The best strategy for the management of inguinodynia is prevention

[Good intentions]

Hello watchful. One of your paragraphs caught my eye. I think that you have over-simplified, maybe kind of extrapolated from how easy it looks to implant the mesh. The thought that the peritoneum is a weakly attached membrane that can be easily peeled from the fascia, to allow a piece of innocuous woven plastic mesh to be placed between it and the fascia.

I am at five years plus since mesh removal and the area that has had the peritoneum peeled off of the mesh, repositioned, and sewed back together is not really close to the way it was before surgery, although some fo my past posts seem hopeful. It is still stiff and gets sore after things like extended walks. It is much better than with the mesh but the damage that was done is still very obvious, even today. I still feel like somebody who suffered a severe accident eight years ago (a mesh-based hernia repair) and is still recovering. My broken collar bone and damaged ankles and knee all seemed very significant when they happened but they have recovered to a much higher degree than the ravaged mesh area.

“One last thing on this is that most tissue repairs (including Shouldice) aren’t really reversible. The anatomy is changed, and you can’t go back to the original if you have problems. With mesh, you can have the mesh removed. This can be a difficult and complex surgery, but it’s at least possible to get pretty close to a “normal” groin since the anatomy isn’t modified.”

[Watchful]

ajm222 – Sounds like you’re improving, so going in the right direction. Not sure why you have bulging. Is it visible from the outside, or do you just feel it when palpating the area?

These open surgeries are traumatic. Healing can indeed take a very long time, particularly if you get some stubborn scar tissue or nerve damage. I’m also hoping for continued improvement. I think in my case some aspects are still likely to improve, but not sure if everything will improve and to what degree. My understanding is that improvement can continue even up to one year and possibly beyond.

[Watchful]

Thanks, MarkT. If it’s based on people coming back complaining about pain after 3 months, then it’s hard to know what to conclude exactly. Proactive follow up is really needed. Still, it’s an impressive result.

It’s interesting that he cuts the ilioinguinal nerve. I wonder what symptoms patients have from that (numbness in certain areas?)

Chronic pain studies seem to be all over the place, which is very confusing. It really feels like it’s ultimately really the choice of surgeon that makes the most difference, and not the particular procedure or its details. I once asked a urologist what procedure he would recommend for hernia surgery. He basically said pick the surgeon, not the procedure. He said go with a surgeon who has done a very large number of whatever particular procedure he prefers with good results, and don’t worry about the choice of procedure because that doesn’t make much difference. I was a bit skeptical of this advice at the time since I had this whole tissue repair vs mesh dilemma stuck in my head, but I now think that he was right.

[MarkT]

He defined it as post-op pain that persists after three months.

Because it is a retrospective study, it is looking back on data that had already been collected (vs. a prospective study that purposefully collects specific data to evaluate certain outcomes).

It *could* be a subtle difference, if they employed a proactive follow-up protocol with all patients…but it seems that they relied upon post-op visits to the institution. This speaks to his 4th limitation where he notes the retrospective nature of the study not necessarily reflecting the true rate. It seems like a very good result if the observed rate is a close approximation of the true rate…we just can’t be too sure how close it is.

Also worth noting the inguinodynia analysis consisted of 838 patients, all of whom received an open Lichtenstein repair.

Only nine patients had a lap repair…and if those were included in the analsysis, than having a lap repair would also be predictive for inguinodynia (but that is a very small number of people so we should not infer anything from that)

[Watchful]

Just 12 out of 874 with inguinodynia is an amazingly good result. Again, I wonder how he defines it, and how he followed up. Did he actively follow up with 874 patients, and find out that only 12 had related pain of any degree at 3 months or later? That would be superb and very different from results of other studies.

[MarkT]

Slight clarification to above…it covers 953 hernias in 874 patients.

Statistically significant predictors of inguinodynia were younger age (54 vs. 61yr old), smoker at time of operation, history of prior contralateral repair, and postoperative complication.

Cumulative post-op problems were 11.9% (urinary retention, post-op pain that is not chronic, seroma, site bleeding, etc)…and 12 had inguinodynia, 10 had recurrences.

There is a lot more to the study, including some discussion of inguinodynia…he cites the low rate here as perhaps due to “1) a standardized technique with division of the inguinal nerve when encountered; (2) an almost exclusive male cohort of patients; (3) an older patient population; and (4) the retrospective nature of our study and not a true reflection of the actual rate.”

“It is unclear if dividing the ilioinguinal nerve reduces the rate of inguinodynia. Three randomized trials have addressed inguinal neuronectomy to prevent inguinodyania. Two had favorable results, and one argued against it.”

[MarkT]

For what it’s worth, the first link covers 953 of his repairs between 2005 and 2015…patients were 99% male, same avg age and confidence interval.

