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Tapp

This study evaluates the necessity of peritoneal closure during laparoscopic TAPP inguinal hernia repair using composite coated mesh. Results indicate that omitting peritoneal closure significantly reduces operative time without increasing early postoperative complications. The findings suggest that routine closure may not be mandatory with modern anti-adhesive meshes, though further research is needed for long-term safety and efficacy.

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7 views7 pages

Tapp

This study evaluates the necessity of peritoneal closure during laparoscopic TAPP inguinal hernia repair using composite coated mesh. Results indicate that omitting peritoneal closure significantly reduces operative time without increasing early postoperative complications. The findings suggest that routine closure may not be mandatory with modern anti-adhesive meshes, though further research is needed for long-term safety and efficacy.

Uploaded by

xpt9mckqsj
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Re-evaluating the Necessity of Peritoneal Closure in

Laparoscopic TAPP Repair with Composite Mesh:


Prospective Comparative Outcomes

Background

Peritoneal closure during laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia


repair is traditionally performed to prevent bowel contact with mesh and internal herniation.
With the advent of anti-adhesive coated meshes, the necessity of routine peritoneal closure
remains uncertain. This study compares perioperative and short-term outcomes of peritoneal
closure versus non-closure in TAPP repair using coated mesh.

Methods

This prospective comparative study included 32 adult patients undergoing unilateral primary
inguinal hernia repair by TAPP technique. Patients were divided into two groups: Group A
(peritoneal closure, n=16) and Group B (non-closure, n=16). All patients received composite
coated mesh (15 × 10 cm). Primary outcome was operative time. Secondary outcomes
included postoperative pain (VAS at 6, 24, 48 hours), complications, length of hospital stay,
and 3-month recurrence. Statistical analysis was performed using Student’s t-test and Chi-
square/Fisher’s exact test. A p-value <0.05 was considered significant.

Results

Mean operative time was significantly lower in the non-closure group (54.8 ± 7.2 minutes)
compared to the closure group (68.4 ± 8.5 minutes) (p < 0.001). Postoperative VAS scores
were comparable at all time points (p > 0.05). Seroma occurred in 12.5% of closure cases and
18.7% of non-closure cases (p=0.62). No mesh infection, bowel obstruction, or recurrence
was observed during 3-month follow-up.

Conclusion

Omission of peritoneal closure in TAPP repair using coated mesh significantly reduces
operative time without increasing early postoperative complications. Routine closure may not
be mandatory when modern anti-adhesive meshes are used. Larger randomized trials with
longer follow-up are required.

Keywords: TAPP, inguinal hernia, peritoneal closure, coated mesh, laparoscopy


Introduction

Inguinal hernia repair remains one of the most commonly performed surgical procedures
worldwide. Over the past three decades, minimally invasive techniques have increasingly
replaced conventional open approaches in selected patients. Laparoscopic transabdominal
pre-peritoneal (TAPP) repair is now widely accepted as a safe and effective method, offering
advantages such as reduced postoperative pain, earlier ambulation, shorter recovery time, and
improved visualization of bilateral groin anatomy [1,2].

The essential principle of TAPP repair involves placement of mesh in the preperitoneal
space, followed by closure of the peritoneal flap to isolate the prosthesis from intra-
abdominal viscera. Historically, peritoneal closure has been considered mandatory to prevent
direct contact between bowel loops and polypropylene mesh, thereby reducing the risk of
adhesion formation, bowel obstruction, and internal herniation through peritoneal defects
[3,4].

However, peritoneal closure adds an additional technical step that may increase operative
time and procedural complexity. Closure using sutures, tacks, or stapling devices may
contribute to postoperative pain, increased costs, and, in rare cases, peritoneal tearing or
hematoma formation [5]. Moreover, tension during closure may theoretically compromise
flap vascularity.

The introduction of modern composite meshes with absorbable anti-adhesive coatings has
changed the landscape of laparoscopic hernia surgery. These meshes are specifically
engineered to reduce adhesion formation when placed intraperitoneally [6,7]. Experimental
studies have demonstrated significantly lower adhesion scores with coated meshes compared
to conventional polypropylene mesh [7,9]. As a result, some surgeons have questioned
whether routine peritoneal closure is still necessary when such meshes are used.

