Groin Pain After Inguinal Hernia Repair

Safety and efficacy revisited: a systematic review and meta-analysis of glue versus tack mesh fixation in laparoscopic inguinal herniorrhaphy

Background

This analysis addresses the uncertainty surrounding the efficacy of glue mesh fixation (GMF) compared with tack mesh fixation (TMF) in laparoscopic herniorrhaphy. Our meta-analysis incorporates recently conducted randomized controlled trials (RCTs) to enhance the reference for assessing the efficacy and safety of GMF.

Methods

PubMed Central, Google Scholar, Science Direct, and Cochrane Library were extensively reviewed for articles in the English language performed from inception to May 2023 using the keywords "Glue mesh repair," "Tack mesh repair," "Inguinal Hernia," "Herniorrhaphy," "Laparoscopic," "Mesh Fixation," and "Randomized controlled trials."

Results

In this meta-analysis, we incorporated a total of 20 randomized controlled trials, evaluating each article individually using quality ratings. Compared with TMF, GMF demonstrated a significant reduction in the incidence of chronic pain [RR: 0.40, (0.23, 0.68)] and pain scores on postoperative day 1 [MD: -1.07, (-1.90, -0.25)]. We also used funnel plots and Egger's regression to test for publication bias.

Conclusion

In summary, this meta-analysis establishes the significance of GMF in reducing chronic pain and postoperative day 1 pain compared with TMF. However, no statistically significant difference was noted between the GMF and TMF groups concerning hematoma, seroma, operation time, recurrence rate, and total complications. Nonetheless, given the small number of cases in this study, the findings must be validated in the future by multicenter, large-sample, high-quality RCTs.

Sutureless Repair for Open Treatment of Inguinal Hernia: Three Techniques in Comparison

Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy.

Investigating the safety and efficacy of nerve stimulation for management of groin pain after surgical herniorrhaphy: a systematic review and meta-analysis

PURPOSE

Chronic post-operative inguinal pain (CPIP) following inguinal hernia repair has been a major sequela affecting 4000-48000 patients annually. Optimal management of CPIP has been a challenge, and pharmacological management particularly with opioids has shown unsatisfactory results. The main objective of this systematic review is to investigate the safety and efficacy of neuromodulation as an alternative intervention for the management of post-operative inguinal pain.

METHODS

A literature search was conducted by three reviewers to identify all relevant studies on the use of neuromodulatory interventions for treating post-operative inguinal pain. Data on study characteristics, neuromodulatory modalities, and patient's clinical data such as pre/post-interventional pain scores and analgesic requirements were extracted and reported.

RESULTS

A total of 389 patients with 357 (95.9%) males and 15 (4.1%) females were evaluated. The mean age of study participants was 47.9 ± 10.4 years. There were 187 (48.1%) and 202 (51.9%) patients allocated to the control and trial groups, respectively. The most common neuromodulation modality was TENS (4, 36.4%), followed by SCS (3, 27.3%), PNS (3, 27.3%), and acupuncture-assisted (2, 18.2%). The overall mean follow-up duration of the entire cohort was 3.8 months. The mean difference between pre-operative and post-operative VAS scores in the trial groups was 4.65 (95% Confidence Interval [CI], 2.97, 6.33), which was statistically significant (P value < 0.05). Patient-reported outcome measures showed significant responsiveness toward their treatments.

CONCLUSION

Nerve stimulation, in its many forms, is a safe and feasible option for the management of post-operative inguinal pain.

Mesh-based inguinal hernia repairs in an integrated healthcare system and surgeon and hospital volume: a cohort study of 110,808 patients from over a decade

PURPOSE

The aim of this study was to describe a cohort of patients who underwent inguinal hernia repair within a United States-based integrated healthcare system (IHS) and evaluate the risk for postoperative events by surgeon and hospital volume within each surgical approach, open, laparoscopic, and robotic.

METHODS

Patients aged ≥ 18 years who underwent their first inguinal hernia repair were identified for a cohort study (2010-2020). Average annual surgeon and hospital volume were broken into quartiles with the lowest volume quartile as the reference group. Multiple Cox regression evaluated risk for ipsilateral reoperation following repair by volume. All analyses were stratified by surgical approach (open, laparoscopic, and robotic).

