Surgical management of chronic inguinal pain syndromes - Liespijn

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n (%)1. Neuropathic cause 72 (46.5)Inguinal nerves* 71 (45.8)LFCN (Meralgia paresthetica)** 1 (0.6)2. Non-neuropathic causes 40 (25.8)Periostitis (pubic tubercle) 18 (11.6)Recurrent inguinal hernia 13 (8.4)Femoral hernia 1 (0.6)Iliopectineal bursitis 1 (0.6)Adductor tendinitis 1 (0.6)Osteoarthritis of the hip 1 (0.6)Referred lumbosacral pain 3 (1.9)Urological problems 2 (1.3)3. Tender spermatic cord/ tight feeling 43 (27.7)Total number of diagnoses 155 (100)Table 4 Classification of chronic inguinal pain in patients following elective inguinal hernia repair (n=148).Values between parentheses are percentages, unless otherwise specified, 7 patients were diagnosed with two conditions,*Ilioinguinal, Iliohypogastric, Genitofemoral nerve, **Lateral Femoral Cutaneous Nerve.DISCUSSIONThe issue of unravelling the dilemma of long-term moderate to severe postherniorrhaphypain is not new 16 . However, to our knowledge this is the first study in which alarge cohort of patients was examined at the outpatient department to clarify theunderlying mechanisms that are responsible for pain following hernia repair. A similarbut smaller study was conducted by Cunningham et al. in 1996 8 . A subset of 10 patientsreferred to a pain clinic with persisting pain was investigated two years after inguinalrepair. He proposed three distinct pain syndromes; somatic (n=9), neuropathic (n=1) andvisceral (n=1). The first one was judged as a ligamentous pain syndrome caused bysuture insertion in the iliopubic tract and periosteum. The second syndrome was neuralgicand caused by inguinal sensory nerve damage whereas a third complex wasassociated with ejaculation pain. They concluded that severe pain syndromes followinghernia repair are most commonly somatic in origin. Similar groups of patients wereidentified in the present study. Pain of neuropathic origin was suspected in nearly halfof the patients and confirmed by nerve block in 28 per cent of all patients. If one extrapolatesthese results to the initial patient population encompassing 1,766 individuals,one could cautiously assume that approximately 4 per cent of all corrected inguinalhernias are associated with nerve entrapment or damage. Previous authors have estimateda similar prevalence varying between 3 and 5% 9 . Chronic nerve irritation shouldbe considered as an important cause of moderate or severe chronic pain after inguinalhernioplasty.Another well known source of postherniorrhaphy pain is periostitis of the pubic tubercle10 . A too deeply positioned suture aimed at medially fixing the mesh may causeinflammation and chronic irritation. In the present examined cohort one in every eightpatients experienced pain while exerting digital pressure on the pubic tubercle. Thispain syndrome can be avoided by careful placement of suture material ideally sparingthe bone’s periostal layers. An injection with a local anaesthetic and corticosteroids inpainful periosteum could be tried first as this was effective in a substantial number ofour patients. Surgical suture removal must be considered if pain persists.When a patient presents with residual pain following hernia repair, a recurrent herniais often the only diagnosis that surgeons consider and rule out. Although relativelyinfrequent in the present study, thirteen patients were encountered with such a recurrence.This number approximates the 1% of the initial 1766 patients used in our previousquestionnaire study. The real recurrence rate is probably higher due to the fact thatasymptomatic and mild symptomatic recurrences remain undetected.A variety of additional musculoskeletal problems was observed in the remainder of thepatients with recurrent pain including iliopectineal bursitis, adductor tendinitis, andreferred low back pain. These pain syndromes are very likely the secondary result ofpostural and functional changes in the presence of persisting inguinal pain. However,a third group of 43 individuals demonstrated a clearly distinct history and physicalexamination. They presented with a tender spermatic cord (after open mesh repair) ora tight aching feeling of the lower abdomen (after laparoscopic procedures). Compressionby scar tissue or prosthetic material may possibly explain this type of groin pain 12 .Compromised musculotendinous structures might play a roll as well. It remains unclearif venous congestion contributes to pain in this group of patients. Overall pain intensityis less pronounced compared to the neuropathic pain group although most patientsexperience some limitations in daily activities. Except for pain medication no optimaltreatment is currently available for them. We suggest to name this type of pain ‘funiculodynia’as this syndrome is mainly characterized by pain in structures surroundingthe spermatic cord.Prevalence, etiology and treatment of genital complications following hernia repairincluding erectile and ejaculatory pain are largely unknown. In a recently publishedDanish questionnaire study three per cent of younger male patients with inguinal herniarepair exhibited pain during sexual activity and subsequent sexual dysfunction 13 . In thepresent study dysejaculation was reported by one in every five male patients. Severalpathophysiologic mechanisms have been suggested, for instance intraoperative nerve72 Chapter 5Classifying postherniorrhaphy pain syndromes following elective groin hernia repair 73
damage, dysfunction of periurethral structures involved in ejaculation, or encasementof the spermatic cord caused by mesh or scar tissue. This is supported by anecdotalreports on patients with dysejaculation in which dissection of twisted fibrotic spermaticcords combined with an ilioinguinal neurectomy provided total pain relief 14 . Due to itshigh incidence and the scarce literature, more research on etiology and treatment ofdysejaculatory complaints after inguinal hernioplasty is recommended.Over thirty per cent of all postherniorrhaphy pain patients reported to suffer from otherchronic pain syndromes as well. A correlation between the onset of postherniorrhaphypain and other pain syndromes has been previously described in hernia literature andmay be due to genetic and psychosocial factors 13 . Patients with a tendency to developchronic pain are more susceptible to develop additional pain syndromes as well.Classifying postherniorrhaphy pain syndromes may allow for tailored treatmentregimens. The first step in a protocol for treatment of postherniorrhaphy neuralgiadescribed by Lichtenstein nearly two decades ago consisted of primary diagnosis andtreatment by injections 16 . Surprisingly, in the present study a single diagnostic nerveblock with Lidocain led to a long-term (>1 month) pain reduction in twenty-five percentof our patients, confirming the therapeutic potential of such injections. Althoughrecognized, the phenomenon of permanent or long-term cure following injection ofshort acting anaesthetics is not well understood 15 . If (repeated) injection therapy fails,the second step might be an operative transsection 16 . Later on it was suggested by Amidthat transsection should include all three groin nerves (‘triple neurectomy’) 12 . Becauseof central and peripheral communication and possible involvement of all three nerves,a maximal length of ilioinguinal, iliohypogastric and genitofemoral in both directionsshould be transsected and removed.Reports on the effect of mesh on nerves and chronic pain are scarce. According to arecent animal study, inserted mesh may lead to an inflammatory and fibroblasticresponse resulting in adhesions and mechanical entrapment of adjacent nerve fibresand structures such as the spermatic cord 17 . Whether these mesh-related nerve changesare responsible for any pain sensation is unknown. One study comparing mesh withsuturing techniques using the body’s own tissue showed similar incidence rates ofchronic pain 11 . Nevertheless, removal of mesh in combination with a neurectomyappeared to be successful in 60% of patients with chronic inguinodynia 18 . Apart of itsinflammatory potential, implanted mesh may also exert mechanical pressure onneighbouring structures or may fold or wrinkle (‘meshoma’) causing chronic pain 19 . A(partial) removal of mesh in combination with a (triple) neurectomy may be consideredthe preferred treatment in patients with severe neuropathic pain in the presence of ameshoma. In concert with a recent review on surgical management of chronic painafter groin hernia repair there is an obvious need for more prospective research 20 .The results of the present study demonstrate that the differential diagnosis of moderateor severe