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Chronic Postoperative Inguinal Pain (CPIP)
207
17
(GB) with 189 cases in which the nerves were
divided. Aer 6 months, there was signicant
more moderate-to-severe pain in the nerve dividing group (4.7% vs 0%; p<0.02). e authors concluded that the three inguinal nerves should be
identied and preserved.
Several randomized trials have studied prophylactic neurectomy vs preservation of the
ilioinguinal nerve. ree meta-analyses concluded that there was no signicant dierence
in chronic pain [25–27]. e most recent metaanalyses reported more sensory loss 6months
and 1 year aer neurectomy of the IIN [27].
Two RCT on preservation vs neurectomy of the
IHN revealed no dierence in chronic pain but
more numbness aer neurectomy. ere are no
RCT comparing preservation and neurectomy
of the GB.
According to relevant trials, meta-analyses,
and guidelines, a general prophylactic neurectomy in open inguinal hernia repair cannot be
recommended since it does not reduce the risk of
CPIP and adds sensory loss which is in itself a risk
factor for chronic pain [12, 25–27].
In recent years the term pragmatic neurectomy
has been coined for the resection of nerves being
damaged by the hernia, scar tissue, and surgical
trauma or nerves being at risk for damage mainly
due to interference with mesh [28, 29]. Despite the
fact that no RCTs have been conducted on this
issue and the term “nerve at risk” has not been
clearly dened, the pragmatic neurectomy
approach is currently favored by the majority of
specialized hernia surgeons. Currently it is considered good surgical practice to preserve only intact
nerves who are unlikely to cause chronic pain.
e pragmatic neurectomy approach is
strongly supported by a prospective nonrandomized two-phase trial of 781 patients with
primary inguinal hernias who had a Shouldice
operation (LI, LII, MI inguinal hernias) or
Lichtenstein repair (LIII, MII, MIII hernias; 12).
Aer 5years Lichtenstein repair with ilioinguinal nerve mobilization and preservation repair
was an independent signicant risk factor for
chronic pain. Eleven out of 12 patients with relevant chronic pain (VAS > 3) at 5 years had
Lichtenstein repair with mobilization of the ilioinguinal nerve. e conclusion of this study was
that mesh contact with a nerve removed from its
natural bed should be avoided, supporting the
notion that nerve resection is superior to leaving
an injured nerve intact or allowing mesh/nerve
contact to occur [12].
17.8 Treatment ofChronic Post-
inguinal Hernia Repair Pain
e treatment of chronic pain aer inguinal hernia
repair remains a signicant challenge due to the
complexity of overlapping etiologies, variable neuroanatomy, and psychologic and social factors that
confound the presentation and complicate treatment. Because of this intrinsic heterogeneity, there
is little high-level evidence regarding standard
treatment algorithms, and most recommendations
are based upon expert experience and opinion.
Obvious anatomic or pathologic abnormalities related to the prior repair should be corrected when identied. Infection should be
treated with appropriate antibiotic therapy and
may necessitate mesh removal for resolution. If
hematoma or seroma are identied, these may
be drained if conservative management fails.
Recurrence, if identied, should be addressed. In
general, a recurrence encountered aer open
surgery is best xed laparoscopically, while a
laparoscopic recurrence may be addressed using
an open anterior approach, thereby avoiding the
prior scarred eld and risks associated with
reoperative anatomy. However, in the patient
that presents with pain and recurrence, oentimes evaluation of the initial repair and operative eld is revealing and necessary to correct the
component of pain.
An expectant period of at least 3months aer
the original index operation is recommended
prior to consideration for any remedial operation
as the denition of chronic pain implies a sucient duration to allow for resolution of normal
and typical postoperative inammation [13, 32].
With regard to mesh repair, this period is typically
extended to 6months because of the normal healing processes, inammation, integration, and
remodeling that occur at the mesh-tissue interface. During this period, conservative measures,
pharmacologic and behavioral treatments, and
nonoperative interventions should be employed.
Involvement of a multidisciplinary team including a pain management specialist is recommended
[13, 32].
