Risk factors for long-term pain after hernia surgery

Genetic susceptibility to postherniotomy pain. The influence of polymorphisms in the Mu opioid receptor, TNF-α, GRIK3, GCH1, BDNF and CACNA2D2 genes

BACKGROUND AND AIMS

Despite improvements in surgical technique, 5%-8% of patients undergoing herniorrhaphy still suffer from clinically relevant persistent postherniotomy pain. This is a problem at both individual and society levels. The aim of this study was to determine whether or not a single nucleotide polymorphism in a specific gene contributes to the development of persistent pain after surgery.

METHODS

One hundred individuals with persistent postherniotomy pain, along with 100 without pain matched for age, gender and type of surgery were identified in a previous cohort study on patients operated for groin hernia. All patients underwent a thorough sensory examination and blood samples were collected. DNA was extracted and analysed for single nucleotide polymorphism in the Mu opioid receptor, TNF-α, GRIK3, GCH1, BDNF and CACNA2D2 genes.

RESULTS

Patients with neuropathic pain were found to have a homozygous single nucleotide polymorph in the TNF-α gene significantly more often than pain-free patients (P=0.036, one-tailed test).

CONCLUSIONS

SNP in the TNF-α gene has a significant impact on the risk for developing PPSP.

IMPLICATIONS

The result suggests the involvement of genetic variance in the development of pain and this requires further investigation.

A scoping review of perineural steroids for the treatment of chronic postoperative inguinal pain

PURPOSE

To review the literature on the efficacy and safety of perineural steroid injections around the ilioinguinal, iliohypogastric, and genitofemoral nerves for chronic postoperative inguinal pain (CPIP).

METHODS

A scoping review was performed to find all relevant case reports, case series, prospective or retrospective cohort studies, case-control studies, and randomized controlled trials (RCTs) where a steroid was used for perineural procedures around ilioinguinal, iliohypogastric, and/or genitofemoral nerves for CPIP. Databases searched included Ovid MEDLINE, EMBASE, CINHAL, Cochrane CENTRAL, and Google Scholar.

RESULTS

A total of five publications were found-three studies were prospective case series, one a retrospective cohort study, and one a RCT. The most common steroids used were methylprednisolone and triamcinolone. The average methylprednisolone-equivalent dose used per procedure was 46 mg (SD 21.9). Procedural guidance included anatomic landmarks (three studies), nerve stimulation and ultrasound (one study), and computed tomography guidance (one study). Four studies reported analgesic benefit in 55-75 % of included patients, with one study documenting an effect up to 50 months later after steroid perineural injections. The RCT demonstrated no benefit of adding steroid to a local anesthetic in the perioperative setting but it did not enroll patients with existing neuropathic pain. No adverse outcomes of perineural steroids were documented within reviewed studies.

CONCLUSIONS

The paucity of data, heterogeneity and lack of appropriate control groups in the available literature precludes firm conclusions on the efficacy and safety of perineural steroids for CPIP. Future adequately powered, high-quality, placebo-controlled studies are needed.

Quality of life and outcomes for femoral hernia repair: does laparoscopy have an advantage?

BACKGROUND

Due to their relative scarcity and to limit single-center bias, multi-center data are needed to study femoral hernias. The aim of this study was to evaluate outcomes and quality of life (QOL) following laparoscopic vs. open repair of femoral hernias.

METHODS

The International Hernia Mesh Registry was queried for femoral hernia repairs. Laparoscopic vs. open techniques were assessed for outcomes and QOL, as quantified by the Carolinas Comfort Scale (CCS), preoperatively and at 1, 6, 12, and 24 months postoperatively. Outcomes were evaluated using the standard statistical analysis.

RESULTS

A total of 80 femoral hernia repairs were performed in 73 patients: 37 laparoscopic and 43 open. There was no difference in mean age (54.7 ± 14.6 years), body mass index (24.2 ± 3.8 kg/m²), gender (60.3 % female), or comorbidities (p > 0.05). The hernias were recurrent in 21 % of the cases with an average of 1.23 ± 0.6 prior repairs (p > 0.1). Preoperative CCS scores were similar for both groups and indicated that 59.7 % of patients reported pain and 46.4 % had movement limitations (p > 0.05). Operative time was equivalent (47.2 ± 21.2 vs. 45.9 ± 14.8 min, p = 0.82). There was no difference in postoperative complications, with an overall 8.2 % abdominal wall complications rate (p > 0.05). The length of stay was shorter in the laparoscopic group (0.5 ± 0.6 vs. 1.3 ± 1.6 days, p = 0.02). Follow-up was somewhat longer in the open group (23.8 ± 10.2 vs. 17.3 ± 10.9 months, p = 0.02). There was one recurrence, which was in the laparoscopic group (3.1 vs. 0 %, p = 0.4). QOL outcomes at all time points demonstrated no difference for pain, movement limitation, or mesh sensation. Postoperative QOL scores improved for both groups when compared to preoperative scores.

CONCLUSION

In this prospective international multi-institution study of 80 femoral hernia repairs, no difference was found for operative times, long-term outcomes, or QOL in the treatment of femoral hernias when comparing laparoscopic vs. open techniques. After repair, QOL at all time-points postoperatively improved compared to QOL scores preoperatively for laparoscopic and open femoral hernia repair. While international data supports improved outcomes with laparoscopic approach for femoral hernia repair, no data had existed prior to this study on the difference of approach impacting QOL. In the setting where recurrence and complication rates are equal after femoral hernia repair for either approach, surgeons should perform the technique with which they are most confident, as the operative approach does not appear to change QOL outcomes after femoral hernia repair.

Factors Determining Outcome After Surgery for Chronic Groin Pain Following a Lichtenstein Hernia Repair

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.

A mechanism of mesh-related post-herniorrhaphy neuralgia

PURPOSE

The objective is to compare nerve densities in explanted polypropylene meshes in patients with or without chronic pain. Pain has supplanted recurrences as a complication of hernia surgery. The increased incidence of pain mirrors a parallel increase in the use of polypropylene meshes. Neither triple neurectomy nor careful nerve preservation has brought relief. Perhaps because we have forgotten that nerves, in response to some evolutionary mechanism, tend to regenerate, undergo changes imposed by prosthetic elements and architecture, mimicking entrapment and compartment syndromes.