I pulled that article too…he used general anaesthesia in vast majority…99% were open, with lap reserved for bilateral, recurrence, or both. Worth noting their reporting system captures a pile of data…56 variables includes various dates, operative details, hernia characteristics, demographics, drinking and smoking history, co-morbidities, and outcomes.

He describes his repair in some detail. For the vast majority that were open repairs, the mesh part:

“The floor is then repaired with a 6.0 × 3.0 inch propyprolyne mesh (ETHICON Inc.) that is cut in a cone configuration to accommodate the size of the inguinal floor by crating tails around the cord structures. This is secured laterally to the shelving edge of the inguinal ligament with 0-polydioxanone in a running fashion and medially to the conjoint tendon with interrupted 0-ethabond sutures”.

For the 1% of repairs that were lap: “A piece of (small, medium, or large) mesh (Knitted Polyprplylene Pre-formed Mesh; Bard #DMax Mesh; BARD Davol, Inc; Warwick, RI) is introduced and placed in such fashion to cover the myopectineal orifice. It is tacked to the pubic tubercle and Cooper’s ligament medially and laterally to the abdominal wall musculature anterior to the superior iliac spine with a 5-mm absorbable fixation device (AbsorbaTack [ABSTACK30X] COVIDIEN; New Haven, CT).”

Inguinodynia was defined as postoperative pain persisting beyond 3 months after surgical intervention. Data regarding this information were extracted from CPRS by P.M.P. who was unbiased to the patient population or the operation.

[MarkT]

He does not define inguinodynia in his letter.

He does not disclose what % of his repairs were mesh or tissue, though my suspicion would be that the majority of them are mesh, given that he cites an avg patient age of 60.4?±?1.4 years.

To expand on that, he says that he does Shouldice on younger patients with an indirect hernia, and also notes that younger patients in his practise are more likely to have inguinodynia (he does not link that to the tissue repair though).

His unusually narrow age range is likely due to his practise being located in a Veterans Affairs hospital. It is a letter to the editor, not a journal article, so the data and methods are not detailed. I’m simply including exactly what data he provided which was avg age (and confidence interval), and total number of repairs.

Looking at his numbers over that timeframe, he is clearly a specialist but perhaps not a ‘high volume’ specialist in comparison to what some surgeons do…but likely ‘high enough’ to at least partially explain why his chronic pain outcomes are better than average (he doesn’t cite his recurrence rate, merely noting that it does not differ between his mesh and tissue repairs).

As we have suspected for a while now, surgeon skill and experience (volume) is are likely key factors in achieving above avg outcomes, regardless of repair type.

To publish his full data in a study, he would have needed consent from his patients and ethics board approval through the hospital, though he notes “…part of these data has been published previously”.

Among his seven references are three studies he was involved in:

https://www.americanjournalofsurgery.com/article/S0002-9610(16)30193-3/fulltext

https://www.americanjournalofsurgery.com/article/S0002-9610(08)00598-9/fulltext

https://www.journalofsurgicalresearch.com/article/S0022-4804(19)30162-3/fulltext

[Watchful]

Not mentioned in this letter (not what this surgeon does), but doing laparoscopic instead of open surgery also seems to be helpful in reducing the incidence of chronic pain. Not by a large amount, though.

[pinto]

MarkT, thanks, you helped satisfy our curiosity. Let me note a couple of observations: I found inguinodynia defined as that related to mesh surgery. Not a crucial aspect but you do wish for preciseness of terms. The article combines both mesh and tissue repair, which if continued will require a redefining of terms. Not mentioned in the post above is the proportion of cases for each type of repair. Could be important.

Stranger still is nearly 2,000 patients observed but have a very very narrow range of age. Not only that but they are “all older vets, around 60yrs old.” These people have or had a physically vigorous occupation–the military. I believe in the general population a much, much wider range of age of patients would be the case. Or would it?

What might be happening is that many individuals 35-45 are coming with symptoms but he massages them into watchful waiting, at least some. It’s probably good in that he’s not pushing surgery on them. Finally, he might not include these patients in his case load figure until they actually get surgery.

That the article is a letter to the editor explains why data is not included. The doc is probably concurrently preparing a full article for publication somewhere.

Overall I think the biggest factor of his success is that he is likely a highly skilled surgeon based on his emphasis of correctly fitting mesh by size/shape for each patient and his neurectomy. This seems borne out by his using the same mesh since 2005. Was he just lucky in choosing mesh or has surgeon skill been much much more a factor than kind of mesh all along?

If we stick to GI’s original question, “what[‘s] the best prevention for post-hernia-repair pain” rather than treatment, then we must be confined to interventions before and up to completion of surgery. Thus treatment is excluded, which puts more emphasis on surgeon skill and patient physical condition.

[Watchful]

Thanks for the summary, MarkT.