RESULTS

110,808 patients underwent 131,629 inguinal hernia repairs during the study years; procedures were performed by 897 surgeons at 36 hospitals. Most repairs were open (65.4%), followed by laparoscopic (33.5%) and robotic (1.1%). Reoperation rates at 5 and 10 years of follow-up were 2.4% and 3.4%, respectively; rates were similar across surgical groups. In adjusted analysis, surgeons with higher laparoscopic volumes had a lower reoperation risk (27-46 average annual repairs: hazard ratio [HR] = 0.63, 95% confidence interval [CI] 0.53-0.74; ≥ 47 repairs: HR 0.53, 95% CI 0.44-0.64) compared to those in the lowest volume quartile (< 14 average annual repairs). No differences in reoperation rates were observed in reference to surgeon or hospital volume following open or robotic inguinal hernia repair.

CONCLUSION

High-volume surgeons may reduce reoperation risk following laparoscopic inguinal hernia repair. We hope to better identify additional risk factors for inguinal hernia repair complications and improve patient outcomes with future studies.

Efficacy and safety of ilioinguinal neurectomy in open tension-free inguinal hernia repair: A meta-analysis of randomized controlled trials

BACKGROUND

There is still controversy surrounding routine ilioinguinal neurectomy in open tension-free inguinal hernia repair.

METHOD

PubMed, Cochrane Library and EMBASE databases were searched for randomized controlled trials of ilioinguinal neurectomy in open tension-free inguinal hernia repair. Revman 5.3 software was used for meta-analysis.

RESULT

Meta-analysis revealed that the incidence of severe pain on the first postoperative day was lower in the ilioinguinal neurectomy group (ING) than in the ilioinguinal nerve preservation group (INPG) [P < 0.0001]. The incidence of no pain in the first month postoperatively [P = 0.0004], the incidence of no pain in the sixth months postoperatively [P < 0.00001], and the numbness incidence in the first month postoperatively [P = 0.001] in the ING was higher than that in the INPG. There was no significant difference in the incidence of severe pain in the first month postoperatively [P = 0.20], the numbness incidence in the sixth postoperative month [P = 0.05], the hypoesthesia incidence in the first [P = 0.15] and sixth [P = 0.85] postoperative months between the two groups.

CONCLUSION

Ilioinguinal neurectomy in open tension-free inguinal hernia repair can better prevent postoperative pain.

Efficacy and safety of glue mesh fixation for laparoscopic inguinal hernia: A meta-analysis of randomized controlled trials

It is still controversial whether glue can be used for mesh fixation in laparoscopic inguinal hernia repair. The aim of this meta-analysis was used to systematically evaluate the effectiveness and safety of glue mesh fixation in laparoscopic tension-free inguinal hernia repair. The PubMed database, EMBASE database and Cochrane Library were searched to collect published randomized controlled trials (RCTs) on laparoscopic tension-free inguinal hernia repair with glue mesh fixation. Sixteen RCTs and 2409 patients with inguinal hernia were included. The meta-analysis showed that compared with the mechanical mesh fixation group(MMFG), the glue mesh fixation group(GMFG) had significantly reduced incidences of chronic pain[relative risk (RR) = 0.40, 95% confidence interval (CI) (0.28,0.57), P < 0.00001], urinary retention[RR = 0.53, 95% CI(0.29,0.97), P = 0.04], haematoma[RR = 0.23, 95% CI(0.09,0.58), P = 0.002] and total complications[RR = 0.28, 95% CI(0.18,0.44), P < 0.00001]; there were no significant differences in pain score on postoperative day 1[MD = -1.33, 95% CI(-2.93,0.26), P = 0.10], operation time[MD = 1.46, 95% CI(-3.97,6.88), P = 0.60] and recurrence rate[RR = 0.72, 95% CI(0.35,1.47), P = 0.37] between the two groups. In conclusion, the application of glue mesh fixation in laparoscopic inguinal hernia repair is safe and reliable with fewer complications. Moreover, it can reduce the incidence of chronic pain without increasing the recurrence rate. However, due to the small number of cases in this analysis and limitations in the quality of the included studies, the findings need to be further verified by multicentre, large-sample and high-quality RCTs in the future.

Psychological disorders in patients with chronic postoperative inguinal pain

PURPOSE

Chronic postoperative inguinal pain (CPIP), a complication of inguinal hernia repair, may negatively affect mental health. The rates of psychological disorders in patients with CPIP are unknown. We aimed to describe the prevalence of psychological disorders coinciding with CPIP.

