contraindications include inability to tolerate general anesthesia, uncorrected coagulopathy, or extensive intra-abdominal adhesions that make laparoscopic entry unsafe.

Patient Preparation and Positioning

The patient undergoes standard preoperative investigations, and prophylactic antibiotics are administered. General anesthesia is mandatory.

The patient is placed in the supine position with arms by the side.

A slight Trendelenburg tilt (head down) is applied, allowing abdominal contents to fall cephalad, thus clearing the operative field.

A urinary catheter may be inserted in selected cases to decompress the bladder and prevent accidental injury.

Port Placement

Typically, a three-port technique is used:

A 10 mm camera port at the umbilicus.

Two 5 mm working ports, placed in the right and left lower abdomen, lateral to the rectus muscle.

This configuration provides triangulation for ergonomic dissection.

Surgical Technique of TAPP Repair

The operation can be divided into systematic steps:

Access and Exploration
After establishing pneumoperitoneum with CO₂, a diagnostic laparoscopy is performed to confirm the diagnosis and rule out occult hernias on the contralateral side.

Peritoneal Incision
A peritoneal flap is created approximately 3–4 cm above the hernia defect. The incision extends from the anterior superior iliac spine medially toward the umbilical ligament.

Dissection of the Preperitoneal Space
Using sharp and blunt dissection, the preperitoneal space is developed. Critical landmarks include the pubic bone, Cooper’s ligament, inferior epigastric vessels, and vas deferens in males. Care is taken to preserve important nerves and avoid injury to vessels in the so-called “triangle of doom” and “triangle of pain.”

Hernia Sac Reduction
The hernia sac is carefully dissected free. For indirect hernias, the sac is separated from the spermatic cord structures; for direct hernias, the sac is reduced back into the abdominal cavity.

Mesh Placement
A large polypropylene or composite mesh (10 × 15 cm) is placed in the preperitoneal space, covering all potential hernia sites within the myopectineal orifice. This ensures coverage of direct, indirect, and femoral defects. Fixation may be done using absorbable tacks, glue, or sometimes left unfixed to reduce postoperative pain.

Closure of Peritoneal Flap
The peritoneal flap is closed over the mesh using sutures or tacks. This prevents bowel loops from adhering to the prosthesis.

Advantages of TAPP Repair

Dr. Mishra and other experts highlight several advantages of laparoscopic TAPP repair compared to open techniques:

Clear anatomical visualization of the inguinal region.

Ability to detect and repair bilateral hernias in the same sitting.

Effective option for recurrent hernias after previous open repair.

Reduced postoperative pain, quicker recovery, and earlier return to work.

Cosmetic benefits due to small incisions.

Low recurrence rates when performed with proper technique and mesh placement.

Potential Complications

Although safe in experienced hands, laparoscopic TAPP repair carries potential risks:

Intraoperative complications: injury to inferior epigastric vessels, bladder, bowel, or spermatic cord structures.

Bleeding from the iliac vessels in the “triangle of doom.”

Nerve injury in the “triangle of pain,” leading to chronic neuralgia.

Seroma or hematoma formation in the inguinal canal.

Recurrence if the mesh is too small or improperly placed.

Mesh-related complications, such as infection or adhesions if peritoneum is not closed properly.

However, with meticulous technique and careful patient selection, these complications are uncommon.

Postoperative Care

Most patients can be discharged within 24 hours. Postoperative management includes:

Early ambulation to prevent thromboembolic events.

Analgesics for pain relief.

Advice to avoid strenuous activity or heavy lifting for at least 2–4 weeks.

Follow-up visits to monitor wound healing and rule out recurrence or chronic pain.

Conclusion

Laparoscopic TAPP inguinal hernia repair has established itself as a safe and effective alternative to open repair, offering patients the advantages of minimal access surgery. By providing excellent visualization of the inguinal anatomy, it enables accurate dissection, reliable mesh placement, and durable repair. As emphasized by leading laparoscopic surgeons such as Dr. R. K. Mishra, the success of TAPP depends on adherence to surgical principles, precise technique, and awareness of potential pitfalls. With proper training and expertise, TAPP repair provides long-lasting relief and rapid recovery for patients with inguinal hernias.