Etiology and Management of Hernia-Related Chronic Pain: Implications of Robotics

Abstract

Chronic pain following ventral or inguinal hernia repair is a prevalent and clinically impactful complication resulting from all options of open, laparoscopic, and robotic surgery. Nociceptive, somatic, and visceral pain can result from recurrence, infection, tissue inflammation, adhesions, and prosthetic reaction or failure. Development of neuropathic pain is caused by nerve injury, typically by dissection, scarring, exposure to mesh, development of neuroma, or entrapment by suture or fixation devices. Prevention is the most important and effective strategy to address chronic pain due to hernia repair with careful attention to neuroanatomy, proper hernia repair technique, and utilization of prosthetic and fixation materials. Surgical remediation may achieve symptomatic relief in carefully selected patients. In the case of ventral hernia repair or chronic neuropathic pain following hernia repair above the groin, surgical management focuses on repair of recurrence, treatment of infection, and removal of entrapping suture, mesh, or fixation material. For pain after inguinal hernia repair, the most common mechanisms include recurrence, infection, orchialgia, and neuropathic pain. Neurectomy is the preferred surgical treatment for neuropathic pain, and consists of resecting a portion of the ilioinguinal nerve, iliohypogastric nerve, and/or the genital branch of the genitofemoral nerve depending on likely involvement. This may be achieved by open, laparoscopic preperitoneal or retroperitoneal, robotic-assisted, or hybrid approaches. With the development and increasing adoption of robotic-assisted options for inguinal and ventral hernia repair, the implications of pain caused by adoption of these robotic techniques and the use of the robotic platform to assist in the treatment of chronic pain are important novel topics in hernia repair.