- Research article
- Open Access
Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience
- Alessia MDG Ferrarese1Email author,
- Stefano Enrico†1,
- Mario Solej†1,
- Alessandro Falcone†1,
- Silvia Catalano†1,
- Enrico Gibin†1,
- Silvia Marola†1,
- Alessandra Surace†1 and
- Valter Martino†1
© Ferrarese et al; licensee BioMed Central Ltd. 2013
- Published: 8 October 2013
Aim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables.
We described our standardized TAPP technique according with Stuttgart technique , and we evalutated our team's experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs).
We retrospectively reviewed our Surgery Division's experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients.
According with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.
- Incisional Hernia
- Inguinal Hernia Repair
- Polypropylene Mesh
- Recurrent Hernia
- Major Vascular Injury
Aim of this study is to evaluate the feasibility of our technique in the elderly, as far as concerns preoperative and postoperative variables.
Our work is a retrospective study conducted at University Section of General Surgery in "San Luigi Gonzaga" Hospital, Orbassano (Torino). At first we described our standardized TAPP technique.
We rewieved our experience from July 2007 to December 2012 about TAPP in elderly patients (> 65 yrs - TAPPe Group) and in young patients (< 65 yrs - TAPP Group). In our division of General Surgery the first TAPP was performed on 02/05/2007. In TAPP and TAPPe Groups were excluded patients with: important comorbidities, severe chronic obstructive pulmonary disease (COPD), previous retinal detachment, glaucoma. We also excluded patients who refused general anesthesia. We didn't excluded patients with previous abdominal surgery.
All procedures were conducted by three surgeons with more than 15 years laparoscopic experience.
We first used polypropylene high-weight meshes  fixed with absorbable clips, then we started to use polypropylene low-weight meshes fixed with fibrin glue [4, 13] and finally we started to use self-locking Polyester meshes : currently 30 TAPP (6 in elderly) were performed using this mesh, in these cases without any fixation device.
Following literature pattern, complications were divided into: recurrence (early and late), early minor complications (minor vascular lesions, seroma, scrotal hematoma), early major complications (major vascular injury, bladder injury, visceral injury, umbilical cord injury), late minor complications (chronic pain) and late major complications (incisional hernia, mesh infection, mesh rejection, intra-abdominal infection, exitus).
We finally asked patients to express an opinion from 0 to 4 as a score for their satisfaction about the TAPP procedure received.
Pneumoperitoneum in left hypochondrium by Veress needle, and access in the umbilical region by Hasson reusable trocar. Intra-abdominal pressure is maintained at 12 mmHg. Placing a disposable 5/12 mm operating trocar in the right side and a reusable 5 mm trocar in the left hip. Peritoneal incision from the anterior superior iliac spine to the median ligament. Medial dissection up to discover Cooper's ligament. Dissection on the upper side of Psoas muscle. Median dissection till complete reduction of the hernia sac and of the pre-lipomatous formation in the abdomen
In case of bilateral defects we find it useful to proceed to the contralateral preparation before mesh placement, and we prefer to prepare two separate preperitoneal pockets
Mesh preparation and its shaping of approximately 13 × 11 cm in the medial part, 8-9 cm in the lateral part, with median notch for the umbilical cord
Mesh introduction and its placement in the preperitoneal pocket
Closure of the peritoneal flap by continuous suture with Prolene 2/0 absorbable, secured with clips, after eversion of the sac in the abdomen.
From January 2007 to December 2012 in our University General Surgery division 730 hernioplasty were performed, 492 with open approach and 185 with laparoscopic approach.
133/ 21 (82,05% - 17,95%)
29/2 (93,5% - 6,5%)
Caracteristics of defects
Total TAPP Group (TAPP)
Elderly TAPP Group (TAPPe)
Mean operative time (min)
Majior vasular lesions
Minor vascular lesion
Umbilical cord injury
There were no major vascular injury, visceral injury or bladder injury in any case.
There were no wound infections or mesh infections in either group.
Caracteristics of meshes
Polprolylene mesh-non absorbable tacks
Polprolylene mesh-absorbable tacks
Polprolylene mesh-fibrin glue
Late reoperation rate
Total hospital stay (Mediana, gg)
Early recurrence rate
Early reoperation rate
1/31 (3,2 %)
8/154 (2,6 %)
GR 0: bad
GR 1: medium
GR 2: good
GR 3: excellent
Laparoscopic treatment of inguinal hernias is a difficult procedure that requires an adequate learning curve . In our experience, operative time and hospital stay appear to be acceptable and in accord with the experience of most centres.
According to literature, satisfaction of patients who underwent laparoscopic procedure in our TAPP experience was excellent.
In our opinion the best short and long term perioperative results depend on careful and bloodless dissection of the preperitoneal space, meticulous reduction of the hernia sac, appropriate mesh size, its positioning and fixation; also fundamental is to completely close the peritoneal flap, leaving no gaps .
We consider surgery approach more difficult in the elderly in some cases  but we also considered laparoscopic approach is, in general, a safe and feasible technique in acute pathology  and a safe approach also in the elderly [16, 17]. In our experience, laparoscopic repair of wound defects is a good standard technique also in the elderly.