208
W. Reinpold and D. Chen
17
17.9 Pharmacologic and
Non- pharmacologic
Treatment Options
Patients with signicant chronic post-inguinal
repair pain are initially primarily managed with
pharmacologic therapy including opioid and
non-opioid analgesics. Opioids are oen administered because of the severity and intensity of
pain but are rarely eective in addressing the
underlying cause of pain. Because of their numerous side eects, risks, and addictive potential,
long-term usage is best managed by a pain specialist using long-acting formulations to mitigate
these risks. Nonsteroidal anti-inammatory analgesics may be of benet but also have long-term
implications. Neuropathic pain may be initially
addressed with pharmacologic agents. Atypical
antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors) and nerve stabilizing anticonvulsants (gabapentin and
pregabalin) have demonstrated benet with neuropathic pain and are routinely used for postinguinal herniorrhaphy pain [33]. Remarkably,
all pharmacologic treatments (e.g., NSAIDs,
acetaminophen, TCAs, SSRIs, gabapentin, pregabalin, and opioids) used in the specic treatment
of post-hernia inguinal repair pain have rarely
been studied, and ecacy is extrapolated from
the generalized pain literature [34, 35]. Limited
evidence exists for the use of lidocaine patches,
but the minimal morbidity and side eect prole
makes a trial reasonable [36]. Similarly, capsaicin
patches can serve as an adjunctive therapy with
little risk, low cost, and some potential for clinical
benet [37].
ere is little evidence specically supporting
non-pharmacologic treatment options for postinguinal herniorrhaphy chronic pain (e.g., psychotherapy, hypnosis, behavioral therapy, biofeedback,
acupuncture, mind-body therapy). However, the
interaction of psychologic, cognitive, and emotional factors on physical pain cannot be ignored.
Within the generalized pain management literature, these non-pharmacologic options have been
used to modulate perceptions and responses to
chronic pain [34]. A stepwise approach using multimodal treatment is important and reasonable;
noninterventional options should be exhausted
prior to consideration for reoperation.
17.10 Role ofInterventional
Nerve Blocks
ere is insucient high-quality evidence
regarding the value of nerve blocks in the management of neuropathic post-inguinal repair
pain. In clinical practice however, nerve blocks
of the ilioinguinal, iliohypogastric, or genital
nerve serve both a diagnostic and therapeutic
role. is may be performed using anatomic
landmarks, nerve stimulation, or ultrasound
guidance to improve nerve identication and
accuracy. No study has proven that adjunctive
techniques (e.g., ultrasound, nerve stimulation)
improve the ecacy of blocks [38, 39]. If blocks
transiently alleviate the pain, this helps to delineate a neuropathic component and provides a
reasonable prognostic justication for future
neurectomy if needed. If blocks are eective at
reducing pain, repeat blocks are recommended
as they may interrupt the pain cycle and in some
cases alleviate pain. If this positive eect is
achieved but not durable, neuroablative techniques (e.g., radiofrequency ablation, chemo/
cryoablation) or operative neurectomy is indicated. Cryoablation of the inguinal nerves has
been eective in limited series [40]. Pulsed
radiofrequency ablation has been demonstrated
to be an eective treatment for chronic pain aer
inguinal hernia repair [41]. As with neurectomy,
the ecacy of these techniques is predicated
upon proper patient selection, identifying nerve
lesions that are likely to respond to ablation, procedural technique, and being able to access the
nerve proximal to the injury.
An ineective nerve block may or may not be
indicative of neuropathic involvement as ecacy,
and success is operator and anatomy dependent.
Computed tomography guidance has been used
to access the genitofemoral nerve proximal to
prior posterior repair over the psoas muscle [39].
Additionally, paravertebral and epidural blocks
may be helpful as they access the nerves proximally closer to the nerve root origins where the
neuroanatomy is more consistent and predictable.
is is especially useful aer ineective inguinal
nerve blockade and with pain aer prior posterior
repair (laparoscopic and preperitoneal herniorrhaphy) where the level of nerve injury is likely
proximal to the inguinal canal.