Does he define inguinodynia? Many of these studies don’t clarify if it’s any pain, or pain over a certain level of severity, and what that level is.

Does he describe the follow up method? I know it’s a closed system, but some patients may not come back even if they have pain simply because they don’t think it’s bad enough, or they don’t think they can be helped.

Did he mention what percentage was tissue repair?

[MarkT]

It’s not long (my summary is barely shorter, but for the sake of not violating copyright…)

It’s a letter to the editor from S. Huerta, Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center

– Best estimate of incidence of inguinodynia is 10%, but widely ranges between institutions (0-64%).
– Has done 1805 open (tissue and mesh) inguinal repairs in his practice since 2005, which is in a VA hospital with a closed system, so complications are dealt with in-house.
– Patients are all older vets, around 60yrs old with little variation in age, and he cites a rate of inguinodynia of 1.7%.

He does the following to keep that rate low:

1. Watchful waiting, especially for younger patients, because many with inguinal pain don’t have a hernia, so surgery should only be done when hernia presents itself over time.

2. Elective ilioinguinal neurectomy. Cites meta-analysis of 16 RCTs comparing it with nerve preservation that found a significant reduction of inguinodynia at 6 months (9% vs. 25%), but no statistically significant difference at 12 months (9% vs. 18%). He electively resects the nerve, particularly in young patients, but elects to preserve it in cases where it is not readily identified (i.e. not typically located).

3. Cuts mesh to fit the inguinal canal of each patient, as it is possible (but not confirmed) that inguinodynia results from nerve entrapment following inflammatory reaction to mesh…less mesh, less likely to have reaction. He has used the same proline mesh since 2005.

4. Tissue repair. No one strategy fits all. Does Shouldice repair on young patients, with recurrence no different than mesh, because even if risk of recurrence was greater, can do posterior recurrence repair when they are older.

5. Smoking cessation – cites study that smoking is predictive of inguinodynia, so highly recommends his patients to stop six weeks prior to repair.

– notes that while intro of mesh has reduced recurrence rates overall, tissue repair is still appropriate for some cohorts.
– notes Desarda has similar recurrence to Lichetenstein, but carries lower inguinodynia risk.
– Can’t release his data due to privacy/legal reasons.

[pinto]

Save your money because I don’t think the article will reveal “the best prevention” of post-op chronic (mesh) pain. Given that the field appears not yet to wholly recognize “inguinodynia,” I suppose that little has developed into effective management of pain. So my guess is the article will promote more effective surgery as a preventive.

[Good intentions]

SAGES has an interesting article about it.

https://www.sages.org/wiki/inguinodynia/

[ajm222]

I hear you. I’ve often thought the same thing about having a job that requires manual labor. Hard enough just focusing on a desk job when sitting can be uncomfortable. And years of discomfort and pain, even if mild, just wear a person down. Seems impossible at this point to even believe I had a life before when I wasn’t dealing with all this.

[Watchful]

The body can indeed keep healing over very long periods of time. I had a minor fracture in my elbow that took a decade to heal fully, and stop causing any pain, but that’s a bone. Soft tissue can take a long time to heal as well, and nerves are certainly notorious for that.

It really is a big hit when these surgeries go badly, and having to do additional surgeries at the same location feels like digging a deeper hole to some extent, but sometimes it’s necessary and helpful overall. Too bad these hernia surgeries are such a crapshoot with some going very well, and some leading to a domino effect of more trouble and reoperations.

I’m just going to give it time. Definitely not going under the knife again unless things take a radical turn for the worse, and it’s something that additional surgery could truly fix. I’m just glad I’m not in an occupation that requires physical labor, and that I didn’t have any athletic hobbies. Still, pain and discomfort have a bad effect regardless of your occupation and hobbies.

[ajm222]

It can definitely take over a year. I’ve heard people mention continued improvement even after two or three years.

Bulge is visible but it’s slight, and looks like it did after removal but before recurrence. I’m also quite thin now so it may be more obvious than it otherwise would be. I may just have an area on that side that will always be a little puffy because of all the surgeries. Additionally, given everything I’ve been through, I’m traumatized enough not to even expect this is going to work for me. But I’ll give it at least a year or so before I come to any final conclusions.

• This reply was modified 1 year, 6 months ago by  ajm222.

[ajm222]

Thanks, and all that makes sense. I am in a similar situation though my recently tissue-repaired hernia was a smaller indirect hernia, and I previously had robotic mesh removal. My surgeon used something similar to Bassini and absorbable stitches. I will be at two months Monday and still feel tightness with occasional discomfort and soreness, though it seems to be improving some. Certainly the testicular discomfort has improved and I’ve gotten much stronger, though the area itself still feels a bit weak. And there’s more bulging than I would like (though much better than early on). I am hoping in several months it continues to improve though who knows. I know healing can take a very long time.

