Pain after inguinal hernia surgery

It seems unbelievable, but even in the age of instant communication, where scientific knowledge can be transmitted and shared in real time, many Surgeons say that the problem of pain after inguinal hernia surgery does not exist, and that they do not remember having had, nor having treated, any patient with this type of problem.

However, the Literature reveals to us that in Centers where there is nodedicated abdominal wall surgery team, pain and burning after inguinal hernia surgery do exist, affecting, in extreme cases, as many as 60% of operated patients.

More realistically. Chronic inguinal pain after inguinal hernioplasty surgery may occur in about 20% of patients, predominantly outnumbering hernial recurrences, which instead occur in 3.3-10% of cases1.

But what exactly are we talking about?

Pain after inguinal hernia surgery, or chronic inguinal pain, is that pain that follows inguinal hernia surgery; it is due to nerve injury and must be present at least 3 months after surgery and persistent for at least 6 months. It can be caused by, among other things, inflammatory reactions of the periosteum of the pubis (the periosteum is a thin, tough membrane that lines the bones; pain in this case may be triggered, for example, by the so-called "stitch on the pubis" that so pleases surgeons not especially dedicated to hernial surgery, and which has been absolutely proscribed by wall surgeons for years now), by nerve injuries occurring during surgery fromentrapment of nerve branches in the inguinal region at mesh fixation sites (for this we prefer the Trabucco technique, which does not require stitches on the mesh), from "perforations" of nerve branches due to theuse of tacks (tacks are clips, usually resorbable, that can be used laparoscopically to fix the mesh; although wall surgeons well know that, for example, in laparoscopic inguinal hernia surgery, it is not necessary to fix the mesh...) or from theinclusion of nerve branches in "meshomas " ("mesh" = mesh), granulomatous lesions caused by the inflammatory reaction of the patient's tissues toward the implanted mesh (normally in the case of heavy or not well stretched mesh; that's why wall surgeons, well aware of this problem, try whenever they can to use light mesh).

Pain after inguinal hernia surgery may be associated with paresthesias (i.e., "different" skin sensitivity than normal), hypoesthesias (i.e., reductions in skin sensitivity), and hyperesthesias (i.e., a conspicuous increase in skin sensitivity), and radiate toward the scrotum, labia majora, and Scarpa's triangle (the root of the thigh). Symptoms may be triggered, or exacerbated, by certain positions, such ashyperextension of the thigh, or activities, such as walking; and sometimes may decrease with thigh flexion or when lying down.

Following inguinal hernia surgery, pain months after surgery can thus be defined as chronic inguinal pain; and chronic inguinal pain can cause changes in the central nervous system that contribute to its persistence and aggravation. The consequence is the appearance of two conditions that are typical of chronic groin pain:hyperalgesia (exaggerated response to painful stimuli) andalodynia (pain triggered by stimuli that would not normally elicit any painful response). Therefore, it is important to treat postoperative inguinal hernia pain before it becomes chronic, since its chronicity implies plastic changes in the brain centers of pain: early treatment, on the other hand, can prevent such changes from occurring.

Pain after inguinal hernia surgery: how to treat it?

The initial treatment of the pain after inguinal hernia surgery is medical; only later is surgery used. The first, fundamental step in the Treatment of pain and burning after inguinal hernia surgery is to draw a Skin map of the pain itself, as in the figure opposite. With the patient lying down, you Inguinal hernia pain after monthsprovoke tactile stimuli in the groin region affected by the pain: depending on the type of sensation reported by the patient (pain, hypoesthesia, normoesthesia, hyperesthesia...) a circle or a cross of different color is drawn at the various stimulated points. Eventually you will get a map like the one opposite, which will allow the surgeon to know which injured nerve is causing the pain. The Surgeon will then prescribe topical or oral medication, according to a well-established and validated schedule: if, at the end of the treatment period, there is no satisfactory improvement, the Surgeon will propose surgery.

The surgery for the treatment of chronic inguinal pain consists of triple neurectomy, that is, theremoval of the nerve branches that cause the onset of the pain itself. This surgery can be performed either by the traditional route, reoperating the inguinal region (with the risk, however, given the inflammatory and scarring processes following hernia repair surgery, that the nerve branches will be very difficult to identify), or by the laparoscopic route, with an extremely refined technique. Our group prefers this second route, although sometimes it may be necessary to use a mixed technique, either open or laparoscopic, to satisfactorily complete the operation.

In conclusion, when a Surgeon treats a person with chronic groin pain he must, first of all, become a Physician again; and not just any Physician, but the best Physician possible for his "patient. In the end, only in the end, he must put on the shoes of the Surgeon again; and not just any Surgeon, but the best Specialist Surgeon possible.

Do you suffer from chronic groin pain resulting from inguinal hernia surgery? Contact us!

1. K.-J. Lundström H. Holmberg A. Montgomery P. Nordin. Patient-reported rates of chronic pain and recurrence after groin hernia repair. Br J Surg. 2018;105(1):106-112

 

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Dr. Salvatore uccomarino
Medical Surgeon Specialist in General Surgery
Laparoscopic inguinal hernia surgery REPA, the minimally invasive endoscopic surgery for diastasis of the rectus
51 Amerigo Vespucci Street
Turin
EN
Phone 0110438161