What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry

Incidence and predictors of chronic pain after inguinal hernia surgery: a systematic review and meta-analysis

PURPOSE

The mesh is currently the preferred treatment option for hernia repair surgery. Chronic postoperative inguinal pain (CPIP), lasting more than 3 months after surgery, is a complication that significantly impacts patients' quality of life. Currently, there is a lack of evidence-based information describing the incidence and independent predictive factors of chronic pain, posing a serious challenge in clinical practice for devising personalized prevention strategies. Hence, we conducted this systematic review and meta-analysis to investigate the incidence and predictive factors, aiming to provide a reference for developing plans to prevent chronic pain.

METHODS

We conducted a systematic search of PubMed, Cochrane, Embase, and Web of Science, with the retrieval cutoff date set at December 17, 2022. The included studies underwent assessment using the NOS scale, and subgroup analysis for the incidence was carried out based on different regions.

RESULTS

Ultimately, 18 studies were included, involving 29,466 patients. Meta-analysis showed that the pooled incidence of chronic pain was 17.01% (95%CI 12.78% ~ 21.71%). The incidence was 18.65% (95%CI 13.59% ~ 24.29%) in Europe, 14.70% (95%CI 7.87% ~ 23.17%) in Asia, and 6.04%(95%CI 4.62 ~ 7.64) in North America. Furthermore, We also found that the risk factors for CPIP are younger age [OR = 2.261 (95%CI 1.126 ~ 4.549)], presence of other postoperative complications [OR = 1.849 (95%CI 1.034 ~ 3.305)], hernial sac defect < 3 cm [OR = 1.370 (95%CI 1.012 ~ 1.853)], being female [OR = 1.885 (95%CI 1.024 ~ 3.472)], postoperative pain [OR = 1.553 (95%CI 1.276 ~ 1.889)], preoperative pain [OR = 2.321 (95%CI 1.354 ~ 3.979)], and having a history of ipsilateral inguinal hernia repair [OR = 2.706 (95% CI 1.445 ~ 5.069)].

CONCLUSIONS

The incidence of persistent pain following hernia repair surgery is high in current clinical practice, a concern that should not be overlooked. Stratified assessment tools need to be established for patients experiencing early chronic pain, and personalized follow-up strategies and preventive interventions should be developed for those with potentially high risks. These measures aim to enhance the quality of life for patients after hernia repair.

The association of permanent versus absorbable fixation on developing chronic post-herniorrhaphy groin pain in patients undergoing laparoscopic inguinal hernia repair

INTRODUCTION

Fixation of mesh during minimally invasive inguinal hernia repair is thought to contribute to chronic post-herniorrhaphy groin pain (CGP). In contrast to permanent tacks, absorbable tacks are hypothesized to minimize the likelihood of CGP. This study aimed to compare the rates of CGP after laparoscopic inguinal hernia repair between absorbable versus permanent fixation at maximum follow-up.

METHODS

This is a post hoc analysis of a randomized controlled trial in patients undergoing laparoscopic inguinal hernia repair (NCT03835351). All patients were contacted at maximum follow-up after surgery to administer EuraHS quality of life (QoL) surveys. The pain and restriction of activity subdomains of the survey were utilized. The primary outcome was rate of CGP, as defined by a EuraHS QoL pain domain score ≥ 4 measured at ≥ 1 year postoperatively. The secondary outcomes were pain and restriction of activity domain scores and hernia recurrence at maximum follow-up.

RESULTS

A total of 338 patients were contacted at a mean follow-up of 28 ± 11 months. 181 patients received permanent tacks and 157 patients received absorbable tacks during their repair. At maximum follow-up, the rates of CGP (27 [15%] vs 28 [18%], P = 0.47), average pain scores (1.78 ± 4.38 vs 2.32 ± 5.40, P = 0.22), restriction of activity scores (1.39 ± 4.32 vs 2.48 ± 7.45, P = 0.18), and the number of patients who reported an inguinal bulge (18 [9.9%] vs 15 [9.5%], P = 0.9) were similar between patients with permanent versus absorbable tacks. On multivariable analysis, there was no significant difference in the odds of CGP between the two groups (OR 1.23, 95% CI [0.60, 2.50]).

CONCLUSION

Mesh fixation with permanent tacks does not appear to increase the risk of CGP after laparoscopic inguinal hernia repair when compared to fixation with absorbable tacks. Prospective trials are needed to further evaluate this relationship.

Sutureless Repair for Open Treatment of Inguinal Hernia: Three Techniques in Comparison

Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy.