Chronic Postoperative Inguinal Pain (CPIP)
209
17
17.11 Nerve Stimulation, Spinal
Cord Stimulation,
andNeuromodulation
Nerve stimulation, spinal cord stimulation, and
neuromodulation have been used to address neuropathic chronic post-inguinal herniorrhaphy
pain. ese modalities approach the nerve
pathology proximal to the groin at the level of the
peripheral nerve, spinal cord, or dorsal root ganglia. As with most of the literature related to this
topic, there is only weak evidence supporting
their use limited to case series, retrospective
reviews, and case reports. Implantable peripheral
nerve stimulators have demonstrated pain reduction in small series [42]. Spinal cord stimulation
has also been used to treat refractory neuropathic
inguinodynia [43]. Early ndings suggest that
neuromodulation of the dorsal root ganglia
(DRG) may be a more targeted and eective
treatment for chronic neuropathic pain conditions in the groin region than nonselective nerve
stimulation. Preliminary studies are all low level
of evidence (retrospective, case series, lack control groups, short follow-up periods) but report
promising outcomes with sustained pain relief,
quality-of-life improvement, and/or reduction of
analgesic use [44]. e drawbacks of these
modalities include that these technologies are
extremely expensive and are non-focused with
regard to the underlying pathology. In general,
these options should be reserved for refractory
cases in which a solution cannot be found within
the inguinal region or for inguinal and regional
pain syndromes not secondary to prior hernia
repair. For cases of refractory inguinodynia unresponsive to remedial surgery, proximal nerve
stimulation or neuromodulation provides a
promising option [34, 35].
17.12 Operative Treatment ofPost-
inguinal Herniorrhaphy
Inguinodynia
Patients that are refractory to conservative measures and out of the expectant period of normal
healing from the herniorrhaphy may be considered for operative remediation. However, failure
of conservative therapy in of itself is not a justi-
cation for surgery. Successful outcomes are predicated upon careful patient selection to identify
specic neuroanatomic, structural, and meshrelated problems that are amenable to correction.
In general, mesh-related problems (folding, wrinkling, meshoma), foreign body reaction (suture,
tacks, xation), nerve lesions of the inguinal
nerves, and recurrence may be corrected with
operative intervention. In-depth knowledge of
the inguinal and retroperitoneal neuroanatomy,
technical details of the original repair, review of
current cross-sectional imaging, and evaluation
of response to prior interventions and nonoperative treatment are essential to determine the likely
mechanism for pain and the options for surgery
and the optimal operative approach [13, 32].
17.13 Neurectomy forNeuropathic
Inguinodynia
High-level evidence is lacking regarding operative
neurectomy for chronic post-inguinal herniorrhaphy pain. However, there is a signicant volume of experiential data from the last 30 years
regarding the role and ecacy of selective and
triple inguinal neurectomy of the inguinal nerves
[17, 45–52]. Retrospective and prospective series
reporting outcomes of triple neurectomy operations range from 85 to 100% pain improvement.
Selective single or double neurectomy studies
generally report slightly lower success rates. ere
are no studies comparing selective and triple neurectomies, and, given the heterogeneity of patients
and etiologies, a systematic study is unlikely.
Triple neurectomy data is mostly derived from a
single institute reporting sequentially accumulated data with over 600 open and 80 endoscopic
neurectomies performed over 30 years [17, 48,
49]. However, similar results have been achieved
by others [50]. In both selective and triple neurectomy studies, systematic evaluation with pain
scores, follow-up, questionnaire and neurologic
examination techniques is inconsistent and oen
absent. Consideration regarding the choice of
selective versus triple neurectomy must balance
the diculty of being able to reliably identify and
access the aected inguinal nerves with the resultant numbness and collateral damage of a more
extensive neurectomy.
17
210
W. Reinpold and D. Chen
In 2011, an international consensus conference developed guidelines for the treatment of
chronic post-inguinal herniorrhaphy pain recommending best available clinical practices [13]. In
2016, Hernia Surge, a collaboration from the ve
major international hernia societies, developed
evidence-based guidelines for the treatment of
chronic post-inguinal repair pain based upon the
available literature, expert recommendations, and
consensus voting [53]. As the source data has
remained relatively constant, both guidelines
advise an expectant period before remedial surgical treatment and weak level of evidence recommendations supporting both selective and triple
neurectomy. Uniformly, expertise in diagnosing
and treating this condition is recommended. An
algorithm for management of postherniorrhaphy
chronic pain was developed using the Delphi
method citing similar principles [32]. is group
advocated triple neurectomy and/or mesh explantation by an experienced hernia surgeon for
refractory cases failing conservative measures.
