Early pain after laparoscopic inguinal hernia repair. A qualitative systematic review

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.

In vivo comparison of mesh fixation solutions in open and laparoscopic procedures for inguinal hernia repair: A meta-analysis

Background

Abdominal hernia repair surgeries involve the fixation of a surgical mesh to the abdominal wall with different means such as suture, tacks, and glues. Currently, the most effective mesh fixation system is still debated. This review compares outcomes of mesh fixation in different surgical procedures, aiding surgeons in identifying the optimal technique.

Methods

A meta-analysis was conducted according to PRISMA guidelines. Articles published between January 2003 and January 2023 were searched in electronic databases. Randomized controlled trials (RCTs) comparing mesh fixation with cyanoacrylate-based or fibrin glues with classical fixation techniques (sutures, tacks) in open and laparoscopic procedures were included.

Results

17 RCTs were identified; the cumulative study population included 3919 patients and a total of 3976 inguinal hernias. Cyanoacrylate-based and fibrin glues were used in 1639 different defects, suture and tacks in 1912 defects, self-gripping mesh in 404 cases, and no mesh fixation in 21 defects. Glue fixation resulted in lower early postoperative pain, and chronic pain occurred less frequently. The incidence of hematoma was lower with glue fixation than with mechanical fixation. Recurrence rate, seroma formation, operative and hospitalization time showed no significant differences; but significantly, a higher number of people in the glue group returned to work by 15- and 30-days after surgery when compared to the tacker and suture groups in the same time frame.

Conclusion

Cyanoacrylate and fibrin glue may be effective in reducing early and chronic pain and hematoma incidence without increasing the recurrence rate, the seroma formation, or the operative and hospitalization time.

Transversus abdominis plane blocks in laparoscopic inguinal hernia repair: a review

INTRODUCTION

Throughout its history, there have been significant advances in pain control of inguinal hernia repairs. One of the most recent developments is locoregional pain blocks. There is a multitude of literature available on laparoscopic inguinal hernia repair and transversus abdominis plane (TAP) blocks.

OBJECTIVES

This paper seeks to provide a thorough and systematic literature review on the role of TAP blocks in laparoscopic inguinal hernia repairs.

METHODS

PubMed and Google Scholar were searched for relevant literature using predetermined medical subject heading (MeSH) terms: "(TAP block)" AND "(Laparoscopic inguinal hernia repair)".

RESULTS

A total of 166 publications were identified, from which 18 publications were included in the final review after eligibility criteria were applied.

CONCLUSION

The majority of studies conclude that TAP blocks performed in the setting of laparoscopic inguinal hernia repair improve post-operative pain and mobility, decrease opiate analgesic usage, and are superior in pain control compared to other modalities of regional anesthesia. Thus, to improve post-operative outcomes and patient satisfaction, TAP blocks should be heavily considered for routine use in surgical practice for laparoscopic inguinal hernia repair.

Predictive factors of postoperative acute pain in laparoscopic inguinal hernia repair in men: A single-centre retrospective study in Japan

INTRODUCTION

Laparoscopic inguinal hernia repair has significantly reduced the incidence of postoperative acute and chronic pain compared to open repair, but it remains problematic. This study's purpose was to retrospectively identify predictive factors of acute pain after laparoscopic inguinal hernia repair.

METHODS

We reviewed the medical records of 193 patients. After excluding atypical cases and female patients, 156 patients were analysed. Factors affecting rescue analgesic requirements were investigated via multivariable logistic regression analysis. Independent variables included age, body mass index, analgesics used during surgery and surgical factors (unilateral/bilateral, primary/recurrent). The degree of postoperative pain and the hospital stay duration after surgery were also investigated.

RESULTS

Of the 156 patients, 40 (25.6%) required rescue analgesics. Patients under 60 years of age were about seven times more likely to need rescue analgesics than patients over 80 years of age. Primary surgery patients were about 5.5 times more likely to need rescue analgesics than recurrent surgery patients. The maximum verbal rating scale score was less than 3 in 89% of patients. All patients were discharged by two days postoperatively.

