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Revista argentina de cirugía

versión On-line ISSN 2250-639X

Rev. argent. cir. vol.112 no.4 Cap. Fed. dic. 2020

http://dx.doi.org/10.25132/raac.v112.n4.1487.ei 

Articles

Multidisciplinary approach to chronic postoperative inguinal pain

Cristian A. Angeramo1 

Patricio Méndez2 

Oscar H. D. Gómez3 

Emmanuel E. Sadava1  * 

1 Sector Cirugía de Paredes Abdominales, Servicio de Cirugía General. Hospital Alemán de Bue nos Aires, Argentina

2 Sector de Radiología Intervencionista, Servi cio de Diagnóstico por imágenes. Hospital Alemán de Bue nos Aires, Argentina

3 Sector de tratamiento del dolor, Servicio de Cuidados paliativos. Hospital Alemán de Bue nos Aires, Argentina

Introduction

Inguinal hernia is one of the most common surgical conditions, and it is estimated that twenty million inguinal hernia repairs are performed worldwide every year.1 The introduction of the “tension free” concept by Lichtenstein et al. at the beginning of the 1980s,2 and the use of prostheses (meshes) to reinforce inguinal repair have significantly reduced the recurrence rate to less than 5%.3

After the convalescence period, which generally coincides with the end of the healing process and integration of the prosthesis, most patients return to their daily lives. However, there is a group of patients who repeatedly consult for pain in the “operated site”, altering their quality of life (QoL). In recent years, a better understanding of this condition has been achieved through surveys4. The incidence of this condition varies between 8-16%.5

The treatment of patients with chronic postoperative inguinal pain (CPIP) is complex; several professionals have often been consulted, and different therapies have been proposed. The aim of this study is to describe a multidisciplinary therapeutic approach in stages for patients with chronic inguinal pain after a mesh inguinal hernia repair, and to assess the outcomes.

Material and methods

We reviewed the medical records of all patients treated in the Department of Surgery of the Hospital Alemán, who had undergone inguinal hernia repair in the hospital or in other centers between January 1, 2010 and December 31, 2018, with at least 12-month follow-up. Patients with diagnosis of CPIP were included.

A high-weight polypropylene mesh and non-absorbable fixation materials (sutures or tacks) were used in the initial surgery for all patients.

CPIP was defined as the presence of inguinal pain due to nerve damage or involvement of the tissular somatosensory system persisting more than 6 months after surgery.

The neuropathic origin of CPIP was determined by dermatome mapping, described by Alvarez et al.6 (Fig. 1). Postoperative inguinal pain was assessed by the Visual Analogue Scale (VAS) numbered from 0 to 10, in which 0 is absence of pain and 10 is maximum pain. Pain was defined as mild, moderate, and severe, with 0-4, 5-6, > 7 scores, respectively.7,8,9

Figure 1 Example of dermatome mapping prior to neurectomy in a patient with CPIP, in which (O) indicates normal sensation, (+) stands for pain or allody nia, and (-) indicates hypesthesia or anesthesia. 

The same therapeutic algorithm based on a multidisciplinary staged approach was adopted in all patients with CPIP, including pain management service, interventional radiology service, and abdominal wall sector of the department of general surgery as the leader of the attending team.10 The CPIP in the first three months was treated with non-steroidal anti-inflammatory drugs (NSAIDs), after clinical and ultrasound evaluation to rule out recurrence. If the pain persisted beyond 6 months, it was considered CPIP, and the patient was referred to the pain management service, where a new drug-therapy scheme (gabapentinoids, tricyclic antidepressants, selective serotonin reuptake inhibitors, NSAIDs, opioids) was administered. If pain still continued despite medical therapy, patients were referred to the interventional radiology service, where ultrasound-guided blocks with triamcinolone and lidocaine were performed. Blocks were carried out under ultrasound guidance with a 38 mm broadband (10-5 MHz) linear transducer for soft tissue imaging. The transducer is placed in the area delimited by the anterior superior iliac spine, the inguinal ligament and a line connecting the anterior superior iliac spine to the umbilicus. The ilioinguinal nerve is located between the internal oblique and the transverse or external oblique muscles, and within 1-3 cm of the anterior superior iliac spine. The iliohypogastric nerve lies immediately adjacent or medial to the ilioinguinal nerve. A needle is inserted laterally through the entry point of the transducer, and 4 ml of 1% lidocaine and 80 mg of triamcinolone are injected. The correct location of the injected solution is then confirmed, observing the nerve surrounded by a hypoechoic halo. Only patients with positive response to the blockage were performed ultrasound-guided pulsed radiofrequency.11

Patients with persistent pain despite medical therapy and percutaneous treatment were selected for surgery. The intervention included the removal of the prosthetic material and triple neurectomy. The route of approach depended on the approach previously followed, the anterior route for conventional inguinal hernia repair and the posterior route for laparoscopy.

