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Mehdizadeh-Shrifi A, Soll C, Vuille-Dit-Bille RN, Köckerling F, Adolf D, Staerkle RF. Outcome of incisional hernia repair in patients 80 years and older: results from the Herniamed-Registry. Hernia 2023; 27:1273-1281. [PMID: 37633864 PMCID: PMC10533642 DOI: 10.1007/s10029-023-02866-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION More and more often complex abdominal surgeries are performed in the elderly. Together with the ageing population these patients are at risk for incisional hernias. We aimed on assessing outcomes following incisional hernia surgery in patients 80 years and older. MATERIAL AND METHODS Using the Herniamed-Registry, a prospective multi-institutional database, data on patients undergoing surgery for incisional hernias were retrospectively assessed. 46,040 patients were included and divided by age. Intraoperative-, general-, and postoperative complications as well as 1-year follow-up outcomes were assessed and compared between patients 80 years and older vs younger than 80 years. RESULTS Intra- (2.3% vs 1.5%; p < 0.001) and postoperative (8.6% vs 7.2%; p = 0.001) complications, general complications (5.5% vs 3.0%; p < 0.001), as well as reoperations (3.8% vs 3.0%; p = 0.007) were more likely to occur in elderly patients. By contrast, recurrences (3.6% vs 4.5%; p = 0.007), pain at rest (7.3% vs 10.1%; p < 0.001) and on exertion (11.3% vs 18.3%; p < 0.001), as well as pain requiring treatment (5.4% vs 7.7%; p < 0.001) was less likely in the group of patients aged ≥ 80 years. CONCLUSION Incisional hernia repair in patients 80 years and older is associated with a slightly higher complication risk but is quite acceptable and also have improved pain scores. The recurrence difference is also clinically unimportant.
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Affiliation(s)
| | - C Soll
- Ventravis - Practice for Abdominal Surgery, Dorfplatz 1, 6330, Cham, Switzerland
- University of Zurich, Zurich, Switzerland
| | - R N Vuille-Dit-Bille
- Department of Pediatric Surgery, University Children's Hospital of Basel, Basel, Switzerland
| | - F Köckerling
- Hernia Center, Vivantes Humbold Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
| | - D Adolf
- StatConsult GmbH, Magdeburg, Germany
| | - R F Staerkle
- Ventravis - Practice for Abdominal Surgery, Dorfplatz 1, 6330, Cham, Switzerland.
- University of Lucerne, Lucerne, Switzerland.
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Quevedo Orrego E, Robla Costales J, Rodríguez Aceves C, Diana Martín R, González Álvarez A, Socolovsky M. Neuropathic inguinal pain due to nerve injury after a laparoscopic appendectomy: first pediatric case described in the literature. Childs Nerv Syst 2021; 37:1825-1830. [PMID: 33904935 DOI: 10.1007/s00381-021-05177-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the first pediatric case in the literature of neuropathic inguinal pain secondary to iatrogenic nerve injury that occurred during a laparoscopic appendectomy, detailing clinical and morphological findings before and after surgery. The literature on adult patients is reviewed and pathophysiological, therapeutic, and prognostic factors are discussed. CLINICAL PRESENTATION A 14-year-old female patient presented with a history of a laparoscopic appendectomy 3 years previously. Three months post-operatively, she developed progressively worsening neuropathic inguinal pain refractory to neuromodulators and several nerve blocks. Given her deterioration, poor response to conservative therapy, and clearly meeting the criteria for chronic post-operative inguinal pain (CPIP), surgical management was undertaken. RESULTS Open surgery was performed through the previous incision, during which injury to a branch of the iliohypogastric nerve (IH) was confirmed. Neurolysis of the affected branch was performed, after which the patient experienced significant pain relief, resolution of allodynia, and reversal of skin hyperpigmentation. After discharge, analgesic therapy was gradually withdrawn and, ultimately, discontinued altogether. CONCLUSIONS Understanding the neuroanatomy of the inguinal region is an indispensable requirement for all surgeons operating in this region, to avoid complications including CPIP and optimize patient outcomes. Surgical management of CPIP can be effective for controlling severe pain in patients in whom conservative management has failed. Studies are needed in the pediatric population to identify specific characteristics of this entity in youth.
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Affiliation(s)
| | - Javier Robla Costales
- Neurosurgical Department, HM Hospitales Regla/San Francisco, Calle Cardenal Landázuri 2, 24003, León, Spain.
| | | | - Rubén Diana Martín
- Neurosurgical Department, Complejo Asistencial Universitario de León, León, Spain
| | | | - Mariano Socolovsky
- Neurosurgical Department, Complejo Asistencial Universitario de León, León, Spain.,Peripheral Nerve & Plexus Program, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Min L, Yong P, Yun L, Balde AI, Chang Z, Qian G, He L, Fang P. Propensity score analysis of outcomes between the transabdominal preperitoneal and open Lichtenstein repair techniques for inguinal hernia repair: a single-center experience. Surg Endosc 2020; 34:5338-5345. [PMID: 32157406 DOI: 10.1007/s00464-019-07324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The mechanism of persistent chronic pain after TAPP and OLR remains controversial. Therefore, more prospective and well-designed studies are needed to determine the predictive risk factors that will lead to better pain prevention and possibly elimination. The aim of the present study was to investigate the risk factors of chronic pain after TAPP repair and OLR in a single institution. METHODS A single-center, retrospective study of propensity score-matched patients who underwent TAPP or OLR surgery between 2008 and 2018 was conducted. To overcome selection bias, we performed 1:1 matching using 6 covariates to generate the propensity score. RESULTS A total of 400 patients treated with TAPP and 424 patients treated with OLR were balanced to 400 pairs of matched patients. The patients' age (P < 0.001), BMI (P < 0.001), foreign body sensation within 3 months after surgery (P < 0.001), and persistent sensation loss (P = 0.002) were different between the two groups. The OLR group had a shorter operative time than did the TAPP group (P < 0.001). The univariate analysis of factors predicting a difference in VAS between the preoperative assessment and the assessment 3 months after surgery showed that the type of surgery (P = 0.004), hernia grade (P = 0.001), type of mesh (P < 0.001), presence of scrotal invasion (P = 0.024), and foreign body sensation within 3 months (P = 0.047) were risk factors. The multivariate analysis revealed that only hernia grade III (CI - 8.524, - 2.783; P < 0.001), OLR operation type (CI 1.069, 4.987; P = 0.002), and the use of polypropylene mesh (CI - 5.400, - 1.489; P = 0.001) were independently associated with chronic pain. CONCLUSION These results suggest that compared to OLR, TAPP leads to less postoperative pain and a better long-term quality of life.
