AMERICA'S HERNIA CENTER and NATIONAL LEADER in HERNIA SURGERY

NORTH PENN
HERNIA INSTITUTE

125 Medical Campus Dr.
Suite 310
Lansdale, PA 19446

215-368-1122
Fax:215-368-3569


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"POST-HERNIORRHAPHY PAIN SYNDROME"
Chronic Pain after Inguinal Hernia Repair
  • INTRODUCTION (SEE SURVEY BELOW)

    While many patients have some degree of prolonged post-operative discomfort after any surgery, which may last for several months before resolving, approximately 3-5% of such patients may develop chronic or persistent pain in the region of a surgical incision. This can also occur and be especially bothersome after inguinal hernia repair. Post-operative pain, after inguinal hernia surgery particularly, can develop from a variety of causes. Often, only with an examination by a surgeon or Hernia Specialist, can the exact cause be identified. Even then, the exact cause may not be identifiable.

    There are many causes for this persistent, post-operative inguinal hernia area pain, also called 'Inguinodynia' including, but certainly not limited to:

    • Nerve damage (directly at the time of surgery)
    • Nerve entrapment in scar tissue, mesh or sutures
    • Post-operative benign nerve tumors (Neuromas)
    • Scar Tissue itself or tissue damage
    • Misplaced Mesh (if used)
    • Contracted, scarified and hardened mesh plugs ("Meshomas")
    • Infection (usually noted early post-op.)
    • Recurrent (or Persistent) Hernia.
    • Constriction or Narrowing of the Internal Inguinal Ring around the spermatic cord
    • Periostitis-Inflammation of the outer membrane of the bone (pubic) due to the presence of permanent suture material inadvertently placed into this layer resulting in chronic inflammation and pain
    • Pain from Unrelated Causes, associated with neither the prior inguinal hernia nor its operative repair (i.e., Non-hernia musculoskeletal, Intra-abdominal, Intra-pelvic, Neurologic, Genitourinary, Infectious or Vascular origin etc.)

    A number of pre-, intra-, and postoperative risk factors have been identified for the development of Post-Herniorrhaphy Pain Syndrome (PHPS), which can and does occur regardless of the surgical approach (open and laparoscopic). The existence and intensity of preoperative pain is a real predictive risk factor for the development of PHPS after hernia repair. Patients with preoperative pain are also more prone to develop chronic post-operative pain. Moreover, it is often more common and more severe in younger patients. Genetic factors and susceptibility also likely to play a role in the development of PHPS.

    The exact cause of any individual patient's groin pain cannot be determined of course, nor can specific treatment be recommended without an examination. The diagnosis is a clinical one, and imaging studies such as X-rays, MRI or CT scans are often normal in these circumstances. Imaging studies in cases of persistent post-operative pain are however of value in excluding intra-abdominal or other unrelated causes for pain that is not associated with the prior hernia surgery.

    Many Patients are referred to us from other Surgeons and Pain-Management physicians with persistent post-operative groin pain following open inguinal hernia surgery. In addition to a comprehensive medical and surgical history, a complete physical examination is performed. We also will review the "operative report" (dictated at the time of the initial surgery by the surgeon) in hopes of finding clues as to the possible cause(s) of the persistent pain. For most patients, we initially recommend conservative, non-operative treatment measures, especially in cases where the pain is not too severe. These treatment modalities may include:


    Often, but only in severe, debilitating or persistent cases of groin pain lasting more than one (1) year following a prior open inguinal hernia repair, repeat operation is offered in an attempt to improve the status of the patients. We attempt to identify the cause of the pain at surgery and if possible correct the problem based on our intraoperative findings. Examples of surgical steps utilized in this formal, remedial groin re-exploration procedure may include:

    • Identifying nerve fibers that may be slightly encased in scar tissue, a possible source for pain. When found and if possible, they are surgically released.
    • If the nerves are inextricably caught in scar, as is more often the case, the nerves are severed or cut.
    • Recurrent hernias may also be present. These too are searched for and repaired if found.
    • Conglomerated and bunched up mesh (meshomas) is removed.
    • Folded or pleated mesh is unfolded and flattened or if necessary excised.
    • Benign nerve tumors from nerve injury or post-operative scarring (called "neuromas") are searched for and if found excised along with its adjacent nerve.
    • Excessively knotted permanent suture material, especially in the region of the pubic bone, is also removed.
    • The spermatic cord structures (blood vessels, vas deferens) are mobilized and freed from surrounding scar tissue.