Age, sex, body mass index (BMI), physical status according to the American Society of Anesthesiologists (ASA) classification, route of approach, prosthetic material and type of fixation were analyzed. The affected nervous territory was also assessed by dermatome mapping.6 Response to treatment and quality of life were assessed with the EuraHS Quality of Life score pre- and post-multidisciplinary approach.12

Statistical analysis

Data were stored using a Microsoft Office Excel© spreadsheet (2019 version). Descriptive statistics of demographic and surgical variables were carried out. For the CPIP, the Student t test was performed for samples related to the R program (version 3.6.3, 2020- 02-29) to compare the results from the EuraHS Quality of Life score surveys, pre- and post-multidisciplinary approach. A p value < 0.05 was considered statistically significant.

Results

Medical records of 1540 patients were reviewed. A hundred and fifty (15%) patients consulted for inguinal pain, which subsided in 135 (90%) patients within 6 months of the postoperative period. Mild and moderate CPIP was diagnosed in 15 (1%) patients, and severe CPIP was diagnosed in 8 (0.5%). Five of the 8 patients were operated on in other medical centers.

Demographic variables are summarized in Table 1.

Table 1 Preoperative variables  

The initial procedure was laparoscopy (transabdominal preperitoneal [TAPP] inguinal hernia repair), performed in 4 (50%) patients.

The affected nerve territories identified by dermatome mapping were: the territory of the lateral femoral cutaneous nerve in 1 patient (operated with laparoscopy), the territory of the ilioinguinal nerve in 3 patients (2 patients operated with laparoscopy, and 1 with conventional technique), the territory of the iliohypogastric nerve in 3 patients (2 patients operated with conventional technique and 1 with laparoscopy), and pain in the pubic spine in 1 patient (operated with conventional technique).

All 8 patients were assessed by the pain management service, and were treated with 3 or more drugs.

All of them required at least one selective or CT-guided root block. Of the 5 patients with positive response, 2 consented to undergo ultrasound-guided pulsed radiofrequency. The other 3 patients received blocks every 3-6 months.

Three patients (38%) persisted with inguinal pain despite the blocks, so they were selected for surgery. In all 3 patients, the prosthetic material was removed, and in 2 of them a triple neurectomy was performed, one by conventional approach and the other by laparoscopy.

Of the 8 patients, 5 (83%) were able to return to their usual work duties.

The analysis of the data from the EuraHS Quality of Life score surveys carried out pre- and post-multidisciplinary approach in stages showed a statistically significant decrease in pain at rest (p = 0.04), pain during activity (p = 0.02), and pain experienced in the last week (p = 0.01), as well as a statistically significant average pain reduction (p = 0.02) (Table 2).

Table 2 EuraHS Quality of Life score for pain assessment before and after the multidisciplinary approach.  

A tendency to decrease daily activity restrictions (p = 0.08), moderate activity (p = 0.08) and average activity restrictions (p = 0.10) was also observed. No statistically significant difference in sports activity (p = 0.33) and in intense physical activity (p= 0.40) was observed (Table 3).

Table 3 EuraHS Quality of Life score for pain assessment before and after the multidisciplinary approach.  

Discussion

This study is intended to demonstrate the importance and complexity of the diagnosis and management of patients with chronic postoperative inguinal pain (CPIP) following inguinal hernia repair. We observed that: a) more than 50% of our patients with severe CPIP had undergone hernia surgery in another center, so it is likely that the incidence of CPIP is underestimated in most series; b) implementing a staged strategy with a multidisciplinary team would allow selecting those patients most likely to benefit from surgery.

CPIP can be neuropathic, non-neuropathic, or originated in inguinal nerve injury or trauma. Non-neuropathic CPIP is classified into visceral pain when a visceral structure is affected (e.g. funiculodynia), or somatic pain when some non-nervous inguinal structure is affected (e.g. in pubic periostitis). Pain assessment by dermatome mapping confirmed that specific nervous territories were damaged in our patients (Figures 1, 2, 3).

Figure 2 Dermatome mapping on the 15th postoperative day, in which (O) indi cates normal sensation, (+) stands for pain or allodynia, and (-) indicates hypesthesia or anesthesia. 

Figure 3 Dermatome mapping on the 30th postoperative day, in which (O) indi cates normal sensation, (+) stands for pain or allodynia, and (-) indicates hypesthesia or anesthesia. 

Medical literature offers multiple definitions of CPIP. The International Association for the Study of Pain defines it as pain that persists for more than three months.13 The arguments against this definition state that it does not include surgical patients, and that inflammation around the prosthesis (mesh) placed during hernia repair is still ongoing after 3 months.5 Considering the disparity in those definitions, the reported incidence of CPIP may reach up to 37%,14,15,16,17 with some inability between 11 and 17%, even with inability to work in up to 3% of patients.18

In our series, all patients showed significant inability with impaired quality of life, abandonment of physical activity, and absence from work. The most surprising characteristics of these patients are their pilgrimage among different professionals, their adherence to the different diagnostic methods proposed, and the fact that they are more demanding for short-term results.