METHODS

A retrospective chart review was performed of all patients seen at the Cleveland Clinic Center for Abdominal Core Health's inter-disciplinary Chronic Groin Pain Clinic. This clinic is unique in that all patients are evaluated by a surgeon, a sonographer and radiologist, and a behavioral medicine psychologist. Patient psychological history and treatment, Depression Anxiety and Stress Scale (DASS) scores, pain catastrophizing, and trauma or abuse history were captured.

RESULTS

From January 2018 to January 2022, 61 patients were evaluated and included in the study. Psychological treatment had been provided to 37 (61%) patients (present: 16 (27%), past: 21 (35%)). The most common psychological disorders represented were depression (N = 13, 22%), anxiety (N = 10, 17%), and post-traumatic stress disorder (N = 5, 8%). DASS scores indicated that 20 (33%) patients were reporting symptoms of depression and 16 (27%) patients were reporting symptoms of anxiety. Of the 40 patients assessed for pain catastrophizing, 28 (70%) reported rumination, 9 (23%) reported magnification, and 23 (58%) reported feelings of helplessness. A childhood history of emotional or physical abuse was reported by 11 (18%) patients.

CONCLUSION

An inter-disciplinary groin pain clinic has revealed that patients with CPIP frequently have pre-existing complex psychosocial issues. A multi-specialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair with preperitoneal closed-suction drainage reduced postoperative complications

BACKGROUND

Although laparoscopic total extraperitoneal (TEP) inguinal hernia repair has the advantages of less bleeding, less trauma, less pain, and fast recovery, there are several issues that need to be addressed. This study aims to evaluate the effectiveness of preperitoneal closed‑suction drainage on reducing postoperative complications in TEP inguinal hernia repair.

METHODS

A retrospective analysis of 122 patients who underwent TEP inguinal hernia repair between June 2018 and June 2021 was performed. The patients were divided into the drainage group and the non-drainage group according to whether the drainage tube was placed or not. Clinical data, surgical procedures and outcome of these patients were collected and analyzed to assess the effectiveness of drainage.

RESULTS

A total of 122 patients undergoing TEP surgery were screened, of which 22 were excluded. Most of the patients were male with right indirect inguinal hernia. There was no difference in the mean length of hospital stay between the two groups. Postoperative pain was alleviated by preperitoneal closed‑suction drainage 24 h after operation (p = 0.03). The rate of complications such as scrotal edema, seroma and urinary retention in the drainage group was significantly lower than that in the non-drainage group (p < 0.05). Multivariate regression analysis showed that drainage was beneficial to reduce postoperative complications (OR, 0.015; 95% CI, 0.002-0.140; p < 0.01). In addition, it was worth noting that in subgroup analysis, patients with hernia sac volume > 10 cm³ might receive more clinical benefits by placing drainage tube.

CONCLUSION

In TEP inguinal hernia repair, placing drainage tube is a simple and feasible traditional surgical treatment, which can promote postoperative recovery without increasing the risk of infection, especially in patients with large hernia sac volume.

The Harald Breivik lecture 2022. Pathophysiology in persistent severe pain after groin hernia repair

The transition from a healthy to a persistent severe pain state following otherwise successful elective surgery is a feared complication. Groin hernia repair, previously considered minor surgery, is a standard surgical procedure annually performed on 2,000 individuals per one million residents. A trajectory into persistent severe pain is, unfortunately, seen in 2-4%, severely impeding physical and psychosocial daily functions.

Cost-effectiveness analysis of mesh fixation techniques for laparoscopic and open inguinal hernia surgeries

Purpose

This study reports economic evaluation of mesh fixation in open and laparoscopic hernia repair from a prospective real-world cohort study, using cost-effectiveness analysis (CEA) and cost-utility analysis (CUA).

Methods

A prospective real-world cohort study was conducted in two university-based hospitals in Thailand from November 2018 to 2019. Patient data on hernia features, operative approaches, clinical outcomes, associated cost data, and quality of life were collected. Models were used to determine each group’s treatment effect, potential outcome means, and average treatment effects. An incremental cost-effectiveness ratio was used to evaluate the incremental risk of hernia recurrences.

