Chronic groin pain can be a troubling and on occasion disabling symptom that affects between 5-10% of patients who undergo an inguinal hernia repair. Reasons for this are unclear although a number of patient and operative factors have been identified. It was thought that entrapment of the ilio-inguinal nerve might be a factor leading surgeons to plan to divide the nerve at surgery to prevent it becoming trapped.
Although planned division of the nerve may reduce severity and frequency of pain for up to 6 months after surgery, this effect is not maintained and after 12 months there is no differences in pain between those who underwent nerve division and those where the nerve was not dividied. However, not unsurprisingly, this group has a loss of sensation.
Research studies suggest that 3-10% of patients report postoperative pain or discomfort persisting beyond one year after hernia surgery. This can have a significant negative impact on social activities, sex life, and quality of life. As a consequence, there has been increased recent interest in the use of lightweight meshes in groin hernia repair. It is hoped that the use of lightweight meshes might lead to less discomfort and less chronic pain. However, there is a shortage of high quality evidence showing a clear benefit with the use of such lightweight meshes.
A recent Swedish study (reported Jan 2018) has addressed this issued in a multi-centre study. The authors randomized a total of 412 male patients to undergo a tension free inguinal hernia repair using either a heavyweight mesh (90 g/m2, Bard™ Flatmesh, Davol) or a lightweight mesh (28 g/m2, ULTRAPRO™, Ethicon ). It was possible to analyse results in 363 patients. There were 185 patients in the lightweight-mesh group and 178 patients in the heavyweight group. Patient characteristics including age, weight and ASA grade were similar in both groups. Patients were followed for up to 3 years.
The lead author, Martin Rutegård, MD, of Umeå (Sweden) University and his colleagues reported that there were significant differences in patient awareness of a groin lump and groin discomfort, favouring the lightweight group at one year after surgery. A total of 6% of the lightweight group reported the groin lump awareness at 1 year, vs. 18% of the heavyweight group.
Initial groin discomfort was reported by 18% of the lightweight group vs.28% of the heavyweight group. However, after a year, these differences between the groups became less noticeable. No statistically significant or clinically relevant differences in groin discomfort was noted between types of mesh, with 263/288 patients (91.3%) reporting an improvement in groin pain/discomfort after 12 months follow-up, 19/288 patients (6.6%) experiencing no change, and 6/288 patients (2.1%) having worsened.
Recurrence rates were similar for both groups (2.4%).
Patients reported significantly better quality of life from as early as 11 days after their operation. This improvement in quality of life after surgery was maintained for the duration of the study. There was no difference in quality of life between the two groups. In addition, there was no difference between the groups in their reported sexual life after surgery at 4 and 12 months subsequent to the operation.
These results suggest that the light weight mesh may be associated with a reduction in a feeling of lumpiness after hernia surgery. However, the lightweight mesh was not associated with a better long-term outcome in terms of reduced pain or discomfort. It is reassuring that the lightweight mesh was not associated with an increased risk of hernia recurrence. It is also reassuring to note that patients very quickly felt that their operations lead to a significant improvement in their quality of life, despite the small but definite risk of long term groin discomfort and groin lumpiness.
Chronic pain, discomfort, quality of life and impact on sex life after open inguinal hernia mesh repair: an expertise-based randomized clinical trial comparing lightweight and heavyweight mesh. Rutegård M, Gümüsçü R, Stylianidis G, et al. Hernia. 2018 Jan 20. doi: 10.1007/s10029-018-1734-z.
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