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Affiliation(s)
- Liuwei Min
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China.
| | - Pengzhi Yong
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
| | - Liuying Yun
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
| | - Alpha I Balde
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China.
| | - Zhanghuan Chang
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
| | - Gao Qian
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
| | - Liangzheng He
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
| | - Panyan Fang
- Department of General Surgery, Qingxin District People's Hospital, BP: 511800, Qingyuan City, Guandong Province, People's Republic of China
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Konschake M, Zwierzina M, Moriggl B, Függer R, Mayer F, Brunner W, Schmid T, Chen DC, Fortelny R. The inguinal region revisited: the surgical point of view : An anatomical-surgical mapping and sonographic approach regarding postoperative chronic groin pain following open hernia repair. Hernia 2019; 24:883-894. [PMID: 31776877 PMCID: PMC7395915 DOI: 10.1007/s10029-019-02070-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/11/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Inguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal "management" of the nerves during surgery. METHODS We present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management. RESULTS Surgically and ultrasonographically relevant structures ("landmarks") in open hernia repair are the anterior-superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = "blue line"), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels. CONCLUSION A detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.
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Affiliation(s)
- M Konschake
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstr. 59, 6020, Innsbruck, Austria.
| | - M Zwierzina
- Department of Plastic, Reconstructive and Aesthetic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - B Moriggl
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Müllerstr. 59, 6020, Innsbruck, Austria
| | - R Függer
- Department of Surgery, Elisabethinen Hospital, Linz, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - W Brunner
- Department of Surgery, Kantonspital St. Gallen, St. Gallen, Switzerland
| | - T Schmid
- Department for Visceral-, Transplantation- and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - D C Chen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Lichtenstein Amid Hernia Clinic, Santa Monica, CA, USA
| | - R Fortelny
- Department of General-, Visceral- and Oncological Surgery, Wilhelminenspital, Vienna, Austria
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Patterson TJ, Beck J, Currie PJ, Spence RAJ, Spence G. Meta-analysis of patient-reported outcomes after laparoscopic versus open inguinal hernia repair. Br J Surg 2019; 106:824-836. [PMID: 30990238 DOI: 10.1002/bjs.11139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Inguinal hernia repair is a common low-risk intervention. Patient-reported outcomes (PROs) are being used increasingly as primary outcomes in clinical trials. The aim of this study was to review and meta-analyse the PROs in RCTs comparing laparoscopic versus open inguinal hernia repair techniques in adult patients. METHODS A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. Only RCTs in peer-reviewed journals were considered. PubMed, Ovid Embase, Scopus and the Cochrane Library were searched. In addition, four trial registries were searched. The search interval was between 1 January 1998 and 1 May 2018. Identified publications were reviewed independently by two authors. The review was registered in the PROSPERO database (CRD42018099552). Bias was assessed using the Cochrane Collaboration risk-of-bias tool. RESULTS Some 7192 records were identified, from which 58 unique RCTs were selected. Laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from 2 weeks to within 6 months after surgery (risk ratio (RR) 0·74, 95 per cent c.i. 0·62 to 0·88), 6 months to 1 year (RR 0·74, 0·59 to 0·93) and 1 year onwards (RR 0·62, 0·47 to 0·82). Paraesthesia (RR 0·27, 0·18 to 0·40) and patient-reported satisfaction (RR 0·91, 0·85 to 0·98) were also significantly better in the laparoscopic repair group. CONCLUSION The data and analysis reported in this study reflect the most up-to-date evidence available for the surgeon to counsel patients. It was constrained by heterogeneity of reporting for several outcomes.
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Affiliation(s)
- T J Patterson
- Department of General Surgery, Ulster Hospital, Dundonald, BT16 1RH, UK
| | - J Beck
- Department of General Surgery, Ulster Hospital, Dundonald, BT16 1RH, UK
| | - P J Currie
- Department of General Surgery, Ulster Hospital, Dundonald, BT16 1RH, UK
| | - R A J Spence
- Department of General Surgery, Ulster Hospital, Dundonald, BT16 1RH, UK
| | - G Spence
- Department of General Surgery, Ulster Hospital, Dundonald, BT16 1RH, UK
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Groin anatomy, preoperative pain, and compression neuropathy in primary inguinal hernia: What really matters. Am J Surg 2019; 217:873-877. [PMID: 30878217 DOI: 10.1016/j.amjsurg.2019.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 02/09/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Enlargement of the ilioinguinal nerve distal to the inguinal ring is common in primary open inguinal herniorrhaphy and is histologically consistent with compression neuropathy. However, the origin of this neuropathy has not been thoroughly studied in primary inguinal hernia. METHODS In this prospective study, 143 primary inguinal herniorrhaphies were performed. Prior to surgery, all patients completed a preoperative pain questionnaire from the Carolina Comfort Scale and Visual Analog Scale-evaluating pain with various activities. Pain scores were statistically compared with several different anatomical surgical observations. RESULTS When each variable is individually compared with pain scores, a significant positive correlation exists between nerve enlargement and increased pain compared to those without enlargement for preoperative "most of the time pain" (P < 0.0017). There is also a statistically significant positive correlation between nerve enlargement and external ring fibrosis (P < 0.001). 81% of patients with enlargement have histological abnormalities. CONCLUSION Preoperative pain in primary inguinal hernia is correlated with ilioinguinal nerve enlargement, which is also correlated with fibrosis of the external oblique fascia at the external ring.
