Page 78 - International guidelines for groin hernia management

Hernia

Evidence in literature Discussion
Until the 1970s, high ligation of the indirect hernia sac was Three RCTs have reached similar conclusions regarding
generally considered a crucial part of the hernia repair in postoperative pain. Indirect hernia sac invagination or resec-
preventing recurrence. The 1978 edition of Hernia dis- tion without ligation results in less local pain in the immediate
cussed this approach. 195 A 1977 randomized study found postoperative months and does not confer a long-term recur-
no support for suturing of the peritoneum at abdominal rence risk. There is a high level of evidence for this finding.
wound closure. 196 However, a large register study with a 5-year follow-up term
In the anterior abdominal wall, the peritoneum is found that reoperation rates for recurrence were worse in
innervated by parietal nerves also innervating the skin and invagination or resection without ligation patients. Therefore,
muscles as opposed to the visceral and posterior peri- our final recommendation received only a weak grade.
toneum having a visceral innervation through the par-
197
avertebral ganglia and the vagal nerve. A prospective Pubic pain and orchialgia
randomized study of hernia sac ligation of 110 indirect
hernias in 105 male patients found that sac resection Introduction
without ligation did not result in increased recurrences at The periosteum is highly innervated, and if violated by
1–3-year follow-up. There was, however, a significant fixation sutures or tacks, pain—intense and long-lasting—
decrease in severe postoperative pain at 2-week and in is likely to occur. The resultant pain is somatic in nature,
moderate pain at 6-week follow-up in the non-ligated but, if intense, may be misinterpreted as neuropathic.
group. 198 Increased pain after hernia sac ligation was
attributed to peritoneal ischemia. A 2007 study randomized Key question
477 Lichtenstein repair patients to ligated or non-ligated
hernia sac groups. Significantly fewer non-ligated subjects KQ19P.k Does mesh fixation to the pubic bone increase
had postoperative pain during a 30-day follow-up period the incidence of acute and/or chronic pain?

and pain levels were significantly higher in the ligated Evidence in literature
group. 199 Another study from 2014 randomized 167 While no studies focus specifically on periosteal pain, this
Lichtenstein indirect hernia repair patients to one of three entity is recognized as one of a number of causative factors
groups: sac dissected, not opened and inverted into the in postherniorrhaphy pain syndromes. 149, 202–205
peritoneal cavity; sac excised without ligation; and sac One study found at 2-year follow-up that non-neuro-
resected and transfixed at the neck. 200 Postoperative pain pathic pain is the most common cause of chronic pain.
scores were 3.04, 3.98, and 4.06, respectively, significantly Tenderness over the medial insertion of the inguinal liga-
higher in the ligation group. Chronic pain and recurrence ment is the most common clinical finding. Therefore,
were not significantly different amongst the groups at authorities recommend against placing sutures in the area
80-month follow-up. of the pubic bone. 149 Another study mentions the issue of
A Swedish Hernia Registry study of 48,433 open ante- pain related to periosteal sutures but does not cite an
rior indirect IH repairs examined hernia sac manage- incidence. 202
ment. 201 Hernia sac excision and ligation occurred in A third study found that 18 of 40 patients with non-
49.5%, invagination in 37.6%, and division (the distal sac neuropathic pain had periosteal pain probably caused by
left in situ) in 12.9%. Reoperations for recurrence occurred sutures. The 18 patients represented 12% of the total group
in 1.7, 2.7, and 1.7%, respectively. However, within the of those with chronic postherniorrhaphy pain. 203 Eight of
subgroups of sutured repairs including a total of 6217 these received an injection with lidocaine and corticos-
repairs, invagination of the sac did not increase the recur- teroids resulting in pain reduction of more than 50% in
rence rate significantly. their VAS scores. From a group of 237 Swedish Hernia
Register patients operated on for persistent pain after groin

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