CONCLUSION

Laparoscopic inguinal hernia repair results in less postoperative acute pain. However, analgesia management should be considered prudently for younger patients and primary surgery patients.

Extraperitoneal Laparoscopic Approach in Inguinal Hernia—The Ideal Solution?

Background: After more than 20 years since laparoscopy was proposed as a solution for one of the most common surgical pathologies, inguinal hernia, the choice of an intra- or extraperitoneal approach has remained a highly debated topic. Purpose and objectives: This study aimed at analyzing the feasibility of the extraperitoneal approach, by routine for this team/ and answering the question of whether this type of approach can be considered a safe one. Although indications for an intra- or extraperitoneal approach largely overlap, it may also be a matter of surgeon preference in choosing one technique. Methods: The study was retrospective, conducted on a group of 493 patients operated on for inguinal hernia in the clinic, by a single operating team, between January 2012 and March 2022. Results: It was proven that out of the 493 surgeries for inguinal hernia, 95.1% (n = 469) were operated upon by laparoscopic TEP (total extra peritoneal patch plasty approach); 1.62% (n = 8) by laparoscopic TAPP (transabdominal intraperitoneal); and 3.24% (n = 16) by the open, anterior approach (Lichtenstein). There were no intraoperative complications recorded in any of the procedures, while postoperative complications were found in 10.23% of cases (n = 48) in the extraperitoneal approach, and recurrences after the TEP approach were recorded in 0.40% of cases (n = 2). Conclusions: For correctly selected cases, TEP hernia surgery can be considered a safe and reliable approach.

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.

The efficacy and safety of preoperative glucocorticoids in herniorrhaphy: a systematic review and meta-analysis

Postoperative pain is the main reason for delayed recovery after herniorrhaphy. Preoperative glucocorticoid administration may improve postoperative recovery. The present study assessed the efficacy of preoperative glucocorticoids in facilitating recovery after herniorrhaphy. Randomized controlled trials (RCTs) conducted up to January 2021 were searched in electronic databases and trial registries. Meta-analyses were performed using random effects models. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence. Seven RCTs (744 patients) were included in the meta-analysis. Preoperative glucocorticoid administration reduced patients' pain on postoperative day 0 (standard mean difference [SMD] = - 0.73, 95% confidence interval [CI] - 1.45 to - 0.01; I² = 94%). However, there was no marked difference in rescue analgesic use (risk ratio [RR] = - 0.06, 95% CI - 0.28 to - 0.16; I² = 0%) or vomiting (RR = 0.78, 95% CI 0.50-1.20; I² = 30%) between preoperative glucocorticoid administration and control. The certainty of evidence was moderate because of inconsistencies or imprecision. No serious adverse effects were observed. Preoperative glucocorticoid administration reduced pain in patients following herniorrhaphy without increasing the occurrence of adverse events. Further studies will be required to confirm the efficacy of preoperative glucocorticoids.

Laparoscopic repair of inguinal hernias: Risk factors for urinary retention and chronic pain after totally extraperitoneal repair and transabdominal preperitoneal repair

Purpose

There are various opinions about the postoperative complications of the two methods for laparoscopic inguinal hernia surgery; totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). The aim of this study was to compare the postoperative course after TAPP and TEP, focusing on immediate postoperative pain, incidence of postoperative urinary retention (POUR), and chronic pain.

Methods

This study retrospectively analyzed a consecutive series of 344 inguinal hernia patients who were treated with laparoscopic surgery between November 2016 and December 2019 at a single tertiary referral center.

