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15 Inguinal Hernia Recurrence
15.5 Special Attention to the Femoral Canal
higher than at primary groin hernia repair [14, 21]. Although femoral hernias
surgery is thought to be related to either overlooking a femoral hernia present
at the time of the original surgery or the spontaneous development of a femoral
primary and recurrent inguinal hernia repair operations [21, 22].
15.6 Conclusions
Inguinal hernia recurrence remains a common pathology encountered by the
-
approaches to hernia repair. As recommended by the EHS, approach to recurrent
groin hernia repair should be different than the original inguinal hernia repair
of the femoral canal due to the increased risk of femoral hernia diagnosis during
presumed recurrent inguinal hernia repair.
References
1. Kulacoglu H (2011) Current options in inguinal hernia repair in adult patients. Hippokratia
15:223–231
2. Fegade S (2008) Laparoscopic versus open repair of inguinal hernia. World J Lap Surg 1:41–48
J Am Coll Surg 209:653–658
and approach. J Minim Access Surg 2:147–150
repair. Ann Surg 234:122–126
156
I.N. Haskins and M.J. Rosen
laparoscopic versus open repair of inguinal hernia: early results. BMJ 311:981–985
8. Gilbert AI, Graham MF, Voigt WJ (2000) Inguinal hernia: anatomy and management.
9. Nillson E, Happaniemi S, Gruber G et al (1998) Methods of repair and risk for reoperation
11. Thompson JS, Gibbs JO, Reda DJ et al (2008) Does delaying repair of an asymptomatic
pitfall of transabdominal preperitoneal laparoscopic hernia repair. Surg Endosc 13:585–587
15. Bisgaard T, Bay-Nielsen M, Kehlet H (2008) Re-recurrence after operation for recurrent
Surg 247:707–711
16. McNally M, Byrd KA, Duncan JE et al (2009) Laparoscopic versus open inguinal hernia repair:
Br J Surg 97:4–11
18. Bisgaard T, Bay-Nielsen M, Kehlet H (2003) Recurrence rate after laparoscopic repair of
repair. Ann Surg 234:122–126
a preoperative diagnosis of recurrent inguinal hernia. Hernia 16:381–385
21. Mikkelsen T, Bay-Nielsen M, Kehlet H (2002) Risk of femoral hernia after inguinal
herniorrhaphy. Br J Surg 89:486–488
surgery in Denmark. Hernia 14: 351–355
157
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_16, © Springer-Verlag Italia 2017
G. Campanelli ()
of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Istituto Clinico
Sant’Ambrogio
Milan, Italy
e-mail: giampiero.campanelli@grupposandonato.it
16
Chronic Pain after Inguinal Hernia Repair
Giampiero Campanelli, Piero Giovanni Bruni, Andrea Morlacchi,
and Marta Cavalli
16.1 Definition and Clinical Assessment
hernia repair and can compromise the patient’s quality of life. Although this com-
regarding its incidence, terminology, pathogenesis and treatment strategies.
In an attempt to unify the terminology, the International guidelines for pre-
direct consequence of a nerve lesion or a disease affecting the somatosensory
operation, or, if they did, the postoperative pain differs from the preoperative pain.
pain (neuralgia), burning sensation (paresthesia), hypoesthesia, hyperesthesia,
(Tinel’s test) [2].
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G. Campanelli et al.
include neurophysiological assessment, preoperative characteristics (nociceptive
function, pain genes, psychosocial factors, pain in other parts of the body) and the
16.2 Etiology
causes (and not infrequently a combination of both). Non-neuropathic causes
vas deferens and nerves, periosteal reaction (due to a suture or staple in the
pubic tubercle), or scar tissue formation. Neuropathic pain can be caused by
of the nerves [2].
16.3 Incidence
Regarding the incidence of chronic pain, the literature data are fairly heterogeneous:
times of assessment and different methods of measurement [1]. In the literature,
chronic pain diminishes over time [7, 8].
16.4 Risk Factors and Causes
preoperative Activity Assessment Scale (AAS) score, preoperative pain to tonic
surgery) postoperative pain, nerve damage (assessed as sensory dysfunction in the
groin at 6 months) [9], open surgery [10] and younger age [3, 11].
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16 Chronic Pain after Inguinal Hernia Repair
16.5 Prevention of Postoperative Chronic Pain
Since surgeons cannot modify patients’ risk factors for chronic pain, their
attention focuses on preoperative patients selection and intraoperative features
16.5.1 Selection of patients
history investigation reveal a different cause for their pain: back disease, hip
Among all pathologies that can cause inguinodynia, the so-called pubic
normal physical activity and that it absolutely not a real hernia. This has to be
indeed this could be the results of a misdiagnosis and an uncorrected treatment.