Despite technological advancements, there remains limited prospective clinical data directly
comparing peritoneal closure versus non-closure in TAPP repair using coated mesh.
Concerns persist regarding potential risks such as mesh exposure, bowel adhesion, seroma
formation, and internal herniation.

The present study was therefore designed to evaluate perioperative outcomes, recovery
parameters, and early complications associated with peritoneal closure versus non-closure in
TAPP repair using composite coated mesh.

Materials and Methods


Study Design and Setting

Prospective comparative study conducted at a tertiary care teaching hospital.

Patient Selection

Thirty-two consecutive adult patients with primary unilateral inguinal hernia were enrolled.

Inclusion Criteria
Age 18–70 years
Primary unilateral inguinal hernia
ASA I–III

Exclusion Criteria
Recurrent or bilateral hernia
Complicated/strangulated hernia
Prior lower abdominal surgery

Surgical Technique

Standard TAPP repair was performed in all patients. After reduction of hernia sac and
adequate pre-peritoneal dissection, a 15 × 10 cm composite coated mesh was placed.
Group A: Peritoneal flap closed using absorbable sutures.
Group B: Peritoneal flap left unclosed.

Outcome Measures
Operative time
Postoperative pain (VAS at 6, 24, 48 hours)
Early complications (seroma, hematoma, ileus, infection)
Length of hospital stay
Recurrence at 3 months

Statistical Analysis

Data were analyzed using SPSS version 26. Continuous variables were expressed as mean ±
standard deviation and compared using independent Student’s t-test. Categorical variables
were compared using Chi-square or Fisher’s exact test as appropriate. A p-value <0.05 was
considered statistically significant. Confidence interval was set at 95%.

Results
Table 1. Baseline Demographics
No statistically significant differences were observed between groups in age, gender
distribution, or hernia type

Variable Closure Non-closure p-value


(n=16) (n=16)
Mean Age (years) 46.2 ± 11.4 44.8 ± 10.9 0.71
Male (%) 93.7 87.5 0.54
Indirect Hernia (%) 62.5 56.2 0.72

Table 2. Operative and Recovery Outcomes


Mean operative time was significantly reduced in the non-closure group (p < 0.001). Hospital
stay was comparable.

Parameter Closure Non-closure p-value


Operative Time (min) 68.4 ± 8.5 54.8 ± 7.2 <0.001
Intraoperative Blood Loss (ml) 38 ± 12 35 ± 10 0.42
VAS at 6 hrs 4.6 ± 0.8 4.3 ± 0.9 0.31
VAS at 24 hrs 3.1 ± 0.7 2.9 ± 0.6 0.39
VAS at 48 hrs 1.9 ± 0.5 1.8 ± 0.4 0.52
Analgesic Doses (24 hrs) 2.3 ± 0.8 2.1 ± 0.7 0.48
Time to Ambulation (hrs) 7.2 ± 1.5 6.8 ± 1.3 0.36
Return to Normal Activity 5.8 ± 1.2 5.4 ± 1.0 0.29
(days)
Hospital Stay (days) 1.8 ± 0.6 1.6 ± 0.5 0.28

Table 3. Postoperative Complications

Complication Closure (n=16) Non-closure p-value


(n=16)
Seroma 2 (12.5%) 3 (18.7%) 0.62
Hematoma 1 (6.2%) 1 (6.2%) 1.00
Urinary Retention 1 (6.2%) 0 0.31
Port-site Infection 0 1 (6.2%) 0.31
Ileus 0 0 —
Chronic Groin Pain (3 1 (6.2%) 1 (6.2%) 1.00
mo)
Recurrence (3 mo) 0 0

Discussion
The optimal management of the peritoneal flap during TAPP repair remains a subject of
debate. Traditional surgical teaching emphasizes peritoneal closure as a protective measure to
prevent mesh–visceral contact and subsequent adhesion formation [3,4]. However, evolving
mesh technology and emphasis on procedural efficiency necessitate re-evaluation of this
practice.

In the present study, omission of peritoneal closure resulted in a statistically and clinically
significant reduction in operative time, with a mean difference of approximately 14 minutes.
This finding is particularly relevant in high-volume surgical centers, where cumulative time
savings may translate into improved operating room efficiency, reduced anesthesia exposure,
and potential cost reduction. Similar observations have been reported in comparative
analyses of TAPP technical variations [5].

