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 13% of patients.  Some of the risk factors include significant pain before the surgery and being under 50 years old.  The sources of pain after hernia surgery are many, but can include shrinkage of implanted mesh, creating a hard mass that compresses against other tissues or organs.  Also, mesh placement without shrinkage can impact nearby structures such as nerves, blood vessels and even the intestine.  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 no mesh hernia repair options, like the Shouldice repair.  However, using mesh often leads to less dissection and less identification of the three most common nerves that can be damaged during hernia surgery.  Those nerves include the ilioinguinal, iliohypogastric and genitofemoral nerves.  When a sheet of mesh is placed or sutured near or to one of these nerves, significant pain begins immediately after surgery.  In fact, most of the patients that we see in our office who suffer Chronic Groin Pain ( CGP) complain of severe pain in the recovery room, that never subsides.  We feel that there is a clear relationship between the location of the mesh placement and the 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 don’t only block the hernia opening, but constantly poke the intestine through the thin peritoneal membrane separating the two. As you can imagine, this patient experience chronic pain after his hernia surgery

Mesh plugs from inguinal hernia causing chronic pain by poking at intestine

Are no 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 will be a higher incidence of the hernia returning ( hernia recurrence), necessitating additional surgery.  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 – Pre-peritoneal – hernia repairs better?

Recent data has shown that posterior mesh repairs – Open Pre-peritoneal, Laparoscopic or Robotic have a lower incidence of chronic pain than the more 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 15 years Dr. Reinhorn has performed over 2000 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.    It is important to learn what your unique options are by speaking with a qualifies hernia doctor.

 

About Dr. Reinhorn

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.   This focused practice has been designed to provid a superior clinical experience. Dr. Reinhorn has published his outcomes and continues to participate in hernia and surgery societies.  His research led to a reduction in opioid prescribing after hernia surgery. His team performs approximately 400 hernia surgeries every year.