Page 72 - International guidelines for groin hernia management

Hernia

In spite of these varied interpretations of chronic pain, Follow-up interval is an important metric, since pain
we recommend that the widely accepted C 3-month time tends to decrease over time. In the same Danish Hernia
period be used to define CPIP. We also recommend that the Database group, those with pain after 1 year were followed
definition of CPIP includes a level of discomfort rated by up after 6 years. After 6 years, less pain was reported by
the patient as C moderate and impacting daily activities. 75.8% of patients, the same pain by 16.7%, and increased
pain by 7.5%. 53
Prevalence of chronic pain In a meta-analysis of open preperitoneal versus Licht-
enstein repair, chronic postoperative pain of greater than
As noted in various guidelines, CPIP incidences vary from 6-month duration was found in 7.1 and 12.3%, respec-
104, 147 86
0.7 to [ 75%. The reported incidence of pain varies tively. In another meta-analysis of TEP versus Lichten-
greatly due in part to the pain definition used in the stein, chronic postoperative pain of greater than 3 months
guideline. duration was reported in 12.5 and 16.8%, respectively. 76
One RCT looking at Kugel versus Lichtenstein repair Meta-analyses and guidelines on surgical technique find
considered any visual analog score (VAS) of pain [ 0at3 that chronic pain occurs less frequently after endoscopic
months to be chronic pain, and reported incidences of 20.7 versus open procedures. 83, 84 Mesh use reduces the risk of
and 40.5%, respectively. 148 Another prospective follow-up chronic pain and surgical ‘‘fine tuning’’ on mesh choice and
study of hernia repairs performed during 1992–1993 (pre- fixation method (or no fixation) may help to decrease its
mesh) used different definitions. Mild pain was defined as incidence (see chapters 10 and 11).
occasional pain/discomfort, not limiting activity, with Overall, the incidence of clinically significant CPIP is in
return-to-prehernia lifestyle. Moderate pain was defined as the 10–12% range, decreasing over time. 53, 147, 151 Debil-
pain preventing return-to-preoperative activities. Severe itating CPIP affecting normal daily activities or work
pain was defined as pain incapacitating the patient fre- ranges from 0.5 to 6%. 147
quently or interfering with daily activities. 149 Systematic reviews published within the last decade
Follow-up data in this study and reporting on any groin/ have generally found similar predictors for CPIP devel-
inguinal pain within the last month found a 62.9% inci- opment. 104, 146, 151, 152 The International Endohernia
dence at 1 year and a 53.6% incidence at 2 years. The Society guidelines summarized from the literature: young
incidence of moderate-to-severe pain was 11.9% at 1 year age, female gender, preoperative pain level, and postop-
and 10.6% at 2 years. erative pain intensity as risk factors for chronic postoper-
A Danish Hernia Database 1-year questionnaire follow- ative pain. 104 One author has summarized risk factors for
152
up study found that 28.7% of patients reported hernia-area postherniorrhaphy inguinal pain (Table 3).

pain in the last month, 11% reported work- or leisure-ac- Population-based studies from the Swedish Hernia
tivity impairment, and 4.5% had received medical treat- Register on long-term pain after hernia repair are in accord
ment for pain. 150 with the systematic reviews cited above. Pain interfering
with daily activity occurred in 98 of 2421 (6%) patients

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