Results

Patient demographics did not differ significantly between the groups. The operation time was significantly shorter in the TEP group than in the TAPP group (43.1 ± 14.9 minutes vs. 63.5 ± 16.5 minutes, p < 0.001). The postoperative pain scores were significantly lower in the TEP group than in the TAPP group immediately (3.6 ± 1.3 vs. 4.4 ± 1.1, p < 0.001) and 6 hours (1.5 ± 1.4 vs. 2.3 ± 1.8, p < 0.001) after the operation. The other complications did not differ significantly between the groups. Age was a significant risk factor for POUR (odds ratio [OR], 1.083; 95% confidence interval [CI], 1.018–1.151; p = 0.011), and history of benign prostate hyperplasia (BPH) was a significant risk factor for chronic pain (OR, 5.363; 95% CI, 1.028–27.962; p = 0.046).

Conclusion

TEP and TAPP seem to be safe and effective for laparoscopic inguinal hernia repair and have similar postoperative outcomes. Age was a significant risk factor for POUR, and BPH history was a significant risk factor for chronic pain.

Determination of the efficacy of ultrasound-guided bilateral transversus abdominis plane (US-TAP) block in laparoscopic total extraperitoneal (TEP) repair of unilateral hernia surgeries: A randomized controlled trial

Background and Aims:

Bilateral ultrasound-guided transversus abdominis plane (US-TAP) block has been successfully used to provide analgesia for most lower abdominal procedures. Our aim was to determine the efficacy of US-TAP block with levobupivacaine in laparoscopic total extraperitoneal (TEP) repair of unilateral hernia surgeries under general anaesthesia (GA) as compared to no block.

Material and Methods:

It is prospective randomised controlled study done in a tertiary care centre in South-East Asia. After obtaining Institute Ethics Committee approval and consent, 60 patients of ASA I-II aged between 18 to 80 years were randomized into two groups.After receiving GA, Group TAP - received bilateral US-TAP block with levobupivacaine 0.25% 0.3ml kg^-1 on either side whereas, the control group did not receive any block.The time taken to first request for rescue analgesic (T Rescue) by the patient and the Numeric Rating Scale (NRS) at that time point were noted and tramadol 50mg i.v. was administered, followed by 50mg i.m. PRN for 24 h from the time of extubation. The 24 h analgesic requirement was noted in mg kg^-1.

Results:

Results were analysed using SPSS 16 and P < 0.05 was considered significant. T Rescue was significantly longer in the TAP Group (P = 0.02) with lower NRS at time points 24 h (P = 0.02) and 12 h (P = 0.004). Postoperative nausea and vomiting were significantly less in TAP Group (P < 0.001).

Conclusion:

Bilateral US-TAP block provided better analgesia and side effect profile as compared to no block when administered in laparoscopic TEP repair of hernia surgeries.

Novel local anaesthesia technique 'NATURE' (Nerves And Transversalis-fascia Using RopivacainE) to improve outcomes during endo-laparoscopic inguinal hernia repair

BACKGROUND

The use of local anaesthesia infiltration techniques may attenuate pain following endo-laparoscopic inguinal hernia surgery. We aim to reduce post-operative pain and the subsequent need for analgesia using a novel technique of local anaesthesia infiltration 'NATURE' (Nerves And Transversalis-fascia Using RopivacainE).

METHODS

This is a retrospective study of patients who underwent endo-laparoscopic inguinal hernia repair in two institutions in Singapore. Patients who received the local anaesthesia according to the new technique (intervention group) were compared to patients who received local anaesthesia only over their surgical incisions (control group).

RESULTS

Data on 97 patients were analysed. There were 50 (51.5%) patients in the intervention group and 47 (48.5%) patients in the control group. No significant differences were observed in the two patient population's baseline characteristics, operative time and cumulative need for medications. The intervention group reported lower pain levels immediately after surgery (1.4 ± 1.7 versus 2.4 ± 1.9, p<0.01) and at 4 hours post-surgery (0.9 ± 1.1 versus 1.4 ± 1.2, p = 0.02). They also had lower levels of post-operative complications (4% versus 21.3%, p = 0.03).