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7
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Scimia P, Basso Ricci E, Petrucci E, Behr AU, Marinangeli F, Fusco P. Ultrasound-Guided Transversalis Fascia Plane Block: An Alternative Approach for Anesthesia in Inguinal Herniorrhaphy: A Case Report. A A Pract 2018; 10:209-211. [DOI: 10.1213/xaa.0000000000000666] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry. Surg Endosc 2017; 32:1971-1983. [PMID: 29075969 PMCID: PMC5845068 DOI: 10.1007/s00464-017-5893-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/13/2017] [Indexed: 10/26/2022]
Abstract
BACKGROUND In inguinal hernia repair, chronic pain must be expected in 10-12% of cases. Around one-quarter of patients (2-4%) experience severe pain requiring treatment. The risk factors for chronic pain reported in the literature include young age, female gender, perioperative pain, postoperative pain, recurrent hernia, open hernia repair, perioperative complications, and penetrating mesh fixation. This present analysis of data from the Herniamed Hernia Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique. METHODS In total, 20,004 patients from the Herniamed Hernia Registry were included in uni- and multivariable analyses. For all patients, 1-year follow-up data were available. RESULTS Multivariable analysis revealed that onset of pain at rest, on exertion, and requiring treatment was highly significantly influenced, in each case, by younger age (p < 0.001), preoperative pain (p < 0.001), smaller hernia defect (p < 0.001), and higher BMI (p < 0.001). Other influencing factors were postoperative complications (pain at rest p = 0.004 and pain on exertion p = 0.023) and penetrating compared with glue mesh fixation techniques (pain on exertion p = 0.037). CONCLUSIONS The indication for inguinal hernia surgery should be very carefully considered in a young patient with a small hernia and preoperative pain.
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9
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Wright R, Born DE, D'Souza N, Hurd L, Gill R, Wright D. Pain and compression neuropathy in primary inguinal hernia. Hernia 2017; 21:715-722. [PMID: 28819736 DOI: 10.1007/s10029-017-1641-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 08/06/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Enlargement of the ilioinguinal nerve at the external inguinal ring is observed in 34% of patients undergoing primary open inguinal herniorrhaphy; in 88% of patients it occurs at the fascial edge where the hernia mushrooms with abdominal pressure. Compression neuropathy occurs near many anatomical nerve constriction sites and is associated with enlargement of the peripheral nerve accompanied by sensory changes. METHODS In this prospective study, Carolina Comfort Scale (CCS) questionnaire data was collected for 35 primary hernia repairs. Each patient underwent primary inguinal herniorrhaphy that included ilioinguinal neurectomy. All nerves were sampled proximal to the external inguinal ring. Any nerves with grossly increased overall diameter to any degree distal to the external ring were additionally sampled in the thickened portions. A neuropathologist performed histologic evaluation of the H&E-stained cross sections. RESULTS Paired comparison of proximal and distal nerves revealed a greater overall diameter and greater measured nerve-specific diameter in distal nerve segments. Nerves with increased overall diameter were also found to have a statistically significant positive correlation with four of eight pain measures. Additionally, increased nerve-specific diameter correlates with increased pain on four of eight pain values, but age effect on nerve diameter blunts this finding. CONCLUSIONS Increased preoperative CCS pain values in primary open inguinal hernia are significantly correlated with gross enlargement of the overall diameter and nerve-specific diameter of the ilioinguinal nerve beyond the external inguinal ring. This is consistent with a compression neuropathy.
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Affiliation(s)
- R Wright
- Cascade Hernia Institute, 208 17th Ave SE Suite 201, Puyallup, WA, 98372, USA.
| | - D E Born
- Department of Pathology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA
| | - N D'Souza
- Pacific Northwest University of Health Sciences, Yakima, USA
| | - L Hurd
- Pacific Northwest University of Health Sciences, Yakima, USA
| | - R Gill
- Creighton University, Omaha, USA
| | - D Wright
- University of Denver, Denver, USA
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Transabdominal Preperitoneal (TAPP) versus Lichtenstein operation for primary inguinal hernia repair - A systematic review and meta-analysis of randomized controlled trials. BMC Surg 2017; 17:55. [PMID: 28490321 PMCID: PMC5424320 DOI: 10.1186/s12893-017-0253-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/03/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Transabdominal Preperitoneal (TAPP) and Lichtenstein operation are established methods for inguinal hernia repair in clinical practice. Meta-analyses of randomized controlled studies, comparing those two methods for repair of primary inguinal hernia, are still missing. In this study, a systematic review and meta-analysis of published randomized controlled trials was performed to compare early and long term outcomes of the two methods. METHODS A literature search was carried out to identify randomized controlled trials, which compared TAPP and Lichtenstein repair for primary inguinal hernia. Outcome measures included duration of operation, length of hospital stay, acute postoperative and chronic pain, time to return to work, hematoma, wound infection, neuralgia, numbness, scrotal swelling, seroma and hernia recurrence. A quantitative meta-analysis was performed, using Odds Ratios (OR) or Standardized Mean Difference (SMD), and Confidence Interval (CI). RESULTS Eight controlled randomized studies were identified suitable for the analysis. The mean duration of the operation was shorter in Lichtenstein repair (SMD = 6.79 min, 95% CI, -0.68 - 14.25), without significant difference. Comparing both techniques, patients of the laparoscopic group showed postoperatively significantly less chronic inguinal pain (OR = 0.42; 95% CI, 0.23-0.78). Analyses of the remaining outcome measures did not show any significant differences between the two techniques. CONCLUSION The results of this analysis indicate that complication rate and outcome of both procedures are comparable. TAPP operation demonstrated only one advantage over Lichtenstein operation with significantly less chronic inguinal pain postoperatively.