Intraneural fibrosis within ilioinguinal nerve in inguinal hernia patients with preoperative pain: it's the sign of irreversible nerve injury, isn't it?

PURPOSE

Preoperative pain is known as one of the most powerful risk factors for chronic postoperative inguinal pain (CPIP), while its pathogenesis has not been fully elucidated. The aim of the present study was to evaluate patients with preoperative pain from the pathological perspective and discuss the potential pathogenesis of CPIP in those patients.

METHODS

This was a single-institutional retrospective study. The study population was inguinal hernia patients with preoperative pain who underwent open anterior hernia repair for primary inguinal hernia with pragmatic ilioinguinal neurectomy during surgery between March 2021 and March 2023. The primary and secondary outcomes were proportion of collagen deposition and mucus accumulation within ilioinguinal nerve in those patients, respectively, which were evaluated histologically using Image J software.

RESULTS

Forty patients were evaluated. Median value of proportion of intraneural collagen deposition was 38.3% (27.7-95.9). These values were positively correlated with the duration of pain (r2=0.468, P<0.001). Median value of proportion of mucus accumulation in ilioinguinal nerve was 50.1% (0-82.0). These values had no correlation with any clinicopathological variables.

CONCLUSIONS

In the present study population, all patients with preoperative pain had intraneural fibrosis within ilioinguinal nerve, and its degree had a positive correlation with the pain duration.

Lichtenstein versus TIPP versus TAPP versus TEP for primary inguinal hernia, a matched propensity score study on the French Club Hernie Registry

PURPOSE

Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry.

METHODS

Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP.

RESULTS

After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02).

CONCLUSION

This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

Postoperative Analgesics Score as a Predictor of Chronic Postoperative Inguinal Pain After Inguinal Hernia Repair: Lessons Learned From a Retrospective Analysis

BACKGROUND

Chronic postoperative inguinal pain (CPIP) is a common complication after inguinal hernia surgery and occurs in up to 10-14% of cases. CPIP has a significant impact on daily life, work ability and thus compromises quality of life. The aim of this retrospective study was an in-depth analysis of patients undergoing inguinal hernia repair to further refine the prediction of the onset of CPIP reliably.

METHODS

A single center retrospective analysis of patients with who underwent open or minimally invasive inguinal hernia repair from 2016 to 2021 was carried out. Complication rates, detailed analysis of postoperative pain medication and quality of life using the EuraHS Quality of Life questionnaire were assessed.

RESULTS

Out of 596 consecutive procedures, 344 patients were included in detailed analyses. While patient cohorts were different in terms of age and co-morbidities, and the prevalence of CPIP was 12.2% without differences between the surgical procedures (Lichtenstein: 12.8%; TEP 10.9%; TAPP 13.5%). Postoperative pain was evaluated using a newly developed analgesic score. Patients who developed CPIP later had a significant higher consumption of analgesics at discharge (p = 0.016). As additional risk factors for CPIP younger patient age and postoperative complications were identified.

CONCLUSION

The prospective use of the analgesic score established here could be helpful to identify patients that are at risk to develop CPIP. These patients could benefit from a structured follow-up to allow early therapeutic intervention to prevent chronification and restore the quality of life.

Efficacy and safety of glue mesh fixation for laparoscopic inguinal hernia: A meta-analysis of randomized controlled trials

It is still controversial whether glue can be used for mesh fixation in laparoscopic inguinal hernia repair. The aim of this meta-analysis was used to systematically evaluate the effectiveness and safety of glue mesh fixation in laparoscopic tension-free inguinal hernia repair. The PubMed database, EMBASE database and Cochrane Library were searched to collect published randomized controlled trials (RCTs) on laparoscopic tension-free inguinal hernia repair with glue mesh fixation. Sixteen RCTs and 2409 patients with inguinal hernia were included. The meta-analysis showed that compared with the mechanical mesh fixation group(MMFG), the glue mesh fixation group(GMFG) had significantly reduced incidences of chronic pain[relative risk (RR) = 0.40, 95% confidence interval (CI) (0.28,0.57), P < 0.00001], urinary retention[RR = 0.53, 95% CI(0.29,0.97), P = 0.04], haematoma[RR = 0.23, 95% CI(0.09,0.58), P = 0.002] and total complications[RR = 0.28, 95% CI(0.18,0.44), P < 0.00001]; there were no significant differences in pain score on postoperative day 1[MD = -1.33, 95% CI(-2.93,0.26), P = 0.10], operation time[MD = 1.46, 95% CI(-3.97,6.88), P = 0.60] and recurrence rate[RR = 0.72, 95% CI(0.35,1.47), P = 0.37] between the two groups. In conclusion, the application of glue mesh fixation in laparoscopic inguinal hernia repair is safe and reliable with fewer complications. Moreover, it can reduce the incidence of chronic pain without increasing the recurrence rate. However, due to the small number of cases in this analysis and limitations in the quality of the included studies, the findings need to be further verified by multicentre, large-sample and high-quality RCTs in the future.

