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Digital Issues

Archive >  January, 2014 XV, No. 1

Prevent Post-Hernia Chronic Pain

Surgeons must recommit to limiting risks of the condition that affects hundreds of thousands of patients each year.

Jeffrey Mazin, MD, FACS

— ATTENTION TO DETAILSurgeons must operate carefully during open hernia repairs to prevent chronic pain from occurring.

Discomfort after hernia surgery is expected. But when the pain persists past 30 days, it becomes a source of dismay for patients and frustration for surgeons, who are often unaware of the scope of the issue. There are upwards of 1 million hernia repairs done each year. If an estimated 15% to 35% of those patients experience post-op chronic pain, hundreds of thousands of individuals are in discomfort following surgery. But understanding the many factors that contribute to the problem can prevent it from happening in the first place.

  • Patients. Experts agree that laparoscopic repair is best for patients with previous complicated open mesh repairs or bilateral hernias. Research has shown that male patients younger than 40 years old who show pain symptoms out of proportion with pre-op physical exams typically don't do well with mesh repair. Additionally, patients undergoing recurrent hernia repair and patients who experience high levels of pre-op pain are more likely to suffer from post-op chronic pain.
  • Technique. Very few surgeons are attentive to avoiding hernia surgery's "blue line" — the internal spermatic vein and the genital branch of the genitofemoral nerve — that leads to the significant number of patients who suffer post-op chronic pain.

Most chronic pain occurs after open surgery dissection that requires surgeons to carefully move tissue and the spermatic cord. They show varying attention to detail in identifying the 3 sensory nerves found in the groin: the ilioinguinal, genito-femoral and iliohypogastric. Exaggerated scarification responses or the surgeon's lack of meticulous dissection while operating (injuring the nerves with suture or compressing them with mesh) can damage one or more of these nerves.

The laparoscopic approach results in fewer overall nerve issues because the anatomical location of the sensory nerves in the preperitoneal space is predictable. If no dissection is done inferior to the iliopubic tract, and no mesh affixation is performed with devices such as tacks or staples below the tract, the operation likely won't result in significant chronic pain. However, surgeons can still injure the lateral femoral cutaneous nerve during laparoscopic procedures, leaving patients with pain on the anterior lateral side of the thigh.

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