17.14 Selective Neurectomy
Selective neurectomy of the ilioinguinal (IIN),
iliohypogastric (IHN), genitofemoral (GFN), or
lateral femoral cutaneous (LFC) nerve(s) is an
eective treatment option in patients with refractory neuropathic inguinodynia. Successful selective neurectomy of the involved inguinal,
preperitoneal, or retroperitoneal nerve(s) is predicated on accurate identication of the likely
injured nerve(s) based upon anatomy, mechanism, prior operation, symptoms, somatosensory
mapping, and adjunctive imaging and blocks.
7 Box 17.2 lists common hernia repairs and the
nerves that must be considered at risk with neuropathic inguinodynia. Operative neurectomy may
be combined with removal of mesh and xation
material and/or revision of prior hernia repair as
indicated based upon symptoms and intraoperative ndings [45–47]. Removal of mesh and xation material alone may eliminate some of the
common nociceptive causes of pain but fails to
address injured nerves. Additionally, nerves may
be injured during reoperation in the scarred operative eld. A key operative principle is that neurectomy of the injured nerve should be performed
proximal to the injury. Selective neurectomy may
be performed as an open anterior inguinal opera-
Box 17.2 Sites ofPotential Injury: Associated Operations andNerves at Risk forInjury
Anterior to transversalis fascia
Initial operation:
Tissue repair (Shouldice, Bassini, McVay,
Desarda)
Lichtenstein repair, Trabucco (mesh repair!),
bilayer mesh (PHS/UHS)
Plug and patch
Open transinguinal preperitoneal repairs
(Kugel, ONSTEP, TIPP)
Laparoscopic repair (TEP/TAPP) using
penetrating xation
Nerves at risk:
Ilioinguinal nerve (IIN)
Visible and intramuscular segment of
iliohypogastric nerve (IHN)
Inguinal segment of genital branch of
genitofemoral nerve (GFN)
Posterior to transversalis fascia (preperitoneal
space)
Initial operation:
Open preperitoneal (plug, plug/patch, PHS/
UHS, Stoppa, Kugel, TIPP, TREPP, ONSTEP, GPRVS)
Laparoscopic preperitoneal repair (TEP/TAPP)
Nerves at risk:
Preperitoneal segment of genital branch of GFN
Preperitoneal segment of femoral branch of GFN
Main trunk of GFN
Lateral femoral cutaneous nerve (LFC)
tion typically employed aer prior open repair
techniques. It may also be performed via a laparoscopic or retroperitoneal approach aer prior
laparoscopic preperitoneal repair, failed open
reoperation, and in the absence of recurrence or
meshoma requiring remediation. Selective neurectomy series demonstrate improvement in
patients with CPIP [45–47]. Careful patient selection and diagnostic expertise may improve the
likelihood of success while minimizing the side
eects and collateral damage (numbness, deaerentation hypersensitivity, pain, recurrence, disruption of prior repair, abdominal wall laxity)
caused by a more extensive neurectomy.
17.15 Triple Neurectomy
In general, neuroanatomic, technical, and logistic
factors make triple neurectomy more denitive
and reliable for neuropathic inguinodynia. In
reported series, triple neurectomy has higher ecacy rates of diminishing or resolving neuropathic
Chronic Postoperative Inguinal Pain (CPIP)
211
17
inguinodynia as compared to selective neurectomy [48–50]. However, the overall level of evi-
dence regarding selective versus triple neurectomy
is weak consisting of primarily retrospective or
prospective cohort series. e primary arguments
for triple neurectomy as the standard approach
are as follows: (1) there is signicant variation and
cross-innervation of the inguinal nerves in the
retroperitoneum and inguinal canal making
selective neurectomy less reliable, (2) dermatosensory mapping alone is not precise enough to
denitively exclude involvement of adjacent
nerves with overlapping sensory distributions, (3)
predicting which nerves are injured based upon
visualization is imprecise with ultrastructural
damage seen in otherwise normal appearing triple neurectomy nerve specimens, and (4) multiple
reoperations in the scarred eld make nerve identication more dicult; increase the risk of recurrence, vascular injury, testicular compromise, and
visceral injury; decrease the likelihood of success;
and in general should be avoided. ese diagnostic, therapeutic, and technical advantages to triple
neurectomy come at a cost of increased collateral
damage.