In conclusion, in our experience, despite the retrospective study limitations, TAPP technique for inguinal hernia repair is an effective and safe technique when performed by experienced hands, also in the elderly. Perioperative intervention related morbidity appears to be within normal limits, and the superiority of laparoscopic technique in terms of post-operative discomfort, improved aesthetic results and early return to work is to be confirmed also in this type of intervention and also in the elderly.
Funding for this article came from personal funds.
This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://0-www.biomedcentral.com.brum.beds.ac.uk/bmcsurg/supplements/13/S2
- Bittner R, Leibl BJ, Jäger C, Kraft B, Ulrich M, Schwarz J: TAPP - Stuttgart technique and result of a large single center series. J Minim Access Surg. 2006, 2: 155-159. 10.4103/0972-9941.27730.PubMed CentralView ArticlePubMedGoogle Scholar
- Yoon Young Choi, Sun Wook Han, Sang Ho Bae, Sung Yong Kim, Kyung Yul Hur, Gil Ho Kang: Comparison of the outcomes between laparoscopic totally extraperitoneal repair and prolene hernia system for inguinal hernia; review of one surgeon's experience. J Korean Surg Soc. 2012, 82: 40-44. 10.4174/jkss.2012.82.1.40.View ArticleGoogle Scholar
- Kulacoglu H: Current options in inguinal hernia repair in adult patients. Hippokratia. 2011, 15: 223-231.PubMed CentralPubMedGoogle Scholar
- Kukleta JF, Freytag C, Weber M: Efficiency and safety of mesh fixation in laparoscopic inguinal hernia repair using n-butyl cyanoacrylate: long-term biocompatibility in over 1,300 mesh fixations. Hernia. 2012, 16: 153-62. 10.1007/s10029-011-0887-9.PubMed CentralView ArticlePubMedGoogle Scholar
- Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M: European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009, 13: 343-403. 10.1007/s10029-009-0529-7.PubMed CentralView ArticlePubMedGoogle Scholar
- Gonzalo Torres-Villalobos, Laura Sorcic, George Ruth R, Rafael Andrade, Luis Martin-del-Campo A, Kyle Anderson J: Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair. JSLS. 2010, 14: 95-102. 10.4293/108680810X12674612014824.View ArticleGoogle Scholar
- Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Paß C, Singh K, Timoney M, Weyhe D, Chowbey P: Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia [International Endohernia Society (IEHS)]. Surg Endosc. 2011, 25: 2773-2843. 10.1007/s00464-011-1799-6.PubMed CentralView ArticlePubMedGoogle Scholar
- Asuri Krishna, Misra MC, Virinder Kumar Bansal, Subodh Kumar, Rajeshwari S, Anjolie Chabra: Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial. Surg Endosc. 2012, 26: 639-649. 10.1007/s00464-011-1931-7.View ArticleGoogle Scholar
- Amato B, Moja L, Panico S: Shouldice technique versus other open techniques for inguinal hernia repair (Review). Cochrane database of systematic reviews (online). 2012, 4: CD001543-Google Scholar
- Amato B, Compagna R, et al: Feasibility of inguinal hernioplasty under local anesthesia in elderly patients. BMC Surg. 2012, 12 (Suppl 1): S2-10.1186/1471-2482-12-S1-S2.PubMed CentralView ArticlePubMedGoogle Scholar
- Ashraf Abbas E, Mohamed Abd Ellatif E, Nashat Noaman, Ahmad Negm, Gamal El-Morsy, Mahmoud Amin, Ahmad Moatamed: Patient-perspective quality of life after laparoscopic and open hernia repair: a controlled randomized trial and Other Interventional Techniques. Surg Endosc. 2012, 26: 2465-70. 10.1007/s00464-012-2212-9.View ArticlePubMedGoogle Scholar
- Randomized controlled multicenter international clinical trial of self-gripping ParietexTM ProGripTM polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months. Hernia. 2012, 16: 287-94. 10.1007/s10029-012-0900-y.Google Scholar
- Fortelny RH, Petter-Puchner AH, May C, Jaksch W, Benesch T, Khakpour Z, Redl H, Glaser KS: The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study. Surg Endosc. 2012, 26: 249-254.View ArticlePubMedGoogle Scholar
- Ferrarese A, Martino V, Falcone A, Solej M, Destefano I: Perforated duodenal diverticulum: case report and short review of the literature. su Chirurgia,Google Scholar
- Solej M, Martino V, Mao P, Enrico S, Rosa R, Fornari M, Destefano I, Ferrarese AG, Gibin E, Bindi F, Falcone A, Ala U, Nano M: Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Minerva Chirurgica. 2012, 67 (5): 381-387.PubMedGoogle Scholar
- Ferrarese A, Martino V, Nano M: Elective and emergency laparoscopic cholecystectomy in the elderly: early or delayed approach. BMC Geriatrics. 2011, 11 (Suppl 1): A14-10.1186/1471-2318-11-S1-A14.PubMed CentralView ArticleGoogle Scholar
- Ferrarese A, Martino V, Nano M: Wound defects in the elderly: our experience. BMC Geriatrics. 2011, 11 (Suppl 1): A15-10.1186/1471-2318-11-S1-A15.PubMed CentralView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.