Post herniorraphy pain syndrome

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Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater than 3 months after surgery of inguinal hernia. Randomized trials of laparoscopic vs open inguinal hernia repair have demonstrated similar recurrence rates with the use of mesh and have identified that chronic groin pain (>10%) surpasses recurrence (<2%) and is an important measure of success. [1] [2]

Contents

Chronic groin pain is potentially disabling with neuralgia, parasthesia, hypoesthesia, and hyperesthesia. Patients may be unable to work, have limited physical & social activities, sleep disturbances, and psychologic distress. The management of inguinodynia is a difficult problem for many surgeons and 5–7% of patients experiencing post-hernia repair groin pain litigate.[ citation needed ]

Cause

Neuropathic pain is defined as pain in the sensory distribution of an offended nerve. This may be due to preexisting stretch injury or intraoperative nerve injury. It is often described as stabbing and burning. Nociceptive pain includes somatic and visceral pain. Somatic pain may be due to chronic inflammation from tissue injury and is described as gnawing, tender, and pounding. Visceral pain can manifest as testicular and ejaculatory pain which may be associated with mesh ingrowth into spermatic cord structures.[ citation needed ]

Prevention

Nerves management

Avoiding nerve entrapment and injury is critical. The current consensus is that routine identification and preservation of nerves is the best method for prevention. [3] [4] [5] [ self-published source? ]

Transection of the nerves routinely is not a recommended strategy, as it can sometimes increase the pain further. It also increases sensory disturbances in the area of distribution of the transected nerve. [6]

No identification at all is the worst, and many surgeons are not making this identification. For example, in daily practice, surgeons identify all three inguinal nerves as three single nerves in less than 40% of the cases, while the literature shows that this identification can be done in 70-90% of the cases. [3] The challenge is that the course of both ilioinguinal and iliohypogastric nerves is found to be consistent with that described in anatomical texts in only 42% of patients. However, these anatomical variations are readily identifiable. [7]

Mesh

Method of fixation has also been hotly debated with varying results reported with few consistent findings of decreased long term groin pain. However, fibrin glue seems to have a slight advantage. Types of mesh have also been studied, suggesting a small advantage for lightweight over heavyweight, and for biologic mesh over synthetic. [8]

Hernia sac

The role of hernia sac ligation is also being discussed. [9] When ligation and excision of the sac is omitted, there is less reported short-term post-operative pain. [10] [11] However, the impact of this omission on long-term pain has not been widely studied so far.[ citation needed ]

Treatment

Nonsurgical management

Evaluation and treatment can be very challenging in this patient population. Exam and imaging to exclude occult recurrence is important. Following that, use of antiinflammatories, nerve blocks, neuromodulators, and pain clinic referrals should be considered. [12] Unless there is evidence of a recurrence, operative intervention should be deferred for at least 1 year since groin pain decreases with time elapsed from surgery.[ citation needed ]

Triple neurectomy and/or mesh removal

If operative repair is chosen, mesh excision +/- triple neurectomy may be considered with small studies suggesting good outcomes. [13] [14] [15] [16] The largest series encompassing 415 patient, most following open or suture repair, demonstrates significant improvement following triple neurectomy. [17]

However, standard triple neurectomy does not address inguinodynia secondary to neuropathy of the genitofemoral nerve and the preperitoneal segment of its genital branch. But extension of the standard triple neurectomy to include the genitofemoral nerve has given good results, on a small series of 16 patients. [18]

Mesh removal should only be considered in last resort. Meshes are easy to place but difficult to remove, due to their incorporation inside the peritoneum.