17.16 Approach: Open Triple
Neurectomy
Traditional open triple neurectomy involves reexploration through the prior inguinal operative
eld. It is indicated for neuropathic CPIP when a
recurrence or meshoma is present or for patients
that underwent anterior repair without placement
of preperitoneal mesh [34, 48–50]. is operation
is more complex due to the technical diculty of
reoperating in the scarred eld, the challenge of
identifying all three nerves, and the increased
morbidity with risk to the testicle, cord structures,
vascular structures, and the prior repair. e
operation begins with the inguinal incision
extended cephalad and lateral to enter into the
canal in an unscarred area proximal to the prior
repair or mesh. e ilioinguinal nerve is typically
found proximal and lateral to internal ring
between the ring and anterior superior iliac spine.
e distal end of the iliohypogastric nerve is identied at its exit from the inguinal canal in the anatomic cleavage plane between external and
internal oblique. is is then traced back proxi-
mally within bers of internal oblique cephalad
and lateral to prior operative eld. e internal
oblique aponeurosis is split to access the subaponeurotic intramuscular segment of the IHN that
may be injured by suture or xation [48]. e
genital branch of the GFN is identied coursing
lateral within the cord adjacent to the external
spermatic vein and is traced laterally to the internal ring. e nerves are resected proximal to prior
operative eld and potential injury. It is our practice to ligate the cut nerve ending to prevent
sprouting and neuroma formation. is is then
buried into the internal oblique to keep nerve
stump away from future scarring. In cases of pain
aer prior preperitoneal repair, the genitofemoral
trunk must be accessed upstream of the mesh and
repair. e main trunk of GFN is identied and
resected in the retroperitoneum over the psoas
muscle by dividing the oor of inguinal canal
either cephalad from the internal ring or in the
split internal oblique muscle where the intramuscular segment of the iliohypogastric nerve is identied (extended triple neurectomy) [49, 50]. All
nerves are sent to pathology for histologic conrmation. If a plug or meshoma is present or recurrence is identied, this may be addressed at this
time with meshectomy and subsequent inguinal
hernia repair. If coexisting orchialgia is present,
resection of paravasal autonomic nerve bers
enveloping the vas deferens may help to ameliorate neuropathic testicular pain [49].
17.17 Approach: Endoscopic
Retroperitoneal Triple
Neurectomy
Laparoscopic or endoscopic access to the retroperitoneum may be performed using a transabdominal or retroperitoneal approach to allow for
proximal access to the inguinal nerve upstream of
all potential sites of peripheral neuropathy. e
neuroanatomy of the retroperitoneum is less variable than within the inguinal canal [51, 52]. e
IIN and IHN trunks are identied overlying the
quadratus lumborum just distal to the L1 nerve
root [30]. e main trunk of the genitofemoral
nerve is found exiting from the psoas muscle [30].
is may have a single common trunk or present
as separate genital and femoral trunks. In case of
lateral femoral cutaneous nerve injury, this trunk
212
W. Reinpold and D. Chen
17
may be found exiting from L3 and coursing over
the iliacus muscle lateral to the psoas in the triangle of pain. is technique is indicated for neuropathic inguinodynia aer laparoscopic or open
preperitoneal mesh repair and in patients that
have undergone multiple failed anterior reoperations [34, 52].