METHODS

A total of 33 hernia meshes have been analyzed: 17 excised due to severe pain, two for combined pain and recurrence, 14 sampled during revision for recurrence without pain. Each mesh had standardized sampling for histology and the nerves were highlighted by S100 stain. Nerve densities were assessed within the mesh spaces and in tissue outside the mesh.

RESULTS

The density of nerves present in the standardized mesh samples of patients complaining of pain was much more elevated than in the mesh of those patients who had a recurrence but no pain. The difference was statistically significant (p < 0.001). Excluding two patients who had both pain and recurrence, the difference was even more marked (p < 0.0001).

CONCLUSIONS

Re-innervation and neo-innervation are known to take place following hernia repairs in indigenous tissue as well as through polypropylene meshes. However, when pain is an overriding issue dictating mesh explant, the degree of mesh innervation is significantly higher when compared to mesh excised for recurrence. That increase has been confirmed statistically.

Open ventral hernia repair using ProGrip self-gripping mesh

PURPOSE

Secure mesh fixation in incisional hernia repair is mandatory to prevent mesh dislocation and possible recurrence. Traditional fixation methods have been implicated as a source of chronic postoperative pain. We report 2-year outcomes with a self-gripping mesh for open tension-free repair of large incisional hernia.

METHODS

This prospective case series enrolled 20 patients with large primary incisional hernia (mean defect size: 84 cm(2)). Patients were electively treated by a single surgeon using a macroporous polyester mesh with resorbable polylactic acid microgrips (ProGrip, Covidien, Mansfield, MA, USA) using open onlay technique. Main outcomes included pain severity, Carolinas Comfort Scale (CCS), complications, and hernia recurrence. Patients returned for follow-up at 1, 3, 6, 12, and 24 months.

RESULTS

Median mesh fixation time was 2 min. Mean operative time was 38 min and blood loss was minimal (50 cc). Most patients (75%) were discharged same day. The only perioperative complication was a minor seroma in one patient. Patient follow-up compliance through 2 years was 100%. Mean pain score was 1.8 at discharge, 0.9 at 1 month, 0.7 at 1 year, and 0 at 2 years. At 2-years, all patients were "very satisfied" with treatment and hernia-specific quality of life was excellent (mean CCS score = 0). No infection, mesh removal, or hernia recurrence occurred during follow-up.

CONCLUSIONS

Open repair using a self-gripping mesh is a viable treatment option in patients with large incisional hernia. Immediate mesh fixation facilitates a safe and durable tension-free repair.

The Role of Psychological Factors in Persistent Pain After Cesarean Delivery

This French multicenter prospective cohort study recruited 391 patients to investigate the risk factors for persistent pain after elective cesarean delivery, focusing on psychosocial aspects adjusted for other known medical factors. Perioperative data were collected and specialized questionnaires were completed to assess reports of pain at the site of surgery. Three dependent outcomes were considered: pain at the third month after surgery (M3, n = 268; risk = 28%), pain at the sixth month after surgery (M6, n = 239; risk = 19%), and the cumulative incidence (up to M6) of neuropathic pain, as assessed using the Douleur Neuropathique 4 questionnaire (n = 218; risk = 24.5%). The neuropathic aspect of reported pain changed over time in more than 60% of cases, pain being more intense if associated with neuropathic features. Whatever the dependent outcome, a high mental component of quality of life (SF-36) was protective. Pain at M3 was also predicted by pain reported during current pregnancy and a history of miscarriage. Pain at M6 was also predicted by report of a postoperative complication. Incident neuropathic pain was predicted by pain reported during current pregnancy, a previous history of a peripheral neuropathic event, and preoperative anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00812734.

PERSPECTIVE

Persistent pain after cesarean delivery has a relatively frequent neuropathic aspect but this is less stable than that after other surgeries. When comparing the risk factor analyses with published data for hysterectomy, the influence of preoperative psychological factors seems less important, possibly because of the different context and environment.

Risk factors for reoperation due to chronic groin postherniorrhaphy pain

BACKGROUND

Chronic groin postherniorrhaphy pain (CGPP) is common and sometimes so severe that surgical treatment is necessary. The aim of this study was to identify risk factors for being reoperated due to CGPP.

METHODS

All 195,707 repairs registered in the Swedish Hernia Register between 1999 and 2011 were included in the study. Out of these, 28,947 repairs were excluded since they were registered as procedures on the same patient after a previous repair. Age, gender, hernia anatomy (indirect reference), method of repair (anterior sutured repair reference) and postoperative complications were included in a multivariate Cox analysis with reoperation due to CGPP as endpoint.

RESULTS

Of the patients included in the study cohort, 218 (0.13%) later underwent reoperation due to CGPP, including 31 (14%) women. Median age at the primary repair was 61.5 years. Risk factors for being reoperated were age < median [hazard ratio (HR) 3.03, 95% confidence interval (CI) 2.22-4.12], female gender (HR 2.13, CI 1.41-3.21), direct hernia (HR 1.35, CI 1.003-1.81), other hernia (HR 6.03, CI 3.08-11.79), Lichtenstein repair (HR 2.22, CI 1.16-4.25), plug repair (HR 3.93, CI 1.96-7.89), other repair (HR 2.58, CI 1.08-6.19), bilateral repair (HR 2.58, CI 1.43-4.66) and postoperative complication (HR 4.40, CI 3.25-5.96).

CONCLUSIONS

Risk factors for being reoperated due to CGPP in this cohort included low age, female gender, a direct hernia, a previous Lichtenstein or plug repair, bilateral repair and postoperative complications. Further research on how to avoid CGPP and explore the effectiveness of surgery for CGPP is necessary.

Short-term results of open inguinal hernia repair with self-gripping Parietex ProGrip mesh in China: A retrospective study of 90 cases

OBJECTIVES

This study investigated short-term outcomes of Lichtenstein hernia repair using self-gripping Parietex ProGrip mesh in Chinese patients with inguinal hernias.

