Risk factors for long-term pain after hernia surgery

Effect of Ilioinguinal Neurectomy on Chronic Pain following Herniorrhaphy

Background

Inguinal hernia is one of the most common male diseases all over the world with an incidence rate of 18-24% throughout life. Chronic inguinal pain is one of the complications that prolong return to work time.

Objectives

The main aim of this study was to determine the effect of ilioinguinal neurectomy on postoperative chronic pain (PCP) in patients that underwent open inguinal hernia repair via the Lichtenstein method.

Materials and Methods

In this randomised controlled clinical trial, male patients with unilateral inguinal hernia were randomized into two groups: 74 cases in the preserved-nerve group and 66 cases in the nerve-excised group. The method of herniorrhaphy was the classic Lichtenstein method. Pain and numbness were evaluated at 1 day, 1 week, 1 month, 6 months and 1 year after surgery via visual analogue scale (VAS) system. We used SPSS ver.16 for analysis.

Results

All patients were male with mean age of 39.1 years (with a range of 18 to 68 years). The follow-up rate was 100% after 1 year. Pain severity was significantly lower in nerve-excised patients at 1 day, 1week, 1 month and 6 months after surgery; but it was not significant after one year, although overall pain severity was low. Numbness was significantly higher in excised patients at all endpoints (1 day, 1month, 3 months, 6 months and one year after surgery).

Conclusions

Ilioinguinal nerve excision at the time of inguinal hernia repair decreased post-surgical inguinal pain, and it can be used as a routine method in herniorrhaphy.

Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial

OBJECTIVE

Test the hypothesis that fibrin sealant mesh fixation can reduce the incidence of postoperative pain/numbness/groin discomfort by up to 50% compared with sutures for repair of inguinal hernias using the Lichtenstein technique.

BACKGROUND

Inguinal hernia repair is the most common procedure in general surgery, thus improvements in surgical techniques, which reduce the burden of undesirable postoperative outcomes, are of clinical importance.

METHODS

A randomized, controlled, patient- and evaluator-blinded study (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair [TIMELI]; trial NCT00306839) was conducted among patients eligible for Lichtenstein repair of uncomplicated unilateral primary inguinal small-medium sized hernia. Patients were subject to mesh fixation with either fibrin sealant or sutures. Main outcome measures were visual analogue scale (VAS) assessments for "pain," "numbness," and "groin discomfort" on a scale of 0 = best and 100 = worst outcome. The primary endpoint was a composite that evaluated the prevalence of chronic disabling complications (VAS score >30 for pain/numbness/groin discomfort) at 12 months after surgery.

RESULTS

In total, 319 patients were randomized between January 2006 and April 2007 (159 fibrin sealant, 160 sutures). At 12 months, the prevalence of 1 or more disabling complication was significantly lower in the fibrin sealant group than in the sutures group (8.1% vs 14.8%; P = 0.0344). Less pain was reported in the fibrin sealant group than in the sutures group at 1 and 6 months (P = 0.0132; P = 0.0052), as reflected by a lower proportion of patients using analgesics in the fibrin group over the study duration (65.2% vs 79.7%; P = 0.0009). Only 3 of 316 patients (0.9%) experienced recurrence. The incidences of wound-healing complications and other adverse events were comparable between groups.

CONCLUSIONS

Fibrin sealant for mesh fixation in Lichtenstein repair of small-medium sized inguinal hernias is well tolerated and reduces the rate of pain/numbness/groin discomfort by 45% relative to sutures without increasing hernia recurrence (NCT00306839).

The impact and burden of chronic pain in the workplace: a qualitative systematic review

BACKGROUND

Chronic pain (CP) poses a diverse and substantial burden for employees, employers, and society. The deleterious consequences of CP in the workplace are frequently underestimated.

OBJECTIVE

To estimate the burden of CP in the European workplace.

METHODS

A systematic review following PRISMA statement guidelines was conducted to identify studies reporting work-related outcomes for people with CP. EMBASE, MEDLINE, EconLit, and Cochrane Library databases were searched up to 18th August 2010.