Results

The 261 patients in this study were divided into six groups: laparoscopic with tack (LT, n = 47), glue (LG, n = 26), and self-gripping mesh (LSG, n = 30), and open with suture (OS, n = 117), glue (OG, n = 18), and self-gripping mesh (OSG, n = 23). Hernia recurrence was most common in LSG. The mean utility score was highest in OG and OSG (both 0.99). Treatment costs were generally higher for laparoscopic than open procedures. The cost-effectiveness plane for utility and hernia recurrence identified LSG as least cost effective. Cost-effectiveness acceptability curves identified OG as having the highest probability of being cost effective at willingness to pay levels between $0 and $3,300, followed by OSG.

Conclusion

Given the similarity of hernia recurrence among all major procedures, the cost of surgery may impact the decision. According to our findings, open hernia repair with adhesive or self-gripping mesh appears most cost-effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08491-4.

Risks of therapeutic versus prophylactic neurectomies

INTRODUCTION

Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them.

METHODS

All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively.

RESULTS

66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively.

DISCUSSION

We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program

PURPOSE

Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial.

METHODS

Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured.

RESULTS

Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise.

CONCLUSION

Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Use of Groin Neurectomies for Noniatrogenic Testicular and Groin Pain

Background Chronic groin neuralgia is a life-debilitating condition that plagues patients worldwide. While groin neuralgia is usually traced to iatrogenic causes (inguinal hernia repairs, vasectomy, and hysterectomy), there is a unique subset of patients that present with noniatrogenic groin neuralgia. The diagnosis and treatment of these patients present a particular challenge.

Methods A total of 30 patients (current mean age, 46.5 [range: 19–72] years) who presented with noniatrogenic groin neuralgia and received neurectomies on the iliohypogastric, ilioinguinal, and genitofemoral nerves between 2008 and 2017 were identified. A retrospective review of preoperative and immediate postoperative pain scores was compared with prospectively collected current pain on a Likert's scale (0–10). Additionally, patients were asked to complete a Short Form (SF)-20 and identify current pain medications. A two-sided Wilcoxon–Mann–Whitney test was used to analyze the data.

Results Of the 30 patients identified, 16 could participate (mean follow-up = 61 months). The average pain reduction for the entire group was 62.7%. When using an established 30% reduction pain as a marker for clinical significance, 12 successful and 4 unsuccessful patients had an average reduction of 81.1 and 7.68%, respectively (success rate of 75%). Patients with successful group showed a statistically significant increased social functioning (p = 0.012) and near-significant increase in mental health (p = 0.063). Improvements, albeit nonsignificant, in mean scaled scores for every other SF-20 quality of life (QoL) category were observed when comparing both groups.

Conclusion Neurectomy is a potentially beneficial surgery that can assuage pain and improve quality of life for patients with noniatrogenic groin neuralgia.

Surgical treatment for chronic pain after inguinal hernia repair: a systematic literature review

PURPOSE

Chronic postoperative inguinal pain (CPIP) is a frequent complication after inguinal surgery with a significant decrease in quality of life. There is still no clear algorithm regarding surgical treatment. The aim of this systematic review was to provide an overview on the principles and outcome of surgical interventions for CPIP based on the available literature.

MATERIALS AND METHODS

A literature search was performed using the databases PubMed and SCOPUS following the PRISMA statement. Used Mesh terms and keywords were "postoperative pain," "chronic pain," "inguinal hernia," and "surgical treatment." All articles were reviewed regarding surgical technique and outcome. MINORS criteria for the assessment of the methodological quality of non-randomized surgical studies were applied.

RESULTS

Eighteen articles, of which 17 cohort studies and one randomized controlled trial (RCT), described the surgical management of CPIP. Selective as well as triple neurectomy, often in combination with mesh removal and removal of suture material, was performed. Success rate, defined as significant or complete relief of pain, ranged from 33 until 100%, with most articles reaching success rates above 70%, showing a clear advantage of surgical therapy for chronic pain.

CONCLUSIONS

The use of surgical triple neurectomy seems effective and helpful in a high percentage of patients with CPIP. Surgical treatment should only be considered after adequate preoperative diagnostic evaluation of which the dermatome sensory mapping seems a useful tool for detailed neurophysiological assessment of patients with persistent post-herniorrhaphy pain undergoing remedial neurectomy.

Ultrasound-guided microwave ablation in the treatment of inguinal neuralgia

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.

Cyanoacrylate Glue Versus Absorbable Tacks in Mesh Fixation for Laparoscopic Extraperitoneal Inguinal Hernia Repair: A Randomized Controlled Trial

BACKGROUND

Cyanoacrylate glue (Glubran 2) is a synthetic adhesive mesh fixation material. Its utility is being evaluated in laparoscopic total extraperitoneal (TEP) inguinal hernia repair (IHR). A multicentre randomized controlled trial was performed comparing Glubran 2 to standard of care absorbable tacks, particularly assessing chronic postoperative inguinal pain and its effects.