CONCLUSION

Infiltration of local anaesthesia at specific anatomical locations during endo-laparoscopic inguinal hernia surgery can be effective in minimising post-operative pain. Prospective randomised controlled trials are needed to further substantiate this technique.

Visceral versus somatic pain: an educational review of anatomy and clinical implications

Somatic and visceral nociceptive signals travel via different pathways to reach the spinal cord. Additionally, signals regulating visceral blood flow and gastrointestinal tract (GIT) motility travel via efferent sympathetic nerves. To offer optimal pain relief and increase GIT motility and blood flow, we should interfere with all these pathways. These include the afferent nerves that travel with the sympathetic trunks, the somatic fibers that innervate the abdominal wall and part of the parietal peritoneum, and the sympathetic efferent fibers. All somatic and visceral afferent neural and sympathetic efferent pathways are effectively blocked by appropriately placed segmental thoracic epidural blocks (TEBs), whereas well-placed truncal fascial plane blocks evidently do not consistently block the afferent visceral neural pathways nor the sympathetic efferent nerves. It is generally accepted that it would be beneficial to counter the effects of the stress response on the GIT, therefore most enhanced recovery after surgery protocols involve TEB. The TEB failure rate, however, can be high, enticing practitioners to resort to truncal fascial plane blocks. In this educational article, we discuss the differences between visceral and somatic pain, their management and the clinical implications of these differences.

The learning curve of laparoscopic inguinal hernia repair: a comparison of three inexperienced surgeons

Introduction

Studies with inexperienced surgeons in terms of the learning curve for laparoscopic totally extraperitoneal (TEP) inguinal hernia repair are limited.

Aim

To compare three inexperienced surgeons in terms of the learning curve without supervision.

Material and methods

Patients’ data, which were from consecutive laparoscopic TEP hernioplasties between December 2017 and February 2020, were analysed retrospectively. The primary outcome was to compare the learning curve of three surgeons (Surgeon A, B, and C) in terms of complications, conversion, and duration of surgery. Secondary outcomes were recurrence rates.

Results

A total of 299 patients were included in the study. Conversion and intraoperative complication rates decreased after the first 60 cases (from 10% to 2.5%, p = 0.013 and from 9% to 2.5%, p = 0.027, respectively). The mean operative time reached a plateau of less than 40 min after 51–81 cases (Surgeon A 51, B 71, and C 81 cases). Ageing was a risk factor for intraoperative complications and recurrence (p < 0.001, p = 0.008, respectively), and higher body mass index (BMI) was a risk factor for conversion (p = 0.004). Age ≥ 60 years compared to age < 60 years increased intraoperative complications five-fold and recurrence six-fold (p = 0.001). On the other hand, BMI ≥ 30 kg/m² increased the possibility of conversion to open surgery nine-fold (p < 0.001). In addition, a positive correlation was found between the operative time and the BMI and VAS score (p = 0.004, p = 0.015, respectively).

Conclusions

In order to reach the plateau in the operative time during the TEP learning curve period, more than 50 cases should be experienced, whereas more than 60 cases are needed for conversion, intraoperative complications, and recurrence.

Comparison of types 2 and 3 quadratus lumborum muscle blocks : Open inguinal hernia surgery in patients with spinal anesthesia

OBJECTIVE

The efficacy of quadratus lumborum muscle block (QLB) in abdominal surgery is known; however, the efficacy of different QLB types is unclear. The objective of this study was to investigate the effects of ultrasound-guided QLB type 2 and type 3 on postoperative opioid consumption and pain scores in patients undergoing inguinal hernia surgery.

MATERIAL AND METHODS

In this study 60 patients undergoing open inguinal hernia surgery were randomly assigned to 3 groups. Group QLB2 received ultrasound-guided QLB type 2 and group QLB3 received ultrasound-guided QLB type 3 with 0.25% 20 mL bupivacaine. In the control group (group C) no intervention was performed. Postoperative analgesia was performed intravenously with 1000 mg paracetamol every 6 h and patient-controlled analgesia with fentanyl. Postoperative visual analog scale scores (VAS), opioid consumption, and first analgesic requirement time were evaluated.