Impact of titanium-coated polypropylene mesh on functional outcome and quality of life after inguinal hernia repair

Objective

This study aims to compare the clinical outcomes of complications, quality of life, and chronic pain between titanium-coated polypropylene mesh and polypropylene mesh after Lichtenstein or TAPP surgery.

Methods

A retrospective cohort study was conducted, involving patients who underwent inguinal hernia repair using Timesh light®, Optilene LP®, or 3DMax™ meshes between January 2020 and May 2022. Based on the surgical method, patients were divided into Lichtenstein and TAPP groups, and further categorized according to the type of mesh used. The primary endpoints assessed postoperative complications, postoperative pain, and postoperative quality of life. Secondary endpoints included postoperative sensation in the surgical area and postoperative recurrence rate.

Results

A total of 180 Lichtenstein procedures and 478 TAPP procedures were included in the analysis after propensity score matching. The findings revealed that patients with titanium-coated polypropylene mesh did not exhibit significant advantages in perioperative data. Within three months to one year after TAPP surgery, patients with the titanium-coated polypropylene mesh reported improved foreign body sensation during activities (P = 0.002) and a lower incidence of chronic pain (P = 0.008). However, after one year, these advantages of titanium-coated polypropylene mesh were no longer significant during activity or at rest. In the TAPP group, the titanium-coated polypropylene mesh depicted advantages in the single score of the SF-36 questionnaire.

Conclusions

The utilization of titanium-coated polypropylene mesh resulted in reduced foreign body sensation and chronic pain in activity within one year after TAPP surgery, significantly enhancing certain aspects of the patient's quality of life compared to polypropylene mesh.

Gender differences in epigastric hernia repair: a propensity score matching analysis of 15,925 patients from the Herniamed registry

INTRODUCTION

In recent surgical literature, gender-specific differences in the outcome of hernia surgery has been analyzed. We already know that female patients are at higher risk to develop chronic postoperative pain after inguinal, incisional, and umbilical hernia surgery. In this study, we evaluated the impact of gender on the outcome after epigastric hernia surgery.

METHODS

A covariable-adjusted matched-paired analysis with data derived from the Herniamed registry was performed. In total of 15,925 patients with 1-year follow-up data were included in the study. Propensity score matching was performed for the 7786 female (48.9%) and 8139 male (51.1%) patients, creating 6350 pairs (81.6%).

RESULTS

Matched-paired analysis revealed a significant disadvantage for female patients for pain on exertion (12.1% vs. 7.6%; p < 0.001) compared to male patients. The same effect was demonstrated for pain at rest (6.2% in female patients vs. 4.1% in male patients; p < 0.001) and pain requiring treatment (4.6% in female patients vs. 3.1% in male patients; p < 0.001). All other outcome parameters showed no significant differences between female and male patients.

CONCLUSIONS

Female patients are at a higher risk for chronic pain after elective epigastric hernia repairs compared to the male patient population. These results complete findings of previous studies showing the same effect in inguinal, umbilical, and incisional hernia repair.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

The effect of mesh fixation on migration and postoperative pain in laparoscopic TEP repair: prospective randomized double-blinded controlled study

PURPOSE

The development of chronic pain is one of the major post-surgery problems after inguinal hernia repair. Although the possibility of chronic pain formation decreases with laparoscopic methods, pain may develop due to the staples used. It is thought that absence of mesh fixation in total extra-peritoneal (TEP) repair does not increase the recurrence rate. This study aims to investigate the absence of mesh fixation in the TEP on the development of postoperative pain, mesh displacement, and recurrence rate.

METHODS

Between December 2019 and December 2020, 100 patients who underwent TEP repair due to unilateral inguinal hernia in the General Surgery Clinic of Hitit University were included in the study. Study was registered at http://Clinicaltrials.gov (NCT05152654). Patients were divided into two groups as repairs in which the mesh was fixed with a tacker and no-fixation (NF) was used. The mesh is marked with radiopaque clips. Patients were compared in terms of postoperative pain, mobilization time, hospital stay, return to work, chronic pain, early-late mesh displacement, and recurrence.