Other algorithms proposed have included diagnostic laparoscopy at the start for evaluation of adhesions, removal of mesh, and repair of any recurrences. If there is no improvement then a staged procedure to remove mesh and neurectomy may be considered.[ citation needed ]

Prognosis

Chronic groin pain is more common than recurrence, and it may be lower following laparoscopic hernia repair. Pain often resolves with conservative measures. Following complete evaluation of patient and attempts at non surgical treatment, surgery may be considered. Various treatment algorithms exist with promising results.[ citation needed ]

Incidence

The true incidence is difficult to determine, pain having a subjective component. A prospective series of open Lichtenstein (419 patients) noted that at 1 year followup, 19% of patients had pain, 6% with moderate or severe degree. Predictors of moderate or severe pain included: recurrent hernia, high pain score at 1 week postop, and high pain score at 4 weeks postop. [19]

A Scottish population based study of 4062 patients identified at 3 months postop an incidence of 43% mild pain and 3% severe or very severe pain. The severe and very severe group was associated with young age and female gender. A further survey of the 3% severe pain cohort (at a median of 30 months) found that 29% resolved, 39% improved and 26% continued with severe, or very severe pain. [20]

A followup of a randomized study of 750 laparoscopic vs. open hernia repair followed patients’ pain scores at 2 and 5 years post hernia repair via questionnaire. At 2 years, the chronic pain rate was 24.3% (lap) vs. 29.4% (open), and at 5 year follow up it was 18.1% (lap) vs. 20.1% (open). At 5 years, 4.3% in lap group and 3.7% in open group had attended a pain clinic. [21]

A larger and more recent study which was a followup at 5 years of 1370 from a randomized study of TEP vs. open repair demonstrated lower pain rates in the laparoscopic group (10% vs. 20%). Inguinodynia symptoms decreased over time, even in those in the moderate to severe pain group. In addition, when an inguinal pain questionnaire was administered to these individuals at a median followup of 9.4 years, physical ability was affected more in the open repair group. Predictors of chronic pain in the TEP group included Body Mass Index ≤ 3rd quartile (OR: 3.04), difference in preop and postop physical testing (OR: 2.14) and time to full recovery exceeding the median (OR: 2.09). In the open group, the only association was noted with postoperative pain score exceeding the third quartile (OR: 1.89 ). [22]

Use of mesh-based repair vs. suture-based repair has also been discussed. Some results suggest less inguinodynia after Shouldice (suture) than Lichtenstein (open mesh) for young men. [4] Other studies find equal results between Shouldice and laparoscopic TEP. [23] The experience of the surgeon critically impacts the results, especially for Shouldice and laparoscopic repairs, which are fairly technical operations.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks. Various types of hernias can occur, most commonly involving the abdomen, and specifically the groin. Groin hernias are most commonly inguinal hernias but may also be femoral hernias. Other types of hernias include hiatus, incisional, and umbilical hernias. Symptoms are present in about 66% of people with groin hernias. This may include pain or discomfort in the lower abdomen, especially with coughing, exercise, or urinating or defecating. Often, it gets worse throughout the day and improves when lying down. A bulge may appear at the site of hernia, that becomes larger when bending down. Groin hernias occur more often on the right than left side. The main concern is bowel strangulation, where the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness in the area. Hiatus, or hiatal hernias often result in heartburn but may also cause chest pain or pain while eating.

<span class="mw-page-title-main">Inguinal hernia</span> Medical condition in which contents of the abdominal cavity protrude through the inguinal canal

An inguinal hernia or groin hernia, is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

<span class="mw-page-title-main">Hernia repair</span> Surgical procedures to fix abnormal openings through which tissue or organs may protrude

Hernia repair is a surgical operation for the correction of a hernia—a bulging of internal organs or tissues through the wall that contains it. It can be of two different types: herniorrhaphy; or hernioplasty. This operation may be performed to correct hernias of the abdomen, groin, diaphragm, brain, or at the site of a previous operation. Hernia repair is often performed as an ambulatory procedure.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh.

<span class="mw-page-title-main">Umbilical hernia</span> Medical condition

An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The bulge can often be pressed back through the hole in the abdominal wall, and may "pop out" when coughing or otherwise acting to increase intra-abdominal pressure. Treatment is surgical, and surgery may be performed for cosmetic as well as health-related reasons.

Athletic pubalgia, also called sports hernia, core injury, hockey hernia, hockey groin, Gilmore's groin, or groin disruption, is a medical condition of the pubic joint affecting athletes.

