chronic pain post surgery

[drtowfigh]

Most studies show that risk factors for postoperative chronic pain after open inguinal hernia repair with mesh include: women, younger patients, thin patients.

The definition of chronic pain is ANY symptom that continues after 3 months postoperatively. The data is around 12% risk (range is very wide based on which study you look at). These symptoms may include a twinge of pain or chronic debilitating pain. The serious pain risk is around 3%.

The data is all over the place for hernias. In general, laparoscopic repair has less chronic pain than open. Also, most recent study shows no difference between non-mesh open and open mesh repairs in terms of chronic pain. Also, a recent study shows lightweight mesh causes more chronic pain than heavy weight mesh. Like I said… the data is all over the place.

It’s best if your surgeon expert helps you digest the data as it pertains to your specific situation and needs.

[joep]

Re posting again as my prev reply got somehow flagged as spam

Thanks John Fortem for that link and paper. that was informative :)… anyways some of my recent update below:

i was able to visit a Hernia specialist. He told me his main experience is in laparoscopic mesh repair. First he asked me about how i got the pain in the first place.

I explained to him about my incidence in gym. I was lifting weights (dumbbell), using my left arm, and during my last rep i was unable to lift it, so i used my abdomen muscles to slightly aid my biceps just in the last rep (in summary it was improper lifting). Immediately after that i felt the pain. Surgeon told me that was unfortunately and silly. He told i might have gotten a grade 3 muscle strain (complete rupture). Then he asked me if the pain have subsidized since it first occurred. It has been now over 3 months, and i told him that pain was about 60-70% of the pain in initial days. He told me that my abdomen muscles are still not recovered, and that could be a contributing factor to the pain (in addition to nerve irritation caused when fatty tissue protrudes). He told me grade 3 strain might need 4-6 months for pain to subsidize. He asked me to come back for review after 3 months (so total 6 months after accident).

As per this surgeon, i will still probably need surgery. That hole for sure wont close itself. But there is a good chance that i might become asymptomatic or under very negligible pain within few more months of waiting. And i do have the luxury of waiting as my intestine/bowels have still not come out and as there is still no visible bulge. He agreed with me doing surgery with pre-op pain, would only increase the risk of chronic post-op pain. So its best to wait for now and to do surgery when the pain have subsidized.

Will sure post my update within next few months.

Thanks all for the advice and info.

[dog]

quote John Fortem:

I read an interesting article yesterday regarding chronic post operative inguinal pain (CPIP). You may want to read it.

https://www.degruyter.com/view/j/iss…-2017-0017.xml

Two of the predictors for chronic pain appear to be pre-operative and post-operative inguinal pain. Females also seem to be more predisposed to chronic pain. It contains a lot of interesting discussions about chronic pain. It was published in 2017, so it’s very recent, and it is a systematic overview.

The question of whether or not the use of a mesh can reduce the risk of chronic pain compared to suture repair is inconclusive.

“The use of mesh seems to reduce the risk of CPIP compared to suture repair. Many trials have investigated the question whether lightweight meshes (LWM) may reduce the risk of CPIP. The interpretation of these studies is difficult due to the large variety of mesh materials and mesh properties such as weight, pore size, tensile strength, weaving pattern, and elasticity.”

The conclusion states:

“The avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. This problem preceded modern mesh-based techniques; however, as recurrence rates have decreased, pain has become the more prevalent and important complication. Understanding the causative mechanisms and risk factors of inguinodynia help to prevent, diagnose, and treat this condition. Groin pain, especially in the absence of a bulge, often needs interdisciplinary diagnostics and no operation. Detailed diagnostics, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance. Further research on how to avoid CPIP and explore the effectiveness of treating it is necessary.”

This is interesting. Because when you read the statements of mesh promoters, they will all almost unanimously say that meshes have helped reduce recurrence rates down to practically zero. I agree with this author though that recurrence should not be the primary clinical outcome measure, while chronic pain should.