RESULTS

While there was no significant difference between the groups in terms of mesh displacement and recurrence, it was observed that the NF group developed significantly less pain in the early and late postoperative period compared to the other group. The time-dependent reduction rate of postoperative pain was higher in NF group than in other group. In addition, operation time was shorter in the NF group.

CONCLUSION

While the absence of mesh fixation in TEP hernia repair does not increase the recurrence rate, it can be used safely, because it causes less acute and chronic pain.

TRAIL REGISTRATION

Clinicaltrials number: NCT05152654.

Adolescent inguinal hernia repair: a review of the literature and recommendations for selective management

BACKGROUND

The choice of how to repair inguinal hernias in adolescents has historically been a matter of experience and differed between pediatric surgeons who traditionally performed a high ligation of the sac and general surgeons who typically perform a repair using mesh. This up-to-date review thoroughly examines the subject and discusses the suitability of both types of repairs in this unique age group.

METHODS

A 20-year Pub Med search was performed for the following terms: adolescent hernia repair including reports of mesh hernia repair in adolescents and postoperative complications including chronic inguinal pain and recurrences.

RESULTS

The evidence in the literature suggests that while there appears to be no difference between the two types of repairs with regards to recurrence and complications, changes in the pelvic floor physiology in adolescents suggest that a selective, individualized approach can be recommended depending on the size and nature of the presenting pathology.

CONCLUSIONS

A selective approach to the inguinal hernia in adolescent patients based on the size of the defect appears justified.

Inguinal hernia – epidemiology, risk factors, treatment methods (literature review)

Inguinal hernias (IH) are widespread in the human population and occur in 27–43 % of men and 3–6 % of women. Many risk factors for IH have been overestimated in the last decade: male gender is considered the leading factor (the ratio between men and women is approximately 1:7), less significant factors are heredity (most significant for women), physical activity (more significant for men), age (peak prevalence of IH occurs at 5 years and 70–80 years), congenital or acquired connective tissue dysplasia, history of prostatectomy, low body mass index.Hernioplasty with the use of synthetic mesh prostheses remains the most popular technique for surgical correction of IH. Performing non-prosthetic hernioplasty is only recommended if mesh prostheses are not available, for example in poor countries. In open hernioplasty using mesh prostheses, different methods are used today: Plug & Patch, Prolene Hernia System, Parietene Progrip, sutureless plastic according to Trabucco, Stoppa, preperitoneal techniques TIPP (trans-inguinal pre-peritoneal), TREPP (transrectus pre-peritoneal), TEP (total extraperitoneal), however, none of them showed significant advantages over the gold standard of open hernioplasty – tensionfree repair according to Liechtenstein.Laparoscopic IH correction is represented by the TAPP (transabdominal preperitoneal) technique, performed through the abdominal cavity, and TEP (total extraperitoneal) – extraperitoneal prosthetic hernioplasty. None of them has a significant advantage in the treatment of IH; therefore, when choosing a treatment method, the surgeon should be guided by the cost of the operation and the level of proficiency in one or another hernioplasty technique.

Mesh shrinkage is the potential pathogenesis of chronic somatic pain following transabdominal preperitoneal repair: Report of two cases

Although mesh-related pain, termed "somatic pain," is a well-known pain syndrome following Lichtenstein repair, few reports are available on somatic pain following transabdominal preperitoneal repair (TAPP) and its pathogenesis remains unclear. We report on two patients with refractory somatic chronic pain following TAPP. In the present two cases, both mesh fixation with rigid permanent metal tackers and mesh shrinkage resulting in contractile forces on the groin musculature could be considered as potential mechanisms in the etiology of chronic somatic pain following TAPP. The lessons learned from these two cases are: (a) mesh shrinkage resulting in contractile forces on the groin musculature could be considered as potential mechanisms in the etiology of chronic somatic pain following TAPP; (b) partial mesh removal would be an effective alternative to total mesh removal in those patients for remedial surgery.

Comparison of laparoscopic transabdominal preperitoneal hernioplasty and laparoscopic iliopubic tract repair for Nyhus type II hernia in women

BACKGROUND

Indirect inguinal hernia with a dilated internal ring but an intact posterior inguinal wall is classified as Nyhus type II. Females have a higher incidence of indirect hernia than direct hernia. The purpose of this study was to evaluate the efficacy of laparoscopic iliopubic tract repair (IPTR) compared with laparoscopic transabdominal preperitoneal (TAPP) hernioplasty in treating women with Nyhus type II hernia.

