The American Journal of Surgery (2013) 206, 245-252

Review

Transabdominal preperitoneal versus totally extraperitoneal

repair of inguinal hernia: a meta-analysis of randomized
studies
Stavros A. Antoniou, M.D.a,b,*, George A. Antoniou, M.D., Ph.D.c,
Detlef K. Bartsch, M.D., Ph.D.b, Volker Fendrich, M.D., Ph.D.b, Oliver O. Koch, M.D.d,
Rudolph Pointner, M.D., Ph.D.d, Frank A. Granderath, M.D., Ph.D.a

a
Department of General and Visceral Surgery, Center for Minimally Invasive Surgery, Hospital Neuwerk,
Mönchengladbach, Germany; bDepartment of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg,
Marburg, Germany; cDepartment of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Central
Manchester University Hospitals NHS Foundation Trust, Manchester, UK; dDepartment of General Surgery, Hospital Zell
am See, Zell am See, Austria

KEYWORDS: Abstract
Endoscopy; BACKGROUND: The aim of the present study was to comparatively evaluate the outcomes of lapa-
Laparoscopy; roscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair.
Transabdominal METHODS: The electronic databases of Medline, EMBASE, and the Cochrane Central Register of
preperitoneal; Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken.
Totally extraperitoneal; RESULTS: Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A
Transabdominal shorter recovery time (P 5 .02) was found for totally extraperitoneal repair in comparison with transab-
preperitoneal inguinal dominal preperitoneal inguinal hernia repair (weighted mean difference 5 2.29; 95% confidence interval
hernia repair; [CI], 2.71 to .07) although the length of hospitalization (P 5 .89) was similar in the 2 treatment arms
Totally extraperitoneal (weighted mean difference 5 .01; 95% CI, 2.13 to .15). Operative morbidity (P 5 .004) was higher
repair for the preperitoneal approach (odds ratio 5 2.15; 95% CI, 1.29 to 3.61). No differences were found with
regard to the incidence of recurrence, long-term neuralgia, and operative time.
CONCLUSIONS: Current evidence suggests similar operative results for endoscopic and laparoscopic
inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Random-
ized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the
prevention of recurrence.
Ó 2013 Elsevier Inc. All rights reserved.

The introduction of synthetic materials in the surgical
treatment of inguinal hernia has resulted in a significant
The authors declare no conflict of interest.
Address for correspondence: Souniou 11 19001 Keratea, Athens, Greece.
* Corresponding author. Tel.: 149-163-851-8279; fax: 130-229-906-
8845.
E-mail address: Stavros.antoniou@hotmail.com
Manuscript received July 2, 2012; revised manuscript August 20, 2012
decrease of recurrence rates during the past few decades.1
Since the early 1990s, laparoscopic techniques have entered
the field of general surgery; the first cases of minimally in-
vasive inguinal hernia repair were reported in 1994. Trans-
abdominal preperitoneal (TAPP) inguinal hernia repair
includes laparoscopic exploration of both inguinal areas
and a further incision to the overlying peritoneal sheet in
order to explore the myopectineal orifices, to reduce hernia