RESULTS

We identified 91 observational studies. Few were specifically designed to investigate the association between CP, productivity, and employment. The focus for this review was studies clearly reporting outcomes relating to the burden of CP on employment status (n = 37), sickness absence (absenteeism, n = 47), and loss of productivity because of reduced ability at work (presenteeism, n = 8).

CONCLUSION

The body of evidence identified from the systematic review indicates that CP has a substantial negative impact on work-related outcomes, supporting the importance of interventions to reduce the burden of CP. Well-designed prospective studies specifically assessing the direct consequences of CP on employment are needed to confirm these findings.

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months

PURPOSE

To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures.

METHODS

This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively.

RESULTS

Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups.

CONCLUSIONS

Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

Validation of a questionnaire for the assessment of pain following ventral hernia repair--the VHPQ

PURPOSE

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

METHODS

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4 weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3 years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

RESULTS

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p < 0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1 week postoperative (p < 0.05). Kappa levels for test-retest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p < 0.05) in the test-retest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p < 0.05) and more interference with daily activities (p < 0.05) than a non-operated group from the general population.

CONCLUSION

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.

Lichtenstein, prolene hernia system, and UltraPro Hernia System for primary inguinal hernia repair: one-year outcome of a prospective randomized controlled trial

PURPOSE

The optimal technique for open inguinal hernia repair is yet to be determined.

METHODS

Three hundred and nine male patients [median of 60 years (range, 31-75)] undergoing primary open inguinal hernia repair in local anesthesia and day-care surgery were randomly allocated to operation with the Lichtenstein technique (L), Prolene Hernia System (PHS), or UltraPro Hernia System (UHS).

RESULTS

[Median (IQR)] There were no differences in operating time [47 (40-58) vs. 50 (40-57) and 50 (42-56) min in groups L, PHS, and UHS, respectively], intra- or postoperative complications, time until return to normal workload (8 (4-14) vs. 9 (4-14), and 8 (4-14) days) or occurrence of chronic pain at 12 months (15 vs. 12, and 13 patients). Self-reported physical quality of life (SF-36) was reduced compared to matched controls preoperatively and increased similarly to levels not different from controls in all groups at 12 months postoperatively. There was one recurrence in each group during the follow-up period.

CONCLUSIONS

The Lichtenstein technique, PHS, and UHS seem all acceptable approaches for open inguinal hernia repair in local anesthesia and day-care surgery regarding perioperative course, rehabilitation, complications, recurrence rates, development of chronic groin pain, and improvement in quality of life after 12 months. However, due to reduced costs and lack of need for the exploration of the preperitoneal space, the Lichtenstein technique should be recommended as first choice.

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy

Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon.

The transinguinal preperitoneal hernia correction vs Lichtenstein's technique; is TIPP top?

Background

Chronic pain is the main drawback of the Lichtenstein procedure for inguinal hernia repair, with a reported incidence of 15–40%. The transinguinal pre-peritoneal (TIPP) technique seems to be associated with less chronic pain, comparable to the total extra peritoneal (TEP) technique. The aim of this study was to evaluate 3 years of TIPP and Lichtenstein experience since the start of our Hernia Center Brabant in January 2006.

Methods

Patient records of unilateral primary inguinal anterior hernia corrections (TIPP and Lichtenstein) performed since the opening of Hernia Center Brabant (2006–2008) were evaluated in a retrospective study. ASA class 4 and 5, <18 years, recurrences and bilateral hernias were excluded. In the TIPP technique, a Polysoft™ Hernia Patch was placed into the preperitoneal space using an anterior protocol led approach. The Lichtenstein technique was performed as described by Amid [Amid et al (1996) Eur J Surg 162:447–453] and modified with a soft mesh. One of the hernia surgeons decided peroperatively which technique to perform. Baseline characteristics and postoperative complications were assessed retrospectively. The attempted follow up period was 6 months. Chronic pain was assessed in both groups as mild (VAS 1–3), moderate (VAS 4–6) or severe (VAS 7–10). Chronic pain was defined in both groups as any pain sensation lasting longer than 3 months postoperatively, or when local injection of analgesia was necessary. Patients who did not come back because of chronic pain after regular follow up were regarded as free of pain.