METHODS

This retrospective study included 318 women aged ≥ 20 years who were treated for Nyhus type II hernia from January 2013 to December 2018. The patients were categorized into two groups in accordance with the operative technique: the TAPP group (33 patients) and the IPTR group (285 patients). In the IPTR group, intraabdominal suturing of the iliopubic tract and transversalis fascia arch was performed without mesh implantation.

RESULTS

The mean operation time was shorter in the IPTR group (17.2 ± 3.9 min) than the TAPP group (20.5 ± 8.1 min, p = 0.028). The postoperative complication rate was higher in the TAPP group than the IPTR group [6.1% (2/33) vs. 0.4% (1/285), respectively; p = 0.001]. Inguinodynia occurred in one patient in the TAPP group and no patients in the IPTR group. The hospital stay did not significantly differ between the two groups. The numeral rating scale pain scores at 1 day and 1 week postoperatively did not significantly differ between the two groups. There was no recurrence in either group.

CONCLUSIONS

Laparoscopic IPTR was safe and feasible for treating Nyhus type II hernia in women.

A pathological perspective to painful inguinal hernia: Report of two cases

Introduction

Preoperative inguinal pain (painful inguinal hernia) is a well-known factor associated with chronic postoperative inguinal pain (CPIP). However, it remains unclear what preventive measures should be taken in such patients.

Case presentation

We report two patients with painful inguinal hernia who underwent pragmatic ilioinguinal nerve neurectomy during open anterior repair. The nerve was compressed by bulky spermatic cord lipoma in case 1 and by the hernia sac presenting over a few decades in case 2. Hematoxylin and eosin staining of the resected nerves revealed mucoid degeneration. Toluidine blue staining of resin-embedded nerve sections demonstrated that fully-myelinated axons had significantly decreased in case 1 and almost disappeared in case 2, indicating the development of massive demyelination of the ilioinguinal nerve in both cases.

Discussion

In cases where the injured nerve is left in situ, CPIP may occur since demyelinating neuropathy sometimes becomes irreversible.

Conclusion

Planned nerve resection via open anterior inguinal hernia repair may be an option to prevent CPIP in patients with painful inguinal hernia.

•

Painful inguinal hernia is a known risk factor for CPIP; however, preventive measures remains unclear.

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Ilioinguinal nerves were massively demyelinated in two patients with painful inguinal hernia.

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Severe neuropathy induced by chronic compression of the ilioinguinal nerve may be associated with painful inguinal hernia.

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Planned nerve resection via anterior hernia repair is an option to prevent CPIP in patients with painful inguinal hernia.

Longitudinal cohort study on preoperative pain as a risk factor for chronic postoperative inguinal pain after groin hernia repair at 2-year follow-up

PURPOSE

To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain.

METHODS

Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life.

RESULTS

Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia.

CONCLUSION

At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.

The Management of Indirect Inguinal Hernia Sac in Laparoscopic Inguinal Hernia Repair: A Systemic Review of Literature

BACKGROUND

The aim of this study is to investigate the current management strategy of indirect hernia sac during laparoscopic inguinal hernia repair.

OBJECTIVES

The aim was to evaluate the various indirect hernia sac management strategies when performing laparoscopic inguinal hernia repair.

DATA SOURCES

Major databases (PubMed, Embase, Springer, and Cochrane Library).

REVIEW METHODS

MeSH and free-text searching include "laparoscopic inguinal hernia" "TAPP," "TEP," "inguinal hernia," "indirect inguinal hernia sac," "distal sac," "sac transection," "sac ligation," and "sac reduction."

RESULTS

The present study enrolled 7 trials, 4 studies compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated increased seroma formation (odds ratio=2.74, 95% confidence interval: 1.41-4.31), and there was no statistical difference in the incidence of postoperative pain, operative time, hernia recurrence, and time to return to normal activity between the sac transection and sac reduction groups. Two studies reported the application of adjuncts in the management of distal sac during laparoscopic large inguinoscrotal hernia repair. The seroma formation could be reduced by adjuncts of fixing the distal hernia sac to posterior abdominal wall with either suture or tacks.

CONCLUSION

Indirect sac transection during laparoscopic indirect inguinal hernia repair is associated with a higher incidence of postoperative seroma. Additional adjuncts to the divided distal hernia sac, including distal sac fixation with either suture or tacks, are effective methods to prevent postoperative seroma.