0002-9610/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2012.10.041

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246
contents, and to place a prosthetic mesh against the inguinal
wall.2 The technique of totally extraperitoneal repair (TEP)
allows exploration of the myopectineal orifices and place-
ment of the mesh without entering the abdominal cavity.3
These 2 endoscopic modalities have been shown to reduce
early postoperative pain,4–7 and considerable data support
an earlier return to normal activities in comparison with
open mesh repair.8–10 Furthermore, endoscopic repair
allows revision surgery of recurrent hernias after anterior
repair without the need to transect scar tissue, which has
been shown to result in improved pain scores,11,12 although
data on the incidence of rerecurrence are controversial.12–14
Both endoscopic modalities have gained wide popularity
throughout the surgical community. Despite this rapid wide-
spread use of minimally invasive techniques, recent guide-
lines issued by the International Endohernia Society
underscored the lack of high-quality comparative evidence
between endoscopic and laparoscopic inguinal hernia re-
pair.15 A meta-analytic comparison of the 2 techniques,
which was undertaken by the Cochrane Collaboration in
2005, has shown a higher incidence of visceral injuries and
an increased risk for port-site hernias after TAPP repair.16
However, the power of this analysis was limited by the low
quality of the included studies, and the authors emphasized
the need for randomized trials in order to compare the out-
come between endoscopic and laparoscopic hernia repair.
In view of the wide dissemination of minimally invasive
techniques for inguinal hernia repair and the high preva-
lence of this surgical disease, evaluation of currently
available high-quality comparative evidence of current
modalities is essential. A systematic review and meta-
analysis of randomized studies comparing the transabdo-
minal with the preperitoneal approach for inguinal hernia
repair was undertaken, with the objective to evaluate the
outcomes of the 2 techniques, as expressed by the incidence
of recurrence, operative morbidity, length of surgery,
chronic pain, and the time to resume to normal activities.
Materials and Methods
Eligibility criteria and study selection
An ad hoc protocol was established in order to prede-
termine the inclusion criteria and analytic methods. Ran-
domized controlled trials (RCTs) comparing TAPP with
TEP repair were considered for inclusion. No restrictions
were applied with regard to the number of defects (unilat-
eral/bilateral disease), site of defect (inguinal/scrotal/fem-
oral hernia), type of hernia (direct/indirect/combined
hernia), prior hernia repair (primary/recurrent hernia),
hernia status (reducible/strangulated/incarcerated hernia),
type of intervention (elective/urgent surgery), size of study
population, demographic data (sex, age, and health status),
follow-up time, and examined measures of outcome. The
relative risk of recurrence was the primary outcome mea-
sure of the treatment effect in the present meta-analysis,
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The American Journal of Surgery, Vol 206, No 2, August 2013
whereas secondary outcome measures included in-hospital
morbidity, long-term pain or sensory deficits, operative
time, early postoperative pain (within 24 to 48 hours after
surgery), length of hospitalization, and recovery time.
Search strategy
The electronic databases of the National Library of
Medicine (Medline; provider Ovid, from 1966 to July
2011), Excerpta Medica (EMBASE; provider Elsevier,
from 1980 to July 2011), and the Cochrane Central Register
of Controlled Trials were searched in order to identify
relevant articles. No language restrictions were applied, and
abstracts of articles in other than the English language were
translated. The Medical Subject Headings ‘‘laparoscopy’’ and
‘‘inguinal hernia’’ and the terms ‘‘TAPP,’’ ‘‘preperitoneal,’’
‘‘properitoneal,’’ ‘‘TEP,’’ ‘‘totally extraperitoneal,’’ and ‘‘total
extraperitoneal’’ were used in combination with the Boolean
operators AND or OR (Appendix 1). A second-level manual
search included the bibliography of the retrieved articles. The
last search was run on July 30, 2011, and an update of the
literature search was performed on August 12, 2012. Eligibil-
ity assessment was performed independently in an unblinded
standardized manner by 2 reviewers. Disagreements between
reviewers were resolved by consensus. The literature review
conformed to Preferred Reported Items for Systematic Re-
views and Meta-analyses (PRISMA) statement standards.17
Data collection and analysis
An electronic data extraction sheet was developed and
refined accordingly. One review author extracted the data
from the included studies, and a second author checked the
extracted data. The latter included the following: year of
publication; study design (single blinded/double-blinded/
nonblinded RCT); number of participating institutions
(single-center/multicenter RCT); number of participating
patients; number of patients having completed the follow-
up period; duration of follow-up time; type of follow-up
evaluation (physical examination or telephone interview);
demographic data of participants (age, sex, and concomi-
tant diseases); inclusion and exclusion criteria; pain scoring
system; disease characteristics of the examined patient
populations including the number of defects (unilateral/
bilateral hernia), site of defect (inguinal/scrotal/femoral
hernia), type of hernia (direct/indirect/combined hernia),
prior hernia repair (primary/recurrent hernia), hernia status
(reducible/strangulated/incarcerated hernia), prosthetic ma-
terial used, and method of mesh fixation; and study
outcome measures including operative time, amount of
blood loss, intraoperative complications, postoperative
complications, pain score within 24 to 48 hours, length of
hospitalization, time to resume to normal activities, and