Importantly, reduction in operative time did not compromise patient safety. Intraoperative
blood loss, postoperative pain scores, analgesic requirement, and recovery parameters were
comparable between groups. The absence of significant difference in VAS scores suggests
that peritoneal suturing itself may not substantially influence early postoperative pain,
although some authors have proposed that tack fixation can contribute to neural irritation and
discomfort [5,10].

Seroma formation was slightly more frequent in the non-closure group, though the difference
was not statistically significant. This may reflect minor dead space persistence in the
preperitoneal plane. However, all seromas were self-limiting and managed conservatively.
No cases of bowel obstruction, ileus, or mesh infection were observed.

A critical concern with non-closure is the potential risk of internal herniation through
peritoneal defects. In our series, no such complication occurred during short-term follow-up.
This may be attributed to careful peritoneal dissection, adequate mesh overlap, and the use of
composite coated mesh. Experimental data suggest that anti-adhesive barriers significantly
reduce adhesion formation when exposed to visceral surfaces [7,9]. These findings support
the biological plausibility of safe non-closure in selected patients.

From a pathophysiological perspective, adhesion formation is influenced not only by mesh


material but also by peritoneal trauma, ischemia, and inflammatory response. Excessive
peritoneal manipulation during closure may itself contribute to local inflammation.
Therefore, selective omission of closure could theoretically reduce tissue handling without
increasing adhesion risk when modern mesh is used.

Nevertheless, caution must be exercised before generalizing these findings. The study sample
size is limited, and follow-up duration was relatively short. Adhesion-related complications
and recurrence may manifest beyond 3 months. Furthermore, results may vary depending on
surgeon expertise, type of mesh, and patient characteristics.

Future randomized controlled trials with larger cohorts and longer follow-up are necessary to
confirm long-term safety. Additional evaluation of cost-effectiveness and quality-of-life
metrics would further strengthen evidence in favor of selective non-closure strategies.

Overall, our findings suggest that routine peritoneal closure during TAPP repair using coated
mesh may not be mandatory in carefully selected patients, and omission of this step can
improve operative efficiency without increasing early morbidity

.
Conclusion

Non-closure of peritoneum in TAPP repair using coated mesh significantly reduces operative
time without increasing early complications. Routine peritoneal closure may not be
mandatory when modern anti-adhesive meshes are utilized.

Declarations

Ethical Approval:
Approved by Institutional Ethics Committee. Written informed consent obtained from all
participants.

References
Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, et al. Guidelines for
laparoscopic treatment of inguinal hernia (International Endohernia Society). Surg Endosc.
2011;25(9):2773–2843.
McCormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques versus open
techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1):CD001785.
Köckerling F, Bittner R, Jacob DA, Seidelmann L, Keller T, Adolf D, et al. TEP versus
TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral
inguinal hernia. Surg Endosc. 2015;29(12):3750–3760.
Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R. Laparoscopic transperitoneal hernia
repair: complications and recurrence rates in 2000 hernia repairs. Surg Endosc.
2000;14(4):325–331.
Morales-Conde S, Socas M, Fingerhut A. Endoscopic surgeons’ preferences for inguinal
hernia repair: TAPP versus TEP. Surg Endosc. 2012;26(9):2639–2643.
Belyansky I, Tsirline VB, Klima DA, Walters AL, Lincourt AE, Heniford BT. Prospective,
comparative study of postoperative quality of life in TAPP versus open hernia repair. Surg
Endosc. 2011;25(10):3283–3289.
Schreinemacher MH, Emans PJ, Gijbels MJ, Greve JW, Beets GL, Bouvy ND. Degradation
of mesh coatings and intraperitoneal adhesion formation in an experimental model. Br J
Surg. 2009;96(3):305–313.
Köckerling F, Simon T. Current concepts of inguinal hernia repair. Viszeralmedizin.
2014;30(4):263–272.
Fortelny RH, Petter-Puchner AH, Glaser KS, Redl H. Use of intraperitoneal meshes for
ventral hernia repair: experimental comparison of adhesion formation. Hernia.
2012;16(2):203–210.
Bansal VK, Krishna A, Misra MC. A prospective randomized comparison of long-term
outcomes: laparoscopic TAPP versus open Lichtenstein repair. Surg Endosc.
2013;27(8):2686–2696.