Results

A total of 496 patients were included in this study; 225 TIPP and 271 Lichtenstein anterior inguinal hernia operations were analyzed. Data from one TIPP-patient were lost. Both groups were comparable with regard to baseline characteristics regarding age (p = 0.059), gender (p = 0.478) and ASA-classification (p = 0.104). TIPP: mean age 52.7 years, ASA-classification I: 54%, II: 36% and III: 5.3%. A total of 7.6% complications were assessed; recurrence (n = 1), bleeding (and re-operation) (n = 4); 10 patients (4.4%) experienced chronic pain. Persisting sensation loss occurred in 0.9%. Lichtenstein: mean age 57.3 years, ASA-classification I: 51%, II: 38% and III: 11%. A total of 8.5% complications were assessed; recurrence (n = 3), bleeding (and re-operation) (n = 3); 11 Lichtenstein patients (4.1%) experienced chronic pain. Persisting sensation loss occurred in 2.2%. Limitations of this retrospective study were incomplete follow up (31.3% had only one post operative visit 14 days after surgery) and these patients were further regarded as free of pain. Therefore, possible under-reporting of chronic pain could be present. The study was not double blind.

Conclusion

This retrospective study design revealed no significantly better results for the TIPP procedure as compared to the Lichtenstein technique. The incidence of chronic pain reported in this retrospective study has been low in both groups since the opening of the Hernia Center Brabant. These results form the basis for a prospective randomized clinical trial comparing the TIPP and Lichtenstein techniques: ISRCTN93798494.

Inguinal hernia: aetiology, diagnosis, post-repair pain and compensation

BACKGROUND

Inguinal hernia compensation depends on aetiology, diagnosis and complications, particularly post-hernia pain. New studies in these three areas bring confusion to claims.

METHODS

A comprehensive research of the literature using Medline: in aetiology, in diagnoses, the use of ultrasound and/or other investigations, in chronic post-hernia pain and the understanding of the pathogenesis of hernia and post-hernia pain. Using the above data, a creation of a protocol for acceptance of compensation claim.

RESULTS

Although intra-abdominal pressure has been accepted for 200 years as a significant aetiological factor in inguinal hernia, tissue studies and prospective studies suggest an inevitability. In diagnosis, the clinical detection of a lump is the gold standard; investigations are not required. An ultrasonic detection of a hernia without clinical correlation does not require surgery. Post-hernia chronic pain is not singular to hernia, is now considered neuropathic pain and treatment is conservative.

CONCLUSIONS

The work scene is possibly an aggravating factor but not a prime aetiological factor. The diagnosis does not require ultrasound. Chronic pain is neuropathic. A protocol for claim acceptance is presented.

Inguinodynia following Lichtenstein tension-free hernia repair: A review

Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain, as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair, use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other, lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain, though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both non-surgical and surgical options have been tried for chronic groin pain, with their consequent risks of analgesic side-effects, recurrent pain, recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre- and post-herniorraphy.

Nerve-highlighting fluorescent contrast agents for image-guided surgery

Nerve damage is the major morbidity of many surgeries, resulting in chronic pain, loss of function, or both. The sparing of nerves during surgical procedures is a vexing problem because surrounding tissue often obscures them. To date, systemically administered nerve-highlighting contrast agents that can be used for nerve-sparing image-guided surgery have not been reported. In the current study, physicochemical and optical properties of 4,4'-[(2-methoxy-1,4-phenylene)di-(1E)-2,1-ethenediyl]bis-benzenamine (BMB) and a newly synthesized, red-shifted derivative 4-[(1E)-2-[4-[(1E)-2-[4-aminophenyl]ethenyl]-3-methoxyphenyl]ethenyl]-benzonitrile (GE3082) were characterized in vitro and in vivo. Both agents crossed the blood-nerve barrier and blood-brain barrier and rendered myelinated nerves fluorescent after a single systemic injection. Although both BMB and GE3082 also exhibited significant uptake in white adipose tissue, GE3082 underwent a hypsochromic shift in adipose tissue that provided a means to eliminate the unwanted signal using hyperspectral deconvolution. Dose and kinetic studies were performed in mice to determine the optimal dose and drug-imaging interval. The results were confirmed in rat and pig, with the latter used to demonstrate, for the first time, simultaneous fluorescence imaging of blood vessels and nerves during surgery using the FLARE™ (Fluorescence-Assisted Resection and Exploration) imaging system. These results lay the foundation for the development of ideal nerve-highlighting fluorophores for image-guided surgery.