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Wright R, Born DE, D'Souza N, Hurd L, Gill R, Wright D. Why do inguinal hernia patients have pain? Histology points to compression neuropathy. Am J Surg 2017; 213:975-982. [PMID: 28388973 DOI: 10.1016/j.amjsurg.2017.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/31/2017] [Accepted: 03/16/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study is to describe the known soft tissue neuro-histology factors associated with compression neuropathy in relation to the incidence of preoperative pain in primary inguinal hernia. Enlargement of the ilioinguinal nerve occurs in 63% of patients with primary inguinal hernia; compression neuropathy has similar gross features. METHODS Patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. During routine inguinal hernia repair, nerve segments were sampled for histologic evaluation. RESULTS Twenty-two thickened nerve segments (63% of total) with proximal and distal specimens were resected for examination and comparison. We quantified various histologic indicators including nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium. CONCLUSION These findings support the concept that preoperative hernia pain is associated with compression neuropathy.
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Affiliation(s)
| | - Donald E Born
- Department of Pathology, Stanford University, School of Medicine, Stanford, CA, USA.
| | - Natasha D'Souza
- Pacific Northwest University of Health Sciences, Yakima, WA, USA.
| | - Larissa Hurd
- Pacific Northwest University of Health Sciences, Yakima, WA, USA.
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Unilateral paravertebral block compared with subarachnoid anesthesia for the management of postoperative pain syndrome after inguinal herniorrhaphy: a randomized controlled clinical trial. Pain 2017; 157:1105-1113. [PMID: 26761379 DOI: 10.1097/j.pain.0000000000000487] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inguinal herniorrhaphy is a common surgical procedure. The aim of this investigation was to determine whether unilateral paravertebral block could provide better control of postoperative pain syndrome compared with unilateral subarachnoid block (SAB). A randomized controlled study was conducted using 50 patients with unilateral inguinal hernias. The patients were randomized to receive either paravertebral block (S group) or SAB (C group). Paravertebral block was performed by injecting a total of 20 mL of 0.5% levobupivacaine from T9 to T12 under ultrasound guidance, whereas SAB was performed by injecting 13 mg of 0.5% levobupivacaine at the L3 to L4 level. Data regarding anesthesia, hemodynamic changes, side effects, time spent in the postanesthesia care unit, the Karnofsky Performance Status, acute pain and neuropathic disturbances were recorded. Paravertebral block provided good anesthesia of the inguinal region without patient or surgeon discomfort, with better hemodynamic stability and safety and with a reduced time to discharge from the postanesthesia care unit compared with SAB. During the postsurgical and posthospital discharge follow-ups, rest and incident pain and neuropathic positive phenomena were better controlled in the S group than in the C group. The consumption of painkillers was higher in the C group than in the S group throughout the follow-up period. Paravertebral block can be considered a viable alternative to common anesthetic procedures performed for inguinal hernia repair surgery. Paravertebral block provided good management of acute postoperative pain and limited neuropathic postoperative disturbances.
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Factors Determining Outcome After Surgery for Chronic Groin Pain Following a Lichtenstein Hernia Repair. World J Surg 2016; 39:2652-62. [PMID: 26246115 DOI: 10.1007/s00268-015-3183-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Some patients develop chronic groin pain after a Lichtenstein hernia repair. Previous studies have demonstrated beneficial effects of removal of entrapped inguinal nerves or a meshectomy in patients with chronic pain after open inguinal hernia mesh repair. Factors determining success following this remedial surgery are unknown. The aim of the study was to identify potential patient- or surgery-related factors predicting the surgical efficacy for inguinodynia following Lichtenstein repair. METHODS Consecutive adult patients with a history of persistent pain following Lichtenstein repair who underwent remedial surgery were analysed using univariate analysis. Significant confounders (p < 0.05) were combined in a multivariate logistic regression model using a backward stepwise regression method. RESULTS A total of 136 groin pain operations were available for analysis. Factors contributing to success were removal of a meshoma (OR 4.66) or a neuroma (OR 5.60) and the use of spinal anaesthesia (OR 4.38). In contrast, female gender (OR 0.30) and preoperative opioid use (OR 0.38) were significantly associated with a less favourable outcome. Using a multivariate analysis model, surgery under spinal anaesthesia (OR 4.04), preoperative use of opioids (OR 0.37), and meshoma removal (OR 5.31) greatly determined surgical outcome. CONCLUSIONS Pain reduction after remedial surgery for chronic groin pain after Lichtenstein repair is more successful if surgery is performed under spinal anaesthesia compared to general anaesthesia. Removal of a meshoma must be considered as success rates are optimized following these measures. Patients using opioids preoperatively have less favourable outcomes.