Inguinal hernia repair among men: development and validation of a preoperative risk score for persistent postoperative pain

PURPOSE

Persistent postoperative pain (PPP) is a prevalent complication after inguinal hernia repair. The aim of this study was to develop and validate a preoperative risk score for PPP.

METHODS

We developed the risk score based on a cohort of 2,508 Danish men, who answered a questionnaire six months after inguinal hernia repair performed 2015-2016. PPP was defined as a numerical rating scale score ≥ 2 during activity six months postoperatively. Logistic regression analyses were undertaken to determine statistically significant predictors of PPP. Univariable analysis selected potential predictors with a p value ≤ 0.20, and a subsequent multivariable model was built using backward elimination with a criterion of p value < 0.10. We created a risk score based on the β coefficients of the multivariable model. The risk score was validated internally using Hosmer-Lemeshow goodness of fit test, calibration belt test, and receiver operating characteristic curve analyses with 95% confidence intervals based on the bootstrap analysis. External validation was performed in a cohort of 293 men recruited preoperatively.

RESULTS

Predictors of PPP were age 18-49 and 50-59 (versus ≥ 60) years (p < 0.001), total load lifted > 1,000 kg/day (p = 0.001), working in a bent-over position > 1 h/day (p < 0.001), leisure-time physical activity < 2 h/week (p = 0.009), increasing body mass index (per unit) (p < 0.003), and repair of recurrent hernia (p = 0.001).The preoperative risk score predicted risks of 6-61% in the development population. The model showed good internal and external validity.

CONCLUSION

The results suggest that the risk of PPP after inguinal hernia repair can be predicted using a preoperative risk score.

Laparoscopic Transabdominal Preperitoneal Approach with Negative Pressure Drainage for Giant Inguinal Hernia

Background: Giant inguinal hernia (GIH) is a rare disease but it can cause serious complications, such as intestinal obstruction and strangulation. Few studies have explored surgical treatment with respect to the transabdominal preperitoneal (TAPP) approach or measures to reduce the occurrence of postoperative seroma. Purpose: To investigate the safety and efficacy of the TAPP approach with negative pressure drainage in GIHs. Methods: From January 2017 to December 2019, 32 patients who underwent TAPP procedures with negative pressure drainage for GIHs at our hospital were reviewed. Demographic information, surgical characteristics, and follow-up data were obtained. Results: The mean age of the patients was 66, and more than half of them had medical comorbidities. All GIHs were defined as Type 1 and were successfully repaired through the TAPP approach with negative pressure drainage. The mean operative time was 146 minutes (range 122-251). After surgery, the mean drainage time was 7 days (range 5-10 days), and the mean volume of drainage in each patient was 820 mL (range 655-1020 mL). Complications occurred in 3 cases. For 1 case, the inferior epigastric artery was injured during surgery. A seroma was observed in 1 patient, which occurred 2 days after removal of the drainage tube. Finally, 1 patient developed an umbilical puncture site infection, and the wound healed after changing the dressing. The mean follow-up was 13 months (range 1-32), and there was no recurrence or mesh infection during that time. Conclusion: TAPP is a safe and effective approach for treating Type 1 GIHs with low operative complications. Negative pressure drainage through the scrotum to the preperitoneal space may reduce the incidence of seroma. Recurrence of hernias was not observed, and chronic pain seldom occurred during the follow-up period in our study.

A comprehensive study comparing tack and glue mesh fixation in laparoscopic total extraperitoneal repair for adult groin hernias

BACKGROUND

Glue mesh fixation is thought to cause less pain compared to tack mesh fixation during laparoscopic total extraperitoneal inguinal hernia repair (TEP). However, the clinical benefits of glue mesh fixation are still controversial. This study aimed to evaluate the acute pain, chronic pain, and recurrence rate between these two fixation methods.

METHODS

After reviewing all patients in our prospective hernia repair database from February 2008 to December 2017, we identified 583 patients who underwent TEP with tack mesh fixation and 70 patients with glue fixation by a single surgeon. Acute post-operative pain and activity level were evaluated using a Visual Analog Score (VAS) and the modified Medical Outcome Study (MOS) score. The primary endpoint was chronic pain 6 months after TEP. The secondary endpoints were acute pain, activity level, complications, and recurrence.