METHODS

Retrospective analysis of patients undergoing Lichtenstein hernia repair using the Parietex ProGrip mesh at a single hospital in China between July 2012 and June 2013. All patients completed the EuroQol-five dimensions (EuroQoL-5D) and short form-36 questionnaires and were followed up at 1 day, 7 days, 1 month. and 6 months, postoperatively.

RESULTS

Ninety cases (66 males, 24 females) were studied. Mean ± standard deviation (SD) patient age was 48.7 ± 16.8 (range, 21-87) years. Most hernias were Gilbert's type II (23%) or III (31%). During 6 months of follow-up, none of the patients had recurrent hernia or systemic postoperative complications. The mean ± SD pain visual analog scale score decreased from 32 ± 10.6 at postoperative Day 1 to 0.67 ± 2.5 at 6 months. From postoperative Day 1 to 6 months, there were marked improvements in health and health-related quality of life; mean ± SD visual analog scale EuroQoL score increased from 55.3 ± 8 to 95.2 ± 3 and mean ± SD HR EuroQoL score from 0.31 ± 0.07 to 0.95 ± 0.02. At 6 months, mean scores in all eight dimensions of the short form-36 questionnaires had increased from baseline.

CONCLUSION

The use of self-fixating Parietex ProGrip mesh in open inguinal hernia repair is simple, rapid, effective, and safe, and is associated with low postoperative pain and improved quality life among patients.

Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia

PURPOSE

Chronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy.

METHODS

We dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images.

RESULTS

The courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine.

CONCLUSION

Nerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior triple neurectomy can be considered.

Is chronic post-herniorrhaphy pain always chronic? A literature review

INTRODUCTION

Chronic post-surgery pain (CPSP) has gained increased recognition as a major factor influencing health-related quality-of-life following most surgical procedures, in particular following surgery for benign conditions. The natural course of CPSP, however, is not well-known.

METHODS

A literature review was undertaken, searching for studies with repeated estimates of post-herniorrhaphy pain. The hypothetical halvation time was calculated from the repeat estimates.

RESULTS

Eight studies fulfilling the criteria were identified. With one exception, the extrapolated halvation times ranged from 1.3 to 9.2 years.

DISCUSSION

Even if CPSP is generally very treatment-resistant, in many cases it eventually dissipates with time. Further studies are required to evaluate the prevalence of pain beyond the first decade.

Biomechanical evaluation of three fixation modalities for preperitoneal inguinal hernia repair: a 24-hour postoperative study in pigs

PURPOSE

Tacks and sutures ensure a strong fixation of meshes, but they can be associated with pain and discomfort. Less invasive methods are now available. Three fixation modalities were compared: the ProGrip™ laparoscopic self-fixating mesh; the fibrin glue Tisseel™ with Bard™ Soft Mesh; and the SorbaFix™ absorbable fixation system with Bard™ Soft Mesh.

MATERIALS AND METHODS

Meshes (6 cm ×6 cm) were implanted in the preperitoneal space of swine. Samples were explanted 24 hours after surgery. Centered defects were created, and samples (either ten or eleven per fixation type) were loaded in a pressure chamber. For each sample, the pressure, the mesh displacement through the defect, and the measurements of the contact area were recorded.

RESULTS

At all pressures tested, the ProGrip™ laparoscopic self-fixating mesh both exhibited a significantly lower displacement through the defect and retained a significantly higher percentage of its initial contact area than either the Bard™ Soft Mesh with Tisseel™ system or the Bard™ Soft Mesh with SorbaFix™ absorbable fixation system. Dislocations occurred with the Bard™ Soft Mesh with Tisseel™ system and with the Bard™ Soft Mesh with SorbaFix™ absorbable fixation system at physiological pressure (,225 mmHg). No dislocation was recorded for the ProGrip™ laparoscopic self-fixating mesh.

CONCLUSION

At 24 hours after implantation, the mechanical fixation of the ProGrip™ laparoscopic self-fixating mesh was found to be significantly better than the fixation of the Tisseel™ system or the SorbaFix™ absorbable fixation system.

[Intervention-specific complications of hernia surgery]

Hernia surgery is generally a rewarding task, patient satisfaction is high and the long-term results are generally good. Incisional hernias are more heterogeneous and there is a higher variability of morphologies to be matched with the available therapeutic approaches but the majority of patients are also satisfied with the results. This positive scenario for hernia surgery can be largely attributable to careful preoperative planning, effective surgical techniques and a high degree of standardization. The picture is somewhat clouded by the complications associated with hernia surgery. If complications do arise, the outcome largely depends on how well the surgeon responds. For inguinal and femoral hernias, the risk profile of the patient is crucial to the surgical planning and the wrong operation on the wrong patient can be disastrous. Open procedures have complication risks in common but the question of how best to deal with the nerves has yet to be answered. Endoscopic procedures are an indispensable part of the hernia surgery repertoire and the hernia specialist should be proficient in TEP and TAPP techniques. Ventral and incisional hernias have higher complication rates and the treatment is similar despite differences in etiology and pathophysiology. Although open procedures are better for morphological reconstruction they are accompanied by a higher complication rate. Laparoscopic procedures had a severe complication profile early on but the situation has greatly improved today due to continued refinement of the learning curve. A critical approach to the application of methods and meshes, a deep knowledge of anatomical peculiarities and the careful planning of tactics for dealing with intraoperative problems are the hallmarks of today's good hernia surgeon.

A capsaicin (8%) patch in the treatment of severe persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Persistent pain after inguinal herniorrhaphy is a disabling condition with a lack of evidence-based pharmacological treatment options. This randomized placebo-controlled trial investigated the efficacy of a capsaicin 8% cutaneous patch in the treatment of severe persistent inguinal postherniorrhaphy pain.

METHODS

Forty-six patients with persistent inguinal postherniorrhaphy pain were randomized to receive either a capsaicin 8% patch or a placebo patch. Pain intensity (Numerical Rating Scale [NRS 0-10]) was evaluated under standardized conditions (at rest, during movement, and during pressure) at baseline and at 1, 2 and 3 months after patch application. Skin punch biopsies for intraepidermal nerve fiber density (IENFD) measurements were taken at baseline and 1 month after patch application. Quantitative sensory testing was performed at baseline and at 1, 2, and 3 months after patch application. The primary outcome was comparisons of summed pain intensity differences (SPIDs) between capsaicin and placebo treatments at 1, 2 and 3 months after patch application (significance level P < 0.01).