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Olasehinde O, Lawal OO, Agbakwuru EA, Adisa AO, Alatise OI, Arowolo OA, Adesunkanmi ARK, Etonyeaku AC. Comparing Lichtenstein with darning for inguinal hernia repair in an African population. Hernia 2016; 20:667-74. [PMID: 27146504 DOI: 10.1007/s10029-016-1498-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost. METHOD Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months. RESULT Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups. CONCLUSION Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.
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Affiliation(s)
- O Olasehinde
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria.
| | - O O Lawal
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - E A Agbakwuru
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A O Adisa
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - O I Alatise
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - O A Arowolo
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A R K Adesunkanmi
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A C Etonyeaku
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
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Factors predicting chronic pain after open mesh based inguinal hernia repair: A prospective cohort study. Int J Surg 2016; 29:165-70. [DOI: 10.1016/j.ijsu.2016.03.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 03/27/2016] [Accepted: 03/30/2016] [Indexed: 11/18/2022]
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16
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Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, Halevy A. Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial. J Am Coll Surg 2013; 218:102-7. [PMID: 24210149 DOI: 10.1016/j.jamcollsurg.2013.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 08/28/2013] [Accepted: 09/04/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic pain after inguinal hernia repair occurs in 16% to 62% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for the procedure. We hypothesize that nonabsorbable sutures used for mesh fixation to the surrounding tissues are associated with higher rates of chronic groin pain after surgery. STUDY DESIGN We conducted a single-blind randomized clinical trial to compare the effect of absorbable braided sutures (Vycril; Ethicon) and nonabsorbable monofilament sutures (Prolene; Ethicon) used in inguinal hernia repair on the rate of chronic pain. We assessed chronic pain using a 4-point verbal-rank scale during a 1-year postoperative follow-up period. RESULTS Study groups included 100 patients in each group. No age, sex, or hernia-side differences were observed between the study groups. Chronic pain rate after surgery was higher in the nonabsorbable monofilament suture group compared with the absorbable braided suture group (37 vs 26 patients; p = 0.056). Time to pain disappearance was longer in the nonabsorbable monofilament suture vs the absorbable braided suture group (115.3 days; 95% CI, 88-142.7 vs 77.4 days; 95% CI, 54.3-100.3; p = 0.038, respectively). A 1-year age increment reduces the risk for chronic pain occurrence by 2.2% (odds ratio = 0.978%; 95% CI, 0.961-0.995; p = 0.013). The use of nonabsorbable sutures increases the risk for chronic pain in 94.9% compared with absorbable sutures (odds ratio = 1.949; 95% CI, 1.039-3.658; p = 0.038). CONCLUSIONS Nonabsorbable suture use in inguinal hernia repair is associated with a higher rate of chronic pain and a longer time to pain disappearance as compared with absorbable sutures.
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Affiliation(s)
- Igor Jeroukhimov
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Itay Wiser
- Department of Plastic Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Evgeny Karasic
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Vladimir Nesterenko
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Natan Poluksht
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ron Lavy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Halevy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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18
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Eldabe Mikhail A, Palomo Luquero A, Reoyo Pascual JF, Seco Gil JL. Fijación del material protésico en la hernioplastia inguinal abierta: sutura vs. cola sintética. Cir Esp 2012; 90:446-52. [DOI: 10.1016/j.ciresp.2012.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 04/20/2012] [Accepted: 05/07/2012] [Indexed: 10/28/2022]
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19
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Kastler A, Aubry S, Barbier-Brion B, Jehl J, Kastler B. Radiofrequency Neurolysis in the Management of Inguinal Neuralgia: Preliminary Study. Radiology 2012; 262:701-7. [DOI: 10.1148/radiol.11110727] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Aasvang EK, Hansen JB, Kehlet H. Pre-operative pain and sensory function in groin hernia. Eur J Pain 2012; 13:1018-22. [DOI: 10.1016/j.ejpain.2008.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Revised: 09/12/2008] [Accepted: 11/23/2008] [Indexed: 10/21/2022]
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21
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Sadowski B, Rodriguez J, Symmonds R, Roberts J, Song J, Rajab MH, Cummings C, Hodges B. Comparison of polypropylene versus polyester mesh in the Lichtenstein hernia repair with respect to chronic pain and discomfort. Hernia 2011; 15:643-54. [DOI: 10.1007/s10029-011-0841-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 06/10/2011] [Indexed: 12/01/2022]
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22
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Hakeem A, Shanmugam V. Current trends in the diagnosis and management of post-herniorraphy chronic groin pain. World J Gastrointest Surg 2011; 3:73-81. [PMID: 21765970 PMCID: PMC3135872 DOI: 10.4240/wjgs.v3.i6.73] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/24/2011] [Accepted: 05/01/2011] [Indexed: 02/06/2023] Open
Abstract
Inguinodynia (chronic groin pain) is one of the recognised complications of the commonly performed Lichtenstein mesh inguinal hernia repair. This has major impact on quality of life in a significant proportion of patients. The pain is classified as neuropathic and non-neuropathic related to nerve damage and to the mesh, respectively. Correct diagnosis of this problem is relatively difficult. A thorough history and clinical examination are essential, as is a good knowledge of the groin nerve distribution. In spite of the common nature of the problem, the literature evidence is limited. In this paper we discuss the diagnostic tools and treatment options, both non-surgical and surgical. In addition, we discuss the criteria for surgical intervention and its optimal timing.
