Inguinal hernia is one of the most common surgical conditions encountered worldwide. It occurs when abdominal contents, usually a portion of the intestine or preperitoneal fat, protrude through a weakness in the inguinal canal. While open hernia repair techniques have been in practice for centuries, laparoscopic surgery has become increasingly popular because of its minimal invasiveness, reduced postoperative pain, and quicker recovery. Among laparoscopic approaches, Transabdominal Preperitoneal (TAPP) repair is one of the most widely performed and effective techniques for inguinal hernia management.

Understanding the TAPP Approach

The term “TAPP” stands for Transabdominal Preperitoneal repair. In this method, the surgeon enters the peritoneal cavity, creates a peritoneal incision, and develops the preperitoneal space where the hernia defect lies. A synthetic mesh is placed to cover the myopectineal orifice, which includes potential hernia sites such as direct, indirect, and femoral spaces. After mesh placement, the peritoneum is closed, isolating the mesh from intra-abdominal organs.

This technique provides excellent exposure of bilateral inguinal areas, making it particularly useful for recurrent or bilateral hernias.

Indications for TAPP Surgery

TAPP laparoscopic hernia repair is indicated in:

Primary inguinal hernias (direct and indirect).

Bilateral inguinal hernias.

Recurrent hernias after open repair.

Femoral hernias.

Patients desiring early return to activity or reduced postoperative pain.

Patients unfit for general anesthesia or those with extensive intra-abdominal adhesions may not be suitable candidates.

Advantages of TAPP Repair

Dr. R. K. Mishra and other pioneers in laparoscopic surgery often emphasize the advantages of TAPP over conventional open techniques:

Minimally invasive: Small incisions and reduced tissue trauma.

Better visualization: Direct view of the entire myopectineal orifice, reducing missed hernias.

Bilateral access: Both sides can be repaired through the same incisions.

Faster recovery: Earlier mobilization and return to work.

Less postoperative pain: Compared to open Lichtenstein repair.

Low recurrence rate: With proper mesh placement and fixation.

Step-by-Step Surgical Technique
Patient Positioning and Anesthesia

The patient is placed supine under general anesthesia. A Trendelenburg tilt of 10–15 degrees allows bowel loops to fall away from the pelvis, improving exposure.

Port Placement

A standard three-port technique is used:

A 10 mm umbilical port for the laparoscope.

Two 5 mm working ports placed in the lower abdomen lateral to the rectus muscles.

Exploration and Identification

The peritoneal cavity is inspected. The hernia defect and landmarks such as the inferior epigastric vessels, vas deferens, and spermatic vessels are identified.

Peritoneal Incision

A horizontal peritoneal incision is made 2–3 cm above the hernia defect, extending from the medial umbilical ligament to the anterior superior iliac spine. The peritoneal flap is carefully dissected downward to expose the preperitoneal space.

Hernia Sac Reduction

The hernia sac, whether direct or indirect, is dissected and reduced. Care is taken to preserve vital structures like the vas deferens, testicular vessels, and femoral vessels.

Mesh Placement

A synthetic mesh, usually 10 × 15 cm, is introduced through the 10 mm port. The mesh is spread over the myopectineal orifice, covering all potential sites of herniation (direct, indirect, and femoral).

Mesh Fixation

The mesh may be fixed with absorbable tackers, non-absorbable tackers, or fibrin glue. Some surgeons prefer non-fixation in small hernias if the mesh remains stable. Proper placement ensures long-term durability.

Peritoneal Closure

The peritoneal flap is closed over the mesh using sutures, tacks, or clips. This step prevents direct contact between the mesh and abdominal contents, reducing the risk of adhesions or bowel obstruction.

Completion

Pneumoperitoneum is released, ports are removed, and skin incisions are closed.

Postoperative Care

Most patients recover rapidly after TAPP hernia surgery. They can resume oral intake within hours and are encouraged to ambulate early. Hospital discharge often occurs within 24 hours. Mild discomfort may persist for a few days, but pain is significantly less compared to open repair. Normal activities can usually be resumed within a week, although strenuous lifting is avoided for 4–6 weeks.

Potential Complications

While TAPP is safe and effective, potential risks include:

Injury to vas deferens or testicular vessels.

Injury to the bladder, bowel, or inferior epigastric vessels.

Seroma formation in the hernia sac area.

Neuralgias due to nerve irritation.

Recurrence if mesh placement is inadequate.

The complication rate is low when performed by experienced surgeons.

TAPP vs. Other Techniques

Compared to TEP (Totally Extraperitoneal Repair), TAPP provides wider exposure and is technically easier for beginners, though it requires peritoneal entry. TEPP avoids entry into the peritoneal cavity but has a steeper learning curve. Both approaches yield excellent long-term outcomes when performed correctly.

Conclusion

Laparoscopic hernia surgery using the TAPP technique has become a cornerstone of modern inguinal hernia management. It combines the benefits of minimally invasive surgery with durable outcomes, making it a preferred choice for bilateral, recurrent, and complex hernias. With proper training, adherence to anatomical landmarks, and meticulous technique, TAPP repair provides patients with reduced pain, faster recovery, and low recurrence rates. As laparoscopic expertise continues to grow globally, TAPP will remain a vital procedure in the armamentarium of hernia surgeons.