Ilioinguinal nerve division does not reduce pain after hernia surgery
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.
Inguinal hernias: A brief overview
Diagnosis
Patients often diagnose that they have a hernia as the lump or swelling is usually obvious. Your GP will usually be able to confirm the diagnosis. The lump may be more obvious when standing and coughing.
If the diagnosis isn’t obvious, investigations such as an abdominal ultrasound, CT scan or MRI may be helpful to confirm the diagnosis.
Treatment
Small hernias that are not causing any symptoms do not always require treatment. In part the decision to treat or not will depend on your symptoms from the hernia, where it is located and other factors such as your general health. A watchful waiting approach may be best for some people.
Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications.
There are two general types of hernia operations — open hernia repair and laparoscopic repair.
Open hernia repair
Open hernia repair (also called a tension-free mesh repair) is perhaps the most commonly performed hernia operation and can usually be done with local anesthesia and sedation or general anesthesia. An incision in made in your groin and the surgeon pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh. The opening is then closed with stitches, staples or surgical glue.
After the surgery, you’ll be encouraged to move about as soon as possible, but it might be several weeks before you’re able to resume normal activities.
Laparoscopy
In this minimally invasive procedure, which requires general anesthesia, the surgeon operates through several small incisions in your abdomen. Gas is used to inflate your abdomen to make the internal organs easier to see.
A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other incisions to repair the hernia using synthetic mesh.
Many patients who have had a keyhole or laparoscopic repair have less discomfort and scarring after surgery and perhaps, a quicker return to normal activities. However, some studies indicate that the risk of the hernia coming back is a little more likely with laparoscopic repair compared to an open tension-free repair.
Laparoscopy allows the surgeon to avoid scar tissue from an earlier hernia repair, so we usually recommend this approach for people whose hernias recur after traditional hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral).
Some studies indicate that a laparoscopic repair can increase the risk of complications and of recurrence. Having the procedure performed by a surgeon with extensive experience in laparoscopic hernia repairs can reduce the risks.
Open vs. Laparoscopic repair of inguinal hernias: Lap. repair may be better.
A recent study published in the March issue of Archives of Surgery 2012 suggests that patients who undergo a laparoscopic inguinal hernia repair (Total extraperitoneal inguinal hernia repair (TEP)), report higher patient satisfaction, less chronic pain and less impairment of inguinal (groin) sensation compared to those who undergo a tension-free open Lichtenstein repair.
Chronic pain, quality of life and impact on sexual function after open tension-free mesh repair: trial comparing lightweight vs. heavyweight mesh
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.
References
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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