So for all these reasons, it is evident that surgery should not limit the treatment
preoperative pain relief cannot be completely achieved [13].
16.5.2 Choice of Technique and Approach
and Lichtenstein) have been compared and no clinically relevant differences in
6.9–9.2 years).
foreign material of the mesh and the spermatic cord and nerves, placement of the
placement of the mesh can be achieved by a laparoscopic approach or by an open
anterior or open posterior approach.
open inguinal hernia repair and laparoscopic inguinal hernia repair for primary
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open approach, there continued to be a reduced risk of chronic groin pain, but
16.5.3 Identification and Respect of All Three Nerves
described, including inadvertent suture entrapment, partial division, crushing,
diathermy burn, or scar encroachment [18].
during inguinal hernia repair has been proposed as a method for avoiding
postoperative neuralgia [19].
[16] indicated that preserving the ilioinguinal nerve during open mesh repair of
occurrence of chronic groin pain or numbness.
For this reason, the European Hernia Society Guidelines for the treatment of
inguinal hernia in adults [20] do not recommend routine prophylactic resection of
the ilioinguinal nerve (Grade A).
It should be noted that several studies comparing nerve preservation and
prophylactic neurectomy included only the ilioinguinal nerve, forgetting that all
concomitantly undetected [23].
For all these reasons, the authors strongly recommend to identify and protect
all three inguinal nerves, to avoid removing the nerves from their natural bed as
much as possible, and to avoid removing their covering fascia, as recommended
161
16 Chronic Pain after Inguinal Hernia Repair
in the International guidelines [1]. Only in the event of a suspected or frankly
Care should also be taken during mesh placement to prevent the mesh from
encroaching the course of the nerve (the medial edge of the mesh sometimes
meets and crosses the ilioinguinal or often the iliohypogastric nerve): in this case
16.5.4 Choice of Mesh: Lightweight versus Heavyweight
Although the use of a synthetic mesh substantially reduces the risk of hernia
recurrence [27], polypropylene meshes have been found to cause chronic
effects, including chronic pain [28].
Fig. 16.1 Left inguinal region
during surgery for the treatment of
chronic postoperative pain: isolation
of the previously placed mesh and
suture also involves the genital branch
of genitofemoral nerve.
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33], although the incidence of severe chronic groin pain is not decreased [34].
respect to either short- or long-term outcomes.
16.5.5 Choice of Fixation
laparoscopic approach (none vs. atraumatic vs. resorbable or non-resorbable
repair, the type of hernia, the type of mesh and the type, number and location of
increasing the recurrence rate at 1 year.
16.6 Treatment
Data in the literature are poor and inconsistent due to limited information on
Initial acute postoperative pain treatment should be as effective as possible and
standard pharmacological pain treatment (gabapentanoids, tricyclics, etc.) [53]
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16 Chronic Pain after Inguinal Hernia Repair
inguinal hernia repair decided to consider reasonable surgical treatment only after
of evidence 5, grade of recommendation “D”) [1].
pressure) [55].
peripheral neuropathy after inguinal surgery [56, 57]. Varying success rates have
been reported, but the relative ease of application is a main advantage [58, 59].
Several studies [60–68] reported the use of diagnostic blocks presurgery. The use of
ultrasound-guided regional anesthesia has increased in the last decade and enables
painful neuromas [69]: e.g., if a diagnostic nerve block is ineffective in relieving
electromagnetic energy deposited in or near nerve tissue [70, 71]. An insulated
indication of adequate positioning of the needle tip. The voltage applied to the
of the nerve tissue is believed to temporarily block the nerve conduction.
Conventional continuous radiofrequency (CRF) produces temperatures at the
various chronic pain states [70]. A recent retrospective uncontrolled study reported
a longer duration of pain relief in the CRF group than in the local anesthetic block
and femoro-cutaneous lateral nerve (anterior surface quadratus lumborum muscle)
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G. Campanelli et al.
-
-
-
ered adequate and study designs should be improved in regard to control groups,
three studies reported a combined approach. All studies included neurectomy
In spite of these shortcomings, the data on surgical management clearly
hernia repair.
The authors propose a total simultaneous double approach to the inguinal
sensitive nerves, and safely remove the plug (if any) placed during previous surgery
impossible, to pinpoint the involved nerve because peripheral communication
nerve is very common and results in an overlap of their sensory innervation. The
the real reason for pain (neuropathic or non-neuropathic) cannot be detected.
References
15:239–249
prevention. Lancet 367:1618–1625
4. Franneby U, Gunnarsson U, Andersson M et al (2008) Validation of an inguinal pain