RESULTS

The maximum difference in SPID, between capsaicin and placebo treatments, was observed at 1 month after patch application, but the pain reduction was not significant (NRS, mean difference [95% CI]: 5.0 [0.09 to 9.9]; P = 0.046). No differences in SPID between treatments were observed at 2 and 3 months after patch application. Changes in IENFD on the pain side, from baseline to 1 month after patch application, did not differ between capsaicin and placebo treatment: 1.9 [-0.1 to 3.9] and 0.6 [-1.2 to 2.5] fibers/mm, respectively (P = 0.32). No significant changes in sensory function, sleep quality or psychological factors were associated with capsaicin patch treatment.

CONCLUSIONS

The study did not demonstrate significant differences in pain relief between capsaicin and placebo treatment, although a trend toward pain improvement in capsaicin treated patients was observed 1 month after patch application.

TRIAL REGISTRATION

Clinicaltrialsregister.eu 2012-001540-22 ClinicalTrials.gov NCT01699854.

Description of robotically assisted single-site transabdominal preperitoneal (RASS-TAPP) inguinal hernia repair and presentation of clinical outcomes

BACKGROUND

The aim of our study is to report our initial clinical experience with robotically assisted single-site transabdominal preperitoneal (RASS-TAPP) hernia repair, to verify the safety and efficacy of the procedure and to describe the surgical procedure.

METHODS

We retrospectively reviewed all patients undergoing RASS-TAPP at our institution from March 2013 through December 2013. Data regarding patient demographics, type and location of hernia, operative time and clinical outcomes were collected and analyzed.

RESULTS

Fourty five hernias were repaired in 34 patients (30M, 4F) by a single surgeon. The mean age was 49.3 years and mean BMI was 26.5. 31 lateral defects, 13 medial defects and 1 femoral defect were repaired. Three patients presented with recurrent hernias and nine had bilateral defects. The mean operative time for all cases was 80.5 min and for all unilateral hernias 69 min. Considering just the unilateral hernias without any additional procedures, operative time was 63 min. The mean follow-up time was 5.5 months. There has been one superficial surgical site infection, but no observed clinical recurrence or neuralgia to date.

CONCLUSION

Robotically assisted single-site transabdominal preperitoneal hernia repair is safe and effective. The absence of clinical evidence of recurrence or neuralgia is encouraging and should promote further study.

Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair

BACKGROUND

Postoperative pain is an important adverse event following inguinal hernia repair. The aim of this trial was to compare postoperative pain within the first 3 months and 1 year after surgery in patients undergoing open mesh inguinal hernia repair using either a self-gripping lightweight polyester mesh or a polypropylene lightweight mesh fixed with sutures.

METHODS

Adult men undergoing Lichtenstein repair for primary inguinal hernia were randomized to ProGrip™ self-gripping mesh or standard sutured lightweight polypropylene mesh.

RESULTS

In total 557 men were included in the final analysis (self-gripping mesh 270, sutured mesh 287). Early postoperative pain scores were lower with self-gripping mesh than with sutured lightweight mesh: mean visual analogue pain score relative to baseline +1·3 and +8·6 respectively at discharge (P = 0·033), and mean surgical pain scale score relative to baseline +4·2 and +9·7 respectively on day 7 (P = 0·027). There was no significant difference in mid-term (1 month) and long-term (3 months and 1 year) pain scores between the groups. Surgery was significantly quicker with self-gripping mesh (mean difference 7·6 min; P < 0·001). There were no significant differences in reported mesh handling, analgesic consumption, other wound complications, patient satisfaction or hernia recurrence between the groups.

CONCLUSION

Self-gripping mesh for open inguinal hernia repair was well tolerated and reduced early postoperative pain (within the first week), without increasing the risk of early recurrence. It did not reduce chronic pain.

REGISTRATION NUMBER

NCT00827944 (http://www.clinicaltrials.gov).

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

INTRODUCTION

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

METHODS

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

RESULTS

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03-2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04-6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher's exact test).

CONCLUSIONS

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.

Post-operative benefits of Tisseel(®)/Tissucol (®) for mesh fixation in patients undergoing Lichtenstein inguinal hernia repair: secondary results from the TIMELI trial

Purpose

The Tisseel/Tissucol for mesh fixation in Lichtenstein hernia repair (TIMELI) study showed that mesh fixation with human fibrin sealant during inguinal hernia repair significantly reduced moderate–severe complications of pain 12 months post-operatively compared with sutures. Further analyses may assist surgeons by investigating predictors of post-surgical complications and identifying patients that may benefit from Tisseel/Tissucol intervention.

Methods

Univariate and multivariate analyses identified risk factors for combined pain, numbness and groin discomfort (PND) visual analogue scale (VAS) score 12 months post-operatively. Variables tested were: fixation method, age, employment status, physical activity, nerve handling, PND VAS score at pre-operative visit and 1 week post-operatively. The effect of fixation technique on separate PND outcomes 12 months post-surgery was also assessed. Analyses included the intention-to-treat (ITT) population and a subpopulation with pre-operative PND VAS > 30 mm.

Results

316 patients were included in the ITT, with 130 patients in the subpopulation with pre-operative PND VAS > 30. Multivariate analysis identified mesh fixation with sutures, worsening pre-operative PND and worsening PND 1 week post-surgery as significant predictors of 12-month PND in the ITT population; mesh fixation with sutures was a significant predictor of 12-month PND in the pre-operative PND VAS > 30 subpopulation (p < 0.05). Mesh fixation with Tisseel/Tissucol resulted in significantly less numbness and a lower intensity of groin discomfort compared with sutures at 12 months; there was no difference in pain between the treatment groups.

Conclusions

Pre-operative discomfort may be an important predictor of post-operative pain, numbness and discomfort. Tisseel/Tissucol may improve long-term morbidity over conventional sutures in these patients.