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Affiliation(s)
- Abdul Hakeem
- Abdul Hakeem, Department of General Surgery, Aintree University Hospital NHS Trust, Longmoor Lane, Liverpool, L9 7AL, United Kingdom
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23
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Hakeem A, Shanmugam V. Inguinodynia following Lichtenstein tension-free hernia repair: A review. World J Gastroenterol 2011; 17:1791-6. [PMID: 21528050 PMCID: PMC3080712 DOI: 10.3748/wjg.v17.i14.1791] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/22/2011] [Accepted: 01/29/2011] [Indexed: 02/06/2023] Open
Abstract
Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain, as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair, use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other, lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain, though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both non-surgical and surgical options have been tried for chronic groin pain, with their consequent risks of analgesic side-effects, recurrent pain, recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre- and post-herniorraphy.
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24
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Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto GB. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 2011; 15:239-49. [PMID: 21365287 DOI: 10.1007/s10029-011-0798-9] [Citation(s) in RCA: 243] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 01/28/2011] [Indexed: 12/01/2022]
Abstract
PURPOSE To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain. METHODS A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question. RESULTS A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair. Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy. CONCLUSION The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain.
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25
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Affiliation(s)
- Jeong Gill Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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26
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Chung L, Norrie J, O'Dwyer PJ. Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg 2010; 98:596-9. [PMID: 21656724 DOI: 10.1002/bjs.7355] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2010] [Indexed: 01/25/2023]
Abstract
BACKGROUND Up to one-third of patients with an inguinal hernia have no symptoms from the hernia. The aim of this study was to determine the long-term outcome of patients with a painless inguinal hernia randomized to observation or operation. METHODS Some 160 men aged 55 years or more with a painless inguinal hernia were randomized to observation or operation between 2001 and 2003. All were invited to attend a research clinic at 6 and 12 months, and 5 years after randomization. Those unable to attend for clinical review were sent a questionnaire based on the clinical review pro forma. RESULTS After a median follow-up of 7.5 (range 6.2-8.2) years, 42 men had died (19 in the observation and 23 in the operation group); 46 of the 80 men randomized to observation had conversion to operation. The estimated conversion rate (using the Kaplan-Meier method) for the observation group was 16 (95 per cent confidence interval 9 to 26) per cent at 1 year, 54 (42 to 66) per cent 5 years and 72 (59 to 84) per cent at 7.5 years. The main reason for conversion was pain in 33 men, and two presented with an acute hernia. Sixteen men developed a new primary contralateral inguinal hernia and three had recurrent hernias. There have been 90 inguinal hernia repairs in the 80 patients randomized to surgery compared with 56 in those randomized to observation. CONCLUSION Most patients with a painless inguinal hernia develop symptoms over time. Surgical repair is recommended for medically fit patients with a painless inguinal hernia.
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Affiliation(s)
- L Chung
- University Department of Surgery, Western Infirmary, Glasgow, UK
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27
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Morgan-Jones D, Evans M, Stephenson BM. Chronic pain following a Lichtenstein inguinal hernia repair: a clinical and legal dilemma (ANZ J. Surg. 2009; 79: 517-20). ANZ J Surg 2010; 80:113-4. [PMID: 20575896 DOI: 10.1111/j.1445-2197.2009.05187.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioinguinal neurectomy for chronic pain. J Neurosurg 2010; 112:784-9. [PMID: 19780646 DOI: 10.3171/2009.8.jns09533] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECT Ilioinguinal neuralgia is one cause of chronic groin pain following inguinal hernia repair, and it affects approximately 10% of patients. Selective ilioinguinal neurectomy is one proposed treatment option for carefully selected patients. The goal of this study was to determine the long-term outcome of patients who underwent selective ilioinguinal neurectomy for chronic post-hernia pain. METHODS The authors retrospectively reviewed the clinical assessment, surgical treatment, and long-term outcome in 26 patients with ilioinguinal neuralgia who underwent selective ilioinguinal neurectomy performed by the senior author (K.J.B.) at Oregon Health & Science University between 1998 and 2008. Data were collected from patient charts and a follow-up telephone questionnaire. RESULTS Twenty-six patients (14 men and 12 women) had a clinical diagnosis of ilioinguinal neuralgia based on a history of radiating neuropathic groin, medial thigh, and genitalia pain. One patient had bilateral disease (therefore there were 27 surgical cases). A selective nerve block was performed in 21 (81%) of 26 patients and was positive in 20 (77%) of the 26. In all but 2 patients, pain onset followed abdominal surgery (for hernia repair in 18 patients), and was immediate in 16 (67%) of 24 patients. The mean patient age was 48.7 years, and the mean duration of pain prior to neurosurgical consultation was 3.9 years. Surgery was performed after induction of local or general anesthesia in 17 and 10 cases, respectively. The ilioinguinal nerve was identified in 25 cases, and the genitofemoral nerve in 2, either entrapped in mesh, scar, or with obvious neuroma (22 of 27 cases). The identified nerve was doubly ligated, cut, and buried in muscle at its most proximal point. At the 2-week follow-up evaluations, 14 (74%) of 19 patients noted definite pain improvement. Nineteen (73%) of the 26 patients were contacted by telephone and agreed to participate in completing long-term follow-up questionnaires. The mean follow-up duration was 34.78 months. Return of pain was reported by 13 (68%) of 19 patients. Using a verbal numerical rating scale (0-10), pain was completely relieved in 27.8%, better in 38.9%, no better in 16.7%, and worse in 16.7% of patients. CONCLUSIONS Ilioinguinal neurectomy is an effective and appropriate treatment for selected patients with iatrogenic ilioinguinal neuralgia following abdominal surgery. Although a high proportion of patients reported some long-term recurrence of pain, complete or partial pain relief was achieved in 66.7% of the patients observed.
