European Journal of Cardiovascular Medicine

Inguinal hernia repair is one of the most commonly performed operations in general surgical practice, with an estimated 20 million repairs undertaken worldwide every year[1]. The evolution of hernia surgery, from the tissue-based Bassini and Shouldice repairs to tension-free mesh hernioplasty described by Lichtenstein, and subsequently to minimal access surgery, reflects a continuous search for techniques that combine durability of repair with minimal morbidity. The introduction of laparoscopic preperitoneal mesh placement by Ger in 1982, followed by refinement into the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches, marked a paradigm shift in the surgical management of groin hernias[2].

Both TAPP and TEP are based on the same principle of Stoppa — wide preperitoneal mesh placement to cover the myopectineal orifice of Fruchaud, thereby addressing all potential hernia sites (direct, indirect, and femoral) with a single large prosthesis. TAPP involves entry into the peritoneal cavity followed by creation of a peritoneal flap to access the preperitoneal space, whereas TEP avoids the peritoneal cavity altogether, with the extraperitoneal space being developed by balloon or telescopic dissection. This fundamental difference in approach translates into differing learning curves, complication profiles, and suitability for specific clinical scenarios such as recurrent, bilateral, incarcerated, or previously operated (lower abdominal) hernias[3].

In the Indian context, laparoscopic hernia repair has gained wide acceptance in tertiary care and teaching hospitals over the past two decades, with several Indian centres reporting their comparative experience with TAPP and TEP. Krishnan et al., in a prospective randomised controlled trial from a large Indian teaching hospital, compared TAPP and TEP and found comparable recurrence and complication rates between the two techniques, though operative time and cost differed[4]. Similarly, Bansal et al. described the learning curve of laparoscopic inguinal hernia repair at a tertiary care centre in India, emphasising that proficiency and operative time improve substantially after an initial series of cases, a factor that critically influences outcome comparisons between TAPP and TEP[5]. Lal et al. reported one of the earlier large Indian series of TEP repair, establishing its feasibility and safety in Indian patients[6], while Rambhia and Modi, and Choksi et al., in separate Indian comparative studies, observed that although TEP was associated with a shorter hospital stay, TAPP allowed superior visualisation of the peritoneal cavity and contralateral groin[7],[8]. More recently, Jaiswal et al. and Misra et al., from Indian tertiary centres, evaluated functional, sexual and quality-of-life outcomes after TEP and TAPP, adding further nuance to the comparative literature from the Indian subcontinent[9],[10].

Despite this considerable body of literature, no clear consensus exists as to which laparoscopic technique is superior. International guidelines from the HerniaSurge Group and the European Hernia Society state that both TAPP and TEP are acceptable options for experienced laparoscopic surgeons, with the choice largely dependent on surgeon preference, training, and specific patient factors[11]. Given the continuing debate and the paucity of head-to-head prospective data from Indian tertiary care settings with adequately powered sample sizes, the present study was undertaken to compare TAPP and TEP with respect to operative parameters, intraoperative and postoperative complications, pain, recovery, and recurrence, in order to generate contextually relevant evidence to guide technique selection.

 Aims and Objectives

• To compare the operative time and intraoperative complications of TAPP and TEP repair for primary inguinal hernia.
• To compare postoperative pain, complications (seroma, hematoma, wound infection, urinary retention), and hospital stay between the two techniques.
• To compare time to return to work/normal activity and recurrence rate at 12 months of follow-up.
• To compare the cost-effectiveness of TAPP and TEP in a tertiary care Indian teaching hospital setting..

Study Design and Setting

• This was a hospital-based, prospective, comparative, non-randomised interventional study conducted in the Department of General Surgery of a tertiary care teaching hospital over a period of 18 months, after obtaining clearance from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrolment

Sample Size and Grouping

• A total of 120 patients with clinically and sonologically confirmed primary inguinal hernia, satisfying the inclusion criteria, were enrolled and divided into two comparable groups of 60 patients each by alternate allocation:
• Group A (n = 60): Laparoscopic Transabdominal Preperitoneal (TAPP) repair
• Group B (n = 60): Laparoscopic Totally Extraperitoneal (TEP) repair

Inclusion Criteria

• Adult patients aged 18–65 years with primary unilateral or bilateral inguinal hernia
• Patients fit for general anaesthesia (ASA grade I–II)
• Patients willing to give informed consent and available for follow-up

 Exclusion Criteria

• Recurrent inguinal hernia after previous open or laparoscopic repair
• Strangulated hernia requiring emergency bowel resection
• Patients with bleeding diathesis or on anticoagulant therapy
• ASA grade III or above, or patients unfit for pneumoperitoneum
• Previous history of lower abdominal or pelvic surgery precluding a preperitoneal approach.