Nerve identication in the retroperitoneal
lumbar plexus is more reliable and overcomes
many of the limitations that exist with open triple
neurectomy. Accessing the nerves away from the
scar tissue of any prior inguinal hernia repair is
safe and decreases potential morbidity (risk of
cord, testicular, or vascular injury and disruption
of the prior repair). In addition, the anatomy is
consistent with almost uniform ability to identify
the nerves, and the operation itself is technically
simple. Disadvantages of proximal neurectomy
stem from sacricing the nerve proximally and
can include deaerentation hypersensitivity, a
larger region of numbness in groin region and
ank, as well as bulging and laxity of the lower
lateral abdominal wall secondary to loss of motor
function of the IIN and IHN to the transversus
abdominis muscle [52]. e operation is also limited in that accompanying nociceptive causes,
meshoma, or recurrence are not readily addressed
through this retroperitoneal approach. However,
this technique can be combined to remove preperitoneal mesh, tacks, or xation, perform remedial inguinal hernia repair, or resect the autonomic
nerve bers to the testicle along the preperitoneal
spermatic cord in cases of orchialgia.
17.18 Mesh Removal
Meshectomy, or mesh removal, may be benecial
if nociceptive pain due to mesh is present.
Meshoma may occur with wrinkling, folding,
contraction, and migration of the prosthetic
implant. Mechanisms for mesh-related pain
include compression of adjacent structures
(nerves, spermatic cord), brosis and inammation causing entrapment (nerves, cord, vas),
extrusion or migration of three-dimensional
mesh material into adjacent structures (subcutaneous tissue, bowel, bladder, femoral canal, vessels), and entrapment from mesh xation material
(suture, tacks). ese changes may lead to nociceptive type mesh pain oen exacerbated by position and movement. Inguinodynia commonly
will have overlap between nociceptive and neuropathic causes, and the eect of mesh removal
without neurectomy is dicult to interpret. ere
are several series of mesh removal reported, but
the evidence is overall limited and cannot conclude whether mesh removal alone is feasible in
patients with CPIP [34, 35, 54, 55].
In most cases, aected nerves, either preoperatively identied or nerves that are “at risk” due to
iatrogenic injury during mesh removal, are simultaneously removed. Mesh removal remains one of
the most challenging and morbid procedures for
remediation of inguinodynia. Inadvertent vascular
injury, testicular atrophy, orchiectomy, visceral
injury, or disruption of the inguinal canal are possible and may lead to worsened symptoms and
morbidity. Open, laparoscopic, robotic, and hybrid
techniques exist to remove mesh and xation
material from adjacent vessels, viscera, cord structures, and the musculoskeletal components of the
inguinal canal. e importance of appropriate
technical expertise and patient selection cannot be
understated with regard to optimizing outcomes
with this procedure [34, 13, 32, 53].
17.19 Conclusion
e avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. is
problem preceded modern mesh-based techniques, but, as recurrence rates have decreased,
pain has become the more prevalent and important complication. Understanding the causative
mechanisms of inguinodynia helps to prevent,
diagnose, and treat this condition. Signicant
chronic postoperative inguinal pain that is refractory to conservative and interventional measures
may require surgical remediation. An in-depth
understanding of inguinal neuroanatomy and the
mechanism of initial injury help to guide successful operative management. A tailored approach to
each patient based upon individual symptoms,
dermatosensory mapping, physical exam ndings,
imaging, and technical aspects of the prior repair is
essential to properly address this complex problem. With post-inguinal herniorrhaphy inguinodynia, an ounce of prevention with meticulous
operative technique, proper nerve identication
and handling, optimization of prosthetic materials,
and judicious xation is worth a pound of cure.
Chronic Postoperative Inguinal Pain (CPIP)
213
17
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ALN.0b013e3181d318.