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Affiliation(s)
- Andrew C Zacest
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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29
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Pain following the repair of an abdominal hernia. Surg Today 2009; 40:8-21. [PMID: 20037834 DOI: 10.1007/s00595-009-4001-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 01/12/2009] [Indexed: 01/24/2023]
Abstract
Pain and other types of discomfort are frequent symptoms following the repair of an abdominal hernia. After 1 year, the incidence of light to moderate pain following inguinal hernia repair is as high as 10% and 2% for severe disabling chronic pain. Postoperative chronic pain not only affects the individual patient, but may also have a great impact on relatives and society, and may be a cause of concern for the responsible surgeon. This paper provides an overview of the anatomy, surgical procedures, and disposing factors (age, gender, ethnicity, genotype, previous hernia repair, pain prior to surgery, psychosocial characteristics, and surgical procedures) related to the postoperative pain conditions. Furthermore, the mechanisms for both acute and chronic pain are presented. We focus on inguinal hernia repair, which is the most frequent type of abdominal hernia surgery that leads to chronic pain. Finally, the paper provides an update on the diagnostic and treatment routines for postoperative pain.
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30
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Bhattacharjee A, Jayamanne H, Evans MD, Stephenson BM. Groin symptoms 5–7 years after a ‘modified’ plug and patch inguinal hernioplasty. Hernia 2009; 14:171-4. [DOI: 10.1007/s10029-009-0591-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 11/06/2009] [Indexed: 10/20/2022]
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31
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The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg 2009; 251:180; author reply 180-1. [PMID: 19940759 DOI: 10.1097/sla.0b013e3181c76ffe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vuilleumier H, Hübner M, Demartines N. Neuropathy after herniorrhaphy: indication for surgical treatment and outcome. World J Surg 2009; 33:841-5. [PMID: 19156462 DOI: 10.1007/s00268-008-9869-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. METHODS In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel's sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. RESULTS Forty-three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45-95 min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12 months (preoperative 74 [range: 53-87] months versus 0 [range: 0-34] months; p<0.0001). CONCLUSIONS The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.
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Affiliation(s)
- Henri Vuilleumier
- Department of Visceral Surgery, Centre Hospitalier Universtaire Vaudois (CHUV), University Hospital, Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Keller JE, Stefanidis D, Dolce CJ, Iannitti DA, Kercher KW, Heniford BT. Combined Open and Laparoscopic Approach to Chronic Pain after Inguinal Hernia Repair. Am Surg 2008. [DOI: 10.1177/000313480807400805] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic groin pain is the most frequent long-term complication after inguinal hernia repair affecting up to 34 per cent of patients. Traditional surgical management includes groin exploration, mesh removal, and neurectomy. We evaluate outcomes of a combined laparoscopic and open approach to chronic pain after inguinal herniorrhaphy. All patients undergoing surgical exploration for chronic pain after inguinal herniorrhaphy were analyzed. In most, the operation consisted of mesh removal (open or laparoscopic), neurectomy, and placement of mesh in the opposite location of the first mesh (laparoscopic if the first was open and vice-versa). Main outcome measures included pain status, numbness, and hernia recurrence. Twenty-one patients (16 male and 5 female) with a mean age of 41 years (22–51 years) underwent surgical treatment for unilateral (n = 18) or bilateral (n = 3) groin pain. Percutaneous nerve block was unsuccessful in all patients. Four had previous surgery for pain. There were no complications. With a minimum of 6 weeks follow-up, 20 of 21 patients reported significant improvement or resolution of symptoms. A combined laparoscopic and open approach for postherniorrhaphy groin pain results in excellent patient satisfaction with minimal morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after hernia repair.
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Affiliation(s)
- Jennifer E. Keller
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Demitrios Stefanidis
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Charles J. Dolce
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kent W. Kercher
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Dickinson KJ, Thomas M, Fawole AS, Lyndon PJ, White CM. Predicting chronic post-operative pain following laparoscopic inguinal hernia repair. Hernia 2008; 12:597-601. [DOI: 10.1007/s10029-008-0408-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 06/11/2008] [Indexed: 11/25/2022]
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35
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Novitsky YW, Cristiano JA, Harrell AG, Newcomb W, Norton JH, Kercher KW, Heniford BT. Immunohistochemical analysis of host reaction to heavyweight-, reduced-weight-, and expanded polytetrafluoroethylene (ePTFE)-based meshes after short- and long-term intraabdominal implantations. Surg Endosc 2008; 22:1070-6. [PMID: 18188649 DOI: 10.1007/s00464-007-9737-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 10/11/2007] [Accepted: 11/28/2007] [Indexed: 01/05/2023]
Abstract
BACKGROUND Prosthetic meshes induce a variety of inflammatory changes in the host, which may lead to excessive scarring with detrimental clinical consequences, especially in the long term. This study aimed to characterize the degree of short- and long-term inflammatory changes induced by common prosthetic meshes. METHODS Twenty 4 x 4-cm samples each of expanded polytetrafluoroethylene (ePTFE), heavyweight polypropylene (hPP), ePTFE/heavyweight polypropylene (ePTFE/hPP), and reduced-weight polypropylene/regenerated cellulose (rPP) were implanted intraperitoneally in 40 rabbits for 4 or 12 months. After explantation, samples of mesh/tissue complex were analyzed for the degrees of cellular apoptosis (enzyme-linked immunoassay [ELISA]) and cellular turnover (mouse monoclonal antibody). RESULTS In the short term, the degree of apoptosis in the hPP mesh was significantly higher than in the ePTFE and rPP groups. Similarly, it was higher in the ePTFE/hPP group than in either the ePTFE or the rPP group. The amount of Ki-67-positive cells was significantly higher in the hPP group than in the ePTFE or rPP group. The cell turnover in the ePTFE/hPP group was similar to that in the hPP group, but significantly higher than in either the ePTFE or the rPP group. The rPP group, in turn, had a higher Ki-67 score than the ePTFE group. In the long term, both the degree of apoptosis and Ki-67 positivity were significantly lower in the rPP and ePTFE groups than in either the ePTFE/hPP or the hPP group. A significant decrease in Ki-67 scores between the short and long-term groups was found only in the rPP group. CONCLUSION In the short term, heavyweight polypropylene-based meshes were associated with significantly higher cell proliferation and death. A significantly higher degree of apoptosis and cell turnover were associated with heavyweight polypropylene-based meshes even 1 year after implantation, indicating ongoing inflammation and scar remodeling. On the other hand, ePTFE and reduced-weight polypropylene meshes were associated with nearly physiologic levels of inflammatory markers. Overall, an exaggerated and persistent host foreign body response to heavyweight polypropylene-based meshes indicates poor biocompatibility, with potential detrimental clinical sequela.
