For the purpose of clarification, a problem that persists six months after surgery is a long-term problem. Some minor aches, pulling, stiffness or limited numbness will still improve after this point. More troublesome symptoms are of greater concern.

Pain is a significant complaint after the early phase of wound healing. Significantly, the same pain might have been noted immediately after surgery and continuously required consistent narcotic usage. The pain may be under the wound and in the area of the preoperative hernia bulge or the pain might radiate from the wound into the thigh, pubic area or testicle. Motion or position changes might worsen symptoms. If the pain prevents return to normal activity and work after 4-6 weeks, the complaint is of significant concern assuming that malingering is absent.

Nerve entrapment produces burning pain. Radiation of discomfort into the scrotum might be felt for a week or two after surgery but persistence for months is alarming. Nerve entrapment occurs because something is continuously irritating the nerve. This can result from angulations of the re-routed nerve over tissue planes or through reconstructed layers, compression by an aperture produced by tight closure of a ring or swelling of the tissues exiting the shared ring, or inflammation and subsequent thick scar formation that continues to compress the nerve. A nerve might be in a position where it courses over the edge of an irritating mesh. Entrapment by sutures or staples is also possible.

Preoperative preexisting injury to the nerve by stretching or compression by the original hernia mass may not recover after hernia repair and result in persistent pain. These Primary “neuromas” can be created by long term irritation of the nerve as it passes through atypical anatomic exits through fascia and stretched by the expanding underlying hernia bulge. At the original surgery the surgeon might have noted a thin stretched out nerve or a thickened “traumatic neuroma” at the site of continuous irritation. The surgeon might decide to excise these injured nerves, especially if preoperative pain is present. Some surgeons prefer to “prophylactically” remove nerves that are dissected during open repairs. Pain can result from devascularization of the nerve during mobilization. Inflammation related to sutures and pressure from swelling of tissue planes can irritate nerves. Most resorbable sutures are gone by six months and resolution might follow resorption of the suture. Tissue swelling resolves in less time. If permanent suture material is used, reoperation usually will be required to resolve this problem if a nerve is directly impacted by the suture. A diagnostic nerve block (injection of local anesthetic to the nerve) proves that the pain can be relieved by action focused on the nerve. Resolution of this problem might therefore require reoperation to free up or even transect the nerve. Numbness is usually preferable to steady pain.

Rarely, entrapment by suture is obvious within hours of surgery and prompt release is preferable to waiting for months.

Pain related to nerve entrapment or neuromas are best treated by neurectomy which is effective but associated with the substitution of some numbness for the troublesome pain. The nerve is sectioned central to the inciting site of inflammation and scarring and can be performed laparoscopicly as well as with open technique. Most surgeons do not remove mesh if it is thought that the inflammation of the mesh is a causative factor. Inflammation from non-mesh procedures can also be associated with entrapment by scar formation.

Plug pain - Pain caused by plugs is a different issue. The plug might produce pain in the pelvis and can be removed laparoscopicly with microdissection off the irritated pelvic structure.

Early recurrence might produce immediate and persistent postoperative pain or the pain

can occur as recurrence develops. Causes include suture line disruption, herniation at the perimeter of the repair, herniation under a mesh and undetected persistent nearby hernias that might have been present preoperatively. A recurrent hernia protrusion usually becomes obvious within six months but might be difficult to detect because of scar formation in early stages of wound healing. In my experience, small recurrence, especially after mesh repairs, are associated with more pain. These recurrences occur around the edge of the mesh where tissues are irritated and trapped in narrow spaces as the protrusion expands.

Recurrence also occurs later in the first year due to gradual thinning and resorption of the scar or weak tissues contiguous with the repair during wound maturation after about three months. Tissues can tear next to sutures placed under tension. The immediate postoperative phase might have been uneventful. The Shouldice Clinic showed that recurrence is less likely if permanent sutures are used. In other words, the intact suture continues to take tension off the scar. Recurrence is rare when mesh is properly used. The historical surgical literature regarding hernia repairs has shown recurrence rates gradually decreasing from 50% down to less than one percent. Of course, techniques with high recurrence rates were rapidly discarded. Curiously, reports of similar repairs documented recurrence rates ranging from 25% to 5%. The Bassini repair (NO mesh), performed for over a century has a low recurrence in Europe and a high recurrence in the USA. The Canadian Shouldice Clinic (No mesh) claimed a recurrence rate of less than 1%, but American Surgeons had difficulty reproducing these results. The explanation for the different results for the Bassini and the Canadian repairs at different sites is probably a different comprehension of the steps of the techniques as derived from technique descriptions in the Surgical Literature. Modern techniques using mesh have consistently low recurrence rates. Contemporary laparoscopists quote recurrence rates of less than 1%.

Surgeons intuitively know that we do not have a clear idea of overall recurrence rates because reoperation is uncommon. Recurrences are quoted at varying times, i.e. after one or five or ten years. Follow up is almost always incomplete. Patients with recurrences frequently will not return to the same surgeon or avoid surgeons. In some studies, patients with risk factors for recurrence are excluded, e.g.: obesity, neoplasm, elderly, asthmatics, prostatism, constipation and immune compromise.

Some patients do not wish to use mesh. Non mesh techniques, like the Bassini and Canadian Shouldice, can still be performed effectively by experienced hernia surgeons. Recurrences can be treated by either open or laparoscopic techniques by experienced hernia surgeons. Some surgeons prefer to treat all recurrences from laparoscopic repairs with open technique. When we developed laparoscopic hernia surgery in the early 1990’s, laparoscopic hernia repairs were selected for recurrence from open repairs and this indication is still preferable. Laparoscopic hernia repairs are still not performed by the majority of American Surgeons, and many who do perform them are not comfortable with reoperative laparoscopic approaches. (Paradoxically, the minimal access laparoscopic repairs require general anesthesia while open technique can be done with Local anesthesia and sedation.)

Testicular atrophy is rare in initial hernia repairs but a real risk in recurrent hernia repairs (about 3%) because mobilization of the spermatic vessels from scar during recurrent repairs can be very difficult. The same scar makes it hard to mobilize nerves. Loss of the arterial supply will result in loss of the gonad. After a short period of testicular pain, swelling of the testicle (not the scrotum) is noted without much pain, and then over the next three months the testicle shrinks. Testicular injury is rare after initial hernias unless they are long neglected, treated with truss and involved in scarring and anatomic distortion.

Avoidance of the area of the scarring resulting from the initial surgery is best avoided by a laparoscopic approach which repairs the hernia in a fresh unscarred tissue plan, an “end run.” Open preperitoneal approaches can also avoid the previous abdominal wall site of dissection.

Occult deep fluid, blood collections or infection should be ruled out.

Non-hernia related causes of groin pain must also be considered including, but not limited to, new or old soft tissue and skeletal injuries, new intraabdominal diseases, some vascular and lymphatic processes.

    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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