Pain control following inguinal herniorrhaphy: current perspectives

Inguinal hernia repair is one of the most common surgeries performed worldwide. With the success of modern hernia repair techniques, recurrence rates have significantly declined, with a lower incidence than the development of chronic postherniorrhaphy inguinal pain (CPIP). The avoidance of CPIP is arguably the most important clinical outcome and has the greatest impact on patient satisfaction, health care utilization, societal cost, and quality of life. The etiology of CPIP is multifactorial, with overlapping neuropathic and nociceptive components contributing to this complex syndrome. Treatment is often challenging, and no definitive treatment algorithm exists. Multidisciplinary management of this complex problem improves outcomes, as treatment must be individualized. Current medical, pharmacologic, interventional, and surgical management strategies are reviewed.

How Lichtenstein hernia repair affects abdominal and anal resting pressures: a controlled clinical study

PURPOSE

Inguinal hernia repair is the most common surgical procedure performed by general surgeons worldwide. The Lichtenstein tension-free hernioplasty was first introduced in 1984 and evolved through 1988. Today it is the gold standard in hernia repair. The objective of this study was to determine if intra-abdominal and anal pressures changed in patients with inguinal hernias after Lichtenstein hernioplasties were performed.

MATERIALS AND METHODS

A sample of 103 individuals, 92.2% of whom were male (n = 95) and 7.8% of whom were female (n = 8), aged 38.38 ± 14.03 years was used. The sample was divided into two groups: those with inguinal hernia (n = 53) and those without hernia (n = 50), who served as controls. Anal and abdominal manometric measurements were taken from each control patient at baseline and from each study patient before and after surgical repair.

RESULTS

Data analysis revealed differentiation of abdominal and anal pressures between the controls, the study patients before operation, and the study patients after operation. The average [SD] abdominal pressure was -2.58 mmHg [5.35] before hernia repair and 2.33 mmHG [3.62] after repair. The average [SD] abdominal pressure in the control group was 1.16 mmHg [1.96].

CONCLUSIONS

The Lichtenstein tension-free hernioplasty causes increases in abdominal and anal pressures, but this increase is not of a pathological level.

Lidocaine Patch (5%) in Treatment of Persistent Inguinal Postherniorrhaphy Pain

Background:

Evidence-based pharmacological treatment options for patients with persistent inguinal postherniorrhaphy pain are lacking.

Methods:

Twenty-one male patients, with severe, unilateral, persistent inguinal postherniorrhaphy pain, participated in a randomized, double-blind, placebo-controlled crossover trial, receiving lidocaine patch (5%) and placebo patch treatments in periods of 14 days separated by a 14-day wash-out period. Pain intensities (at rest, during movement, and pressure evoked [Numerical Rating Scale]) were assessed before treatment and on the last 3 days of each treatment period. Patients were a priori divided into two subgroups based on quantitative sensory testing (+/− thermal “hyposensitivity”). Skin biopsies for intraepidermal nerve fiber density assessment were taken at baseline, and quantitative sensory testing was performed before and after each treatment period. The primary outcome was change in pain intensity assessed as the difference in summed pain intensity differences between lidocaine and placebo patch treatments.

Results:

There was no difference in summed pain intensity differences between lidocaine and placebo patch treatments in all patients (mean difference 6.2% [95% CI = −6.6 to 18.9%]; P = 0.33) or in the two subgroups (+/− thermal “hyposensitivity”). The quantitative sensory testing (n = 21) demonstrated an increased pressure pain thresholds after lidocaine compared with placebo patch treatment. Baseline intraepidermal nerve fiber density (n = 21) was lower on the pain side compared with the nonpain side (−3.8 fibers per millimeter [95% CI = −6.1 to −1.4]; P = 0.003). One patient developed mild erythema in the groin during both treatments.

Conclusions:

Lidocaine patch treatment did not reduce combined resting and dynamic pain ratings compared with placebo in patients with severe, persistent inguinal postherniorrhaphy pain.

Prospective study of pain, quality of life and the economic impact of open inguinal hernia repair

BACKGROUND

There are variations in quality of life (QoL) and reported risk of chronic pain after inguinal hernia repair. The aim of this study was to investigate the improvement in pain and QoL after open inguinal hernia repair, and the economic impact.

METHODS

Patients undergoing open mesh repair of a primary unilateral inguinal hernia were stratified depending on preoperative levels of symptoms and pain. Short Form 36 (SF-36®) and EQ-5D™ questionnaires were filled in before, and at 3 and 12 months after surgery. EQ-5D™ data, together with information on the mean value of a quality-adjusted life-year and the societal cost of hernia repair, were used to calculate the monetary value of QoL gained and the mean return on investment.

RESULTS

Of 225 patients who began the study, 184 completed follow-up at 12 months. Some 77·2 per cent reported improvement in pain and 5·4 per cent reported increased pain after surgery. Significant improvement in SF-36® scores, pain scores measured on a visual analogue scale (VAS), and symptoms were found in the majority of patients, even those with mild symptoms before surgery. For the whole group, the bodily pain score increased from 56·4 before surgery to 82·6 at 12 months after hernia repair (P < 0·050), and the VAS score decreased from a median of 4 to 0 (P < 0·050). The return on investment was positive for all groups of patients, including those with mild symptoms.

CONCLUSION

QoL improves after open inguinal hernia repair, with a good return on investment independent of symptom severity.

Post-surgical pain syndromes: a review for the non-pain specialist

PURPOSE

This is a selective narrative review of the latest information about the epidemiology, impact, and prevention of chronic post-surgical pain (CPSP), intended primarily for those without a special interest in pain medicine.

PRINCIPAL FINDINGS

Chronic post-surgical pain is an important problem in terms of personal impact. It has staggering economic implications, exerts powerful negative effects on the quality of life of many of those it afflicts, and places a significant burden on chronic pain treatment services in general. It is well known that surgery at certain body sites is apt to cause CPSP, but emerging evidence shows a strong correlation between CPSP and demographic (young age, obesity, and female sex) and psychological characteristics (anxiety, depression, stress, and catastrophizing). Severe acute pain is a strong risk factor for CPSP, and this adds yet more weight to the argument that acute pain should be controlled effectively. In specific circumstances, CPSP can be reduced by regional anesthetic techniques, infiltration of local anesthetic, or preoperative use of gabapentin. The ability of other known interrupters of afferent nociceptive transmission-commonly used to reduce CPSP when administered at the time of surgery-is currently unproven, as is the hypothesis that the use of remifentanil during surgery worsens CPSP.