number of patients suffering from long-term pain or
sensory deficits. Outcome data were collected upon com-
pletion of the follow-up period in all studies. The authors of
S.A. Antoniou et al. TAPP vs TEP: a meta-analysis
studies fulfilling the inclusion criteria were formally con-
tacted by electronic mail; they were informed about the
purpose of the study and were asked to provide missing
data and/or follow-up results of their study. In order to
assess the methodologic quality of eligible RCTs, respec-
tive data from each study protocol were extracted, and the
Jadad score was calculated.18 Study-specific estimates were
combined using random-effects or fixed-effects models as
appropriate. Weighted mean differences (WMDs) with
95% confidence intervals (CI) were calculated to assess
the size of the effect of each type of procedure on continu-
ous variables. Pooled odds ratios (ORs) with 95% CIs were
calculated to measure the effect of each type of procedure
on categorical variables. Heterogeneity among the trials
was assessed using the I2 statistic. Publication bias was as-
sessed using the Egger regression intercept. Statistical anal-
ysis was performed using Comprehensive Meta Analysis
Version 2.0 (Biostat, Englewood, NJ). Statistical expertise
was provided by 1 of the study authors (G.A.A.).
Results
Search results and study selection
A total of 248 records were identified through the
electronic search of the databases. The second-level manual
search of the included articles identified 1 additional ran-
domized trial.19 Based on the abstract, 220 articles were
discarded as nonrandomized studies and another 23 as non-
relevant RCTs. No duplicate studies were identified in the
searched electronic databases. The primary literature search
identified 6 eligible RCTs, and the updated literature search
identified a further eligible RCT.25 A total of 7 articles ful-
filled the eligibility criteria and were included in the meta-
analysis.19–25
Study characteristics
The selected studies were published in English. The year
of publication ranged between 1996 and 2012; 5 studies
have been published within the past 5 years.20–25 One study
was single blinded,23 and another was double blinded.21
The remaining studies failed to report on whether a blind-
ing approach was applied. All but 1 were single-center
studies. Four of the 7 included articles reached a Jadad
score of 1 or 2. The follow-up period ranged between 3
months and 3 years, with a mean duration of 23.4 months.
The type of follow-up examination for the diagnosis of re-
currence was specified in 5 articles (ie, physical examina-
tion), whereas additional ultrasound examination was
performed by 1 author team if hernia recurrence was clin-
ically suspected. The visual analog score in a 10-point scal-
ing system was used to assess postoperative pain in 4
studies.19,20,23–25 One study used a modified 5-point scaling
system, and another did not measure postoperative pain.
Only 1 author team responded to our query on data not
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247
provided in the published article24; however, follow-up
data of this trial were not available at the time the present
study was written. Regarding the inclusion criteria, most
authors considered patients with primary unilateral inguinal
hernia, whereas 1 study exclusively enrolled patients with
recurrent hernia. Irreducible or incarcerated hernia was
commonly considered as an exclusion criterion. The study
characteristics are summarized in Table 1.
A total of 516 participants with 538 hernia defects were
enrolled. The size of the study cohorts ranged between 44
and 119 patients. Ninety-six percent (462/477) of the patients
were men, and the mean age was 48.1 years. Details on
demographic and disease characteristics of the study popu-
lations are presented in Table 2. Two patients with bilateral
disease were included in 1 study.20 However, the expressed
outcome (percentage values) was presented for unilateral dis-
ease; therefore, it was assumed that only 1 side was operated
on. Analytic data were provided by a second study, which en-
rolled 22 patients with bilateral disease.25 Polypropylene
mesh was used by all authors providing relevant data; how-
ever, the prosthetic material was not specified in 1 study.20
Fixation of the mesh was performed with a conventional sta-
pler in 1 study and with a conventional tacker in another; an-
other author team did not fixate the preshaped mesh on the
abdominal wall or the pubic tubercle, whereas the remaining
studies did not specify whether the mesh was fixated or not.
Synthesis of results and outcome
A summary of outcome data of the included studies is
presented in Table 3.
Hernia recurrence. The incidence of hernia recurrence
was 3.1% for laparoscopic repair and 2.4% for endoscopic
repair (OR 5 1.03; 95% CI, .36 to 2.94; P 5 .96). There
was no evidence of study heterogeneity (I2 5 0%), and
the evidence of publication bias was low (P 5 .15) (Fig. 1).
Operative morbidity. The morbidity rate was 24.8% for
laparoscopic repair and 11.9% for endoscopic repair (OR 5
2.15; 95% CI, 1.29 to 3.61; P 5 .004). No significant het-
erogeneity among studies was identified (I2 5 0%), and the
likelihood of publication bias was low (P 5 .75) (Fig. 2).
Sensitivity analysis, which excluded a study that consid-
ered analgesic consumption as a complication and another
study that enrolled only patients with recurrent hernias,
showed marginal results in favor of the TEP approach
(OR 5 1.85; 95% CI, .96 to 3.56; P 5 .07). Heterogeneity
was minimal (I2 5 3%) with low evidence of publication
bias (P 5 .82).
Long-term pain or sensory deficits. The incidence of
long-term pain or sensory deficits was 5.7% for the
laparoscopic group and 8.7% for the endoscopic group
(OR 5 .63; 95% CI, 2.74 to 1.99; P 5 .37). Heterogeneity
was significant among studies (I2 5 96%), whereas publi-
cation bias was low (P 5 .79) (Fig. 3).
 248
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Table 1 Summary of characteristics of RCTs comparing TAPP versus TEP