MATERIALS AND METHODS

Patients undergoing elective TEP IHR at 2 centers from 2017 to 2019 were randomly assigned to Glubran 2 or absorbable tack mesh fixation, and followed for 6 months. All other aspects of surgery and aftercare remained the same. Surgeons documented operative and fixation time, and the placement of fixation on standardized diagrams. Via a questionnaire, aspects of inguinal pain were evaluated before surgery, and at various time-points postoperatively over 6 months. Postoperative clinical factors were also collected.

RESULTS

A total of 106 operative sides were randomized to either glue (51) or tack (55) mesh fixation over a 14-month period. Similar median operative times between tack (83.0 min) and glue fixation (75.0 min) were observed. There were no significant surgical complications or observed hernia recurrences in either group. There was no significant difference in pain scores between the 2 groups at all time-points after analysis through mixed effects modeling. Temporal pain profiles over time were also similar. Totally, 55% of patients in the glue group had returned to work within 2 weeks of surgery. There was no increase in complications or pain scores despite regular lateral fixation of glue in these patients.

CONCLUSION

Adding to known data, we observed no significant difference in postoperative pain, demonstrating that cyanoacrylate glue is a viable and safe alternative fixation method to absorbable tacks in laparoscopic TEP IHR. As secondary outcomes, cyanoacrylate glue permits some patients to return to work early, and we observed regular lateral mesh glue fixation without increased pain or complications.

Potential benefit in information providing and influence on patient anxiety and satisfaction by means of preoperative explanatory videos in total extraperitoneal inguinal hernioplasty: study protocol of a multicentre, double-blinded, randomised parallel-group controlled trial

INTRODUCTION

The use of electronic media in informed consent giving has become increasingly important in recent years. Due to the easy access to information via electronical media, patients are primed in a heterogeneous manner concerning expectations and wishes regarding surgical interventions. Inherent to its nature elective interventions are critically questioned as there is time for information gathering and reflection. In this study, we set out to investigate the effect of an educational video as a supporting element in the process of informed consent giving for one the most frequently performed interventions in general surgery, namely inguinal hernia repair.

METHODS AND ANALYSIS

In a multicentre setup, eligible patients for primary inguinal hernia repair will be randomly assigned to one of three groups. All three groups will have a preoperative informed consent discussion with a physician in which they will eventually sign the informed consent sheet if participation is desired. Eventually, all three groups will get an online link. For two groups, the link will lead to a video with audiovisual information (an inguinal hernia video for the intervention group and a mock video for the control group). The intervention video provides basic principles of endoscopic extraperitoneal hernia repair. The second video is similar in length and design and displays general aspects of day surgery in the two study centres. All the three study groups will be provided with a copy of the informed consent form as it is standard by now. The third group's link will lead to the digital version of the informed consent brochure. Primary outcomes will consist of (1) score in a multiple choice test assessing gain of knowledge regarding hernia repair, (2) difference in the State-Trait Anxiety Inventory and (3) patient satisfaction questionnaire Individual Clinician Feedback (ICF, Picker Institute, Germany) as assessed 1-2 days after the first consultation. The study design guarantees double blinding, there will be no unblinding at any point. All patients will receive the same, quality and number of medical consultations as well as in the same surgical treatment. (Minor differences in the total extraperitoneal technique of the surgical treatment due to anatomical or pathophysiological differences are independent of the group allocation). Except for the additional videos, there will be no difference in in the information provided and the treatment prior, during or after the hernia repair.

ETHICS AND DISSEMINATION

We plan to publish the study in a peer-reviewed journal. The proposed research project has been reviewed by the Cantonal Ethics Committee (BASEC-No 2020-01548). In accordance with national legal regulations in Switzerland stated by the Human Research Act, the proposed project was declared exempt from approval requirement.

TRIAL REGISTRATION NUMBER

NCT04494087; Pre-results.

A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair

BACKGROUND

Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation.

METHODS

The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care.

RESULTS

We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia.

CONCLUSIONS

SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.