Several studies have attempted to determine potential risk factors for CPIP development. Langeveld et al.19 conducted a retrospective analysis of 669 patients, and observed that: a) severe preoperative and immediate postoperative pain, b) patients aged 18-40 years, and c) recurrent hernia repair were associated with CPIP. Pisanu et al.20 carried out a meta-analysis with 7 randomized studies comparing laparoscopic and conventional approaches, and found that minimally invasive surgery has a lower frequency of CPIP. Jeroukhimov et al.21 observed that non-absorbable suture is associated with a higher rate of CPIP as compared to absorbable sutures. Today, there are reports of reduced incidence of CPIP with the use of cyanoacrylate glue22,23 and self-adhering meshes.24,25

The first therapeutic option should be the pharmacological treatment (NSAIDs, gabapentin, tricyclic antidepressants, norepinephrine and serotonin reuptake inhibitors).26 No benefit has been shown with the use of local drugs such as lidocaine and capsaicin patches, therefore they should not be recommended.27,28 Thomassen et al.29 found ultrasound-guided nerve block effective in the treatment of CPIP with a 20-month follow-up, while a double-blind, randomized study showed no usefulness of nerve block for the treatment of CPIP.30 Radiofrequency is an option for those patients with good response to nerve block; it can be used at a moderate temperature (40 °C) that acts through neuromodulation, or at higher temperature to ablate the nerve. It can be performed at the peripheral nerve level or at the vertebral level. Both approaches have shown positive outcomes.31,32

As for the surgical approach, mesh removal should always be considered;33 simple removal of the mesh might not reverse the pain since the nerves might seem normal without macroscopically visible damage perioperatively, but the damage may exist at the microscopic level.5 For this reason, when faced with a fibro-granulomatous formation (meshoma), it is recommended, in addition to mesh removal, to perform triple neurectomy.1 Neurectomy can be performed via an anterior open approach (conventional) or via a posterior approach (laparoscopy), and it is recommended to follow the initial technique for inguinal hernia repair.5 We performed two -one anterior and one posterior- triple neurectomies, and one patient was performed only the removal of the fixation material because of patient’s refusal to undergo triple neurectomy. To date, 100% of them have had a significant clinical improvement.

The limitations of this study include its retrospective nature and the small number of patients included in the series.

Despite those limitations, we believe it is important to contribute with a multidisciplinary, treatment algorithm in stages to approach patients with CPIP, which represents an underestimated and under-registered health and financial problem. Further studies are needed to understand the physiopathology of CPIP in order to standardize its treatment.

Conclusion

CPIP should have a multidisciplinary approach, led by a dedicated surgical team specialized in abdominal wall condition. Proper identification of patients who will benefit from surgery depends on a staged treatment.

Referencias bibliográficas /References

1. Nguyen DK, Amid PK, Chen DC. Groin pain after inguinal hernia repair. Adv Surg. 2016; 50:203-20. [ Links ]

2. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension free hernioplasty. Am J Surg. 1989; 157:188-93. [ Links ]

3. Bittner R, Schwarz J. Inguinal hernia repair: current surgical tech niques. Langenbecks Arch Surg. 2012; 397:271-82. [ Links ]

4. Ramshaw B. Value-Based Clinical Quality Improvement for Chro nic Groin Pain After Inguinal Hernia Repair. In: Jacob BP, Chen DC, Ramshaw B, Towfigh S (eds). The SAGES manual of groin pain. Springer International Publishing; 2016. pp. 505-14. [ Links ]

5. Andresen K, Rosenberg J. Management of chronic pain after her nia repair. J Pain Res. 2018; 11:675-81. [ Links ]

6. Álvarez R. Dermatome mapping: preoperative and postoperative assessment. In: Jacob BP, Chen DC, Ramshaw B, Towfigh S (eds). The SAGES manual of groin pain . Springer International Publis hing; 2016. pp. 277-92. [ Links ]

7. Page B. Chronic pain following inguinal hernia repair. MD thesis. University of Glasgow, 2009. [ Links ]

8. Manangi M, Shivashankar S, Vijayakumar A. Chronic pain after in guinal hernia repair. Int Sch Res Notices. 2014; 2014:839681. [ Links ]

9. Woo A, Lechner B, Fu T, Wong CS, Chiu N, Lam H, et al. Cut points for mild, moderate, and severe pain among cancer and non-can cer patients: a literature review. Ann Palliat Med. 2015; 4(4):176- 83. [ Links ]