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Affiliation(s)
- Y W Novitsky
- Department of Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA.
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Results of the Inguinal Hernia Repair With The Use of Mesh. Analysis of the Operation Technique Influence on Post-Operative Complications. POLISH JOURNAL OF SURGERY 2008. [DOI: 10.2478/v10035-008-0092-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kalliomäki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain 2007; 12:214-25. [PMID: 17606392 DOI: 10.1016/j.ejpain.2007.05.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 05/16/2007] [Accepted: 05/16/2007] [Indexed: 12/14/2022]
Abstract
In the Swedish Hernia Register 2834 inguinal hernia repairs in 2583 patients were registered in the county of Uppsala 1998-2004. In May 2005 the 2421 patients still alive were requested by mail to fill in a validated questionnaire concerning postherniorrhaphy pain. The final response rate became 72%. Altogether 519 patients (29%) stated that they had pain in the operated groin to some extent during past week. In 98 patients (6%) the pain interfered with daily activities. Factors associated with an increased risk of residual pain in a multivariate logistic regression analysis were age below median, operation for recurrence, open repair technique, history of preoperative pain, and less than three years from surgery. Factors not associated with occurrence of residual pain were gender, method of anaesthesia during surgery, hernia sac diameter, postoperative complications, hernia type, need for emergency operation, reducibility of the hernia sac and complete dissection of the hernia sac. Factors found to be associated with impairment of function due to pain in a multivariate logistic regression analysis were: age below median, female gender, medial hernia, open repair technique, postoperative complications, need for operation for recurrence, presence of preoperative pain and less than three years from surgery. The possibility of long-term pain as an outcome after hernia operations should be taken into consideration in the decision making prior to operation.
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Pélissier EP, Monek O, Blum D, Ngo P. The Polysoft® patch: prospective evaluation of feasibility, postoperative pain and recovery. Hernia 2007; 11:229-34. [PMID: 17541701 DOI: 10.1007/s10029-007-0203-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Accepted: 01/22/2007] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The Polysoft patch was conceived to associate the advantages of placement of the patch in the preperitoneal space (PPS) and easiness of the inguinal incision. The aim of this study was to evaluate prospectively the feasibility and postoperative outcome of this method. METHODS Two hundred Polysoft repairs were performed in 191 consecutive patients with Nyhus types III and IV hernias. The anesthesia was spinal in 146 patients (76.4%), local in 36 (18.8%) and general in 9 (4.7%). The patch was placed in the PPS through the hernial orifice in the fascia in direct hernias and through the internal orifice in indirect ones. The technical points and postoperative course data were prospectively recorded and postoperative pain was assessed daily by visual analogue scale (VAS) in 25 patients. RESULTS The method was achieved in all the cases. The type of the hernias was as follows: 59 direct, 129 indirect (including 28 pantaloon and 16 sliding), 3 inguino-femoral and 9 recurrent. The size of the patch used was medium in 152 cases (76%) and large in 48 (24%). The large patch was used more in pantaloon, sliding and inguino-femoral hernias. In direct hernias the patch was not split; in indirect hernias the patch was split (so the wings recreate a new internal orifice around the spermatic cord) in 79 cases (61.2%) and not split (with the cord parietalized) in 50 cases (38.8%). The length of operation, postoperative hospital stay, return to daily activity, to work and analgesics consumption were [median +/- SD (extremes)]: 35 min +/- 9.1 (20-60), 1 day +/- 0.4 (0-5), 3 days +/- 1.8 (0-8), 15 days +/- 9.7 (1-30) and 3 days +/- 2.3 (0-10), respectively. The median number of analgesics units was 8 +/- 5.9 (0-32). The values of pain assessed daily by VAS (on 100) varied from 20.4 +/- 19.7 (0-60) at day 0, 25.0 +/- 24.5 (0-80) at day 1 to 7.5 +/- 13.7 (0-50) at day 7; the mean value for the week was 16.7 +/- 16.7 (0-57). There were 14 (7%) benign postoperative complications. CONCLUSION This study permitted the definition of some technical points and showed that the Polysoft patch can be used for all types of hernias with a weak posterior wall, including complex cases (big scrotal, pantaloon, sliding and recurrent), with a low risk of postoperative complications, a low level of postoperative pain and a short recovery time.
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Affiliation(s)
- E P Pélissier
- Capio Clinique Saint Vincent, 40 Chemin des Tilleroyes, 25000, Besançon, France
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Kang SH, Han HJ, Kim WY, Kim DY, Moon DE. Pulsed Radiofrequency of Lumbar Dorsal Root Ganglia for Treatment of Chronic Inguinal Herniorrhaphy Pain - A case report -. Korean J Pain 2007. [DOI: 10.3344/kjp.2007.20.2.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Seung Hee Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Jo Han
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Young Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Young Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Eon Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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