RESULTS

After adjustment for potential confounding factors, the glue mesh fixation had significant lower VAS at 2 h post operation during rest and coughing and on the first day after surgery during coughing (p = 0.005, p < 0.001, and p = 0.011). The modified MOS on the first day was higher in the glue group (p < 0.001). There were no reduced risk of chronic pain or increased risk of recurrence for the glue group compared to the tack group [Odds ratio (OR) = 0.237, p = 0.169; OR = 2.498, p = 0.299]. In the sub-group analysis for recurrent hernia repair, glue fixation is associated with better modified MOS (p = 0.031) on first day and lower VAS on the operative day and first day at rest (p = 0.003 and p = 0.024) after surgery.

CONCLUSIONS

Glue fixation method was superior to tack fixation method in acute post-operative pain and early post-operative activity level after laparoscopic TEP repair. However, both fixation methods had similar incidence of chronic pain-, recurrence-, and procedure-related complications after laparoscopic TEP repair.

A registry-based 2-year follow-up comparative study of two meshes used in transinguinal preperitoneal (TIPP) groin hernia repair

PURPOSE

Onflex™ mesh has replaced Polysoft™ patch on the market, without being clinically evaluated thus far in the transinguinal preperitoneal (TIPP) technique.

METHODS

All consecutive TIPP registered in our registry during the overlap period of availability of both meshes were included and studied with the chronic postoperative inguinal pain (CPIP) as primary endpoint, assessed with a verbal rating scale (VRS), and included in a patient-related outcome measurement (PROM) phone questionnaire.

RESULTS

A total of 181 Onflex cases vs 182 Polysoft cases were studied with a 2-year follow-up rate of 92% vs 88%. The overall rate of pain or discomfort was not statistically different in the 2 studied subgroups (16.5% vs 17.6%; p = 0.71), while moderate or severe pain were significantly more frequent in the Polysoft subgroup (5.5% vs 11.6%; p = 0.01). These symptoms did not interfere with the patient daily life in 16% vs 16.5% of cases, and they were self-assessed as more bothersome than the hernia in only 0.5% vs 0.5% of cases, suggesting an overestimation of the pain by the VRS. Patients assessed the result of their hernia repair as excellent or good in 97.8% vs 96.7% and medium or bad in 2.2% vs 3.3% (p = 0.53). The cumulative recurrence rate was 0% vs 2.2%. Two reoperations (one for early and one for late recurrence) were reported in the Polysoft subgroup (1%), none related to the non-absorbable memory ring.

CONCLUSIONS

These results suggest that TIPP with Onflex provides results at least similar than those with Polysoft.

Return to outdoor walking, car driving, and sexual activity following elective inguinal hernia repair: surgeons' perspective versus patients' reality

PURPOSE

To determine the time to resumption of outdoor walking, car driving, sports, and sexual activity following elective inguinal hernia repair, and to reveal if there are differences between surgeons' recommendations and patients' real return times.

METHODS

A questionnaire including questions about recommendations to hernia patients for times to resume outdoor walking ability without assistance, driving and sexual intercourse after an elective inguinal hernia repair was sent to surgeons. Also, a short questionnaire was sent to patients who had undergone elective inguinal hernia repair to search the exact times for resuming these physical activities.

RESULTS

Surgeons' thoughts and recommendations to their patients varied significantly. The range of recommendations were same day to 20 days for outdoor walking, and same day to 3 months both for driving and sexual intercourse. Patients' actual resumption of postoperative activities were 1-14 days for outdoor walking, 1 day to 3 months for driving, and 1 day to 2 months for sexual intercourse. When the answers from the two questionnaires were compared, it was observed that the mean times for resumption of outdoor walking and sexual intercourse were significantly longer in the patients' lives than recommended by the surgeons. Patients ≥ 60 years were able to walk outside, drive, and participate in sexual activity earlier than the younger patients. Bilateral and recurrent hernia repairs caused slower resumption of different activities in comparison to primary hernias.

CONCLUSIONS

Patients reported that times for resumption of outdoor walking, driving, and sexual activity were significantly longer than those recommended by surgeons. Age, BMI, bilateral repair, and recurrent hernias were found to be factors affecting return time to different activities.

The transversus abdominis plane block may reduce chronic postoperative pain one year after TAPP ingunial hernia repair

Introduction

Chronic postoperative inguinal pain (CPIP) is defined as pain impacting daily activities lasting at least 3 months. With an incidence of 0.5–6.0%, chronic pain affects many patients who underwent inguinal hernia repair (IHR). Early severe postoperative pain has been described as a risk factor for CPIP. Thus, we aim to investigate the impact of the transversus abdominis plane (TAP) block on CPIP.

Methods

From 2013 to 2019 we collected data from individuals who were operated on electively in TAPP technique and who received a preoperative TAP block.