The author is Dr. Reinpold of Hernia Centre Hamburg-Wilhelmsburg. He does hernia surgeries both with and without the use meshes. You can read more about this doctor and the center here:

https://www.leading-medicine-guide.com/en/Specialist-Hernia-Surgery-Hamburg-Dr-Reinpold

Of course ..It is German Doctor.. The are the best!

[joep]

Thanks John Fortem for that paper, it was incredibly useful. Some of my recent updates below:

I had sought out a hernia specialist surgeon, and had consultation with him yesterday. He told most of the procedures he have done are laparoscopic mesh surgeries. From his experience, the patients who would come with chronic post op-pain is around 6%. Although most patients he told, will have some mild discomfort for 1-2 years, but for most the disabling pain (pain relevant enough to stop physical activities) is almost all gone by 1-2 months post op.

Then he asked me about the first instance when i got pain. I told him i was at gym, and doing dumbbell lifting using my left arm. During my last rep, i was unable to lift the dumbbell and i used my left abdomen muscles to aid it along with my arm (in summary, that was improper weightlifting). He told that was quite unfortunate and silly. I might have a grade 3 strain (complete rupture) of muscle, during that weightlifting which gave raise to hernia. The pain that i am having could also be because muscles are still not fully recovered, and the nerves might still be sensitized (in addiction to the nerve irritation which can happen when the fatty tissue protrudes during physical activities). A grade 3 strain might take 4-6 months for it to be pain free. Then he asked if my pain have decreased from the first day of accident. And i told him yes, its almost 60-70% less than the first few days. As its about 3 months now, since the accident, he told me wait for 3 more months (so total 6 months after incident). And come back for review.

He told most likely i will still need surgery, as hernia is present. That hole sure isn’t gone to close itself. But as my pain have been decreasing since it first occurred, there is a good chance that within few months i might become asymptomatic or at least very mild pain. He agreed with me that doing surgery with pre-op pain will only increase risk of getting post op chronic pain. And its best to wait few more months, especially as my hernia is small and intestines have not yet come out.

I am quite happy so for with his reply, usually the doctors i met before would be quick to suggest surgery. But at least here he explained well, seemed honest, and told me to wait.

[John Fortem]

I read an interesting article yesterday regarding chronic post operative inguinal pain (CPIP). You may want to read it.

https://www.degruyter.com/view/j/iss…-2017-0017.xml

Two of the predictors for chronic pain appear to be pre-operative and post-operative inguinal pain. Females also seem to be more predisposed to chronic pain. It contains a lot of interesting discussions about chronic pain. It was published in 2017, so it’s very recent, and it is a systematic overview.

The question of whether or not the use of a mesh can reduce the risk of chronic pain compared to suture repair is inconclusive.

“The use of mesh seems to reduce the risk of CPIP compared to suture repair. Many trials have investigated the question whether lightweight meshes (LWM) may reduce the risk of CPIP. The interpretation of these studies is difficult due to the large variety of mesh materials and mesh properties such as weight, pore size, tensile strength, weaving pattern, and elasticity.”

The conclusion states:

“The avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. This problem preceded modern mesh-based techniques; however, as recurrence rates have decreased, pain has become the more prevalent and important complication. Understanding the causative mechanisms and risk factors of inguinodynia help to prevent, diagnose, and treat this condition. Groin pain, especially in the absence of a bulge, often needs interdisciplinary diagnostics and no operation. Detailed diagnostics, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance. Further research on how to avoid CPIP and explore the effectiveness of treating it is necessary.”

This is interesting. Because when you read the statements of mesh promoters, they will all almost unanimously say that meshes have helped reduce recurrence rates down to practically zero. I agree with this author though that recurrence should not be the primary clinical outcome measure, while chronic pain should.

