Chronic pain after mesh repair of inguinal hernia: a systematic review

doi:10.1016/j.amjsurg.2007.02.012

The American Journal of Surgery

Volume 194, Issue 3, September 2007, Pages 394-400

https://doi.org/10.1016/j.amjsurg.2007.02.012 Get rights and content

Abstract

Background

Chronic pain is a severe complication of mesh-based inguinal hernia repair. Its perceived risk varies widely in the literature. The current objectives are to review the incidence, severity, and consequences of chronic pain and its etiologies.

Data sources

A multi-database systematic search was conducted for prospective trials on mesh-based inguinal hernia repair reporting the measurement and outcome of pain at least 3 months postoperatively with a minimum follow-up of 80%.

Conclusions

After mesh-based inguinal hernia repair, 11% of patients suffer chronic pain. More than a quarter of these patients have moderate to severe pain, mostly with a neuropathic origin. As a consequence of chronic pain, almost one third of patients have limitations in daily leisure activities. Chronic pain is less frequent after endoscopic repair and with the use of a light-weighted mesh.

Section snippets

Methods

The Medline database, Cumulative Index to Nursing and Allied Health Literature, Embase, and Pubmed, including e-links to related articles, and the clinical trial registry of the Cochrane Collaboration were searched for relevant prospective trials on inguinal hernia repair reporting chronic pain. The strategy was by free text words: hernia and inguinal and pain or neuralgia and mesh or tension-free or laparoscopy, and whenever possible by medical subject headings. Those considered for full

Description of the studies

The cumulative search of the databases identified 680 publications. Based on title and/or abstract, 159 were potentially relevant and underwent critical appraisal on full article. Thirty-four studies were included in the review [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39] Three of them were long-term results of other included trials [12], [14]

Comments

Based on an analysis of 29 good-quality studies meeting our inclusion criteria, 11% of patients suffer chronic pain following mesh-based inguinal hernia repair. More than one quarter of these patients has moderate to severe pain, mostly with a neuropathic origin. As a consequence of chronic pain, almost one third of the patients have limitations in daily leisure activities. Chronic pain is less frequent after endoscopic repair and with the use of a light-weighted mesh. There is a tendency for

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Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial
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Inguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods.
In This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date.
After 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery.
It seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.
Safety of unfixed mesh in laparoscopic total extraperitoneal inguinal hernia repair: A meta-analysis of randomized controlled trials
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Whether the effect of the unfixed mesh during laparoscopic total extraperitoneal (TEP) inguinal hernia repair can lead to hernia recurrence remains controversial.
The PubMed, Cochrane Library, and EMBASE databases were searched to retrieve clinical randomized controlled trials (RCTs) comparing nonfixation of mesh and fixation of mesh in TEP inguinal hernia repair, and we performed a metaanalysis with RevMan 5.3 software.
Fifteen RCTs were included in the metaanalysis, which showed that the operation time (P = 0.001) of the unfixed mesh group was shorter than that of the fixed mesh group; additionally, the postoperative 24-h pain score (P = 0.04) and incidence of urinary retention (P = 0.001) were lower in the unfixed mesh group. There was no significant difference between the unfixed mesh group and the fixed mesh group in terms of hospital stay (P = 0.47), time to resume normal activities (P = 0.51), incidence of haematoma (P = 0.96), incidence of chronic pain (P = 0.20), and recurrence rate (P = 0.09).
Unfixed mesh in TEP inguinal hernia repair shows no elevated recurrence rates compared to fixed mesh and is clinically safe.
Comparing the Efficacy of Dorsal Root Ganglion Stimulation With Conventional Medical Management in Patients With Chronic Postsurgical Inguinal Pain: Post Hoc Analyzed Results of the SMASHING Study
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Approximately 10% of patients who undergo inguinal hernia repair or Pfannenstiel incision develop chronic (> three months) postsurgical inguinal pain (PSIP). If medication or peripheral nerve blocks fail, a neurectomy is the treatment of choice. However, some patients do not respond to this treatment. In such cases, stimulation of the dorsal root ganglion (DRG) appears to significantly reduce chronic PSIP in selected patients.
In this multicenter, randomized controlled study, DRG stimulation was compared with conventional medical management (CMM) (noninvasive treatments, such as medication, transcutaneous electric neurostimulation, and rehabilitation therapy) in patients with PSIP that was resistant to a neurectomy. Patients were recruited at a tertiary referral center for groin pain (SolviMáx, Eindhoven, The Netherlands) between March 2015 and November 2016. Suitability for implantation was assessed according to the Dutch Neuromodulation Association guidelines. The sponsor discontinued the study early owing to slow enrollment. Of 78 planned patients, 18 were randomized (DRG and CMM groups each had nine patients). Six patients with CMM (67%) crossed over to DRG stimulation at the six-month mark.
Fifteen of the 18 patients met the six-month primary end point with a complete data set for a per-protocol analysis. Three patients with DRG stimulation had a negative trial and were lost to follow-up. The average pain reduction was 50% in the DRG stimulation and crossover group (from 6.60 ± 1.24 to 3.28 ± 2.30, p = 0.0029). Conversely, a 13% increase in pain was observed in patients with CMM (from 6.13 ± 2.24 to 6.89 ± 1.24, p = 0.42). Nine patients with DRG stimulation experienced a total of 19 adverse events, such as lead dislocation and pain at the implantation site.
DRG stimulation is a promising effective therapy for pain relief in patients with PSIP resistant to conventional treatment modalities; larger studies should confirm this. The frequency of side effects should be a concern in a new study.
The Clinicaltrials.gov registration number for the study is NCT02349659.
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El dolor inguinal crónico o inguinodinia posthernioplastia es una complicación relativamente común y que puede llegar a ser muy incapacitante. El tratamiento quirúrgico mediante triple neurectomía es una opción terapéutica ante el fracaso de tratamientos previos (terapia oral, local o neuromodulación).
Descripción retrospectiva de la técnica quirúrgica y resultados de la triple neurectomía laparoscópica y con asistencia robótica en el tratamiento de la inguinodinia crónica.
Se describen los criterios de inclusión/exclusión, así como la técnica quirúrgica empleada en 7 pacientes intervenidos en el Complejo Asistencial Universitario de León (Servicio de Urología) tras no responder a otras alternativas terapéuticas.
Los pacientes presentaban dolor crónico inguinal reportando una valoración en la escala EVA del dolor prequirúrgica de 7,43 sobre 10. Tras la cirugía, dicha valoración se redujo a 3,71 al primer día postoperatorio y a 4,2 puntos al año de la intervención. El alta hospitalaria se produjo a las 24 h de la cirugía y no se reportaron complicaciones relevantes.
La triple neurectomía laparoscópica o con asistencia robótica es una técnica segura, reproducible y eficaz en el tratamiento del dolor inguinal crónico refractario a otros tratamientos.
Chronic inguinal pain or inguinodynia following hernioplasty is a relatively common complication that can be very incapacitating. Surgical treatment by triple neurectomy is a therapeutic option when previous treatments (oral/local therapy or neuromodulation) have failed.
Retrospective description of the surgical technique and results of laparoscopic and robot-assisted triple neurectomy for chronic inguinodynia.
We describe the inclusion/exclusion criteria as well as the surgical technique applied in 7 patients operated on at the University Health Care Complex of León (Urology Department) after failure of other treatment options.
The patients presented chronic groin pain, reporting a preoperative pain VAS of 7.43 out of 10. After surgery, this score was reduced to 3.71 on the first postoperative day and to 4.2 points one year after surgery. Hospital discharge occurred 24 hours after surgery with no relevant complications being reported.
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View all citing articles on Scopus