    At this time we will most often also reconstruct the inguinal canal in a Tension-Free fashion to meet our specifications for operative hernia repair. But again, no accurate diagnosis nor treatment plan can be specifically made without an initial evaluation and comprehensive examination.

    Reasonable expectations achieved by repeat operation in patients referred to us with severe or debilitating post-operative "POST HERNIORRHAPHY PAIN SYNDROME" who have failed to improve with the above conservative measures are as follows:

    • 50-60%- Completely or nearly completely Pain-Free (Patients no longer disabled, and require no regular pain medication)
    • 20-25%- Some Residual Pain but much Improved (Patient essentially normally functioning, some medication occasionally used)
    • 12-15%- No Change after Repeat Surgery (Patients feel about the same as before surgery..continues to use analgesics medication)
    • <2-3%- Pain may be worse

    Our experience in these treatment methods is significantly improving, and enhanced by our experience with this intricate problem. We are encouraged by our results. In our research, we are trying to evaluate all of the potential causes and factors leading to this complication. We will then use this data to formulate a contemporary TREATMENT PLAN that hopefully can be effective long term. We hope to also identify safe, quality and effective surgical and non-surgical management protocols for treating patients with this problem which will be beneficial.

    We offer this surgical approach for patients with severe and disabling post-herniorrhaphy groin pain "only" to those who have had a prior "open" surgical repair. Although patients having prior laparoscopic repair can and do also develop this chronic and at times more severe problem, it is far more difficult to effectively treat by repeat surgery. Open methods, such as we offer, are unfortunately far less effective in the management of pain that occurs after laparoscopic hernia repair, and a repeat laparoscopic approach may instead be indicated. Additionally, this surgical re-exploration is currently limited to only patients with prior inguinal hernia repairs. While other hernia repairs (incisional, umbilical, etc.) may also result in chronic pain, as our experience and research continues, we presently limit the treatment of these complications to non-surgical methods. We offer surgery only in those cases following prior open inguinal hernia surgery.
  • SURVEY

    KINDLY COMPLETE THE FOLLOWING FORM FOR OUR RESEARCH!!
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    • WHAT TYPE OF HERNIA DID YOU HAVE REPAIRED?


    • HOW LONG AGO WAS YOUR SURGERY?


    • WERE YOU EVER PAIN FREE AFTER SURGERY


    • AT WHAT TIME AFTER SURGERY DID YOUR CURRENT PAIN LEVEL DEVELOP?


    • BRIEFLY DESCRIBE HOW/WHEN CURRENT PAIN DEVELOPED.


    • WHAT METHOD OF REPAIR WAS USED?


    • IF USED, WHAT MESH PRODUCT WAS USED?


    • WHAT ANETHESIA WAS USED?


    • IF EMPLOYED, WHAT TYPE OF WORK ENVIORNMENT?


    • HAS THE PAIN LIMITED YOUR WORK ABILITY?


    • IF YES, DESCRIBE THE LIMITATIONS AT WORK.
      All Information will be Confidential


    • ARE YOU SELF-EMPLOYED?


    • WEEKLY WORK HOURS?


    • YEARS AT CURRENT JOB?


    • PLEASE DESCRIBE YOUR WORK ACTIVITY BRIEFLY.
      All Information will be Confidential


    • PLEASE DESCRIBE YOUR NON-WORK ACTIVITY LEVEL NOW, AND LIMITATIONS
      All Information will be Confidential


    • PLEASE DESCRIBE ANY TREATMENTS FOR THIS PAIN YOU HAVE RECEIVED! HAS IT HELPED?
      Include Medication, Physical Therapy/Exercises (Describe if Possible), Injections or Repeat Surgery
      All Information will be Confidential


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