<span class="mw-page-title-main">Spigelian hernia</span> Surgical condition

A Spigelian is the type of ventral hernia where aponeurotic fascia pushes through a hole in the junction of the linea semilunaris and the arcuate line creating a bulge. It appears in the abdomen lower quadrant between an area of dense fibrous tissue and abdominal wall muscles causing a.

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all develop in women due to the increased width of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.

An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are often also classified as ventral hernias due to their location. Not all ventral hernias are from incisions, as some may be caused by other trauma or congenital problems.

<span class="mw-page-title-main">Laparoscopic hiatal hernia repair</span> Medical procedure

Laparoscopic hernia repair is the repair of a hiatal hernia using a laparoscope, which is a tiny telescope-like instrument. A hiatal hernia is the protrusion of an organ through its wall or cavity. There are several different methods that can be used when performing this procedure. Among them are the Nissen Fundoplication and the general laparoscopic hernia repair.

A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it may be an alternative to a failed nerve decompression when the target nerve has no motor function and numbness is acceptable. Neurectomies have also been used to permanently block autonomic function, and special sensory function not related to pain.

Amyand's hernia is a rare form of an inguinal hernia which occurs when the appendix is included in the hernial sac and becomes incarcerated. The condition is an eponymous disease named after a French surgeon, Claudius Amyand (1660–1740), who performed the first successful appendectomy in 1735.

<span class="mw-page-title-main">Obturator hernia</span> Medical condition

An obturator hernia is a rare type of hernia, encompassing 0.07-1% of all hernias, of the pelvic floor in which pelvic or abdominal contents protrudes through the obturator foramen. The obturator foramen is formed by a branch of the ischial as well as the pubic bone. The canal is typically 2-3 centimeters long and 1 centimeters wide, creating a space for pouches of pre-peritoneal fat.

In medicine, Carnett's sign is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the examination table to tense the abdominal muscles. An alternative is to ask the patient to raise both legs with straight knees.

Round ligament pain (RLP) is pain associated with the round ligament of the uterus, usually during pregnancy. RLP is one of the most common discomforts of pregnancy and usually starts at the second trimester of gestation and continues until delivery. It usually resolves completely after delivery although cases of postpartum RLP have been reported. RLP also occurs in nonpregnant women.

<span class="mw-page-title-main">Inguinal hernia surgery</span> Medical procedure

Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region.

<span class="mw-page-title-main">Surgical mesh</span> Material used in surgery

Surgical mesh is a medical implant made of loosely woven mesh, which is used in surgery as either a permanent or temporary structural support for organs and other tissues. Surgical mesh can be made from both inorganic and biological materials and is used in a variety of surgeries, although hernia repair is the most common application. It can also be used for reconstructive work, such as in pelvic organ prolapse or to repair physical defects created by extensive resections or traumatic tissue loss.

<span class="mw-page-title-main">Triangle of Doom</span> Anatomical area in the human groin

The Triangle of Doom is an anatomical triangle defined by the vas deferens medially, spermatic vessels laterally and peritoneal fold inferiorly. This triangle contains external iliac artery and vein, the deep circumflex iliac vein, the genital branch of genitofemoral nerve and hidden by fascia, the femoral nerve. It bears significance in laparoscopic repair of groin hernia. Surgical staples are avoided here.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a nerve entrapment condition that causes chronic pain of the abdominal wall. It occurs when nerve endings of the lower thoracic intercostal nerves (7–12) are 'entrapped' in abdominal muscles, causing a severe localized nerve (neuropathic) pain that is usually experienced at the front of the abdomen.