RESULTS

Fentanyl consumption was significantly higher in group C compared to the other groups at all time intervals (p < 0.05). Fentanyl consumption was significantly higher in group QLB2 compared to QLB3 at the 4-8 h, 8-24 h, and total 24 h. Passive VAS 4h and 8 h, active VAS 4h, 8h, and 12 h were significantly lower in group QLB3 compared to QLB2 (p < 0.05). The first analgesic time was significantly later in group QLB2 compared to group C (280.52 ± 89.20 min and 183.75 ± 42.79 min, respectively) and even later in group QLB3 compared to the other two groups (463.42 ± 142.43 min, p < 0.05).

CONCLUSION

The use of QLB2 and QLB3 decreased postoperative opioid consumption and pain scores in patients undergoing inguinal hernia surgery. Furthermore, QLB3 provided more effective and longer lasting postoperative analgesia and lower opioid consumption compared to QLB2.

Consensus on international guidelines for management of groin hernias

BACKGROUND

Groin hernia management has a significant worldwide diversity with multiple surgical techniques and variable outcomes. The International guidelines for groin hernia management serve to help in groin hernia management, but the acceptance among general surgeons remains unknown. The aim of our study was to gauge the degree of agreement with the guidelines among health care professionals worldwide.

METHODS

Forty-six key statements and recommendations of the International guidelines for groin hernia management were selected and presented at plenary consensus conferences at four international congresses in Europe, the America's and Asia. Participants could cast their votes through live voting. Additionally, a web survey was sent out to all society members allowing online voting after each congress. Consensus was defined as > 70% agreement among all participants.

RESULTS

In total 822 surgeons cast their vote on the key statements and recommendations during the four plenary consensus meetings or via the web survey. Consensus was reached on 34 out of 39 (87%) recommendations, and on six out of seven (86%) statements. No consensus was reached on the use of light versus heavy-weight meshes (69%), superior cost-effectiveness of day-case laparo-endoscopic repair (69%), omitting prophylactic antibiotics in hernia repair, general or local versus regional anesthesia in elderly patients (55%) and re-operation in case of immediate postoperative pain (59%).

CONCLUSION

Globally, there is 87% consensus regarding the diagnosis and management of groin hernias. This provides a solid basis for standardizing the care path of patients with groin hernias.

AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region. PERSPECTIVE: Using AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.

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.

TEP for elective primary unilateral inguinal hernia repair in men: what do we know?

INTRODUCTION

Based on the new international guidelines for groin hernia management, there is no one surgical technique that is suited to all patient characteristics and diagnostic findings. Therefore, a tailored approach should be used. Here, a distinction must be made between primary unilateral inguinal hernia in men and in women, bilateral inguinal hernia, scrotal inguinal hernia, inguinal hernia following pelvic and lower abdominal procedures, patients with severe cardiopulmonary complications, recurrent inguinal hernias and incarcerated inguinal and femoral hernias. This paper now explores the relevant studies on TEP for elective primary unilateral inguinal hernia in men, which constitutes the most common indication for repair.

MATERIAL

A systematic search of the available literature was performed in February 2019 using Medline, PubMed, Scopus, Embase, Springer Link and the Cochrane Library. Only meta-analyses, systematic reviews, RCTs and comparative registry studies were considered. 117 publications were identified as relevant.

RESULTS

RCTs and comparative registry analyses demonstrated the advantages of TEP with regard to postoperative complications, complication-related reoperations, and postoperative and chronic pain compared with Lichtenstein repair for elective primary unilateral inguinal hernia repair in men. No relevant differences were found compared with TAPP. Mesh fixation is not needed in TEP, but heavyweight meshes result in a lower recurrence rate. Extraperitoneal bupivacaine analgesia vs placebo does not demonstrate any advantages, but drainage is advantageous for seroma prophylaxis. The risk of chronic pain is negatively influenced by small defects, younger patient age, preoperative pain, higher BMI, postoperative complications, higher ASA score and risk factors.

