Treatment for persistent chronic neuralgia after inguinal hernioplasty

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study

PURPOSE

The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission.

METHODS

A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission.

RESULTS

A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission.

CONCLUSIONS

Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Role of MR Neurography in Groin and Genital Pain: Ilioinguinal, Iliohypogastric, and Genitofemoral Neuralgia

OBJECTIVE

Chronic neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral) is difficult to diagnose and treat clinically. We examined the role of MR neurography (MRN) in the evaluation of border nerve abnormalities and the results of treatments directed at the MRN-detected nerve abnormalities.

MATERIALS AND METHODS

This retrospective cross-sectional study included 106 subjects with groin or genital pain (mean [± SD] age, 50.7 ± 15.4 years) who showed mono- or multifocal neuropathy of the border nerves at 3-T MRN. Subjects who underwent CT-guided perineural injection were assessed for pain response. Injection responses were categorized as positive, possible positive, and negative. Subjects who received hyaluronidase, continuous radiofrequency ablation, or surgery were also evaluated for treatment outcomes.

RESULTS

One hundred forty abnormal nerves were positive for neuropathy in 106 studies. Eighty of 106 subjects had single neuropathy, and 26 had multifocal neuropathy. Fifty-eight subjects underwent CT-guided perineural injections, with five receiving bilateral injections (63 injections). Improvement in subjective pain was seen in 53 of 63 cases (84.2%). A statistically significant improvement in pain response was noted in the isolated ilioinguinal nerve block group as compared with the isolated genitofemoral nerve block group (p = 0.0085). Thirteen of 58 subjects received multiple nerve injections at the same sitting. Both groups receiving single or multiple nerve injections had similar improvement in pain scores of 84% and 85%, respectively, although this difference was not statistically significant.

CONCLUSION

Our retrospective analysis showed improved pain relief in subjects who underwent CT-guided nerve blocks on the basis of a positive MRN.

The role of peripheral afferents in persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial of ultrasound-guided tender point blockade

BACKGROUND

Severe, persistent inguinal postherniorrhaphy pain (PIPP) is a debilitating condition that develops in 2-5% of patients. PIPP may be neuropathic in nature, yet the lesion in the peripheral nervous system has not been located. Most PIPP-patients demonstrate a tender point (TP) in the medial aspect of the inguinal region that triggers pain upon minimal pressure. As TPs may play a role in the pathophysiology of PIPP, the aim of this trial was to investigate the analgesic effects of local anaesthetic TP-blockade.

METHODS

A randomized, double-blind, placebo-controlled, crossover trial was performed in 14 PIPP-patients and six healthy volunteers. All participated in two sessions, seven days apart, receiving 10 ml of 0.25% bupivacaine or normal saline via an ultrasound-guided fascial plane block at the TP. The TP-area was used for pain assessments (at rest, on movement, with 100 kPa pressure-algometry) and quantitative sensory testing (pressure pain thresholds, thermal detection/pain thresholds, supra-threshold heat perception), before and after the TP-blockade.

RESULTS

The median (95% CI) reduction in pain was 63% (44.1 to 73.6%) after bupivacaine compared with 36% (11.6 to 49.7%; P=0.003) after placebo. Significant increases in cool detection (P=0.01) and pressure pain thresholds (P=0.009) with decreases in supra-threshold heat pain perception (P=0.003) were seen after bupivacaine only. In four out of six volunteers, increased thermal and evoked-pain thresholds after bupivacaine compared with placebo, was demonstrated.

CONCLUSIONS

This trial demonstrates that peripheral afferent input from the TP-area is important for maintenance of spontaneous and evoked pain in PIPP.

CLINICAL TRIAL REGISTRATION

NCT02065219.

Perineural steroid injections around ilioinguinal, iliohypogastric, and genitofemoral nerves for treatment of chronic refractory neuropathic pain: A retrospective study

Background: Perineural local anaesthetic and steroid injections around ilioinguinal (II), iliohypogastric (IH), and genitofemoral (GF) nerves are often performed to treat chronic refractory neuropathic pain in the lower abdomen and groin, but there is a lack of published data on outcomes of these interventions. Aims: The objective of this retrospective study was to evaluate analgesic outcomes of ultrasound-guided II, IH, and GF nerve blocks in patients with chronic neuropathic pain in the lower abdominal wall and groin. Methods: Analgesic outcomes were assessed at 6 weeks after injections and patients were classified as "responders" if the numerical rating scale for pain score reduced by 30% or more. Variables analyzed for impact on outcomes included demographics, intensity of pain and duration, etiology, dose of opioid, presence of anxiety, depression, and diabetes mellitus. Results: In this cohort of 54 patients with severe baseline pain who had failed to receive analgesic benefit from recommended first- and second-line medications for neuropathic pain, 30 patients had history of surgery and 24 had pain secondary to visceral inflammatory pathologies. Twenty-five (46.3%) patients were identified as responders. A majority of the patients in this cohort had pain for more than one year. There was a higher incidence of diabetes mellitus in nonresponders compared to responders but the difference was not significant (14% and 0%, respectively; P = 0.115). Conclusions: Ultrasound-guided perineural steroids can ameliorate chronic refractory abdominal wall and groin neuropathic pain in patients who have failed to respond to conventional medical management at 6 weeks after the procedures.