CONCLUSIONS

Reduction of CPSP is a worthy long-term outcome for anesthesia providers to consider as they plan the perioperative care of their patients. More evidence is needed about the effect of currently used analgesics and other perioperative techniques on CPSP.

Incidence of pain after inguinal hernia repair in the elderly. A retrospective historical cohort evaluation of 18-years' experience with a mesh & plug inguinal hernia repair method on about 3000 patients

BACKGROUND

Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age.

METHODS

Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X₂-test.

RESULTS

Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed.

CONCLUSIONS

Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.

Long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia

PURPOSE

To evaluate the long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia.

METHODS

The subjects of this prospective, observational study were 24 patients who underwent emergency Lichtenstein hernioplasty for an incarcerated inguinal hernia between September 2002 and January 2006 at the Faculty of Medicine Siriraj Hospital, Thailand. Patients with bowel strangulation and recurrent hernia were excluded. We evaluated the long-term outcomes over at least a 2-year follow-up.

RESULTS

Long-term follow-up was completed for 20 patients (83.3 %). All of the patients were men, with a median age of 60 years (range 19-78 years) at the time of surgery. The median time to resumption of normal daily activities was 3 weeks (range 1-8 weeks). None of the patients had inguinal paresthesia persisting beyond 1 month after the operation. One patient (5 %) experienced chronic groin pain, which subsided within 4 months after surgery. Clinical recurrence was detected in two patients (10 %) during a median follow-up period of 6 years (range 2.3-7.6 years). Contralateral inguinal hernia was found in two patients (10 %) during follow-up.

CONCLUSIONS

Lichtenstein hernioplasty is a safe and effective operation for non-strangulated incarcerated inguinal hernia, with a recurrence rate of 10 % at the median follow-up time of 6 years. Chronic groin pain and inguinal paresthesia were rare in this series.

Role of orchiectomy in severe testicular pain after inguinal hernia surgery: audit of the Finnish Patient Insurance Centre

PURPOSE

Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain.

METHODS

All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis.

RESULTS

Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early < 7 days, 11 late > 8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (>8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain.

CONCLUSION

Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.

Modified Kugel herniorrhaphy using standardized dissection technique of the preperitoneal space: long-term operative outcome in consecutive 340 patients with inguinal hernia

PURPOSE

The aim of this study was to evaluate the outcome, with a special reference to recurrence and postoperative chronic pain, of the modified Kugel herniorrhaphy (MKH) using standardized dissection of the preperitoneal space.

PATIENTS AND METHODS

Operative results were examined based on medical records and questionnaire surveys in 340 consecutive cases of MKH performed at a single institution. The operation was performed with an original 3-stage dissection of the preperitoneal space only via the internal inguinal ring.

RESULTS

The mean follow-up period was 50.5 ± 24.3 months. The mean operating time was 42.2 ± 13.1 min, and by Nyhus classification, significant difference was observed between types IIIA and IIIB (39.5 ± 10.8 vs. 45.6 ± 15.6 min, P = 0.0279). Eight surgeons performed 10 or more operations, and no significant difference was found in their operating time. Thirty-one patients used additional analgesics postoperatively (9.1 %) and the length of postoperative stay was 1.2 ± 0.7 days. Seven patients (2.1 %) developed complications related to the hernia operation, but none of them required re-operation. The period required to return to normal daily activities was 3 ± 3.2 days. Questionnaire forms were returned from 77.7 % of all the patients, in which 12 patients reported chronic pain (4.7 %). Visual analog scale for patients with chronic pain scored 3.8 ± 2.4, with no patient indicating restrictions on daily life. Recurrence was observed in only one case (0.3 %).

CONCLUSION

MKH using standardized dissection of the preperitoneal space is a highly reproducible procedure with acceptable rate of postoperative chronic pain and recurrence.

Betamethasone in hernia surgery: a randomized controlled trial

BACKGROUND

Post-operative pain and nausea may be a problem in day-case surgery. This study aims to investigate the effect of betamethasone on pain and nausea in inguinal hernia surgery.

METHODS

Patients aged 18-70 years scheduled for open inguinal hernia surgery at two Swedish hospitals, March 2005-December 2009, were eligible for inclusion. Patients were randomized, to either treatment with 12 mg betamethasone intravenously or placebo. Post-operative pain was assessed using a visual analogue scale on the recovery ward, each day the first post-operative week and at 1 month after surgery. One year after surgery, residual pain was estimated by the Inguinal Pain Questionnaire.

RESULTS

A total of 398 patients were included (21 women, 377 men). Pain at rest on the day of surgery was significantly lower in the treatment group (p = 0.012). The pain was also significantly lower in the treatment group the day after surgery (p < 0.001), but not during the remaining part of the first post-operative week. Bleeding complications were reported by 17 patients (8.5%) in the Betamethasone group and seven (3.5%) in the placebo group (p = 0.028). One month after surgery, 21 out of 173 (12%) in the betamethasone group still had pain, compared to 33 out of 159 (21%) in the placebo arm (p = 0.049). After 1 year, no significant difference in pain was seen.

CONCLUSION

A 12 mg betamethasone reduced pain during the first 24 h and at 1 month after inguinal hernia surgery. If combined with diclofenac, however, this dose may increase the risk for bleeding complications.

A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair

PURPOSE

The technique for fixation of mesh has been attributed to adverse patient and surgical outcomes. Although this has been the subject of vigorous debate in laparoscopic hernia repair, the several methods of fixation in open, anterior inguinal hernia repair have seldom been reviewed. The aim of this systematic review was to determine whether there is any difference in patient-based (recurrence, post-operative pain, SSI, quality of life) or surgical outcomes (operative time, length of operative stay) with different fixation methods in open anterior inguinal hernioplasty.

METHODS

A literature search was performed in PubMed, EMBASE and the Cochrane Library databases. Randomised clinical trials assessing more than one method of mesh fixation (or fixation versus no fixation) of mesh in adults (>18 years) in open, anterior inguinal hernia repair, with a minimum of 6-month follow-up and including at least one of the primary outcome measures (recurrence, chronic pain, surgical site infection) were included in the review. Secondary outcomes analysed included post-operative pain (within the first week), quality of life, operative time and length of hospital stay.