References

  1. ↑ Simons, M. P.; Aufenacker, T.; Bay-Nielsen, M.; Bouillot, J. L.; Campanelli, G.; Conze, J.; Lange, D.; Fortelny, R.; Heikkinen, T. (2009). "European Hernia Society guidelines on the treatment of inguinal hernia in adult patients". Hernia. 13 (4): 343–403. doi:10.1007/s10029-009-0529-7. PMC   2719730 . PMID   19636493.
  2. ↑ Rosenberg, Jacob; Bisgaard, Thue; Kehlet, Henrik; Wara, Pål; Asmussen, Torsten; Juul, Poul; Strand, Lasse; Andersen, Finn Heidemann; Bay-Nielsen, Morten (2011). "Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults" (PDF). Danish Medical Bulletin. 58 (2): C4243. PMID   21299930. Archived from the original (PDF) on 2015-01-03.
  3. 1 2 Alfieri, S.; Amid, P. K.; Campanelli, G.; Izard, G.; Kehlet, H.; Wijsmuller, A. R.; Di Miceli, D.; Doglietto, G. B. (2011). "International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery". Hernia. 15 (3): 239–49. doi: 10.1007/s10029-011-0798-9 . PMID   21365287.
  4. 1 2 Alfieri, Sergio; Rotondi, Fabio; Di Miceli, Dario; Di Giorgio, Andrea; Ridolfini, Marco Pericoli; Fumagalli, Uberto; Salzano, Antonio; Prete, Francesco Paolo; Spadari, Antonio (2006). "Il dolore cronico dopo ernioplastica inguinale con protesi: il possibile ruolo della manipolazione chirurgica dei nervi del canale inguinale" [Chronic pain after inguinal hernia mesh repair: Possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases](PDF). Chirurgia Italiana (in Italian). 58 (1): 23–31. PMID   16729606. Archived from the original (PDF) on 2018-12-01. Retrieved 2012-01-23.
  5. ↑ Ballert, Erik (2009). "Chronic Postoperative Inguinodynia: A pain in the *&%^". Archived from the original on 2012-02-29. Retrieved 2012-01-08.
  6. ↑ Picchio, Marcello; Palimento, Domenico; Attanasio, Ugo; Matarazzo, Pietro Filippo; Bambini, Chiara; Caliendo, Angelo (2004). "Randomized Controlled Trial of Preservation or Elective Division of Ilioinguinal Nerve on Open Inguinal Hernia Repair with Polypropylene Mesh". Archives of Surgery. 139 (7): 755–8, discussion 759. doi:10.1001/archsurg.139.7.755. PMID   15249409. S2CID   25278706.
  7. ↑ Al-dabbagh, A. K. R. (2002). "Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs". Surgical and Radiologic Anatomy. 24 (2): 102–7. doi:10.1007/s00276-002-0006-9. PMID   12197017. S2CID   22788426.
  8. ↑ Ansaloni, Luca; Catena, Fausto; Coccolini, Federico; Gazzotti, Filippo; d'Alessandro, Luigi; Pinna, Antonio Daniele (2009). "Inguinal hernia repair with porcine small intestine submucosa: 3-year follow-up results of a randomized controlled trial of Lichtenstein's repair with polypropylene mesh versus Surgisis Inguinal Hernia Matrix". The American Journal of Surgery. 198 (3): 303–12. doi:10.1016/j.amjsurg.2008.09.021. PMID   19285658.
  9. ↑ Mohammadhosseini, Bijan (2010). "Risk Factors for Persistent Postherniorrhaphy Pain: Unresolved". Anesthesiology. 113 (5): 1243–4, author reply 1244. doi: 10.1097/ALN.0b013e3181f69604 . PMID   20966668.
  10. ↑ Shulman, AG; Amid, PK; Lichtenstein, IL (1993). "Ligation of hernial sac. A needless step in adult hernioplasty". International Surgery. 78 (2): 152–3. PMID   8354615.
  11. ↑ Delikoukos, S.; Lavant, L.; Hlias, G.; Palogos, K.; Gikas, D. (2007). "The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: A prospective randomized study". Hernia. 11 (5): 425–8. doi:10.1007/s10029-007-0249-9. PMID   17594052. S2CID   10958963.