Continuous Ilioinguinal-iliohypogastric Nerve Block for Groin Pain in a Breast-feeding Patient after Cesarean Delivery

Ilioinguinal and iliohypogastric (II/IH) nerve injury is one of the most common nerve injuries following pelvic surgery, especially with the Pfannenstiel incision. We present a case of intractable groin pain, successfully treated with a continuous II/IH nerve block. A 33-year-old woman, following emergency cesarean section due to cephalopelvic disproportion, presented numbness in left inguinal area and severe pain on the labia on the second postoperative day. The pain was burning, lancinating, and exacerbated by standing or movement. However, she didn't want to take additional medicine because of breast-feeding. A diagnostic II/IH nerve block produced a substantial decrease in pain. She underwent a continuous II/IH nerve block with a complete resolution of pain within 3 days. A continuous II/IH nerve block might be a goodoption for II/IH neuropathy with intractable groin pain in breast-feeding mothers without adverse drug reactions in their infants.

Usage of a self-adhesive mesh in TAPP hernia repair: A prospective study based on Herniamed Register

INTRODUCTION

Inguinal hernia repair is one of the most frequently performed surgical procedures worldwide in general surgery. The transabdominal laparoscopic (TAPP) approach in the therapy of inguinal hernia seems to be a suitable alternative to classical open inguinal hernia repair mainly in the hands of an experienced surgeon. TAPP repair offers the possibility of gentle dissection with implantation of the mesh and the possibility of non-invasive fixation of the implanted mesh.

MATERIALS AND METHODS

Data analysis encompassed all patients who underwent inguinal hernia surgery at our Surgical Department within the period from July 1, 2012 to September 30, 2014 and who fulfilled the inclusion criteria. The standard surgical technique was used. Data were entered and subsequently analysed on the Herniamed platform. Herniamed is an Internet-based register in German and English, and includes all data of outpatient and hospitalised patients who underwent surgery for some type of hernia. All relevant patient data are collected via Internet.

RESULTS

There were 241 patients enrolled in the group and there were 396 inguinal hernias repaired in total. Standard long-term follow-up after 12 months was evaluated in 205 patients (85.06%), and in the rest of the patients during the closing of the study, but at least 6 months after operation. The mean follow-up was at 19.69 months. At the 1-year assessment, mild discomfort was reported in the groin in 10 patients (4.88%) [1-3 on the visual analogue scale (VAS)]. Post-operative pain lasting over 12 months in the groin of moderate degree (4-6 VAS) was reported in two cases (0.97%). There was no recurrence and no chronic post-operative pain of severe degree reported.

CONCLUSION

Our study demonstrates that laparoscopic inguinal hernia repair using the TAPP technique with the implantation of a self-fixation mesh is fast, effective, reliable and economically advantageous method in experienced hands and, according to our results, reduces the occurrence of post-herniorrhaphy inguinal pain (CPIP) and has a low recurrence rate.

Genitofemoral neuralgia: a review

Genitofemoral neuralgia is a cause of neuropathic pain that is often debilitating in nature. It is characterized by chronic neuropathic groin pain that is localized along the distribution of the genitofemoral nerve. The symptoms include groin pain, paresthesias, and burning sensation spreading from the lower abdomen to the medial aspect of the thigh. It may present with scrotal pain in male, while females experience symptoms radiating to the labia majora and mons pubis. Genitofemoral neuropathy has been attributed to iatrogenic nerve injury occurring during inguinal and femoral herniorrhaphy, with cases developing after both open and laparoscopic techniques. Diagnosis of genitofemoral neuralgia can be challenging, due to the overlap in sensory distribution the nerve shares with the ilioinguinal and iliohypogastric nerve. Differential nerve blocks are recommended in effort to differentiate the nerves when patients present with lower abdominal and groin pain. Once a diagnosis has been made, there exist several treatment options for genitofemoral neuralgia ranging from medical management, non-invasive injections, and surgery. Literature has also brought light to radiofrequency ablation and cryoablation performed under ultrasound guidance as emerging treatments. The aim of the current article is to review the anatomy, diagnostic techniques, and treatment options for patients with genitofemoral neuralgia.

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.

[Management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage]

INTRODUCTION

All surgical procedures require an incision with a risk of nerve damage at the site of the scar or as a result of fibrotic scar tissue. The purpose of this article is to describe the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage.

PATIENTS AND METHODS

A comprehensive review of the literature was performed by searching PUBMED for articles on the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage.

RESULTS

Postoperative lesions of parietal somatic nerves (ilioinguinal, iliohypogastric, genitofemoral, pudendal, obturator, femoral) are frequent after pelvic surgery. Clinical examination of the scars (trigger zone) and detailed analysis of the topography and type of pain are essential elements in the analysis of this pain. Infiltration of local anaesthetic at the trigger point or along the nerve has a diagnostic value. Corticosteroid infiltrations and minimally invasive treatments such as pulsed radiofrequency have provided more or less lasting improvement of the symptoms. Surgical nerve release together with resection of fibrosis and removal of prosthetic material provides good long-term results. The surgical approach depends on the nerve concerned and the level of the lesion.

CONCLUSION

The management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage is based on local infiltration of anaesthetics and corticosteroids. Nerve release surgery with resection of fibrosis provides the best long-term results.

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.