Surgical Technique

All procedures were performed by the same team of experienced laparoscopic surgeons under general anaesthesia, using a standard 3-port technique. In Group A (TAPP), pneumoperitoneum was created and a peritoneal incision was made above the hernial defect to develop the preperitoneal space; after mesh placement covering the myopectineal orifice, the peritoneal flap was closed with continuous sutures or tacks. In Group B (TEP), the extraperitoneal space was developed using balloon dissection followed by telescopic dissection with a 0-degree/30-degree laparoscope without entering the peritoneal cavity, and a similar polypropylene mesh was placed and fixed as required. Bilateral hernias in both groups were repaired in the same sitting using a single large mesh or two separate meshes as per surgeon preference.

2.6 Outcome Parameters and Data Collection

The following parameters were recorded prospectively for each patient: age, sex, body mass index (BMI), ASA grade, type and laterality of hernia, operative time (skin incision to skin closure), intraoperative complications (peritoneal tear, bleeding, visceral or vascular injury, conversion to open repair), postoperative pain using a 10-point Visual Analogue Scale (VAS) at 6, 24 and 48 hours, postoperative complications (seroma, hematoma, surgical site infection, urinary retention, scrotal edema), duration of hospital stay, time to return to work/normal activity, and recurrence at 6 and 12 months on follow-up. Direct hospital cost (excluding indirect costs such as loss of wages) was also compared between the two groups.

 Statistical Analysis

Data were entered in Microsoft Excel and analysed using SPSS (Statistical Package for Social Sciences), version 25.0. Continuous variables were expressed as mean ± standard deviation and compared using the independent samples t-test. Categorical variables were expressed as frequencies and percentages and compared using the Chi-square test or Fisher's exact test as appropriate. A p-value of less than 0.05 was considered statistically significant.

A total of 120 patients were included in the study, 60 in each group. The two groups were comparable with respect to baseline demographic and clinical characteristics (Table 1).

Table 1: Baseline Demographic and Clinical Characteristics

Operative and intraoperative parameters are summarised in Table 2. Mean operative time for unilateral hernia repair was significantly longer with TAPP than with TEP (p = 0.001); however, for bilateral repair the difference was not statistically significant, as TEP required additional dissection time to develop a wider extraperitoneal working space.

Table 2: Operative and Intraoperative Parameters

Postoperative pain scores were slightly higher in the TAPP group in the immediate postoperative period, though the difference narrowed by 48 hours (Table 3, Figure 1 data).

Table 3: Postoperative Pain (VAS Score, Mean ± SD)

Postoperative complications, hospital stay and recovery parameters are shown in Table 4. Seroma formation was more frequent in the TAPP group, while hospital stay and return to work were marginally shorter in the TEP group, although these differences did not reach statistical significance for most parameters.

Table 4: Postoperative Complications and Recovery Parameters

On follow-up at 12 months, recurrence was low and comparable between the two groups — one patient in each group (1.7%) developed recurrence, both of whom were managed successfully by open Lichtenstein repair. Mean direct hospital cost was marginally higher in the TAPP group, largely attributable to longer operative time and anaesthesia charges (Table 5).

Table 5: Recurrence and Cost Comparison

The present prospective comparative study of 120 patients undergoing laparoscopic inguinal hernia repair demonstrated that both TAPP and TEP are safe and effective techniques, with comparable overall complication and recurrence rates, consistent with the wider literature. Our finding of a significantly longer operative time with TAPP for unilateral hernia is in agreement with the results of Krishnan et al., who, in a randomised controlled trial from an Indian tertiary centre, reported a similar trend and attributed it to the additional time required for peritoneal incision, dissection, and flap closure in TAPP[4]. Rambhia and Modi similarly observed a shorter operative time with TEP in their Indian comparative series, while noting that TAPP provided superior panoramic visualisation of the pelvic cavity, which is of particular value in bilateral or occult contralateral hernia detection[7].