10. Lange Jr JFM. Algorithmic Approach to the Workup and Manage ment of Chronic Postoperative Inguinal Pain. In: Jacob BP, Chen DC, Ramshaw B, Towfigh S (eds). The SAGES manual of groin pain . Springer International Publishing; 2016. pp. 245-55. [ Links ]

11. Makharita MY, Amr YM. Pulsed radiofrequency for chronic ingui nal neuralgia. Pain Physician. 2015; 18:E147-E55. [ Links ]

12. Muysoms FE, Vanlander A, Ceulemans R, Kyle-Leinhase I, Michiels M, Jacobs I, et al. A prospective, multicenter, observational stu dy on quality of life after laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh according to the Euro pean Registry for Abdominal Wall Hernias Quality of Life Instru ment. Surgery. 2016; 160(5): 1344-57. [ Links ]

13. Classification of Chronic Pain. Descriptions of chronic pain syndro mes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986; 3:S1-226. [ Links ]

14. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology. 2000; 93(4):1123- 33. [ Links ]

15. Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999; 86(12):1528-31. [ Links ]

16. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impair ment 1 year after inguinal herniorrhaphy: a nationwide question naire study. Ann Surg. 2001; 233(1):1-7. [ Links ]

17. Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg . 2001; 88(8):1122-6. [ Links ]

18. Courtney CA, Duffy K, Serpell MG, O’Dwyer PJ. Outcome of pa tients with severe chronic pain following repair of groin hernia. Br J Surg . 2002; 89(10):1310-4. [ Links ]

19. Langeveld HR, Klitsie P, Smedinga H, Eker H, Van’t Riet M, Wei dema W, et al. Prognostic value of age for chronic postoperative inguinal pain. Hernia. 2015; 19(4):549-55. [ Links ]

20. Pisanu A, Podda M, Saba A, Porceddu G, Uccheddu A. Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair. Hernia. 2015; 19: 355. [ Links ]

21. Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, et al. Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial. J Am Coll Surg. 2014; 218:102-7. [ Links ]

22. de Goede B, Klitsie PJ, van Kempen BJ, Timmermans L, Jeekel J, Kazemier G. et al. Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair. Br J Surg . 2013; 100:735-42. [ Links ]

23. Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A, et al. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtens tein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg . 2012; 255(4):650-7. [ Links ]

24. Chatzimavroudis G, Papaziogas B, Koutelidakis I, Galanis I, Atma tzidis S, Christopoulos P. et al. Lichtenstein technique for inguinal hernia repair using polypropylene mesh fixed with sutures vs. self-fixating polypropylene mesh: a prospective randomized compara tive study. Hernia. 2014; 18(2):193-8. [ Links ]

25. Sanders DL, Nienhuijs S, Ziprin P, Miserez M, Gingell-Littlejohn M, Smeds S. Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair. Br J Surg . 2014; 101:1373-382. [ Links ]

26. Bjurstrom MF, Nicol AL, Amid PK, Chen DC. Pain control following inguinal herniorrhaphy: current perspectives. J Pain Res . 2014; 7:277-290. [ Links ]

27. Bischoff JM, Ringsted TK, Petersen M, Sommer C, Uceyler N, Wer ner MU. A capsaicin (8%) patch in the treatment of severe persis tent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled trial. PLoS One 2014; 9(10):e109144. [ Links ]

28. Bischoff JM, Petersen M, Uceyler N, Sommer C, Kehlet H, Wer ner MU. Lidocaine patch (5%) in treatment of persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial. Anesthesiology . 2013; 119(6):1444- 52. [ Links ]

29. Thomassen I, van Suijlekom JA, van de Gaag A, Ponten JE, Nien huijs SW, et al. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Hernia. 2013; 17:329-32. [ Links ]

30. Bischoff JM, Koscielniak-Nielsen ZJ, Kehlet H, Werner MU. Ultra sound-guided ilioinguinal/iliohypogastric nerve blocks for per sistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial. Anesth Analg. 2012; 114:1323-9. [ Links ]

31. Makharita MY, Amr YM. Pulsed radiofrequency for chronic ingui nal neuralgia. Pain Physician . 2015; 18(2):E147-E155. [ Links ]

32. Kastler A, Aubry S, Piccand V, Hadjidekov G, Tiberghien F, Kastler B. Radiofrequency neurolysis versus local nerve infiltration in 42 patients with refractory chronic inguinal neuralgia. Pain Physician . 2012; 15(3): 237-44. [ Links ]

33. Lange JF, Kaufmann R, Wijsmuller AR, Pierie JP, Ploeg RJ, Chen DC, et al. An international consensus algorithm for management of chronic postoperative inguinal pain. Hernia. 2015; 19(1):33- 43. [ Links ]

Received: March 16, 2020; Accepted: July 15, 2020

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