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Archive September 2020 XXI, No. 9

Preventing Post-Op Hernia Pain Is Paramount

Patient expectations and surgeon technique go hand in hand in achieving successful outcomes.

Jared Bilski


Shirin Towfigh, MD, FACS
ATTENTION TO DETAIL Hernia repairs are meticulous procedures that require surgeons to carefully place mesh around several sensory nerves.

Ahernia repair will always cause patients some level of discomfort. However, there’s a big difference between an annoying ache and acute pain — or worse, chronic pain — that relentless agony patients suffer through for at least 90 days post-op.

Unfortunately, far too many hernia patients walk away with the latter when it could’ve been prevented. To ensure your patients don’t fall into that category, follow these proven strategies.

1. Set expectations

Whether patients are undergoing a common and relatively straightforward inguinal hernia surgery or a more complex ventral hernia procedure, they’re virtually guaranteed to experience some type of pain or, at a bare minimum, significant discomfort following their procedure. During the pre-op visit, patients need to know about what they’re likely to experience following their surgery and what they can do about it — as clearly and in as much detail as possible.

“That’s the responsibility of the surgeon,” says Jeffrey B. Mazin, MD, FACS, a board-certified general surgeon at Scripps Mercy Hospital San Diego. “For instance, 14% to 34% of patients will experience chronic pain syndrome following their surgery. They need to know that it can happen.”

2. Consider underlying issues

The pre-op visit is also critical because it allows surgeons to assess patients as thoroughly as possible for underlying issues that might increase the likelihood of a painful recovery. The biggest issue? The amount of pain the patient is in just prior to the surgical intervention. “Studies have shown patients who have pain issues prior to inguinal hernia repair will have pain issues postoperatively,” says Guy Voeller, MD, FACS, a general surgeon and professor of surgery at the University of Tennessee College of Medicine in Memphis. “These are the patients you have to be very careful with.”

That’s because the pain the patient is experiencing usually isn’t coming directly from the hernia. While hernias are undoubtedly uncomfortable, most aren’t that painful, says Dr. Mazin. “If there’s a lot of pre-op pain, the surgeon has to look into other causes of it,” he adds.

3. Rely on surgeon skill

Ultimately, the post-op success of your facility’s hernia repairs is contingent upon the skill of your surgeons. “The ability of the surgeon is one of, if not the single most important factor, in preventing post-op pain,” says Dr. Voeller. And although tens of thousands of hernia repairs are done on an outpatient basis each year, the procedures require a tremendous amount of skill. “These are laborious, meticulous procedures that require an exquisite attention to anatomical detail on the part of the surgeon,” says Dr. Mazin.

“Surgeon ability is one of the most important factors in preventing post-op pain.”
— Guy Voeller, MD, FACS

This attention to detail is absolutely critical because surgeons are operating in close to proximity to several sensory nerves. “With an inguinal hernia repair, the groin has a number of sensory nerves that are at risk during the surgery itself or during the scarification process afterward,” says Dr. Voeller.

Specifically, notes Dr. Mazin, surgeons must be aware of where they’re operating in relation to the iliohypogastric, ilioinguinal and genitofemoral nerves, and avoid them at all costs.

In terms of technique, there’s compelling evidence that a minimally invasive approach is superior to an open one in terms of preventing post-operative pain. “Virtually every study shows that properly done minimally invasive repairs will have less acute pain and less chance of chronic long-term pain than open repairs,” says Dr. Voeller. That’s because the way mesh is placed during open repairs can cause the sensory nerves to scar into the repair area, which leads to a higher incidence of chronic pain.

With laparoscopic mesh placement, surgeons work behind the muscle so the mesh doesn’t sit on those nerves and there’s less chance of the nerves scarring into the mesh, adds Dr. Voeller.

So surgeons should always perform laparoscopic hernia repairs then, right? It’s not that simple. Surgeons who perform these repairs need to do a high volume of them because of the skill and attention to detail required.

4. Find the right mesh

When it comes to mesh, Dr. Mazin has some simple, straight-forward advice for surgeons who use it and facilities that purchase it: “There is a multiplicity of meshes on the market, and most are good. Surgeons should focus on finding something they’re comfortable placing, do it well and learn to reproduce the procedure again and again.”

In other words, don’t get bogged down in the abundance of options when virtually any type of mesh can give you great results if an adept surgeon who’s comfortable with the material implants it. “There’s really no evidence in the average patient that the mesh type has an effect on the outcomes,” says Dr. Voeller.

However, he does understand the financial component of stocking the right type and amount of mesh, and navigating the endless vendor options — particularly for smaller ASCs where cost-control is critical.

To that end, Dr. Voeller offers some advice for facility leaders. “Find a knowledgeable surgeon who can assess mesh in an unbiased way to let you know the one or two products you should be carrying,” he says. “Outpatient facilities really need a surgeon who can look at the data and say, ‘OK, these are the cost-effective ways to fix hernias.’”

It goes without saying that cost-effective hernia repairs should always focus first and foremost on successful, pain-free outcomes for patients. OSM

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