The higher rate of peritoneal tear observed in our TEP group (18.3% vs 5.0%) mirrors observations by Choksi et al. from a tertiary hospital in Vadodara, who reported that peritoneal breach during balloon and telescopic dissection was more frequent in TEP, particularly in the initial part of the learning curve, though most tears were managed intraoperatively without conversion[8]. This underlines the importance of the learning curve in laparoscopic hernia surgery, a factor extensively described by Bansal et al., who demonstrated that operative time, complication rates and conversion rates for both TAPP and TEP improve significantly after the first 30–50 cases performed by a surgeon[5]. The comparatively low conversion rate and complication profile in our series may partly reflect the fact that all procedures were performed by an experienced laparoscopic surgical team beyond this learning curve threshold.

Postoperative pain in the early postoperative period (6 and 24 hours) was modestly but significantly higher in the TAPP group, a finding also reported by Lal et al. in one of the earlier large Indian series of TEP repair, who attributed the lower early pain scores after TEP to avoidance of peritoneal violation and reduced visceral traction[6]. By 48 hours, however, the difference between groups narrowed and lost statistical significance, suggesting that any early pain advantage of TEP is transient and clinically modest by the time of discharge. This pattern is consistent with the multicentre TEP–TAPP data reported by Jaiswal et al., who found comparable pain scores between the two techniques by the first postoperative week despite an initial difference[9].

Seroma formation was more frequent after TAPP in our study, which may be related to the larger preperitoneal dissection and residual dead space after peritoneal closure. Misra et al., in a prospective randomised comparison of functional and quality-of-life outcomes after TEP and TAPP from a premier Indian institute, similarly reported a marginally higher seroma rate with TAPP, although overall functional and sexual outcomes, including testicular perfusion and semen parameters, were comparable between the two approaches[10]. Our hospital stay and return-to-work data, though statistically significant in favour of TEP, differed by less than a day and one day respectively, and are unlikely to be of major clinical or economic consequence in most settings — a conclusion also drawn by international comparative literature and by the HerniaSurge consensus guidelines, which classify both TAPP and TEP as level 1 evidence-supported options without a clear overall superiority of one over the other[11].

Recurrence rates in our study (1.7% in each group at 12 months) are comparable to the pooled recurrence rates of 0.2–4.7% reported in the international literature for both techniques, and to the recurrence rates reported by Indian series with intermediate to long-term follow-up[4]. The slightly higher direct hospital cost in the TAPP group in our series is largely explained by longer operative and anaesthesia time; however, cost considerations must be balanced against surgeon comfort, case complexity and the specific advantage of TAPP in allowing full diagnostic laparoscopy, which is particularly valuable in cases of diagnostic uncertainty, incarcerated hernia, or where simultaneous evaluation of other intra-abdominal pathology is desired.

Taken together, our results, when viewed alongside the Indian and international comparative literature, suggest that TEP may offer a modest advantage in operative time, early postoperative pain and hospital stay for straightforward unilateral primary hernias in the hands of an experienced surgeon, whereas TAPP retains distinct advantages in bilateral hernia, diagnostic uncertainty, incarcerated or complicated hernia, and in centres where diagnostic laparoscopy adds value. The choice between the two techniques should, therefore, remain individualised, guided by surgeon expertise, hernia characteristics, and available resources, rather than dictated by a uniform preference for one technique over the other.