View full text

ReviewChronic pain after mesh repair of inguinal hernia: a systematic review

Abstract

Background

Data sources

Conclusions

Section snippets

Methods

Description of the studies

Comments

Open mesh versus laparoscopic mesh repair of inguinal hernia

N Engl J Med

Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia

Br J Surg

A review of chronic pain after inguinal herniorrhaphy

Clin J Pain

Chronic postoperative pain: the case of inguinal herniorrhaphy

BJA

Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms

Is there a need for a mesh plug in inguinal hernia repair?Randomized, prospective study of the use of Hertra 1 mesh compared to PerFix Plug

Hernia

Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain

Ann Surg

[Chronic pain after inguinal hernia mesh repair: possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases]

Chir Ital

Inguinal hernia repair with beta glucan-coated mesh: prospective multicentre study (115 cases)—preliminary results

Hernia

Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial

Ann Surg

Early results of a single-blinded, randomized, controlled, Internet-based multicentre trial comparing Prolene and Vypro II mesh in Lichtenstein hernioplasty

Hernia

One year results of a randomised controlled multi-centre study comparing Prolene and Vypro II-mesh in Lichtenstein hernioplasty

Hernia

Inguinodynia after two inguinal herniorrhaphy methods

Surg Laparosc Endosc Percutan Techn

Inguinal hernia repair with beta glucan-coated mesh: results after two year follow-up

Hernia

Randomized clinical trial comparing laparoscopic totally extraperitoneal approach with open mesh repair in inguinal hernia

Surg Laparosc Endosc Percutan Tech

Five-year outcome of laparoscopic and Lichtenstein hernioplasties

Surg Endosc

Sutureless Lichtenstein: first results of a prospective randomised clinical trial

Hernia

[Tension-free methods of surgery of primary inguinal hernias. Comparison of endoscopic, total extraperitoneal hernioplasty with the Lichtenstein operation]

Chirurg

Prolene hernia system compared with mesh plug technique: a prospective study of short to mid-term outcomes in primary groin hernia repair

Hernia

Prevalence and severity of chronic groin pain after endoscopic totally extraperitoneal inguinal hernioplasty

Surg Endosc

Fibrin sealant versus mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial

Ann Surg

Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia

Surg Endosc

Review
Chronic pain after mesh repair of inguinal hernia: a systematic review