Fig. 23.1.
Nerves in the left groin (anterior view and laparoscopic view).
Fig. 23.2.
Mesh placement (preperitoneal and Lichtenstein) and the nerves potentially at risk for the left groin.
For patients who have had an open inguinal hernia repair with a technique including placing mesh in the preperitoneal space and in more superficial locations (plug and patch, Prolene Hernia System, Ultrapro Hernia System, etc.) or a technique where no mesh is placed in the preperitoneal space, it is likely that an open groin exploration will be required to achieve the maximal benefits from a surgical approach. The open exploration includes removal of mesh and any other material that may be causing pain. Nerves that course in the groin in the intermuscular location (the iliohypogastric, ilioinguinal, and genital branch of the genitofemoral) may be divided and the distal ends implanted into muscle. There is some debate about whether to search for and divide all nerves or only the nerves involved in the scar tissue, mesh, or other fixation devices. Because of the difficulty in finding nerves outside of the field of dissection and the potential to cause complications, it has been our practice to divide only the nerves (neurectomy) or free nerves (neurolysis) that are involved in the scar tissue, mesh, and/or fixation devices, but not to look for additional nerves in otherwise normal-appearing tissue. After the open approach is completed, the groin is closed with three layers of absorbable suture, and then the skin is closed with a subcuticular stitch.
At this point in our experience, we have not placed a permanent synthetic, absorbable synthetic, or biologic mesh after mesh removal for pain, regardless of whether the procedure was laparoscopic only or a laparoscopic and open combined procedure. We have not placed a mesh during this operation in an attempt to minimize the potential of causing additional or new pain from a mesh and/or from mesh fixation, when the goal of the operation is to relieve pain. The exception to this is when an interstitial or recurrent hernia is found at laparoscopy. If a hernia defect is identified after a laparoscopic mesh removal, a laparoscopic primary suture repair is performed. For all procedures that include open mesh removal, a three-layer groin reconstruction is performed using absorbable sutures.
Postoperative Management
The patient is often discharged the same day or within 24–48 h of the operation, unless there are complications. However, for patients on high dosages of opioid agonists, a longer hospital stay for pain control and monitoring may be required. In this early postoperative period, the initial treatment of pain is identical to the treatment of nonsevere or acute groin pain and includes rest, ice, and/or heat to the groin, anti-inflammatory medication, and a mild narcotic medication. A bowel regimen to prevent constipation and bloating may also be helpful. It is often helpful to provide the patient with a multitude of pain medication options and then allow them to choose which works best for them, as they may already know from previous experience. Pain control in the immediate postoperative period is essential, as some studies have shown an increased risk for developing chronic pain in patients whose postoperative pain scores are high. Perioperative multimodal pain management inducing transversus abdominis plane (TAP) block and intra-op block with long-acting local anesthetic may help to minimize pain control issues in the immediate postoperative period.
Some patients will have continued difficulty with pain control following surgery, especially if they were taking high doses of opioid medications prior to the operation. All of the pain management techniques previously discussed can be considered for use in the postoperative course. Typically, as the pain and inflammation from the operation resolve, the patient will become increasingly aware of the results from the operation and will report that their improvement levels off 2–4 months after the operation. Following surgery, it is important to track a patient’s progress for improvement. It may help to compare a patient’s preoperative assessment of pain on a standardized questionnaire to their postoperative pain to examine for objective changes.
Postoperative Complications
In the early postoperative period, complications include wound infection, seroma, and hematoma. As mentioned, postoperative pain control may be difficult.
The long-term complications pertinent to this procedure include hernia recurrence and inadequate resolution of pain. Nonsurgical pain management should be continued and adjusted accordingly for pain that is not resolved in an attempt to improve a patient’s quality of life. A continued search for factors that contribute to the development of chronic groin pain after inguinal hernia repair is essential to predict subpopulations at risk for this problem and to potentially alter treatment options based on new knowledge when the concept of predictive analytics and complex systems data management is applied [see Chap. 45, “Value-Based Clinical Quality Improvement (CQI) for Chronic Groin Pain after Inguinal Hernia Repair”].
For the patient who has a hernia recurrence after an operation to relieve pain from a prior hernia repair, the decision to undergo another hernia repair may be a difficult one. If another repair is performed, consideration should be given to the approach (open or laparoscopic) and to the choice of mesh, including options that are not permanent, such as resorbable synthetic and biologic meshes. In this situation, involving the patient in a shared decision process to determine the technique and materials to be used may be helpful to give the patient some control in determining their choice for hernia repair.
Prevention of Chronic Groin Pain After Inguinal Hernia Repair
There have been many attempts to minimize chronic pain over the years, mostly aimed at altering surgical technique. Previous studies have shown mixed results in attempting to prophylactically identify and divide the ilioinguinal, iliohypogastric, and/or genital branch of the genitofemoral nerves during open inguinal hernia repair. In a multicenter prospective study by Alfieri et al., identification and preservation of nerves are directly correlated to the development of chronic pain postoperatively [7].
The laparoscopic approach compared to open inguinal hernia repair has some of the strongest evidence showing a decrease in acute and chronic pain based on several studies. However, some studies have shown a minimal difference in pain after the first 24–48 h, and some studies show increased severity of pain with a laparoscopic repair.
The other most studied factors in the prevention of chronic pain are the mesh and fixation devices used. Several studies have evaluated lightweight mesh to look for a decreased incidence of chronic pain. Some older studies showed inconclusive results or only slight improvement when using lightweight mesh. However, many of these studies also showed a slight increase in hernia recurrence in patients with a lightweight mesh. In two recent studies comparing open and laparoscopic repair, lightweight mesh was associated with a decreased risk of developing chronic groin pain and for the development of other groin symptoms, including stiffness and the sensation of a foreign body, and was not associated with increased risk of hernia recurrence [8, 9]. Decreasing or eliminating tack, staple, and suture fixation, or using glue, has also shown some potential to decrease pain, but with a potential for an increase in recurrence rate.
Related posts:
Introduction to Primary and Secondary Groin Pain: What Is Inguinodynia?
Prevention of Pain: Optimizing the Laparoscopic TEP and TAPP Techniques
Triple Neurectomy Versus Selective Neurectomy
Workers’ Compensation: An Occupational Perspective on Groin Pain, Including Psychosocial Variables, Causality, and Return to Work
Right Inguinal Hernia with Osteitis Pubis: A Case Report of Osteitis Pubis and Ipsilateral Inguinal Hernia
Groin Pain Etiology: Hip-Referred Groin Pain
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