[Predictors of chronic pain following surgery. What do we know?]

Chronic postoperative pain is known to be a significant clinical and economic problem. The estimated mean incidence is high and varies between 10 and 50%, with variations mostly related to procedure-specific conditions. High-risk types of surgeries are e.g. thoracotomy, breast or inguinal hernia surgery and amputations. Although there is increasing knowledge about the incidence of chronic postoperative pain after certain types of surgical procedures, there are only limited data related to the mechanisms and pathophysiology leading to chronic pain after surgery. Neuropathic pain components have been discussed, especially following operations with a high incidence of nerve damage (for example axillary lymphadenectomy). Besides surgical factors it seems that there are a number of other factors which likely increase the risk of chronic postoperative pain. These predictors for the development of chronic postoperative pain are multiple and include individual genetic factors, age and sex of the individual patient, preoperative chronic pain, psychosocial factors, neurophysiological factors, intraoperative nerve and muscle damage, postoperative complications and acute pain in the early postoperative period. Quantitative sensory testing including tests of inhibitory circuits like DNIC might help to predict the risk of individual patients even before surgery has started. The perioperative identification of patients who are at high risk for developing chronic pain after surgery is therefore a major goal for the future. This may help to develop preventive treatment strategies and avoid treatments with side effects for patients who are not at risk for developing chronic pain after surgery. Due to a lack of appropriate data for sufficient preventive approaches an effective postoperative acute pain management and a nerve-conserving surgical technique are the major keys in the prophylaxis of chronic postoperative pain.

Is Postoperative Chronic Pain Syndrome Higher with Mesh Repair of Inguinal Hernia?

Chronic postoperative pain has been associated with mesh repair in meta-analysis of clinical trials. We compared the incidence of early complications, recurrence, and chronic pain syndrome in anatomic and mesh repairs in 200 patients. We defined chronic pain syndrome as pain in the inguinal area more than 3 months after inguinal hernia repair, patient referral to pain management, or necessity of a secondary procedure for pain control. The mean follow-up time was 4 years and 2 months for anatomic repair and 3 years and 7 months for mesh repair. The clinical outcomes did not reveal a significant disparity between the 100 consecutive patients who had mesh repair versus the 100 patients who had anatomic repair with regard to the incidence of superficial wound infection (0 vs 2%, P = 0.497), testicular swelling (12 vs 7%, P = 0.335), hematoma (1 vs 0%, P = 0.99), recurrence (3 vs 2%, P = 0.99), or chronic postoperative pain (4 vs 1%, P = 0.369). The anatomic procedure without mesh should continue to be offered to patients who have an initial inguinal hernia repair.

Commentary: Nationwide analysis of complications related to inguinal hernia surgery in Finland: a 5 year register study of 55,000 operations

BACKGROUND

The aim of this study was to evaluate the incidence of severe complications of adult inguinal hernia surgery from 2003 to 2007 using data from the Finnish National Patient Insurance Association.

METHODS

All major surgical complications are reported to the association because it handles financial compensation for patients' injuries without proof of malpractice. The number of inguinal hernioplasties was obtained from the National Hospital Discharge Registry.

RESULTS

The association received reports of 115 major and 135 moderate complications from 55,000 hernia operations. The overall complication rate was 4.5 per 1,000 hernia procedures. The distribution of injuries consisted of chronic pain (32%), infections (22%), bleeding complications (13%), urologic complications (12%), recurrence (8%), intestinal complications (7%), and miscellaneous disorders (6%). Altogether, 94 patients (38%) received financial compensation from their hospitals. On multivariate analysis, significant associations with chronic pain were found for general anesthesia, length of operation, and the presence of wound complications.