  12. ↑ Ferzli, George S.; Edwards, Eric D.; Khoury, George E. (2007). "Chronic Pain after Inguinal Herniorrhaphy". Journal of the American College of Surgeons. 205 (2): 333–41. doi:10.1016/j.jamcollsurg.2007.02.081. PMID   17660082.
  13. ↑ Palumbo, P.; Minicucci, A.; Nasti, A. G.; Simonelli, I.; Vietri, F.; Angelici, A. M. (2007). "Treatment for persistent chronic neuralgia after inguinal hernioplasty". Hernia. 11 (6): 527–31. doi:10.1007/s10029-007-0268-6. PMID   17668147. S2CID   13018105.
  14. ↑ Delikoukos, S.; Fafoulakis, F.; Christodoulidis, G.; Theodoropoulos, T.; Hatzitheofilou, C. (2008). "Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh". Hernia. 12 (6): 593–5. doi:10.1007/s10029-008-0392-y. PMID   18542838. S2CID   19975450.
  15. ↑ Vuilleumier, Henri; Hübner, Martin; Demartines, Nicolas (2009). "Neuropathy After Herniorrhaphy: Indication for Surgical Treatment and Outcome" (PDF). World Journal of Surgery. 33 (4): 841–5. doi:10.1007/s00268-008-9869-1. PMID   19156462. S2CID   41720538.
  16. ↑ Aasvang, Eske K.; Kehlet, Henrik (2009). "The Effect of Mesh Removal and Selective Neurectomy on Persistent Postherniotomy Pain". Annals of Surgery. 249 (2): 327–34. doi:10.1097/SLA.0b013e31818eec49. PMID   19212190. S2CID   26342268.
  17. ↑ Amid, Parviz K.; Hiatt, Jonathan R. (2007). "New Understanding of the Causes and Surgical Treatment of Postherniorrhaphy Inguinodynia and Orchalgia". Journal of the American College of Surgeons. 205 (2): 381–5. doi:10.1016/j.jamcollsurg.2007.04.001. PMID   17660088.
  18. ↑ Amid, Parviz K.; Chen, David C. (2011). "Surgical Treatment of Chronic Groin and Testicular Pain after Laparoscopic and Open Preperitoneal Inguinal Hernia Repair". Journal of the American College of Surgeons. 213 (4): 531–6. doi:10.1016/j.jamcollsurg.2011.06.424. PMID   21784668.
  19. ↑ Callesen, T.; Bech, K.; Kehlet, H. (1999). "Prospective study of chronic pain after groin hernia repair". British Journal of Surgery. 86 (12): 1528–31. doi: 10.1046/j.1365-2168.1999.01320.x . PMID   10594500. S2CID   45862680.
  20. ↑ Courtney, C. A.; Duffy, K.; Serpell, M. G.; O'Dwyer, P. J. (2002). "Outcome of patients with severe chronic pain following repair of groin hernia". British Journal of Surgery. 89 (10): 1310–4. doi:10.1046/j.1365-2168.2002.02206.x. PMID   12296903. S2CID   23810958.
  21. ↑ Grant, A. M.; Scott, N. W.; O'Dwyer, P. J.; MRC Laparoscopic Groin Hernia Trial Group (2004). "Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia". British Journal of Surgery. 91 (12): 1570–4. doi: 10.1002/bjs.4799 . PMID   15515112. S2CID   25971273.
  22. ↑ Eklund, A.; Montgomery, A.; Bergkvist, L.; Rudberg, C.; Swedish Multicentre Trial of Inguinal Hernia Repair by Laparoscopy (SMIL) study group (2010). "Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair". British Journal of Surgery. 97 (4): 600–8. doi: 10.1002/bjs.6904 . PMID   20186889. S2CID   41990146.
  23. ↑ Wennström, I; Berggren, P; Åkerud, L; Järhult, J (2004). "Equal results with laparoscopic and Shouldice repairs of primary inguinal hernia in men. Report from a prospective randomised study" (PDF). Scandinavian Journal of Surgery. 93 (1): 34–6. doi:10.1177/145749690409300107. PMID   15116817. S2CID   25686860. Archived from the original (PDF) on 2013-10-02.
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