The author is Dr. Reinpold of Hernia Centre Hamburg-Wilhelmsburg. He does hernia surgeries both with and without the use meshes. You can read more about this doctor and the center here:

https://www.leading-medicine-guide.com/en/Specialist-Hernia-Surgery-Hamburg-Dr-Reinpold

[John Fortem]

quote Jnomesh:

I’m addition look into non mesh repairs-they will be harder to find but they are out there.
understand that with mesh they put in a pretty big piece which is standard-bigger for laparoscopic Repairs (5”x7”) which seems out of whack for a small hernia like yours but is standard procedure.
also understand that mesh is permanent and not meant to come out-there is no “do-over”. Another thing to think about if you should have post op pain you will never know for sure if it is do to the mesh itself or Bc you had preoperative.
so research the hell out of both procedures and ideally meet with a Couple of surgeons for both mesh (open/lapro) and non mesh repairs whichever route you decide to take make sure the surgeon is a hernia specialist-this means probably looking outside of a general surgeon.

I can also confirm that a large piece of mesh is used in case of laparoscopic or robot assisted repair. I was watching some surgeon from India yesterday on YouTube, and he was also explaining that you have to make sure the mesh is larger than the hole. It kind of struck a cord with me. Because I was watching a Canadian documentary a few weeks ago about mesh implants, and in that documentary the activists of some British anti-mesh group were emphasizing exactly this: the mesh is larger than it has to be to cover the hole. They have to make it large for obvious reasons. Such as making sure they can fasten it properly and also give it some slack as the mesh will ultimately start to shrink eventually.

Mesh is really a bad invention if you ask me. It has no business being inside the human body. It doesn’t matter what kind or type it is, they are all more or less the same, and it’s not natural. I am even skeptical against the absorbable meshes that are up and coming. It’s incredible how infested this idea of using a mesh for hernia repairs is in the world today. If we are to use some kind of mesh in the body, we have to be absolutely certain that it is 100% compatible and thoroughly tested in the human body. Ideally, we should use a material that is as natural as our own tissues.

[joep]

thanks Good intentions and Jnomesh. I guess my search begins. It is a little frustrating too, initially when i was diagnosed with hernia, i dint worry this much. I though it was a routine surgery and medical community by now would have made it to a stage where risks are low/acceptable. But a quick google search about hernia surgery taught me that its still not “routine” in terms of post surgery risks.

[Jnomesh]

I’m addition look into non mesh repairs-they will be harder to find but they are out there.
understand that with mesh they put in a pretty big piece which is standard-bigger for laparoscopic Repairs (5”x7”) which seems out of whack for a small hernia like yours but is standard procedure.
also understand that mesh is permanent and not meant to come out-there is no “do-over”. Another thing to think about if you should have post op pain you will never know for sure if it is do to the mesh itself or Bc you had preoperative.
so research the hell out of both procedures and ideally meet with a Couple of surgeons for both mesh (open/lapro) and non mesh repairs whichever route you decide to take make sure the surgeon is a hernia specialist-this means probably looking outside of a general surgeon.

[Good intentions]

Be careful when studying chronic pain after surgery and its causes, in order to make an informed decision about a repair method. It is often noted in the papers that attempt to study it that the definition of “pain” is poorly defined. Constant discomfort might not be categorized as pain, for example, so would not be counted. In addition to pain or discomfort there might also be other side effects that are barely addressed at all, in normal body functions. The primary focus for many doctors in hernia repair is short-term, fixing the hole. Long-term effects are somebody else’s problem.

Since you have time, use it to find a doctor who actually stays in touch with their patients and knows how their work performs in the long-term. There are surgeons who do that, although it takes much extra effort. Not a few weeks or months, but years if possible. Or find someone who had a similar hernia repair years ago and does the things that you plan to do, and get the same exact repair by the same surgeon. It’s really the best way to be sure. The hernia repair industry is being taken over by the medical device makers, who are selling and pressuring medical institutions to use their products, mesh-based devices, often ignoring the long-term effects of their devices.

Also be aware that many surgeons believe that the FDA is “watching their backs” and monitoring these devices. It’s not true. The FDA generally trusts the big device makers to monitor their own products and only gets involved if there are obvious and extreme failures, like death. The opioid crisis and the transvaginal mesh situation are current examples of the FDA’s failure.

Sorry to be so negative but you are at a point where the decision you make might be be the most important one of your life. Find a doctor who can actually verify that their method works over many years, with little to no chronic pain or discomfort.

Good luck.