Trajectories in severe persistent pain after groin hernia repair: a retrospective analysis

Objectives

Severe persistent post-surgical pain (PPSP) remains a significant healthcare problem. In the third most common surgical procedure in the U.K., groin hernia repair, including 85,000 surgeries, estimated 1,500–3,000 patients will annually develop severe PPSP. While the trajectory of PPSP is generally considered a continuation of the acute post-surgery pain, recent data suggest the condition may develop with a delayed onset. This study evaluated pain-trajectories in a consecutive cohort referred from groin hernia repair-surgeons to a tertiary PPSP-center. Potential explanatory variables based on individual psychometric, sensory, and surgical profiles were analyzed.

Methods

Patients completed graphs on pain trajectories and questionnaires on neuropathic pain, pain-related functional assessments, and psychometrics. Surgical records and quantitative sensory testing profiles were obtained. Pain trajectories were normalized, and pre- and post-surgical segments were analyzed by a normalized area-under-the-curve (AUC) technique. Principal component analysis (PCA) was applied to the explanatory variables. Significant PCA-components were further examined using multiple logistic regression models.

Results

In 95 patients, the AUC identified groups of post-surgical pain trajectories (p<0.0001): group I (n=48), acute high-intensity pain progressing to PPSP; group II (n=28), delayed onset of PPSP; group III (n=7), repeat-surgery gradually inducing PPSP. Data from groups IV (n=3) and V (n=9) were not included in the statistical analysis due to small sample size and data heterogeneity, respectively. The PCA/logistic analyses indicated that neuropathic pain scores, composite pain scores, and pain-related functional assessments were explanatory variables for groups I and II.

Conclusions

Pain trajectories in PPSP after groin hernia repair are heterogeneous but can be classified into meaningful groups. Examination of pain trajectories, mirroring the transition from acute to severe persistent post-surgical pain, has the potential of uncovering clinically relevant pathophysiological mechanisms.

Buyback Program of Unused Prescription Opioids in US Rural Communities, 2017-2018

Objective. To implement an opioid buyback program after ambulatory surgery.Methods. We performed a prospective cohort study of 578 opioid-naïve patients prescribed opioids after ambulatory surgery at a rural US Veterans Affairs (VA) hospital from 2017 to 2018. We reimbursed $5 per unused opioid pill ($50 limit) returned to our VA for proper disposal. We tracked the number of participants, number of unused opioid pills returned, surgeon prescribing, and refill requests.Results. Out of 578 eligible patients, 171 (29.6%) returned 2136.5 unused opioid pills. Information shared with surgeons after 6 months led to a 27% decrease in opioid prescribing without an increase in refills.Conclusions. With this opioid buyback program, rural patients had a safe and convenient place to dispose of unused opioids. Surgeons used information about returns to adjust opioid prescribing after common ambulatory surgeries without an increase in refill requests.Public Health Implications. Although providers prescribe within state opioid guidelines, there will be variations in patient use after ambulatory surgery. An opioid buyback program helped our patients and surgeons decrease unused prescription opioids available for diversion in our rural communities.

Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia

PURPOSE

The iliopubic tract repair was first introduced by Nyhus in 1959, as an open non-mesh posterior preperitoneal repair for inguinal hernia. We have adapted this repair using a robotic approach to offer a minimally invasive (MIS) non-mesh inguinal hernia repair, termed the robotic iliopubic tract (r-IPT) repair. The aim of this pilot study is to evaluate the safety and effectiveness of this new technique.

METHODS

Starting in 2015, patients were enrolled in a Phase I trial of r-IPT repair. Inclusion criteria included low-risk patients with small inguinal hernias. Using a robotic TAPP approach, the direct and/or indirect defects were repaired by approximating the transversalis arch to the iliopubic tract. This trial was then expanded in Phase II to include a wider range of patients. Outcomes were collected prospectively.

RESULTS

Twenty-four inguinal hernias were repaired in 13 patients via r-IPT as outpatients. Patients were followed for a mean of 24.9 months (range 2.7-55.3, median 24). There were no surgical site occurrences and no recurrences. One (7.7%) patient had acute post-operative genital branch neuralgia, which self-resolved. One (7.7%) patient has chronic pain.

CONCLUSION

The Nyhus-inspired robotic iliopubic tract (r-IPT) repair is an MIS approach to provide a non-mesh repair in inguinal hernia. The repair is safe with acceptable preliminary outcomes in low-risk patients. We propose the r-IPT repair to be a MIS option for non-mesh inguinal hernia repair in low-risk patients.