RESULTS

Twelve randomised clinical trials, which included 1,992 primary inguinal hernia repairs, were eligible for inclusion. Four studies compared n-butyl-2 cyanoacrylate (NB2C) glues to sutures, two compared self-fixing meshes to sutures, four compared fibrin sealant to sutures, one compared tacks to sutures, and one compared absorbable sutures to non-absorbable sutures. The majority of the trials were rated as low or very low-quality studies. There was no significant difference in recurrence or surgical site infection rates between fixation methods. There was significant heterogeneity in the measurement of chronic pain. Three trials reported significantly lower rates of chronic pain with fibrin sealant or glue fixation compared to sutures. A further three studies reported lower pain rates within the first week with non-suture fixation techniques compared to suture fixation. A significant reduction in operative time, ranging form 6 to 17.9 min with non-suture fixation, was reported in five of the studies. Although infrequently measured, there were no significant differences in length of hospital stay or quality of life between fixation methods.

CONCLUSIONS

There is insufficient evidence to promote fibrin sealant, self-fixing meshes or NB2C glues ahead of suture fixation. However, these products have been shown to be at least substantially equivalent, and moderate-quality RCTs have suggested that both fibrin sealant and NB2C glues may have a beneficial effect on reducing immediate post-operative pain and chronic pain in at-risk populations, such as younger active patients. It will ultimately be up to surgeons and health-care policy makers to decide whether based on the limited evidence these products represent a worthwhile cost for their patients.

Predictors of chronic groin discomfort after laparoscopic totally extraperitoneal inguinal hernia repair

BACKGROUND

Chronic groin discomfort is an undesired complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. We examined whether perioperative factors may be associated with an increased risk of developing this problem and if their recognition could lead to preventive strategies.

STUDY DESIGN

We performed a retrospective review of 1 surgeon's experience with 1,479 TEP repairs on 976 patients from 1995 to 2009. A mailed survey, which included a groin discomfort questionnaire (Carolinas Comfort Scale), was distributed to all patients. Symptom severity grading (range 0, none to 5, severe) was used to sort individual responses. Perioperative factors were compared between asymptomatic and symptomatic patients with varying levels of discomfort.

RESULTS

There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort.

CONCLUSIONS

The majority of patients are asymptomatic after a laparoscopic TEP inguinal hernia repair. Most of the symptomatic patients do not have any bothersome symptoms. Given that younger age and a repair for recurrent hernia were predictors of chronic groin discomfort, we counsel these patients about their increased risks.

Surgical treatment of chronic pain after inguinal hernia repair

BACKGROUND

Chronic groin pain is defined as pain arising 3-6 months after inguinal hernia repair that can compromise the patient's quality of life. Many articles in the literature report clinical presentation, but there are no well-defined indications and protocols of treatment.

METHODS

Forty-six patients underwent surgical treatment for chronic groin pain that consisted of a simultaneous double approach, anterior and posterior, to the inguinal region, with 44 triple neurectomies and 2 iliohypogastric neurectomies. Ilio-inguinal and ilio-hypogastric nerves were resected by anterior approach, while genitofemoral trunk was resected by a posterior pre-peritoneal approach. Mesh was removed in 24 cases, and mesh and plug were removed in 16 cases. A new mesh repair was performed in 42 cases. All the patients were examined 1 week, 1 month and 1 year postoperatively.

RESULTS

In 40 patients, the surgical treatment has obtained good response with improvement or complete resolution of the pain. Two patients referred persistent groin pain different from preoperative and in 4 cases the pain persisted without substantial benefit. Mean VAS value was 7.89 before surgery and 1.89 after surgery.

CONCLUSIONS

Choice of the adequate therapy of chronic groin pain after inguinal hernia repair is still controversial. Our surgical approach turned out to be a safe and effective procedure. In this way, an accurate exploration of the whole inguinal region can be performed along with the identification of the nerves involved. Anyway in a certain number of cases, the resolution of pain cannot be achieved; this suggests a possible involvement of differences in the single personality and tolerances of pain in the different patients.

Study protocol for a randomized controlled trial for anterior inguinal hernia repair: transrectus sheath preperitoneal mesh repair compared to transinguinal preperitoneal procedure

BACKGROUND

Anterior open treatment of the inguinal hernia with a tension-free mesh has reduced the incidence of hernia recurrence. The Lichtenstein procedure is the current reference technique for inguinal hernia treatment. Chronic pain has become the main postoperative complication after surgical inguinal hernia repair, especially following Lichtenstein. Preliminary experiences with a soft mesh positioned in the preperitoneal space (PPS) by transinguinal preperitoneal (TIPP) or total extraperitoneal (TEP) technique, showed promising results considering the reduction of postoperative chronic pain. Evolution of surgical innovations for inguinal hernia repair led to an open, direct approach with preperitoneal mesh position, such as TIPP. Based on the TIPP procedure, another preperitoneal repair has been recently developed, the transrectus sheath preperitoneal (TREPP) mesh repair.

METHODS

The ENTREPPMENT trial is a multicentre randomized clinical trial. Patients will be randomly allocated to anterior inguinal hernia repair according to the TREPP mesh repair or TIPP procedure. All patients with a primary unilateral inguinal hernia, eligible for operation, will be invited to participate in the trial. The primary outcome measure will be the number of patients with postoperative chronic pain. Secondary outcome measures will be serious adverse events (SAEs), including recurrence, hemorrhage, return to daily activities (for example work), operative time and hospital stay. Alongside the trial health status, an economic evaluation will be performed. To demonstrate that inguinal hernia repair according to the TREPP technique reduces the percentage of patients with postoperative chronic pain from 12% to <6%, a sample size of 800 patients is required (two-sided test, α = 0.05, 80% power).The ENTREPPMENT trial aims to evaluate the TREPP and TIPP procedures from patients' perspective. It is hypothesized that the TREPP technique may reduce the number of patients with any form of postoperative chronic pain by 50% compared to the TIPP procedure.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN18591339.