CONCLUSION

For the subgroup of elective primary unilateral inguinal hernia in men, accounting for a proportion of less than 50% of the total collective, advantages were identified for TEP compared with open Lichtenstein repair but not versus TAPP.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Transversus abdominis plane block for pain relief in patients undergoing in endoscopic repair of abdominal wall hernia: A comparative, randomised double-blind prospective study

Introduction:

Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia.

Methods:

Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events.

Results:

The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P < 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P < 0.001 in hours. No adverse events were observed in any group.

Conclusion:

This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.

Early Surgical Intervention following Inguinal Hernia Repair with Severe Postoperative Pain

INTRODUCTION

Severe postoperative pain is an important risk factor for onset of chronic inguinal pain following inguinal hernia repair. All measures must be taken to eliminate postoperative pain.

MATERIALS AND METHODS

This case report highlights the problems of severe postoperative pain following transabdominal preperitoneal patch plasty (TAPP) inguinal hernia repair and describes a systematic treatment path that may include surgical intervention.

RESULTS

Following TAPP operation for lateral inguinal hernia, this patient who had been operated on in an external hospital still experienced intense, stabbing inguinal pain on postoperative day 7 during movement, despite optimal pain treatment. Diagnostic examination did not reveal any findings of note. The surgical report documented that the surgeon had used metallic tacks for mesh fixation, i.e., at the pectineal line of the pubic bone, pubic symphysis, upper margin of the mesh, and for closure of the peritoneum. During surgical revision on postoperative day 7, eight tacks and the mesh were removed and, following further dissection, a new mesh was placed and fixed with glue. The patient's intense stabbing pain resolved immediately after surgery.

CONCLUSION

Since the results of late intervention for chronic inguinal pain are anything but satisfactory, early surgical intervention should be considered for patients with severe postoperative pain >3 days of suspected surgical origin.

Endo-laparoscopic inguinal hernia repair: What is its role?

Hernia repair techniques vary greatly depending upon the setting, surgeons, insurance reimbursement systems, resources, and logistical capabilities. Open mesh repair is the most frequently used technique. Choosing the best technique for inguinal hernia repair is a challenge. There is no single technique to manage every type of hernia. Today, laparoscopy and robotics are at the forefront of advanced surgical tools and offer a range of options for general surgeons who are critically evaluating new procedures. However, before using a new procedure, such as endo-laparoscopic hernia repair, surgeons often ask the rhetorical question, "Why change?" The common considerations are the availability of equipment, familiarity with the anatomy when using these techniques, operative time, cost to the patient, and the potential need to convert to an open procedure. Additionally, we are now seeing a significant shift away from surgeon-defined benefits to patient-defined benefits. As patients become more aware of their options for hernia procedures and share their experiences, more and more patients are likely to demand a particular technique. Hence, hernia surgeons should be educated on the different techniques available for inguinal hernia repair, including endo-laparoscopic procedures. In this article, we review the existing literature on the current role of endo-laparoscopic inguinal hernia repair.

Laparoscopic Total Extraperitoneal Hernia Repair Outcomes

Background and Objectives:

Laparoscopic inguinal hernia repair has become increasingly popular as an alternative to open surgery. The purpose of this study was to evaluate the safety and effectiveness of the laparoscopic total extraperitoneal procedure with the use of staple fixation and polypropylene mesh.

Methods:

A retrospective chart review examined outcomes of 1240 laparoscopic hernia operations in 783 patients, focusing on intraoperative and early postoperative complications, pain, and time until return to work and normal physical activities.

