How is pain managed following open inguinal hernia repair?

Updated: Jan 17, 2018
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Answer

Postoperative chronic pain is more frequent than was previously understood and has become one of the most important primary endpoints in hernia surgery. In published reports, the incidence of postherniorrhaphy pain has ranged from 0% to more than 30%. Chronic inguinodynia is defined as pain persisting more than 3 months post herniorrhaphy, after the process of wound healing is complete.

Nonfixation or inadequate mesh fixation results in folding and rolling of the mesh, which can cause chronic pain and recurrence of the hernia.

Chronic pain after mesh hernioplasty also results from neuroma formation after accidental division of the nerves. The ilioinguinal, iliohypogastric, and genitofemoral nerves are visualized and protected throughout the operation. They should not be dissected free from their natural bed; doing so can lead to perineural fibrosis and chronic pain postoperatively.

Deliberate sectioning of the nerves intraoperatively to prevent chronic groin pain has been described but is still controversial. Current recommendations consist of nerve identification, minimal handling, and preservation. [57] Prevention of nerve injury is very important because treatment of chronic neuralgias may not be successful.

Entrapment of a nerve by suture or mesh appears to be an important cause of postoperative pain. The groin nerves should be identified and protected. Fibrin or biologic glues may be used instead of sutures to secure the mesh. It appears that cyanoacrylate glue may be a viable alternative to sutures, and it is anticipated that the use of fewer sutures may be associated with less inguinodynia. [25]

Another cause of significant postherniorrhaphy pain is the placement of a stitch into the periosteum at the pubic tubercle for fixation of the mesh medially. This is often the point of maximal tenderness postoperatively. Therefore, one should avoid taking a deep bite through the periosteum of the pubic tubercle; tough, fibrous tissue in that region should instead be used for fixing the mesh.

The use of a low-density macroporous mesh with semiresorbable, self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence after inguinal herniorrhaphy. [58]


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