Common questions

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Traditional beliefs held that peritoneal closure was crucial in TAPP repair to prevent adhesions and bowel obstructions. However, anti-adhesive coated meshes minimize these risks by themselves, challenging these traditional views. Recent studies indicate no significant increase in adhesion-related complications even when peritoneal closure is omitted, thereby suggesting that the use of such meshes could justify a shift away from routine closure, making the procedure more efficient without compromising safety .

Not closing the peritoneum in TAPP repair using coated mesh markedly decreases operative time, enhancing procedural efficiency without increasing early complications. Operative time reduction translates into potential cost savings and less anesthesia exposure. While the rates of complications like seromas and hematomas remained similar between groups, the absence of significant differences in occurrence of complications supports that non-closure does not compromise patient safety in the short term .

Advancements in mesh technology, such as the development of composite coated meshes, contribute significantly to the surgical management of inguinal hernias by reducing the need for peritoneal closure and minimizing adhesion risks. These technological improvements enable less invasive procedures, reduce operative time, and enhance patient safety. Such innovations might lead to revised surgical protocols prioritizing efficiency and patient-specific adaptations, fostering more widespread adoption of minimally invasive techniques and potentially reducing healthcare costs .

Composite coated meshes are specifically designed to minimize adhesion formation when placed intraperitoneally. This property questions the necessity of routine peritoneal closure, traditionally performed to prevent direct mesh contact with bowel and reduce adhesion risks. Studies have shown that these coated meshes lower adhesion scores, leading some surgeons to reconsider the need for peritoneal closure when such meshes are used, as they may offer similar protection without the additional procedural complexity .

Omitting peritoneal closure in TAPP repair using coated mesh significantly reduces operative time by approximately 14 minutes, which can enhance operating room efficiency and reduce anesthesia exposure and procedural costs. The study found no increase in early postoperative complications such as bowel adhesion or mesh infection in the non-closure group. These advantages suggest that routine peritoneal closure may not be necessary when using modern anti-adhesive meshes .

Omission of peritoneal closure in TAPP repair significantly reduces operative time, approximately by 14 minutes, which can be considerable in high-volume surgical centers. This time saving enhances operating room turnover and efficiency, potentially allowing for more procedures during the same timeframe. Additionally, it could reduce costs related to labor and resources and minimize patient exposure to anesthesia, thus improving overall hospital operations and patient throughput .

Studies comparing closure versus non-closure face challenges such as limited sample sizes and short follow-up periods, which may not capture late-onset complications like adhesions or mesh-related issues. There's also variability in surgical techniques and patient demographics among studies, complicating the generalization of results. Future research demands larger cohorts, standardized methodologies, and extended follow-up to confidently establish long-term safety and efficacy of non-closure in TAPP repairs .

While short-term data suggests safety in omitting peritoneal closure, long-term considerations must include potential adhesion-related complications and recurrence rates beyond the three-month follow-up period. It’s important to consider patient-specific factors and surgeon experience, as variations in these could affect outcomes. Continued long-term studies are necessary to fully understand any delayed complications that might not be immediately apparent, such as internal herniations or mesh migrations .

The findings from studies indicating that omitting peritoneal closure can reduce operative time without increasing complications suggest potential revisions of clinical guidelines. Such evidence may prompt a reevaluation or modification of existing surgical protocols where the use of coated meshes is involved. Clinical practices might shift towards more selective, individualized approaches, minimizing unnecessary procedural steps, and emphasizing efficiency without compromising patient safety, supported by further empirical research .

Surgeon experience is crucial in determining the necessity of peritoneal closure as seasoned surgeons may better select patients who can safely forego this step. Experienced surgeons may adeptly manage the technical demands of TAPP repair, optimizing patient-specific outcomes. Patient characteristics such as age, general health status, and specific hernia factors (e.g., complexity, presence of comorbid conditions) should also guide the decision to ensure that skipping the closure does not elevate risk of complications for certain individuals .

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