CONCLUSIONS

Chronic inguinal pain and deep infections were associated with severe long-term discomfort and financial compensation to patients with inguinal hernias in Finland.

Eklund A, Montgomery A, Bergkvist L, Rudberg C. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair

Background

Chronic postoperative pain is a major drawback of inguinal hernia repair. This study compared the frequency of chronic pain after laparoscopic (totally extraperitoneal patch, TEP) and open (Lichtenstein) repairs.

Methods

A randomized multicentre study with 5 years' follow-up was conducted on men with a primary inguinal hernia. Chronic pain was categorized as mild, moderate or severe by blinded observers. A subgroup analysis was performed on 121 patients who experienced moderate or severe pain at any time during follow-up.

Results

Overall, 1370 of 1512 randomized patients underwent surgery, 665 in the TEP and 705 in the Lichtenstein group. The total incidence of chronic pain was 11·0 versus 21·7 per cent at 1 year, 11·0 versus 24·8 per cent at 2 years, 9·9 versus 20·2 per cent at 3 years and 9·4 versus 18·8 per cent at 5 years in the TEP and Lichtenstein groups respectively (P &lt; 0·001). After 5 years, 1·9 per cent of patients in the TEP and 3·5 per cent in the Lichtenstein group reported moderate or severe pain (P = 0·092). Of the 121 patients, 72 (59·5 per cent) no longer reported pain a median of 9·4 (range 6·7–10·8) years after operation.

Conclusion

Five years after surgery only a small proportion of patients still report moderate to severe chronic pain. Laparoscopic inguinal hernia repair leads to less chronic pain than open repair. Registration number: NCT00568269 (http://www.clinicaltrials.gov).

Influence of nerve identification and the resection of nerves 'at risk' on postoperative pain in open inguinal hernia repair

BACKGROUND

Surgical strategy regarding nerve identification and resection in relation to chronic postoperative pain remains controversial. A central question is whether nerves in the operation field, when identified, should be preserved or resected. In the present study, the hypotheses that the identification and consequent resection of nerves 'at risk' have no influence on postoperative pain has been tested.

METHODS

A single-centre study was conducted in 525 patients undergoing Lichtenstein hernioplasty. One surgeon (364 operations, Group A) consequently resected nerves 'at risk' for being injured and nine surgeons (161 operations, Group B) adhered to the general routine of nerve preservation. All cases were ambulatory surgery on anaesthetised patients and the groups were similar with regard to age, body mass index (BMI) and preoperative pain. Self-reported pain at 3 months was recorded on a 10-box visual analogue scale (VAS). The identification and resection of nerves were continuously registered. Statistical calculations were performed with Fisher's exact test and ordinal logistic regression.

RESULTS

There was no significant difference in the number of identified nerves in the two groups of patients (iliohypogastricus, P = 0.555; ilioinguinalis, P = 0.831; genital branch, P = 0.214). However, the number of resected nerves was significantly higher in Group A for the iliohypogastric nerve, P < 0.001, but not for ilioinguinalis, P = 0.064, and genital branch, P = 0.362. Non-identification of the ilioinguinal nerve correlated to the highest level of self-reported postoperative pain at 3 months. Patients in Group A, who had nerves 'at risk' resected from the operation field, reported significantly less postoperative pain at 3 months, P = 0.007.

CONCLUSION

This register study confirms the importance of nerve identification. Nerve resection strategy with the consequent removal of nerves 'at risk' gives a significantly better outcome in Lichtenstein hernioplasty.

[Pain and dysesthesia following total extraperitoneal hernia repair]

INTRODUCTION

Minimally invasive repair with alloplastic material for inguinal hernia has become a method with few complications and a low recurrence rate. Persistent pain and dysesthesia years after the procedure are however of growing clinical interest. It is still unknown to what degree initial pain or dysesthesia change in the long term. Therefore this study was done to evaluate patient complaints following total extraperitoneal repair (TER) over a long observation period.