Year of Study Exclusion Duration of Type of Jadad
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Study publication design Inclusion criteria criteria follow-up follow-up score

Schrenk et al19 1996 Single-center RCT Elective surgery, Recurrent or incarcerated 3 months Physical examination 2
unilateral inguinal inguinal hernia
hernia
Dedemadi et al20 2006 Single-center RCT Recurrent inguinal ASA III or IV, coagulation 3 years Physical examination 3
hernia disorders, previous abdominal or
pelvic surgery, irreducible hernia,
ascites, previous TAPP
Butler et al21 2007 Single-center, Primary unilateral NR NR Physical examination 4
double-blinded inguinal hernia at 7-day intervals
RCT until patients
returned to work
Pokorny et al22 2008 Multicenter RCT Age 19–85 years, primary unfit for general anesthesia, 3 years Physical examination 2
unilateral inguinal incarcerated, recurrent,
hernia bilateral or femoral hernia

The American Journal of Surgery, Vol 206, No 2, August 2013

Hamza et al23 2010 Single-center, Male gender, primary recurrent, irreducible or obstructed 24 weeks Physical examination 2
single-blinded inguinal hernia inguinal hernia, previous
RCT Nyhus I-III surgery of the lower abdomen,
coagulopathy, COPD, constipation,
obstructive uropathy
Gong et al24 2011 Single-center Male gender, age Urgent surgery, previous 15.6 months* Physical examination 1
RCT 30–70 years, ASA 1/2, surgery of the lower abdomen, at 1 week and 1
primary unilateral irreducible, giant, bilateral or month then phone
inguinal hernia recurrent hernia interview
Krishna et al25 2012 Single-center Primary inguinal Previous surgery of the lower 29.5 months* Physical examination 3
RCT hernia abdomen, irreducible,
strangulated or recurrent hernia,
coagulopathy, poor surgical
candidates, diabetes, hypertension
ASA 5 American Society of Anesthesiologists classification system; COPD 5 chronic obstructive pulmonary disease; NR 5 not reported; RCT 5 randomized controlled trial; TAPP 5 transabdominal
preperitoneal; TEP 5 totally extraperitoneal repair.
*Mean value.
S.A. Antoniou et al. TAPP vs TEP: a meta-analysis
Table 2 Demographic and disease characteristics of the included study populations
Study No. of patients Mean age (y)
Schrenk et al19 52 40.6
Dedemadi et al20 49 NR
Butler et al21 44 NR
Pokorny et al22 119 48.7
Hamza et al23 50 35.8
Gong et al24 102 56.5
Krishna et al25 100 49
NR 5 not reported.
Hospital stay. Five studies reported on the length of
hospital stay, and 3 provided the respective P values or
CIs. The mean length of hospitalization was 3.3 days for
the laparoscopic group and 2.7 days for the endoscopic
group (WMD 5 .01; 95% CI, 2.13 to .15; P 5 .89).
Between-study heterogeneity was significant (I2 5 65%),
whereas there was a low possibility of publication bias
(P 5 .11).
Operative time. The mean length of surgical time was
60.0 minutes for the laparoscopic group and 66.0 minutes
for the endoscopic group (WMD 5 2.13; 95% CI, 2.64 to
.39; P 5 .63). Significant evidence of heterogeneity among
the studies existed (I2 5 82%), whereas the likelihood of
publication bias was low (P 5 .41).
Recovery time. The mean time to resume to normal
activities was 8.5 days for the laparoscopic group and 8.0
days for the endoscopic group (WMD 5 2.29; 95% CI,
2.71 to .07; P 5 .02). There was no evidence of between-
study heterogeneity (I2 5 0%) and a low evidence of pub-
lication bias (P 5 .87).
Comments
Surgical treatment of inguinal hernia intends to restore
the anatomic components of the inguinal canal and provide
long-term relief from associated symptoms. Less invasive
approaches have gained wide popularity, providing lower
pain scores, shorter recovery time, and fewer local compli-
cations.26–28 The surgical decisions on the optimal therapeu-
tic approach of inguinal hernia is of paramount importance,
considering the prevalence of this disease in Western socie-
ties and the subsequent economic implications on health
care delivery systems.29–31 The objective of the present re-
view was to compare the effectiveness and the patient-
oriented outcomes of the 2 most frequently performed
minimally invasive techniques for inguinal hernia repair.
Our meta-analytic model showed similar recurrence rates
for the preperitoneal (2.4%) and the transabdominal ap-
proach (3.1%). However, the length of follow-up time varied
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249
Male/female (n) Type of hernia defects
46/6 Direct, n 5 15; indirect, n 5 37
NR Nyhus II, n 5 30; Nyhus IIIa, n 5 15;
Nyhus IIIc, n 5 5; bilateral, n 5 2
44/0 NR
121/8 NR
50/0 NR
102/0 Direct, n 5 20; indirect/scrotal,
n 5 72; combined, n 5 10
99/1 Direct, n 5 44; indirect, n 5 78;
bilateral, n 5 22
considerably among the studies, ranging between 3 months
and 3 years. Considering that mesh-reinforced inguinal her-
nia repair is associated with late rather than early recur-
rence,32 randomized studies with longer-term follow-up
periods are justified.
Furthermore, the incidence of surgical perioperative
complications was significantly higher for the preperitoneal
approach. This outcome is more pronounced by the low
level of between-study heterogeneity and the consistency of
results in favor of the transabdominal approach. However,
when interpreting this parameter, it should be taken into
account that the high morbidity rates (ie, 11.9% for
endoscopic repair and 24.8% for laparoscopic repair) may
be mainly attributed to the results of 2 single studies.
Pokorny et al22 considered analgesic consumption as a
postoperative complication in 8.4% of their patient popula-
tion, whereas Dedemadi et al20 observed a high incidence
of local complications in their series of recurrent hernia re-
pair. If we exclude these studies from the calculated oper-
ative morbidity, the incidence of surgical complications
for the laparoscopic and the endoscopic repair are 8.7%
and 7.9%, respectively. Nevertheless, sensitivity analysis
could show a trend toward higher operative morbidity for
the TEP repair although the difference in pooled relative
risks was marginal.
Current evidence suggests significantly longer duration
of surgery for endoscopic approaches in comparison with
open repair.21,24,25,30 The present analysis did not show a
significant difference between the TAPP and the TEP repair
with regard to operative time (57.6 vs 67.1 minutes, respec-
tively), whereas significant heterogeneity existed among
studies. The lack of standardized techniques for minimally
invasive inguinal hernia repair is a pragmatic issue and is
reflected by the wide variety of technical details presented
in the contemporary literature. Modification and standardi-
zation of the operative steps, such as the method of en-
trance into the preperitoneal space and the creation of the
operative space, the extent of dissection, the size and type
of mesh, and the fixation of the mesh, may result in a reduc-
tion of operative times in TEP repair. Similarly, the location
of the peritoneal incision, the extent of preperitoneal
250 The American Journal of Surgery, Vol 206, No 2, August 2013

