I’m worried about chronic pain. Is one repair better than another?

How does chronic pain after hernia surgery occur?

Chronic pain after inguinal hernia surgery occurs in approximately 5-15% of patients. The main cause of pain after hernia surgery is mesh placement near nerves. Since 1987, mesh repairs have become much more prevalent due to their advertised decrease in hernia recurrence. Indeed, for most surgeons who perform 50 or less hernia repairs each year, the recurrence rate will be less when using mesh, as opposed to non-mesh hernia repair options.

With a traditional mesh repair, the mesh is placed on the outside of the abdominal wall to patch the hernia defect from the outside (anterior mesh). There are three nerves, the ilioinguinal, iliohypogastric, and genitofemoral nerves, that run along the outside of the abdominal wall in the same location as this mesh. When a sheet of mesh is placed or sutured near or to one of these nerves, the result is often significant pain that begins immediately after surgery.

Most of the patients that we see in our office who suffer from Chronic Groin Pain complain of severe pain in the recovery room after hernia surgery that never subsides. We feel that there is a clear relationship between the location of the mesh placement and the incidence of chronic pain. This is why we recommend a posterior mesh repair, as it avoids these nerves and results in a much lower incidence of chronic pain.

 

Is there an issue with the mesh plug?

We also see patients that complain of a hard mass in their groin and have pain from a mesh plug that was inserted into the internal opening of the inguinal canal (internal ring). As can be seen in the picture here, taken during during laparoscopic surgery, the mesh plugs not only block the hernia opening, but constantly put pressure on the surrounding areas. As you can imagine, this patient experienced chronic pain after his hernia surgery.

Mesh plugs from inguinal hernia causing chronic pain

Are non-mesh hernia repairs better?

Non-mesh hernia repairs have the distinct advantage of not leaving a large piece of mesh against nerves. However, the trade off is that there is a higher incidence of the hernia coming back over time (hernia recurrence). One of the confounding factors about non-mesh repairs is that they are generally only performed by high volume hernia surgeons, and likely have better results because they are performed by hernia specialists rather than the average general surgeon who performs many different types of operations.

Why are posterior – preperitoneal – hernia repairs better?

Recent data has shown that posterior mesh repairs – advanced open preperitoneal repair, laparoscopic or robotic have a lower incidence of chronic pain than the traditional mesh repairs. This is intuitively obvious since the posterior repairs avoid 2 out of the 3 common nerves entirely, unless a fixation tack is used. For the past 20 years Dr. Reinhorn has performed over 5,000 of the posterior mesh repairs with a minimal incidence of chronic pain.

He first performed these under general anesthesia using sophisticated laparoscopic equipment and later learned how to do the same repair without the need for general anesthesia and through one small incision in the groin. Dr. Fullington is an experienced laparoscopic hernia surgeon who has also been extensively trained in the same approach thought the small groin incision. It is important to learn what your unique options are by speaking with a qualified hernia doctor.

 

About Dr. Reinhorn & Dr. Fullington

Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia.  Dr. Reinhorn started his practice as a full service general surgeon in 2001. In 2012 Dr. Reinhorn started to focus on the care of hernia and pilonidal patients. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon performing hundreds of laparoscopic hernia repairs to Boston Hernia. Together with their physician assistant team, they provide a focused practice designed to provide a superior clinical experience.

The team performs approximately 700 hernia surgeries every year and offers a tailored approach for each patient from anesthesia type to consideration of mesh and no mesh repairs, laparoscopic and open surgery. We have published outcomes and continue to participate in hernia and surgery societies.  Our research led to a reduction in opioid prescribing after hernia surgery. Currently, Dr. Reinhorn serves as the chair of the Opioid Reduction Task Force of the Americas Hernia Society Quality Collaborative.