Persistent postsurgical pain: risk factors and prevention

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

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European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Background: Persistent postherniotomy pain (PPP) affects everyday activities in 5-10% of patients. Identification of predisposing factors may help to identify the risk groups and guide anesthetic or surgical procedures in reducing risk for PPP. Methods: A prospective study was conducted in 464 patients undergoing open or laparoscopic transabdominal preperitoneal elective groin hernia repair. Primary outcome was identification of risk factors for substantial pain-related functional impairment at 6 months postoperatively assessed by the validated Activity Assessment Scale (AAS). Data on potential risk factors for PPP were collected preoperatively (pain from the groin hernia, preoperative AAS score, pain from other body regions, and psychometric assessment). Pain scores were collected on days 7 and 30 postoperatively. Sensory functions including pain response to tonic heat stimulation were assessed by quantitative sensory testing preoperatively and 6 months postoperatively to assess nerve damage. Results: Four hundred sixty-four patients were included, whereof 442 were examined at 6 months (95.3% follow-up). Fifty-five patients (12.4%) had "moderate/severe" PPP at 6 months. Logistic regression analysis identified four risk factors for PPP: preoperative AAS score, preoperative pain to tonic heat stimulation, 30-day postoperative pain intensity, and sensory dysfunction in the groin at 6 months (nerve damage) (all P < 0.03). A risk prediction model of only preoperative factors and choice of surgical technique revealed increased preoperative AAS score, increased preoperative pain to heat stimulation, and open surgery to increase the risk for PPP (all P < 0.02). Conclusion: PPP is related to both patient and surgical factors. Patients with a high preoperative AAS score and high pain response to a standardized heat stimulus may preferably be treated using an operative technique with lowest risk for nerve damage.

/pdf/predictive-risk-factors-for-persistent-postherniotomy-pain-4ck4intd3l.pdf

Predictive Risk Factors for Persistent Postherniotomy Pain

BACKGROUND: Chronic pain is a severe complication of mesh-based inguinal hernia repair. Its perceived risk varies widely in the literature. The current objectives are to review the incidence, severity, and consequences of chronic pain and its etiologies. DATA SOURCES: A multi-database systematic search was conducted for prospective trials on mesh-based inguinal hernia repair reporting the measurement and outcome of pain at least 3 months postoperatively with a minimum follow-up of 80%. CONCLUSIONS: After mesh-based inguinal hernia repair, 11% of patients suffer chronic pain. More than a quarter of these patients have moderate to severe pain, mostly with a neuropathic origin. As a consequence of chronic pain, almost one third of patients have limitations in daily leisure activities. Chronic pain is less frequent after endoscopic repair and with the use of a light-weighted mesh.

Chronic pain after mesh repair of inguinal hernia: a systematic review.

Purpose
In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence.

/pdf/update-with-level-1-studies-of-the-european-hernia-society-m7fm4arks1.pdf

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Background:
Severe chronic pain is a long-term problem that may occur after inguinal hernia repair. The aim of this randomized study was to compare pain of any severity at 12 months after inguinal hernia repair with a partially absorbable lightweight mesh (LW group) or with a non-absorbable heavyweight mesh (HW group).

Methods:
Patients were assessed for pain at 1, 3 and 12 months by questionnaire, and were examined clinically at 12 months.

Results:
Some 321 patients were included in an intention-to-treat analysis, 162 in the LW group and 159 in the HW group. At 12 months, significantly fewer patients in the LW group than in the HW group had pain of any severity: 39·5 versus 51·6 per cent (difference—12·1 (95 per cent confidence interval—23·1 to—1·0) per cent; P = 0·033). The recurrence rate was higher in the LW group (5·6 versus 0·4 per cent; P = 0·037). Five of eight recurrences in LW group were associated with a single participating centre.

Conclusion:
Use of lightweight mesh was associated with less chronic pain but an increase in hernia recurrence after inguinal hernia repair. The latter may be related to technical factors associated with fixation of such meshes rather than any inherent defect in the mesh. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair.

Sir Since hernia repair is one of the commonest elective operations, we were disturbed at the high recurrence rate following the use of lightweight mesh (LW). The authors explained this high recurrence as being due to technical aspects of fixation at the one centre that reported most of the recurrences. If this assumption is true, the same technical defect should also have existed with standard mesh repair at that centre. Alternatively, LW mesh may inherently be more prone to recurrence. Mild chronic pain that does not affect physical function is not much of a problem after hernia repair, whereas patients with severe pain are much more troubled. In the paper, the rate of severe pain at 12 months was similar after in both groups (3 per cent after LW compared with 4 percent after standard mesh repair). It could reasonably be concluded that LW mesh repair has a comparable rate of chronic groin pain but a higher risk of recurrence compared with standard mesh repair. T. Amalesh, D. Cooper and A. Singh Department of General Surgery, Basildon University Hospital, Nethermayne, Essex SS16 5NL, UK DOI: 10.1002/bjs.5064

Authors' reply: Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair

https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.5065

Authors' reply: Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair (Br J Surg 2005; 92: 166‐170)

G. Horeyseck

Papers

Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair.

Authors' reply: Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair

Authors' reply: Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair (Br J Surg 2005; 92: 166‐170)