Results:

There were no intraoperative complications in this series; 106 patients experienced early postoperative complications across 8 evaluated categories: urinary retention (4.1%), seroma (3.0%), testicular/hemiscrotal swelling (1.9%), testicular atrophy (0%), hydrocele (0.6%), mesh infection (0.1%), and neurological symptoms (transient, 1.0%; persistent, 0.2%). Patients used an average of 5.6 Percocet pills after the procedure, and mean times until return to work and normal activities, including their routine exercise regimen, were 3.0 and 3.8 days, respectively.

Conclusion:

Complication rates and convalescence times were considered equivalent or superior to those found in other studies assessing both laparoscopic and open techniques. The usage of multiple Endostaples did not result in increased neurologic complications in the early postoperative period when compared with findings in the literature. In the hands of an experienced surgeon, total extraperitoneal repair is a safe, effective alternative to open inguinal hernia repair.

Spinal versus general anesthesia for transabdominal preperitoneal (TAPP) repair of inguinal hernia: Interim analysis of a controlled randomized trial

BACKGROUND

General anesthesia has been used as standard for laparoscopic hernia repair by the transabdominal preperitoneal (TAPP) approach. Regional anesthesia has been occasionally applied in high risk patients where general anesthesia is contraindicated. This randomized clinical trial compares spinal anesthesia with general anesthesia for TAPP inguinal hernia repair in non-high risk patients.

METHODS

Seventy adult American Society of Anesthesiologists I, II and III patients undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia.

RESULTS

Postoperative morphine consumption was significantly less immediately postoperatively (p < 0.001) in the spinal anesthesia group. Postoperative pain was also significantly decreased within the first 8 h postoperatively (p < 0.05) in the spinal anesthesia group.

CONCLUSIONS

Spinal anesthesia offers some advantages in patient analgesia during the early postoperative period after TAPP inguinal hernia repair and can be proposed as an effective alternative method of anesthesia for TAPP repair.

Long-term patterns and predictors of pain following laparoscopic inguinal hernia repair: a patient-centered analysis

BACKGROUND

Laparoscopic inguinal hernia repair has been shown to offer patients the benefit of less postoperative pain as compared to traditional open techniques. However, the risk of experiencing significant postoperative pain may affect patient's decision making. We aimed to elucidate potential patterns of pain and the predictors of such, up to 2 years postoperatively, using both generic and specific quality of life tools.

METHODS

Patients undergoing laparoscopic totally extra-peritoneal inguinal hernia repair were identified from a prospectively maintained database. Short form-36, Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS) surveys were administered pre- and postoperatively at 3 weeks, 6 months, 1 and 2 years. Patients with concomitant procedures were excluded. Significant pain was considered mild but bothersome or worse on either specific tool (SOMS scores ≥3/4, CCS scores ≥2). Predictors of significant pain were determined by logistic regression.

RESULTS

From 2009 to 2015, 482 patients enrolled in our database underwent elective TEP repair of 626 hernias and completed an assessment tool. Mean age was 57 (±15) years, with 93 % male. Reported pain on all three tools improved significantly from baseline over time (p < 0.01). Significant pain on either specific tool, related or unrelated to surgery, was reported by 52 % of respondents (158/301) preoperatively, and postoperatively by 50 % at 3 weeks (111/220), 21 % at 6 months (15/70), 13 % at 1 year (14/108), and 25 % at 2 years (30/121). Significant pain at 6 months-2 years correlated more significantly with general health status than surgical factors.

CONCLUSIONS

Significant pain can be as high as 50 % at 3 weeks on surgery-specific quality of life measures, but with significant improvement by 6 months which is maintained through 2 years. Poor quality of life and general health were the main predictors of pain after 6 months.