[Watchful]

ajm222 – About 5 months ago. I’ll post an update at 6 months. There has been an improvement in some aspects, some others are the same or worse. It’s not debilitating or anything close to that, but I do suffer from pain, discomfort, and some other symptoms. At this point, I can say that it was a mistake to do the surgery this way. I really had to fix the hernia, but I should have done it differently.

If I had to do it all over again, I would go with mesh. Lap mesh would be my preference, but not sure that would have been possible because my hernia was very large (with intestine protruding in it, a scrotal element, etc.), so I’m not 100% sure it would have been possible to reduce it without open surgery. I got mixed opinions about that, although most said it would be ok. One surgeon said there was a 20% chance he would have to convert to open. With hindsight, if lap mesh wasn’t possible, I would still pick mesh (Lichtenstein) over Shouldice in my case.

This doesn’t mean that Shouldice isn’t the better option in some other cases. It just wasn’t the right choice in my case. Unfortunately, it was hard to tell in advance. Based on what I know now, I would say that if you have a very large hernia, go with mesh. I think the Germans are correct in having some guidelines on what cases qualify for Shouldice. For example, indirect hernias not exceeding a defect size of 3cm (mine was double that size.)

Another piece of advice is that watchful waiting is good, but only up to a point. If you see that the hernia isn’t stable anymore, and it is growing significantly, have it fixed, and don’t wait until the repair is more difficult than needed, or you’re forced to rush to fix it.

[ajm222]

watchful – how are you doing at the moment, and when was your surgery again?

[Watchful]

One problem is that there are very few high-volume tissue repair surgeons in the developed world. Your choices are very limited, so it’s hard to create an “all else being equal” scenario. If you have a large hernia (like I had), your choices are even more limited because some of the tissue repair surgeons (like the Germans) will go with mesh on large hernias. Very few places are hard-core enough to do tissue repair on large hernias. These include the Shouldice Hospital, Dr. Tomas, Dr. Kang, and maybe a couple others.

Another problem is that tissue repair isn’t as “one size fits all” as mesh. The picture really changes depending on your particular anatomy, size of the hernia, and tissue quality. For example, I used to think that the Shouldice procedure is pretty generic in its applicability. I knew that it doesn’t work with bad tissue quality, but other than that, I thought it’s fine. Well, not really… I learned this the hard way only after going to the Shouldice Hospital. They will do the surgery on cases with a groin anatomy and hernia size which are problematic for this procedure, but these become long and difficult surgeries, which is something you really want to avoid. My case was like that, and I had discussions with my surgeon afterwards where he described these challenges (primarily related to tissue depth and hernia size) that I hadn’t been aware of because they aren’t really described in the papers about the procedure. You need to talk to a surgeon who does it to learn about how the level of difficulty of the procedure can vary. Lichtenstein, for example, can be a lot easier in such cases. So, for someone like me, it wasn’t really “all else being equal” even though I had a high-volume specialist with significant experience. It was the difference between a difficult surgery and a pretty straightforward surgery.

This led to a difficult recovery, and I’m still dealing with some persistent issues (pretty frequent pain and discomfort). In other words, tissue repair has its problems as well, not just mesh, and in some cases the risk is actually higher with tissue repair (or at least with Shouldice) because the repair is particularly difficult in those cases.

One last thing on this is that most tissue repairs (including Shouldice) aren’t really reversible. The anatomy is changed, and you can’t go back to the original if you have problems. With mesh, you can have the mesh removed. This can be a difficult and complex surgery, but it’s at least possible to get pretty close to a “normal” groin since the anatomy isn’t modified.

I’m certainly not as big a fan of tissue repair as I used to be. I would still go for it on an ordinary inguinal hernia which isn’t particularly large, and if the tissue anatomy and quality are good. The problem is that you can’t necessarily tell much of this in advance. This makes surgeon choice even more challenging because what you really want is someone who is excellent at both tissue repair and mesh, and let them decide what’s best in your case, possibly only during surgery.

[MarkT]

The study claims that there were no complaints of reduced sensation in the scrotum or inner thigh as a result of dividing the nerve, which they did in all cases where it was normally located.

Again, given that this seems to have relied on patient complaints rather than confirmed via comprehensive long-term follow-up, it is tough to say whether there were indeed zero problems.

From all we have learned thus far, I’m very inclined to agree with that last part of your post. Surgeon skill and experience not only appears to be important regardless of procedure, it could indeed be the most important variable, more so than the type of procedure.

I’d chose a lap mesh repair from a high-volume specialist rather than a tissue repair from someone who infrequently performs a small number of them (and vice versa)…but all else being equal (or ‘equal enough’), I’d still rather avoid the potential problems of mesh and would choose a tissue repair.