Effect of mesh type, surgeon and selected patients' characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial

Introduction

Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate.

Aim

In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence.

Material and methods

Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7^th day as well as in the 3^rd and 6^th month after the operation. Statistical analysis was performed with multi-factor regression models.

Results

In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass.

Conclusions

Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.

A multicenter, randomized, controlled study evaluating preventive etanercept on postoperative pain after inguinal hernia repair

BACKGROUND

Chronic postsurgical pain (CPSP) affects between 5% and 70% of surgical patients, depending on the surgery. There is no reliable treatment for CPSP, which has led to an increased emphasis on prevention. In this study, we sought to determine whether preventive etanercept can decrease the magnitude of postoperative pain and reduce the incidence of CPSP.

METHODS

We performed a multicenter, randomized study in 77 patients comparing subcutaneous etanercept 50 mg administered 90 minutes before inguinal hernia surgery with saline. Patients, surgeons, anesthesiologists, the injecting physician, nursing staff, and evaluators were blinded. The primary outcome measure was a 24-hour numerical rating scale pain score. Secondary outcome measures were postanesthesia care unit pain scores, 24-hour opioid requirements, time to first analgesic, and pain scores recorded at 1 month, 3 months, 6 months, and 12 months.

RESULTS

Mean 24-hour pain scores were 3.3 (95% confidence interval [CI], 3.2-4.6) in the etanercept and 3.9 (95% CI, 2.6-4.0) in the control group (P=0.22). The mean number of analgesic pills used in the first 24 hours was 4.0 (SD, 2.8) in the treatment versus 5.8 (SD, 4.2) in the control group (P=0.03). At 1 month, 10 patients (29%) in the treatment group reported pain versus 21 (49%) control patients (P=0.08). The presence of pain at 1 month was significantly associated with pain at 3 months (hazard ratio, 0.74; 99% CI, 0.52-0.97; P=0.03).

CONCLUSION

Although preventive etanercept was superior to saline in reducing postoperative pain on some measures, the effect sizes were small, transient, and not statistically significant. Different dosing regimens in a larger population should be explored in future studies.

A single-surgeon randomized trial comparing three meshes in lichtenstein hernia repair: 2- and 5-year outcome of recurrences and chronic pain

BACKGROUND

Chronic pain may be a major long-term problem related to mesh material and operative trauma in inguinal hernioplasty.

STUDY DESIGN

Lichtenstein hernioplasty was performed under local anaesthesia in 312 patients by the same surgeon and technique between 2003 and 2005. The patients were randomized to receive a partly absorbable polypropylene-polyglactin mesh (Vypro II(®) 50 g/m(2), 104 hernias), a lightweight polypropylene mesh (Premilene Mesh LP(®) 55 g/m(2), 107 hernias) or a conventional densely woven polypropylene mesh (Premilene(®) 82 g/m(2), 101 hernias). The 2- and 5-year recurrences and pain scores were analysed.

RESULTS

Patient's characteristics and the mean duration of operation (30-32 min) were similar between the three groups. After two years, there were 6 recurrences (2 in each group) of which 3 patients were re-operated. A feeling of a foreign body and sensation of pain were comparable with all meshes. After five years, overall recurrence rate was 10/312 (3.2%) with only 4 re-operations. A feeling of a foreign body (6.5-8.1%), chronic pain (13-23%) as well as use of analgesics (0-2.9%) were similar in all groups.

CONCLUSION

There were no statistical differences between the three meshes in pain, a feeling of a foreign body or use of analgesics after 5 years of Lichtenstein hernioplasty, when the same surgeon operated all patients with exactly the same surgical technique. CLINICAL TRIAL REGISTER: NCT01295437.

Jorgensen LN, Sommer T, Assaadzadeh S, Strand L, Dorfelt A, Hensler M, Rosenberg J. Randomized clinical trial of self-gripping mesh versus sutured mesh for Lichtenstein hernia repair

Background

Many patients develop discomfort after open repair of a groin hernia. It was hypothesized that suture fixation of the mesh is a cause of these symptoms.

Methods

This patient- and assessor-blinded randomized multicentre clinical trial compared a self-gripping mesh (Parietene Progrip®) and sutured mesh for open primary repair of uncomplicated inguinal hernia by the Lichtenstein technique. Patients were assessed before surgery, on the day of operation, and at 1 and 12 months after surgery. The primary endpoint was moderate or severe symptoms after 12 months, including a combination of chronic pain, numbness and discomfort.

Results

The intention-to-treat population comprised 163 patients with self-gripping mesh and 171 with sutured mesh. The 12-month prevalence of moderate or severe symptoms was 17·4 and 20·2 per cent respectively (P = 0·573). There were no significant differences between the groups in postoperative complications (33·7 versus 40·4 per cent; P = 0·215), rate of recurrent hernia within 1 year (1·2 per cent in both groups) or quality of life.

Conclusion

The avoidance of suture fixation using a self-gripping mesh was not accompanied by a reduction in chronic symptoms after inguinal hernia repair. Registration number: NCT00815698 (http://www.clinicaltrials.gov).

Chronic postsurgical pain: still a neglected topic?

Background

Surgical injury can frequently lead to chronic pain. Despite the obvious importance of this problem, the first publications on chronic pain after surgery as a general topic appeared only a decade ago. This study tests the hypothesis that chronic postsurgical pain was, and still is, represented insufficiently.

Methods

We analyzed the presentation of this topic in journal articles covered by PubMed and in surgical textbooks. The following signs of insufficient representation in journal articles were used: (1) the lack of journal editorials on chronic pain after surgery, (2) the lack of journal articles with titles clearly indicating that they are devoted to chronic postsurgical pain, and (3) the insufficient representation of chronic postsurgical pain in the top surgical journals.

Results

It was demonstrated that insufficient representation of this topic existed in 1981–2000, especially in surgical journals and textbooks. Interest in this topic began to increase, however, mostly regarding one specific surgery: herniorrhaphy. It is important that the change in the attitude toward chronic postsurgical pain spreads to other groups of surgeries.

Conclusion

Chronic postsurgical pain is still a neglected topic, except for pain after herniorrhaphy. The change in the attitude toward chronic postsurgical pain is the important first step in the approach to this problem.