Persistent Postherniorrhaphy Pain Research Articles

Surgical treatment for chronic pain after inguinal hernia repair: a systematic literature review.

Chronic postoperative inguinal pain (CPIP) is a frequent complication after inguinal surgery with a significant decrease in quality of life. There is still no clear algorithm regarding surgical treatment. The aim of this systematic review was to provide an overview on the principles and outcome of surgical interventions for CPIP based on the available literature. A literature search was performed using the databases PubMed and SCOPUS following the PRISMA statement. Used Mesh terms and keywords were "postoperative pain," "chronic pain," "inguinal hernia," and "surgical treatment." All articles were reviewed regarding surgical technique and outcome. MINORS criteria for the assessment of the methodological quality of non-randomized surgical studies were applied. Eighteen articles, of which 17 cohort studies and one randomized controlled trial (RCT), described the surgical management of CPIP. Selective as well as triple neurectomy, often in combination with mesh removal and removal of suture material, was performed. Success rate, defined as significant or complete relief of pain, ranged from 33 until 100%, with most articles reaching success rates above 70%, showing a clear advantage of surgical therapy for chronic pain. The use of surgical triple neurectomy seems effective and helpful in a high percentage of patients with CPIP. Surgical treatment should only be considered after adequate preoperative diagnostic evaluation of which the dermatome sensory mapping seems a useful tool for detailed neurophysiological assessment of patients with persistent post-herniorrhaphy pain undergoing remedial neurectomy.

Persistent postherniorrhaphy pain following inguinal hernia repair: A cross-sectional study of prevalence, pain characteristics, and effects on quality of life

IntroductionChronic inguinal pain due to the inguinal hernia repair is still a serious consideration, and its incidence is evident in approximately 3%–6% of the patients. The purpose of this study was performed to assess the prevalence of chronic pain after inguinal hernia repair and the effects on the quality of life in our patient. MethodsThe records of the patients who were 18 years of age or older and had had an inguinal hernia repair under spinal anesthesia after receiving a diagnosis of inguinal hernia at this hospital from 2009 to 2015 were accessed through the hospital's data system. Patients who had signed the informed consent agreement were given an Inguinal Pain Questionnaire (IPQ) and a Douleur Neuropathique 4 (DN-4) questionnaire after recording their demographic data on the appointment day. Surgical incision line was evaluated with a dolorimeter and mild touch hypoesthesia, needle-touch hypoesthesia, brushing allodynia were evaluated with cotton, and 0.711 mm diameter Von-Frey filament (Touch-Test Sensory Evaluator Kit; North Coast Medical, Inc., Gilroy, CA, USA). ResultsThe total number of patients who had ASA I-II scores and who had undergone a one-sided inguinal hernia repair under spinal anesthesia in elective conditions with at least three or more months of recovery time months was 619. Of these 264 patients, 203 with absence of pain (score of the severest pain over the past week and now was 0) were classified as the Non-Pain group and 61 patients with inguinal pain (score of the severest pain over the past week or now was 1 or more) were classified as the Pain group.The incidence of chronic pain after inguinal hernia surgery was 23.48% (n = 61) in our study. The pain was localized at and near the surgical incision and radiated into the scrotum in 17.73% (n = 36) of the male patients having chronic pain. While chronic pain developed in 60 out of 239 patients who had pain prior to the surgery. The presence of pain prior to the surgery was evaluated as an effective factor for the chronic groin pain. Neuropathic pain was detected with the DN-4 questionnaire in 6 (2.95%) out of 203 patients who stated that they had no pain during the physical examination and the week prior to the exam. The frequency of chronic pain after inguinal hernia repair was found 23.48% in our study. This is the same rate as previously reported. Quality of life of these patients was affected. We believe that there is an urgent need for prospective randomized studies with the aim of determining a standardized methodology towards preventive measures after determining the risk factors of chronic pain developed in the post inguinal hernia repair period.