dissection, the management of the hernia sac, the fixation of

7/35 (20)
(13) 6/25 (23)
(11) 1/24 (4)

0/25 (0)

0/53 (0)
the mesh, and the type of peritoneal closure are subjects for
further evaluation with regard to their clinical effect on

TEP
pain or sensory patient-oriented outcomes and the length of surgery in the
deficits (%) context of laparoscopic hernia repair.
Long-term

(6)
(4)

(0)
TAPP The posterior approach of minimally invasive techniques
3/28

5/84
3/24

1/25

0/47
seems to result in improved pain scores, a lower incidence

NR

NR
(0)
of sensory deficits, a shorter hospital stay, and a reduced
(5)
(6)

(0)
(8)

(4)

(0)
recovery time after inguinal hernia repair in comparison to
open mesh techniques.30 In these terms, no significant dif-
6.5 1/28 (4) 0/24

1/22 (5) 1/22

4/84 (5) 2/35

6.6 0/50 (0) 0/52

2/24 (8) 2/25

7.5 1/25 (4) 1/25

0/56 (0) 0/66

TEP

ferences were found between the 2 treatment arms although

Recurrence

the mean time to resume to normal activities was slightly

rate (%)

shorter for the endoscopic group (8.5 vs 8.0 days). Never-

TAPP

theless, further evaluation of controversial operative trends,

including the need for mesh fixation,33–35 the use of light-
TAPP TEP TAPP TEP

weight prosthetics, and the extent of dissection,36,37 may

time (d)*

12
13
Recovery

further reduce the incidence of long-term pain and sensory

5.9

6.6
9.8

complications and the length of hospitalization.