Pain Characteristics after Total Laparoscopic Hysterectomy

Background. Total laparoscopic hysterectomy (TLH) causes various types of postoperative pain, and the pain pattern has not been evaluated in detail to date. This prospective observational study investigated the types of postoperative pain, intensity in the course of time, and pain characteristics during the first postoperative 72 hr after TLH. Methods. Sixty four female patients undergoing TLH were enrolled, which finally 50 patients were included for the data analyses. The locations of pain included overall pain, abdominal visceral and incisional pains, shoulder pain, and perineal pain. Assessments were made at rest and in motion, and pain level was scored with the use of the 100 mm visual analog scale. The pain was assessed at baseline, and at postoperative 30 min, 1 hr, 3 hr, 6 hr, 24 hr, 48 hr, and 72 hr. Results. Overall, visceral, and incisional pains were most intense on the day of operation and then decreased following surgery. In contrast, shoulder pain gradually increased, peaking at postoperative 24 hr. Shoulder pain developed in 90% of all patients (44/50). It was not more aggravated in motion than at rest, in comparison with other pains, and right shoulder pain was more severe than left shoulder pain (p=0.006). In addition, the preoperative exercise habit of patients increased the threshold of shoulder pain. Most patients (46/50) had perineal pain, which was more severe than abdominal pain in approximately 30% of patients (17/50). Conclusion. Pain after TLH showed considerably different duration, severity, and characteristics, compared with other laparoscopic procedures. Shoulder pain was most intense at postoperative 24 hr, and the intensity was associated with the prior exercise habit of patients and the high level of analgesic request.

Systematic review: laparoscopic treatment of long-standing groin pain in athletes

OBJECTIVES

No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes.

DATA SOURCES

The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations.

RESULTS

Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266).

CONCLUSIONS

Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair

Background

The mesh fixation technique in laparoscopic incisional hernia repair may influence the rates of hernia recurrence and chronic pain. This study investigated the long-term risk of recurrence and chronic pain in patients undergoing laparoscopic incisional hernia repair with either absorbable or non-absorbable tacks for mesh fixation.

Methods

This was a nationwide consecutive cohort study based on data collected prospectively concerning perioperative information and clinical follow-up. Patients undergoing primary, elective, laparoscopic incisional hernia repair with absorbable or non-absorbable tack fixation during a 4-year interval were included. Follow-up was by a structured questionnaire regarding recurrence and chronic pain, supplemented by clinical examination, and CT when indicated. Recurrence was defined as either reoperation for recurrence or clinical/radiological recurrence.

Results

Of 1037 eligible patients, 84·9 per cent responded to the questionnaire, and 816 were included for analysis. The median observation time for the cohort was 40 (range 0–72) months. The cumulative recurrence-free survival rate was 71·5 and 82·0 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·007). In multivariable analysis, the use of absorbable tacks was an independent risk factor for recurrence (hazard ratio 1·53, 95 per cent c.i. 1·11 to 2·09; P = 0·008). The rate of moderate or severe chronic pain was 15·3 and 16·1 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·765).

Conclusion

Absorbable tack fixation of the mesh was associated with a higher risk of recurrence than non-absorbable tacks for laparoscopic mesh repair of incisional hernia, but did not influence chronic pain.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic versus open inguinal hernia repair

The laparoscopic approach to inguinal hernia surgery is safe and reliable. It has a similar recurrence rate as open tension-free mesh repair. Because the laparoscopic approach has less chronic postoperative pain and numbness, fast return to normal activities, and decreased incidence of wound infection and hematoma, it should be considered an appropriate approach for inguinal hernia surgery. These results can be achieved if a surgeon is proficient in the technique, has a clear understanding of the anatomy, and performs it on a regular basis. This article focuses on questions related to laparoscopic inguinal hernia surgery and provides answers based on published literature.

Female gender is a risk factor for pain, discomfort, and fatigue after laparoscopic groin hernia repair

PURPOSE

Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair.

METHODS

Prospective consecutive enrollment of women and age-matched (± 1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol.

RESULTS

Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0-3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002).

CONCLUSIONS

Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair.

TRIAL REGISTRATION

Registration number NCT00962338 ( www.clinicaltrials.gov ).