Long-term follow-up after mesh removal and selective neurectomy for persistent inguinal postherniorrhaphy pain

Persistent inguinal pain, influencing daily activities, is seen in about 5 % of patients following inguinal herniorrhaphy. Surgical treatment of patients with persistent postherniorrhaphy pain has been associated with pain relief and improvement in functional status. However, the detailed long-term outcome effects remain to be clarified. The aim of this study was to determine the long-term effects of mesh removal and selective neurectomy in patients with persistent postherniorrhaphy pain after previous open repair. The study consecutively included 54 inguinal postherniorrhaphy pain patients treated with mesh removal and aimed neurectomy. Patients completed questionnaires evaluating pain intensity with a numerical rating scale (NRS) and pain-related functional impairment preoperatively, and, 3, 6, 12, 24, and 36 months postoperatively. Endpoints were changes in pain intensity and functional ability when comparing preoperative and postoperative assessments. Pain intensities (average, maximum, and during activity) were significantly lower at all time points during follow-up compared to preoperative values (p < 0.01 for all) with a reduction in median (IQR) average pain intensity from 6.0 (5.0-7.0) preoperatively to 3.0 (1.0-5.5) at 36-month follow-up. There was no association between positive pain outcome and intraoperative nerve identification (p = 0.47). The number of patients who reported a long-term negative effect of the operation (≥ 25 % increase in average pain intensity at 36-month follow-up) was 1 of 8. The functional ability was improved at 3 months after the operation (p < 0.01), but the improvement was not statistically significant in the follow-up period. Preoperative signs of depression, anxiety, and catastrophizing had no influence on outcome. Mesh removal and attempted neurectomy may provide long-lasting analgesic effects in most patients and with a small proportion being worse, without relation to pain history and operative findings. Detailed multicenter collaboration is required to define preoperative diagnostics and the indication for mesh removal and neurectomy, the exact surgical procedure (type of neurectomy) and with detailed follow-up.

Combined Spinal Cord and Peripheral Nerve Field Stimulation for Persistent Post-Herniorrhaphy Pain

Chronic post-hernia pain is a common complication after inguinal herniorrhaphies. Peripheral nerve field stimulation (PNFS) and spinal cord stimulation (SCS) are two new promising treatment modalities. Four patients with persistent neuropathic post-hernia pain were recruited for this prospective study. Electrodes were inserted into the epidural space of the spinal canal and into the subcutaneous tissue in the inguinal region during a single surgical procedure. During a 14-day trial, double-blind stimulation was performed via an external stimulator: three days using the spinal electrode (SCS), three days using the inguinal electrode (PNFS), three days using both (SCS + PNFS), and five days off, with an alternating order from patient to patient. During the trial, pain intensity was assessed thrice daily by the visual analog scale. Additionally, pain intensity and quality of life (QOL) were assessed before and after surgical intervention by the Brief Pain Inventory, SF36 scale, and Pain Disability Index. All patients had a marked pain reduction during the trial phase, and this reduction was more prominent when both electrodes were activated simultaneously (p < 0.001). At the late follow-up, a significant pain reduction and improvement of QOL was observed in three patients. Both SCS and PNFS are effective in treating post-hernia pain, but the magnitude of pain reduction was more prominent with concomitant stimulation. Combined PNFS and SCS should be considered for patients with a less than optimal response to either SCS or PNFS. More studies are necessary to address the cost-effect issues of this new approach to treatment.

