By Dr. Nora Fullington
Women are at higher risk of developing chronic pain after inguinal hernia surgery
In a recent study of almost 41,000 patients from the Swedish hernia registry*, evidence was found to suggest that there are considerable differences between men and women when it comes to hernias. While hernias are much more common in men (evidenced by 37,000 of those in the registry being male compared to almost 4,000 female), the rate of chronic pain after hernia repair was much higher in women. There is a 30% increase in the odds a woman will develop chronic significant pain compared to male patients after inguinal hernia repair.
What is an inguinal hernia?
An inguinal hernia is a hole in the abdominal wall through which structures that normally sit within the abdominal cavity can bulge. This is a problem affecting 25% of men and 8% of women at some time in their lives. About 800,000 inguinal hernia repairs are performed annually in the United States. Chronic pain is estimated to affect 5-15% of all patients who undergo inguinal hernia surgery which translates into somewhere around 80,000 patients developing this problem each year. Chronic pain is pain that persists after the normal recovery period following surgery and is often described as sharp, stabbing pain emanating from the area of surgery into the groin or thigh. The pain can be severe and can significantly limit a patient’s ability to continue normal activities. This debilitating pain is a fate that seems particularly unfair when oftentimes patients who are undergoing hernia surgery are doing so with the goal of returning to their active lifestyles. The rates of this type of outcome are unacceptably high and have been a driving force for hernia specialists, including those in our practice at Boston Hernia, to make every effort to improve the care of patients with a hernia.
Why do some people have chronic pain after inguinal hernia surgery?
Rates of chronic pain are much higher in anterior repairs, those which are performed by suturing the tissues around the hernia hole to tighten up this area and prevent bulging. In most cases, mesh is then placed over this area. The increased risk of chronic pain is attributed to the presence of three nerves in the area which can be inadvertently stitched into the repair and/or irritated by the mesh placed on top of them.
For reasons that are still being studied, this problem unequally affects women undergoing inguinal hernia repair and because of this, we should do everything possible to minimize this risk during surgery. Some approaches to surgery involve mesh placed posteriorly where the nerves are much more protected and less likely to be injured. In repairs that affect the area where nerves are present, finding these three nerves and either moving them or removing them to minimize the chance they are caught in a stitch or scarred to mesh can result in significant reduction of the risk of chronic pain.
What’s the best surgery for inguinal hernia repair?
There are multiple ways to repair an inguinal hernia and we believe that this choice is best made through a tailored approach to each patient. We consider sex assigned at birth, body shape, medical and surgical history, hernia type, activity level and strength of tissues as we make our recommendations for different types of surgical repairs. We aim to offer patients the best, longest lasting repair while ensuring the easiest possible recovery and quickest return to normal daily life. In so doing, we have perfected several approaches to the repair of inguinal hernias which allows us to have multiple options available to our patients when we see them in consultation. There are real differences between men and women when it comes to hernia repair and recovery. Our focus remains on improving the quality of care for each individual through tailoring our approach to what makes each patient unique.
Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia. He started his practice as a general surgeon in 2001, and in 2012 he transitioned to focus on the care of hernia patients. In 2018, he co-founded Boston Hernia, an ambulatory surgery practice focused exclusively on hernia surgery. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon, where she performed hundreds of laparoscopic hernia repairs, to Boston Hernia where she was intensively trained by Dr. Reinhorn in the open preperitoneal and Shouldice techniques. Together with their physician assistant team, they perform approximately 800 hernia surgeries every year. Both surgeons offer a tailored approach for each patient, taking into account individual patient factors to decide if surgery is recommended or not, what type of repair (open, laparoscopic, mesh, non-mesh) is best, and what type of anesthesia is safest. At Boston Hernia, our focus is on each individual patient and continuously improving our own surgical techniques and outcomes. We do this by participating in various hernia societies, studying our own outcomes through a national database, and publishing our data to influence the care of hernia patients nationally and internationally. Boston Hernia is an affiliate practice of the Mass General Brigham system. In addition to operating at Newton-Wellesley Hospital, a Mass General Brigham Hospital, we offer care at ambulatory surgery centers in Waltham, MA and Derry, NH.