MATERIALS AND METHODS

Included in the study were patients from January 2000 to December 2006 who were treated electively for uni- or bilateral inguinal hernia using TER. Exclusion criteria were emergency procedures, incarcerated hernia, and scrotal hernia. The patient data were collected using a prospective online data system and evaluation of long-term results via standardized questionnaires determining persisting pain, dysesthesia, physical limitations from the surgery, satisfaction with the operation, and recurrences. The patients were grouped according to length of follow-up after surgery: 12-36 months (group 1), 37-60 months (group 2), and 61-96 months (group 3).

RESULTS

Since January 2000, 484 patients 18 to 97 years old with 620 inguinal hernias were operated. Of those, 349 were evaluated for this study (proportion of returned questionnaires: 72.1%). No significant differences were noted in patient characteristics or early postoperative complications. The percentage of patients suffering from relevant pain (moderate to severe) dropped significantly: 10.3% (group 1) vs 1.0% (group 2) (P<0.05) and 3.4% (group 3) (P<0.05). No significant differences were found concerning dysesthesia (19.6% in group 1 vs 19.2% in group 3). There were no significant differences in satisfaction with the operation, as 73.8% in group 1, 67.7% in group 2, and 73.3% in group 3 were very satisfied with the results. The number of recurrences increased during the observation period: 1.9% in group 1, 3.1% in group 2, and 5.5% in group 3 (P>0.05).

CONCLUSIONS

Total extraperitoneal repair is a reliable method with low recurrence rate and high patient satisfaction. A relevant proportion of patients complain however of pain and dysesthesia persisting over years. The data from this study show that in the long term, pain incidence drops significantly while the rate of dysesthesia remains constant. Long follow-up is needed to evaluate the long-term course of persistent pain. For more precise understanding of the long-term results of herniotomy, prospective randomized studies are needed with accordingly long follow-up.

Natural course of long-term postherniorrhaphy pain in a population-based cohort

Background

Persistent pain after hernia repair is widely recognised as a considerable problem, although the natural course of postoperative pain is not fully understood. The aim of the present study was to explore the natural course of persistent pain after hernia repair in a population-based cohort and identify risk factors for prolonged pain duration.

Methods

The study cohort was assembled from the Swedish Hernia Register (SHR), which has compiled detailed information on more than 140 000 groin hernia repairs since 1992. All patients operated on for groin hernia in the County of Uppsala, Sweden, 1998–2004 were identified in the SHR. Those who were still alive in 2005 received the Inguinal Pain Questionnaire, a validated questionnaire with 18 items developed with the aim of assessing postherniorrhaphy pain, by mail. Reminders were sent to non-responders 5 months after the first mail. The halving time was estimated from a linear regression of the logarithmic transformation of the prevalence of pain each year after surgery. A multivariate analysis with pain persisting more than 1 month with a retrospective question regarding time to pain cessation as dependent variable was performed.

Results

Altogether 2834 repairs in 2583 patients were recorded, 162 of who had died until 2005. Of the remaining patients, 1763 (68%) responded to the questionnaire. In 6.7 years the prevalence of persistent pain had decreased by half for the item “pain right now” and in 6.8 years for the item “worst pain last week”. The corresponding figures if laparoscopic repair was excluded were 6.4 years for “pain right now” and 6.4 years for “worst pain past week”. In a multivariate analysis, low age, postoperative complication and open method of repair were found to predict an increased risk for pain persistence exceeding 1 month.

Conclusion

Persistent postoperative pain is a common problem following hernia surgery, although it often recedes with time. It is more protracted in young patients, following open repair and after repairs with postoperative complications. Whereas efforts to treat persistent postoperative pain, in particular neuropathic pain, are often fruitless, this group can at least rely on the hope that the pain, for some of the patients, gradually decreases with time. On the other hand, 14% still reported a pain problem 7 years after hernia surgery. We do not know the course after that.

Although no mathematical model can provide a full understanding of such a complex process as the natural course of postoperative pain, assuming an exponential course may help to analyse the course the first years after surgery, enable comparisons with other studies and give a base for exploring factors that influence the duration of the postoperative pain. Halving times close to those found in our study could also be extrapolated from other studies, assuming an exponential course.