Intraoperative nerve identification and chronic postherniorrhaphy pain

First of all, we thank Drs. Chen and Amid [1] for their very thoughtful comments and update on the role of intraoperative nerve identification during groin hernia repair and the risk of development of chronic pain. We agree with all their comments, except that our conclusions in the abstract does not ‘‘conclude that nerve identification does not decrease rates of pain in routine practice’’ as quoted, but rather that ‘‘although intraoperative inguinal nerve identification should be aimed at, other factors may contribute to the risk of nerve damage and persistent pain after open groin hernia repair’’ [2]. This conclusion supports the comments by Chen and Amid [1], despite that we in the present study were not able to demonstrate any influence of nerve identification on signs of nerve damage or on development of persistent pain. The discussion on identification of the ‘‘genitofemoral nerve’’ (which we entirely agree should be named ‘‘genital branch’’) is to some extent semantic as we agree that routine direct identification should not be done, but only if necessary for the herniotomy per se. This may explain our low identification rate of the genital branch (21.3 %) which, interestingly, is within the same range as reported from a recent hernia specialist publication on persistent pain problems, with an identification rate of 26.5 % [3]. Also, we agree that the use of heavy-weight mesh may have contributed to the pain problems, but when the study was conducted there was little conclusive evidence for differences between mesh type and persistent pain. In summary, the valuable comment by Drs. Chen and Amid provides a sound balance on this important (but also difficult) topic of persistent postherniorrhaphy pain compared to our rather negative findings [1]. We entirely support their conclusion that surgical technique is a crucial component to reduce this disturbing problem.

Does nerve identification during open inguinal herniorrhaphy reduce the risk of nerve damage and persistent pain?

Nerve identification during open inguinal hernia herniorrhaphy has been suggested as one of the factors that may reduce the risk of development of persistent postherniorrhaphy pain. In this prospective study, we evaluated whether intraoperative inguinal nerve identification influenced the risk of development of persistent postherniorrhaphy pain, sensory dysfunction in the groin and functional ability score after open hernia repair. A total of 244 men with a primary inguinal hernia underwent open Lichtenstein repair in a high-volume hernia surgery centre, where information on inguinal nerve identification was registered during operation. Before the operation and 6 months postoperatively, functional pain-related impairment was assessed with Activities Assessment Scale and pain intensity scores with Numeric Rating Scale (NRS 0-10). Quantitative sensory testing in the groin was performed before operation and 6 months postoperatively, in order to investigate intraoperative inguinal nerve damage. The intraoperative nerve identification rates for the iliohypogastric, ilioinguinal and genitofemoral nerves were 94.7, 97.5 and 21.3 %, respectively. Thirty-nine patients (16.0 %) had substantial pain-related functional impairment at 6 months follow-up. There was no difference in risk of development of substantial pain-related functional impairment in patients with identification compared with non-identification of the iliohypogastric nerve (P = 1.0), the ilioinguinal nerve (P = 0.59), the genitofemoral nerve (P = 0.40) or all nerves (P = 0.52). There were no differences in regard to sensory loss in the groin area or in regard to improvement in functional outcome following surgery, between patients with and without nerve identification. Although intraoperative inguinal nerve identification should be aimed at, other factors may contribute to the risk of nerve damage and persistent pain after open groin hernia repair.

Risk Factors for Persistent Postherniorrhaphy Pain: Unresolved

Risk Factors for Persistent Postherniorrhaphy Pain: Unresolved

Risk Factors for Persistent Postherniorrhaphy Pain: Unresolved

Risk Factors for Persistent Postherniorrhaphy Pain: Unresolved

Persistent pain after groin hernia surgery: a qualitative analysis of pain and its consequences for quality of life

Despite a high prevalence of persistent groin pain after hernia repair, the specific nature of the pain and its clinical manifestation are poorly known. The aim of this study was to determine the type of post-herniorrhaphy pain and its influence on daily life. In order to assess long-term pain qualitatively and to explore how it affects quality of life, 100 individuals with persisting pain, identified in a cohort study of patients operated for groin hernia, were neurologically examined, along with 100 pain-free controls matched for age, gender and type of operation. The patients were asked to answer the SF-36 questionnaire, the hospital anxiety and depression scale, the Swedish Scales of Personality (SSP) and a standardised questionnaire for assessing everyday life coping. The patients were approached approximately 4.9 years after surgery. Twenty-two patients from the pain group had become pain free by the time of examination, whereas 76 patients still had pain, of whom 47 (68%) suffered from neuropathic pain and 11 from nociceptive pain. The remaining patients suffered from mixed pain, neuropathic and nociceptive, or were found to have another reason for pain. All dimensions of SF-36 were poorer for the pain group than the control group. Persistent post-herniorrhaphy pain is mainly neuropathic and has a substantial impact on health-related quality of life.