Results

Data from 289 patients were selected. 259 patients were male. The mean age was 59.93 years and the mean BMI was 25.72 kg/m2. 252 patients suffered from a primary inguinal hernia. No mesh fixation was conducted. 21 patients reported pain at rest, 26 pain under physical exertion and 13 patients required treatment of their pain. In 6.25% of cases patients reported CPIP. We compared our findings with data from the German Herniamed Registry (unilateral, primary IH, men, no mesh fixation; n = 8.799), because we assume that the majority of these patients did not receive a TAP block. The rate of pain under physical exertion (9.2% vs. 10.05%) and pain requiring treatment (2.45% vs. 2.95%) one year after surgery slightly differs without a statistical significance.

Conclusions

We assume that the TAP block may reduce CPIP, postoperative pain during physical exertion and pain requiring treatment following IHR in TAPP technique. Additional randomized clinical trials are mandatory to evaluate the hypothesis.

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The TAP block may reduce the rate of chronic postoperative inguinal pain.

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The TAP block may reduce the rate of pain requiring treatment and on exertion one year after IHR.

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The TAP should further implemented into daily hernia surgery routine.

Predictive factors of post-laparoscopic inguinal hernia acute and chronic pain: prospective follow-up of 807 patients from a single experienced surgeon

INTRODUCTION

Convalescence after hernia repair is one of the main focuses for hernia surgeons. We analyzed our prospectively collected data to identify possible predictive factors for post-operative acute and chronic pain.

MATERIALS AND METHODS

We prospectively collected the demographic data and peri-operative findings. Post-operative acute pain was evaluated with Visual Analog Pain Scale. The chronic pain (pain persists for > 6 months since operation) was also recorded.

RESULTS

From June 2008 to August 2018, there were 807 patients with 1029 sites of inguinal hernia enrolled in our analysis. Pain before operation was associated with the severity of acute pain on OP (operation) day, POD 1 (post-operative day 1), and POD 7 (post-operative day 7). Younger patients had significantly higher post-operative acute pain on OP day, POD 1, and POD 7. The staple mesh fixation method resulted in a higher pain score at OP day and POD 1. The predictive factors for chronic pain were sex (female), young age (< 65 years), having no past history of hypertension, pain before operation, and mesh material.

CONCLUSION

A younger age and inguinal pain before operation were the main predictive factors for higher post-operative pain. Younger patients, females, having inguinal pain before surgery, and using heavy weight mesh have a higher risk of chronic pain.

The inguinal region revisited: the surgical point of view : An anatomical-surgical mapping and sonographic approach regarding postoperative chronic groin pain following open hernia repair

PURPOSE

Inguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal "management" of the nerves during surgery.

METHODS

We present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management.

RESULTS

Surgically and ultrasonographically relevant structures ("landmarks") in open hernia repair are the anterior-superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = "blue line"), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels.

CONCLUSION

A detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.

Persistent postoperative pain after inguinal hernia repair in relation to occupational lifting and standing/walking: a 6-month follow-up study

OBJECTIVES

This study aims to evaluate the risk of persistent postoperative pain after inguinal hernia repair in relation to occupational lifting and standing/walking.

METHODS

We conducted a 6-month follow-up study that included all men with an inguinal hernia repair registered in the Danish Hernia Database from 1 January 2015 to 31 October 2016, who were born from 1 October 1949 to 1 October 1998, and who were alive, living in Denmark, and active in the labour market in the week before surgery. Members of the cohort received a questionnaire 6 months after surgery. Exposure estimates were allocated by combining self reported job titles with a job exposure matrix. Prevalence ratios of persistent postoperative pain during activity ≥2 on a numerical rating scale (range 0-10) according to occupational lifting and standing/walking were estimated using Poisson regression.

RESULTS

Of 4817 eligible patients, 2609 (54%) returned the questionnaire and 2508 contributed to the analyses. A total of 473 men (18.9%) reported persistent postoperative pain. In the group lifting >1000 to 6125 kg/day, the prevalence was 26.8% compared with 17.5% in the minimally exposed group; adjusted prevalence ratio: 1.44 (95% CI 1.16 to 1.79). For standing/walking >6 hours/day, the prevalence was 23.6% compared with 17.0% in the group standing <4 hours/day; adjusted prevalence ratio: 1.18 (95% CI 0.92 to 1.50).

CONCLUSIONS

The risk of persistent postoperative pain after inguinal hernia repair was elevated among men with occupational lifting exposures >1000 kg/day. This finding suggests a preventive potential.