Anatomical and Technical Consideration

From a technical standpoint, the anatomical basis for both procedures is identical — wide preperitoneal placement of mesh to cover the direct, indirect and femoral spaces, in keeping with the Stoppa principle. The critical view of the myopectineal orifice, with clear delineation of Cooper's ligament, the iliopubic tract, the inferior epigastric vessels, and the ‘triangle of doom’ and ‘triangle of pain’, must be achieved in both TAPP and TEP to minimise the risk of vascular or nerve injury during mesh fixation. In our series, tack-related neuralgia was not observed in either group, likely reflecting selective and judicious use of fixation, limited largely to the pubic tubercle and Cooper's ligament, with lateral fixation avoided below the iliopubic tract. Adequate mesh size (at least 10 × 15 cm, or a mesh with sufficient overlap of at least 2 cm beyond the margins of the myopectineal orifice) was used in all cases in both groups, consistent with recommendations of the HerniaSurge guidelines, and likely contributed to the low recurrence rate observed at one year in both TAPP and TEP groups.

A particular technical advantage of TAPP demonstrated in our series was the ease of managing an inadvertent peritoneal tear during TEP dissection — several such tears required conversion of the extraperitoneal plane into a transabdominal view or placement of an additional port, effectively converting the procedure closer to a TAPP-type exposure. This observation is consistent with the experience of most laparoscopic surgeons that TEP has a technically less forgiving working space, particularly during the initial mobilisation of the peritoneal sac, and that a low threshold to convert to TAPP or open repair should be maintained when extraperitoneal dissection becomes difficult, in order to avoid prolonged operative time and unnecessary complications.

 Bilateral and Complicated Hernia

In our cohort, 12 patients in each group had bilateral inguinal hernia. Although the overall operative time for bilateral repair did not differ significantly between TAPP and TEP, several surgeons in our unit subjectively found TAPP technically more comfortable for bilateral repair, as it allowed a single midline peritoneal incision to access both groins without the need for extensive lateral extraperitoneal dissection on both sides, a difficulty occasionally encountered in bilateral TEP. This observation aligns with the wider surgical opinion, reflected in several Indian and international series, that TAPP may be preferable in bilateral, incarcerated, or diagnostically uncertain hernias, and in patients presenting acutely where simultaneous assessment of bowel viability is required, whereas TEP may be preferred for straightforward, primary, unilateral hernias in an elective setting to avoid violation of the peritoneal cavity and its associated, albeit small, risks of visceral injury and adhesion formation.

 Limitations of the Study

Non-randomised, single-centre design with alternate allocation, which may introduce selection bias. Relatively short follow-up period (12 months), which may underestimate long-term recurrence and chronic pain rates. All procedures performed by experienced surgeons; results may not be generalisable to surgeons early in their learning curve. Indirect costs (loss of wages, travel, caregiver burden) were not analysed.

Both TAPP and TEP are safe, effective, and reproducible techniques for the laparoscopic repair of primary inguinal hernia, with low and comparable recurrence rates at one year. TEP is associated with a shorter operative time for unilateral hernia, marginally lower early postoperative pain, and a modestly shorter hospital stay, but carries a slightly higher risk of intraoperative peritoneal tear during the extraperitoneal dissection. TAPP offers superior anatomical visualisation, easier management of peritoneal tears, and is particularly useful in bilateral, complicated, or diagnostically uncertain cases, though at the cost of a marginally longer operative time and a higher seroma rate. Neither technique demonstrated overall superiority in this study, and the choice between TAPP and TEP should be individualised based on surgeon experience, hernia characteristics, and patient-related factors. Adequately powered, multicentric, randomised controlled trials with long-term follow-up from Indian tertiary care settings are recommended to further refine technique selection and optimise patient outcomes.

Ethical Considerations, Funding and Conflict of Interest

This study was approved by the Institutional Ethics Committee of the study hospital, and was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent, including consent for the use of anonymised clinical data for research and publication purposes, was obtained from every participant prior to enrolment. Patients were free to withdraw from the study at any point without any effect on their ongoing clinical care.

No external funding was received for the conduct of this study. The authors declare no conflict of interest, financial or otherwise, in relation to this work. Mesh and surgical consumables used in both groups were of standard type and cost, procured through the routine hospital supply chain, and no commercial entity had any role in the design, conduct, analysis, or reporting of this study.

Acknowledgements

The authors gratefully acknowledge the Department of General Surgery and the Department of Anaesthesiology of the study hospital for their support in the conduct of this study, the operation theatre and nursing staff for their assistance during data collection, and the Medical Records Department for facilitating retrieval of follow-up data. The authors also thank all patients who consented to participate in this study.

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