215
Costs
G. H.van Ramshorst andReinhardBittner
18.1 Introduction–216
18.2 Part I.Considerations forDaily Practice–216
18.3 Part II.Costs inInguinal Hernia Repair:
Critical Evaluation oftheStudies, Statements,
andRecommendations–217
18.3.1 Factors Inuencing Costs inInguinal Hernia Repair–217
18.3.2 Types ofCosts andCost Dierences Between Open
andLaparoscopic Inguinal Hernia Repair–218
18.4 Part III.1. Evidence-Based Statements
andRecommendations forClinical Practice:
Which Technique Is Most Cost-Eective?–219
18
18.5 Part III.2. How Can Cost- Eectiveness
BeIncreased (by theSurgeon inParticular)?–219
18.6 Part IV.How Can Cost- Eectiveness beIncreased
inLow-Resource Countries?–220
18.6.1 Burden ofDisease–220
18.6.2 Cost-Eectiveness inLow- Resource Setting–220
18.6.3 Use ofAnesthesia–220
18.6.4 Non-commercial Mesh–220
18.6.5 Use ofDilatation Balloons inTEP–221
References–221
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_18
216
G. H. van Ramshorst and R. Bittner
18
18.1 Introduction
Costs associated with surgical treatments are a
dicult topic. ere are several types of costs
which should be considered. It is important to
discern institutional costs, reimbursements by
health insurance companies, and societal costs.
In inguinal hernia surgery, costs associated with
return to work or daily activities, treatment of
recurrence, and (chronic) pain are essential for
discussion. In literature, however, it is rare to nd
complete reports for all cost-associated variables.
is chapter will discuss practical methods for
managing costs in laparo-endoscopic inguinal
hernia repair, along with the available evidence
in literature.
18.2 Part I.Considerations
forDaily Practice
e surgeon’s experience is most important for
choice of technique in terms of costs, under the
condition that patient characteristics (e.g., previous abdominal surgery, recurrence) allow for use
of specic techniques.
From socioeconomic perspective, it should
be recommended to perform the vast majority
of endoscopic inguinal hernia repairs in day
surgery. This is well feasible in most patients,
even in the elderly. If patient comorbidity is
minimal or absent, it may be possible to integrate one-stop visits in institutions. One-stop
visits can include verification of the diagnosis by the referring physician, evaluation by
an anesthesiologist, and subsequent surgery,
followed by discharge on the same day. Local
infrastructure and cooperation between the
institution’s various departments should be
optimal to support this patient- centered
approach. However, it should be considered
that in the western countries with their high
proportion of old people living alone, organization and realization of a well-functioning
home care may be more expensive than one
night stay in the hospital.
Antibiotic prophylaxis is not recommended
in laparo-endoscopic inguinal hernia repair. Not
only is the incidence of surgical site infections
very low in endoscopic inguinal hernia repair, not
giving antibiotic prophylaxis will prevent allergic
reactions and reduce costs.
In order to prevent surgical site infections, it
should be recommended to avoid shaving patient
hair. If this is deemed necessary, hair should be
clipped as shortly as possible before surgery.
Avoiding hair removal will also save time in terms
of cleaning and operation room scheduling.
e largest cost reductions can be made in
laparo-endoscopic hernia surgery in limiting use
of disposable instruments. Balloon trocars can
be replaced by using reusable instruments with
a xating purse-string absorbable suture in the
anterior fascia to prevent air leak. In total extraperitoneal repair (TEP), dissection balloons can
be omitted on the condition that surgeon experience and knowledge of anatomy is sucient
to perform direct (telescopic) blunt dissection.
Blunt dissection without previous balloon dissection can be challenging at rst, as overview is limited and chance of inadvertent (peritoneal) injury
is increased. However, especially in presence of
bilateral hernia, the costs of the dissection balloon might compensate for the additional operation room time needed for (blunt) dissection of
both sides. Furthermore, it should be considered
to use a self-constructed low-cost indigenous dissection balloon.
As with use of disposable instruments, the
choice of mesh is dependent on experience. In
the beginning of the learning curve, preformed
(three-dimensional) meshes can simplify mesh
positioning and thereby reduce operation time
and costs. As surgeon experience grows, mesh
handling and positioning will improve. is can
allow for switching to less costly, non-preformed
meshes. With the grow of institutional experience
and volume, negotiations with industrial partners
can become more dynamic and lower costs of disposable instruments and materials.
Whereas in the early years of laparoendoscopic inguinal hernia repair the mesh was
xed using a large number of clips or tacks, we
have learned that in the vast majority of the cases,
expensive xation devices are unnecessary except
in patients presenting with a wide hernia opening
(>3–4cm).
In terms of reusable instruments, 5mm instrument trocars can be used. It is recommended
to use a three-trocar technique. A standard 30°