NR

NR
12
14

Although similar outcomes were shown for endoscopic

.8
4.4

3.6
1.0

and laparoscopic inguinal hernia repair in the present

stay (d)*

4
Hospital

analysis, clinical interpretation of these results must be

3.7

3.4
.8

1.1

performed with caution. It is noteworthy that several

NR

NR
5

institutions routinely use either the endoscopic or the

laparoscopic technique, which provides a greater amount
postoperative

3.4†
TEP

4.0

1.1

of experience and probably improved outcomes with a

1

specific procedure. Furthermore, if we consider the high

pain*

learning curves of endoscopic hernia repairs,14,38,39 transi-

TAPP
Early

(12) 7/52 (14) 3.2†

(8) 0/25 (0) 4.1

(36) 9/66 (17) 1.8

Summary of outcome data of randomized controlled trials comparing TAPP versus TEP

NR
(4) 1/24 (4) NR

(32) 6/35 (17) NR

(21) 4/25 (16) 1

tion to another technique is not justified for the present.

However, the role of laparoscopic exploration in patients
NR 5 not reported; TAPP 5 transabdominal preperitoneal; TEP 5 totally extraperitoneal repair.

with risk factors for bilateral disease is strongly supported

in the literature.15,40
TEP
complications
Postoperative

Furthermore, these results have to be interpreted with

caution, considering the significant limitations of the
cumulative analysis of the examined outcome measures.
1/28
5/24

27/84
2/25
6/50
17/56
TAPP
(%)

Follow-up periods varied significantly among studies, and

NR

long-term follow-up was performed by telephone interview

(0) 0/24 (0)
(8) 0/25 (0)

(0)
(0)
(0)
(0)

by 1 author team. Although recurrent hernia was a criterion

0/35
0/25
0/52
0/66

for exclusion in most studies, 1 article considered only

Intraoperative

TEP
complications

patients with recurrent hernia for analysis and excluded

(8)
(0)
(0)
(0)

those with primary hernia. Technical details were either not

defined or inconsistently reported by participating studies.
TAPP
0/28
2/24

7/84
0/25
0/50
0/56
(%)

Values adapted to the visual analog scoring system.

NR

Furthermore, only 2 of the included studies were of

excellent methodologic quality. A further limitation to
TEP
loss (mL)*

19

this analysis may be introduced by the potential of publi-

of blood
Amount

cation bias. Although the incidence of hernia recurrence

TAPP

and operative morbidity have been addressed by all reports,

NR
NR
NR
NR
NR

NR
19

the outcome variables of long-term pain and operative time

TEP

were reported by only a few studies, hereby limiting the

NR
42
56

78
77
79
62
of surgery
Duration

power to assess publication bias.

(min)*
TAPP

Current evidence suggests similar results for laparo-

46
55
59
66
36
76
72

scopic and endoscopic inguinal hernia repair with regard to

Dedemadi et al20

the incidence of neuralgia and sensory deficits, operative

*Mean values.
Pokorny et al22
19

Krishna et al25
Hamza et al23

time, and hospital stay. There is a trend toward higher

Butler et al21
Schrenk et al

Gong et al24

operative morbidity for the preperitoneal approach. Ran-

Table 3

domized trials with a longer-term follow-up period are

Study

needed to further assess the relative effectiveness of the 2

procedures in the prevention of hernia recurrence.

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S.A. Antoniou et al. TAPP vs TEP: a meta-analysis 251

Figure 1 Forest plot showing differences in the incidence of hernia recurrence for TAPP and TEP.

Figure 2 Forest plot showing differences in terms of operative morbidity for TAPP and TEP.

Figure 3 Forest plot showing differences in the incidence of long-term pain or sensory deficit after TAPP and TEP.

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252
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S.A. Antoniou et al. TAPP vs TEP: a meta-analysis 252.e1

Appendix 1 Search Strategy

No. Search term
1 laparoscopic (abstract or text)
2 hernia, inguinal (abstract or text)
3 TAPP (abstract or text)
4 preperitoneal (abstract or text)
5 properitoneal (abstract or text)
6 TEP (abstract or text)
7 totally AND extraperitoneal (abstract or text)
8 total AND extraperitoneal (abstract or text)
9 3 OR 4 OR 5
10 6 OR 7 OR 8
11 1 AND 2 AND 9 AND 10

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