Chronic postoperative inguinal pain: A narrative review

Inguinodynia or chronic postoperative inguinal pain is a growing problem between patients who undergo surgical repair of an inguinal hernia. The change in results measurement proposed by many authors towards Patient Reported Outcome Measurement has underlined the importance of chronic postoperative inguinal pain, because of the great limitations in everyday life and the huge socioeconomic impact that it causes. In this article a narrative review of the available literature in PUBMED, EMBASE and Cochrane Library is performed and the most relevant aspects about epidemiology, etiology prevention, diagnosis and treatment of chronic postoperative inguinal pain are discussed. A new management algorithm is also proposed. The variability in its incidence and clinical presentation makes diagnosis of chronic postoperative inguinal pain a very challenging issue. There is no standardized therapy and an adequate etiological diagnosis is key point for a successful treatment. There are many treatment options that have to be sequentially used and adjusted to each patient and their clinical features.

Chronic inguinal pain after laparoscopic transabdominal preperitonal hernioplasty in inguinal hernia

The ubiquitous application of inguinal hernioplasty performed by various methods does not exclude the occurrence of certain late postoperative complications, the cause of which is sometimes extremely difficult to establish. The article describes a clinical case of observing a patient with chronic postoperative pain 6 months after inguinal hernioplasty using the TAPP technique. When studying the possible causes, the presence of a fixing material (tacker) in the triangle of pain was found, the removal of the latter led to a complete leveling of the clinical picture. Thus, despite the simplicity of performing inguinal hernioplasty, the surgeons desire for excessive fixation and a violation of the principles of this operation can lead to undesirable complications and temporary disability of the patient.

Laparoscopic plug removal for chronic pain after inguinal hernia repair using the plug-and-patch technique: A case report

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We must determine whether the plug or the onlay patch is the cause of chronic pain.

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Laparoscopic plug removal for nociceptive pain due to a plug meshoma is effective.

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We could avoid causing new-onset pain by not creating a groin incision.

Introduction

The use of tension-free mesh repair techniques for inguinal hernias has led to uniformly low recurrence rates. The main associated morbidity is chronic postoperative inguinal pain. Mesh removal and triple neurectomy is the indicated procedure; there is insufficient evidence to support mesh removal alone without neurectomy in patients with chronic postoperative inguinal pain.

Presentation of case

A 76-year-old man previously underwent repair of a right inguinal direct hernia using the plug-and-patch technique. Two years later, he experienced groin pain requiring the use of pain medication. Five years after surgery, he expressed the desire to remove the mesh because of chronic pain, rated 8 out of 10 on a numeric rating scale. We suspected that he was experiencing nociceptive pain caused by a plug meshoma, so we performed a laparoscopic plug extraction. His inguinal pain improved to 2 out of 10 on the second postoperative day, and he stopped taking pain medication by 10 months after surgery.

Discussion

The laparoscopic approach to plug removal is safe and simple. We successfully avoided causing new-onset pain by not using a groin incision to remove the mesh plug.

Conclusion

Laparoscopic plug removal for nociceptive pain due to a plug meshoma is effective. However, since there is insufficient evidence to recommend mesh removal without triple neurectomy, informed consent and further consideration of techniques and diagnostic methods are needed.

Primary unilateral not complicated inguinal hernia with an effective, cheap, less invasive, and easy operation: the Trabucco repair

BACKGROUND

In modern abdominal wall hernia surgery, the achievement of the most effective tailored repair for each specific defect with the less possible invasiveness, the quicker recovery, the lower costs and the fewer risk of local occurrences, recurrences and chronic pain is the most desirable and cutting-edge goal.

METHODS

Since 1989 about 4219 primary unilateral not complicated inguinal hernias have been treated with specific indications with a sutureless and minimally invasive anterior open approach. The great majority of these procedures were performed under local anaesthesia in a day surgery regimen, with a systematic and careful nerve sparing, preservation of cremasteric muscle, and with a 3-5 cm skin incision.

RESULTS

The minimally invasive sutureless nerve sparing open approach has shown a very low rate of seromas (0.45%), haematomas (0.24%) and infections (0.07%) while the width of skin incision challenges even laparoscopy. A significant reduction of both postoperative pain (2.7%) and chronic neuralgia (0.047%) has led to excellent outcomes in patients, also in terms of quality of life. Compared to the Lichtenstein's tension-free technique, which is at now the gold standard open treatment for primary inguinal hernia worldwide, there are no significant differences in the observed recurrence rate (well below 1%).