postherniorrhaphy pain is diverse but allow for a classification withresultant treatment options. Proper research concerning different types of therapy forchronic pain after groin hernia repair is recommended. A randomized controlled trialcomparing peripheral injections with neurectomy has recently been initiated by ourgroup of investigators.REFERENCES1 Loos MJA, Roumen RMH, Scheltinga MRM. Chronic sequelae of common elective groin herniarepair. Hernia 2007; 11: 167-1692 Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinalherniorrhaphy: a nationwide questionnaire study. Ann Surg 2001; 233: 1-73 Nienhuijs SW, Boelens O, Strobbe LJA. Pain after anterior hernia repair. J Am Coll Surg 2005;200: 885-8894 Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg1999; 86: 1528-15315 Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic pain andquality of life following open inguinal hernia repair. Br J Surg 2001; 88: 1122-11266 Page B, Paterson D, Young D, O’Dwyer PJ. Pain from primary inguinal hernia and the effect ofrepair on pain. Br J Surg 2002; 89: 1315-13187 Hindmarsh AC, Cheong E, Lewis MP, Rhodes M. Attendance at a pain clinic with severe chronicpain after open and laparoscopic inguinal hernia repairs. Br J Surg 2003; 90: 1152-11548 Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative herniastudy: pain in the postrepair patient. Ann Surg 1996; 224: 598-6029 Starling JR, Harms BA. Diagnosis and treatment of genitofemoral and ilioinguinal neuralgia.World J Surg 1989; 13: 586-59110 Shulman AG. Changes in technique of primary inguinal hernioplasty since 1984. In: the Lichtensteinhernia repairs, how to do them right! 1st ed. United States of America: Wagner design,ISBN 0-9653526-0-9, 1996; 4911 Vrijland WW, van den Tol MP, Luijendijk RW, Hop WC, Busschbach JJ, de Lange DC, van GeldereD, Rottier AB, Vegt PA, IJzermans JN, Jeekel J. Randomized clinical trial of non-mesh versus meshrepair of primary inguinal hernia. Br J Surg 2002; 89: 293-29712 Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia:Triple neurectomy with proximal end implantation. Hernia 2004; 8: 343-34913 Aasvang E, Møhl B, Bay-Nielsen M, Kehlet H. Pain related sexual dysfunction after inguinaherniorrhaphy. Pain 2006; 122: 258-26314 Butler JD, Hershman MJ, Leach A. Painful ejaculation after inguinal hernia repair. J R Soc Med1998; 91: 432-43315 Hahn L. Clinical findings and results of operative treatment in ilioinguinal nerve entrapmentsyndrome. Br J Obstet Gyn 1989; 96: 1080-108374 Chapter 5Classifying postherniorrhaphy pain syndromes following elective groin hernia repair 75
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Page 5 and 6: CHAPTER 1Introduction, aims and out
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Page 19 and 20: INTRODUCTIONThe Pfannenstiel incisi
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Page 23 and 24: Outpatient assessmentAll patients w
Page 25 and 26: 6 Did you ever visit a physician be
Page 27 and 28: CHAPTER 4Evaluating postherniorrhap
Page 29 and 30: INTRODUCTIONThe introduction of mes
Page 31 and 32: VAS*Values no pain mild moderate se
Page 33 and 34: CHAPTER 5Classifying postherniorrha
Page 35 and 36: INTRODUCTIONChronic pain following
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Page 41 and 42: CHAPTER 6Tailored neurectomy for tr
Page 43 and 44: INTRODUCTIONWorldwide, many patient
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Page 51 and 52: INTRODUCTIONHernia recurrence rates
Page 53 and 54: at the outpatient department as wel
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Page 57 and 58: INTRODUCTIONWorldwide millions of l
Page 59 and 60: ‘diagnostic’ nerve block. A one
Page 61 and 62: DISCUSSIONIn the present study a ne
Page 63 and 64: CHAPTER 9Occupational disability du
Page 65 and 66: INTRODUCTIONIn the Netherlands, app
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Page 69 and 70: 17 Madura JA, Madura JA 2nd, Copper
Page 71 and 72: SUMMARIZING DISCUSSION1. Prevalence
Page 73 and 74: Results of our study are in concert
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Page 81 and 82: CHAPTER 12List of publications158 C
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Page 85 and 86: CHAPTER 14Curriculum Vitae166 Chapt

Surgical management of chronic inguinal pain syndromes - Liespijn

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