PERSISTENT PAIN AFTER GROIN HERNIA SURGERY, MANAGEMENT, 2 of 2, *NEW*

Persistent pain after hernia surgery is said to occur between 6-10% of cases.  I have treated different specific causes for pain.  Pain Management and Neurologic consultations are frequently helpful in determining a cause.

 

Recurrence OF A REPAIRED GROIN HERNIA is rare (~2%) with mesh and not uncommon (>10%) without using mesh in the repair and is the initial consideration as the cause of pain.

 

Pain, which is frequently incapacitating, can occur after all repair techniques without recurrence.  Some reasons are shared and others are specific to approaches, technique and materials.  The reason for the original preoperative and postoperative symptoms must be reconciled with the preoperative anatomy, symptoms and radiography.  Persistent postoperative pain is more common when there was preoperative pain, and might be caused by something other than the original hernia having caused the api.

 

I am listing some of the many considerations needed for diagnosis and treatment of post herniorrhaphy pain:

 

  1. Consider and rule out other causes of groin pain:  diverticulitis, appendicitis, intestinal or gynecologic neoplasm or processes, endometriosis, lymphadenopathy, Shingles, femoral aneurysms (after angiography), metastatic cancer.

  2. Consider Repetitive or Overuse myofascial injury, iliopsoas bursitis, pubis osteitis, hip disease, testicular disease, epididymitis, spinal radiculopathies.

  3. Recurrent or unresolved hernia causing bowel obstruction related to adhesions to mesh or occult undetectable recurrence.

  4. New primary hernia.​
    --New Femoral hernia after open inguinal repair, sequella of C-sections, midline suprapubic (after hysterectomy or prostatectomy) incisions, open appendectomy, Robotic Trocar or extraction sites, standard trocar hernias.
    --Recurrent Small hernia at restrictive edges of mesh from open or laparoscopic repairs might cause more pain than an obvious large bulge.
    --Uncommon Obturator or Spiegelian hernia in elderly after muscle loss for multiple reasons.

  5. Chronic Inflammation- infection, seroma or hematoma, suture granuloma, tight suture.

  6. Local Neuropathy- entrapment by scar, mesh or suture, nerve ischemia, angulations, neuroma, suture nerve entrapment,
    (Ilioinguinal, iliohypogastric, genitofemoral branches, lateral and intermediate femoral cutaneous [depending on open or laparoscopic approach], augmentation of peripheral pain by central spinal radiculopathy).

  7. Mesh-migration, mass, plugs impact o neurologic structure or spermatic cord, erosion into bowel or bladder, contraction, mesh clumping, bowel adhesions.

  8. Metal tack laparoscopic fixation- direct pain, fixation of contracted mesh, nerve impact or entrapment.

  9. Ejaculation pain- Kinking of Vas deferens.

 

With a specific diagnosis, a patient focused strategy can be developed and surgery, which is complicated, can target and resolve the cause in the majority of cases.

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

    Dr. Heymann

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