CONCLUSION

In our experience of almost 30 years we have been able to experiment and refine more and more the sutureless technique proposed by Trabucco for the treatment of primitive inguinal hernia, peer to peer, improving the local anaesthesia and the ability to detect hidden defects during the repair (Spigelian included), reducing the width of the incisions and tractions on the tissues, introducing the concept of a gentle and bloodless "finger surgery" according to a minimally invasive, extremely anatomic, safe, inexpensive, very effective anterior open approach.

[ONSTEP procedure for inguinal hernia repair]

AIM

To evaluate early and long-term outcomes of ONSTEP procedure including their comparison with those of Liechtenstein hernia repair.

MATERIAL AND METHODS

The study consists of 2 parts - retrospective and prospective. There were 472 patients in retrospective part. Prospective analysis included 30 patients after ONSTEP hernia repair and 30 patients after Liechtenstein procedure.

RESULTS

Postoperative complications and chronic pain syndrome occurred in 2.9% and 0.4% of cases after ONSTEP surgery, respectively. Moreover, ONSTEP procedure was followed by 2 cases or recurrence. There were no any significant differences between ONSTEP and Liechtenstein procedures.

CONCLUSION

ONSTEP technique is highly effective and safe procedure that can be used in inguinal hernia management.

Patient perceptions of acute pain and activity disruption following inguinal hernia repair: a propensity-matched comparison of robotic-assisted, laparoscopic, and open approaches

Few publications describe the potential benefit of robotic-assisted inguinal hernia repair on acute postoperative groin pain (APGP). This study compared patients’ perceptions of APGP, activity limitation, and overall satisfaction after robotic-assisted- (R), laparoscopic (L), or open (O) inguinal hernia repair (IHR). Random samples of patients from two web-based research panels and surgical practices were screened for patients who underwent IHR between October 28, 2015 and November 1, 2016. Qualified patients were surveyed to assess perceived APGP at 1 week postoperatively, activity disruption, and overall satisfaction. Three cohorts based on operative approach were compared after propensity matching. Propensity scoring resulted in 83 R-IHR matched to 83 L-IHR respondents, while 85 R-IHR matched with 85 O-IHR respondents. R-IHR respondents recalled less APGP compared to respondents who had O-IHR (4.1 ± 0.3 vs 5.6 ± 0.3, p < 0.01) but similar APGP compared to L-IHR (4.0 ± 0.3 vs 4.4 ± 0.3, p = 0.37). Respondents recalled less activity disruption 1 week postoperatively after R-IHR versus O-IHR (6.1 ± 0.3 vs. 7.3 ± 0.2, p < 0.01) but similar levels of activity disruption after R-IHR and L-IHR (6.0 ± 0.3 vs. 6.6 ± 0.27, p = 0.32). At the time of the survey, respondents perceived less physical activity disruption after R-IHR compared to O-IHR (1.4 ± 0.2 vs. 2.8 ± 0.4, p < 0.01) but similar between R-IHR and L-IHR (1.3 ± 0.2 vs 1.2 ± 0.2, p = 0.94). Most respondents felt satisfied with their outcome regardless of operative approach. Patient perceptions of pain and activity disruption differ by approach, suggesting a potential advantage of a minimally invasive technique over open for IHR. Further studies are warranted to determine long-term outcomes regarding pain and quality of life after IHR.

Randomized Clinical Trial Comparing Low Density versus High Density Meshes in Patients with Bilateral Inguinal Hernia

We present a randomized clinical trial to compare postoperative pain, complications, feeling of a foreign body, and recurrence between heavyweight and lightweight meshes in patients with bilateral groin hernia. Sixty-seven patients with bilateral hernia were included in our study. In each patient, the side of the lightweight mesh was decided by random numbers table. Pain score was measured by visual analogue scale, on 1st, 3rd, 5th, and 7th postoperative day, and one year after the surgery. There were no statistically significative differences between both meshes in postoperative complications. About differences of pain average, there were statistically significant differences only on the 1st postoperative day (P <0.01) and the 7th postoperative day (P <0.05). In the review after a year, there were no statistically significative differences in any parameter. In our study, we did not find statistically significative differences between lightweight and heavyweight meshes in postoperative pain, complications, feeling of a foreign body, and recurrence, except pain on 1st and 7th postoperative day.