Pain following the repair of an abdominal hernia

Pain and other types of discomfort are frequent symptoms following the repair of an abdominal hernia. After 1 year, the incidence of light to moderate pain following inguinal hernia repair is as high as 10% and 2% for severe disabling chronic pain. Postoperative chronic pain not only affects the individual patient, but may also have a great impact on relatives and society, and may be a cause of concern for the responsible surgeon. This paper provides an overview of the anatomy, surgical procedures, and disposing factors (age, gender, ethnicity, genotype, previous hernia repair, pain prior to surgery, psychosocial characteristics, and surgical procedures) related to the postoperative pain conditions. Furthermore, the mechanisms for both acute and chronic pain are presented. We focus on inguinal hernia repair, which is the most frequent type of abdominal hernia surgery that leads to chronic pain. Finally, the paper provides an update on the diagnostic and treatment routines for postoperative pain.

Litigation following groin hernia repair in England

PURPOSE

Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.

METHODS

Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.

RESULTS

In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.

CONCLUSION

Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.

[Chronic pain in urology: inguinal pain, post vasectomy pain, and chronic pelvic pain]

Undertreatment of all forms of acute and chronic pain is also present in Germany. Chronic inguinal pain and post vasectomy pain are frequently observed in urological practice and appear as chronic postsurgical pain. Chronic pelvic pain has inflammatory causes in the majority of cases and appears as a challenge for the treating physician. Pain should be treated as early as possible, if necessary also interdisciplinary, with regard to the further chronification process with changes of biological, psychological and social factors. For the patient the pain chronification can be accompanied by the reduction of quality of life and social isolation.

The Tilburg double blind randomised controlled trial comparing inguinal hernia repair according to Lichtenstein and the transinguinal preperitoneal technique

Background

Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain.

Methods

The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.

Success rate of hernia repair and complications will be measured as safeguard for quality.

To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with α = 0,05 and power 80%, a total sample size of 300 patients was calculated.

Discussion

The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.

In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein.

Trial registration

ISRCTN 93798494

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

Persistent post-herniorrhaphy pain is mainly neuropathic and has a substantial impact on health-related quality of life.

Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy

BACKGROUND

Chronic post-surgical pain (CPSP) by definition develops for the first time after surgery and is not related to any preoperative pain. Preoperative pain is assumed to be a major risk factor for CPSP. Prospective studies to endorse this assumption are missing.

METHODS

In order to assess the incidence and the risk factors for CPSP multidimensional pain and health characteristics and psychological aspects were studied in patients prior to radical prostatectomy. Follow-up questionnaires were completed three and six months after surgery.

RESULTS

CPSP incidences in 84 patients after three and six months were 14.3% and 1.2%. Preoperatively, CPSP patients were assigned to higher pain chronicity stages measured with the Mainz Pain Staging System (MPSS) (p=0.003) and higher pain severity grades (Chronic Pain Grading Questionnaire) (p=0.016) than non-CPSP patients. CPSP patients reported more pain sites (p=0.001), frequent pain in urological body areas (p=0.047), previous occurrence of CPSP (p=0.008), more psychosomatic symptoms (Symptom Check List) (p=0.031), and worse mental functioning (Short Form-12) (p=0.019). Three months after surgery all CPSP patients suffered from moderate to high-risk chronic pain (MPSS stages II and III) compared to 66.7% at baseline and 82.3% had high disability pain (CPGQ grades III and IV) compared to 41.7% before surgery. CPSP patients scored significantly less favorably in physical and mental health, habitual well-being, and psychosomatic dysfunction three months after surgery.

CONCLUSIONS

All patients with CPSP reported on preoperative chronic pain. Patients with preoperative pain, related or not related to the surgical site were significantly at risk to develop CPSP. High preoperative pain chronicity stages and pain severity grades were associated with CPSP. CPSP patients reported poorer mental health related quality of life and more severe psychosomatic dysfunction before and 3 months after surgery.