Page 82 - International guidelines for groin hernia management

Hernia

however, patients with immediate severe neuropathic pain conservative modalities and pharmacological options (e.g.,
postoperatively may be offered reoperation with neurec- TCAs, SSRIs, gabapentin, and pregabalin). Then, nerve
tomy if appropriate. blocks and peripheral nerve stimulation were advocated as
necessary. However, they acknowledged that these
Key question modalities are often ineffective and that surgical neurec-
tomy provides the best results. Although the study group
KQ19T.b What should the initial approach be to IH did not research the issue, the question then becomes which
repair patients with chronic postoperative pain (pain still patients are suitable for neurectomy? They proposed a
present [ 3 months after surgery) (see treatment conservative treatment period of at least 6 months before
algorithm)? neurectomy is done.

Evidence in literature In 2011, the international guidelines for the prevention
Our search identified seven reviews describing different and treatment of CPIP were published, providing consen-
151, 157, 230–240
treatment options for chronic pain patients. sus statements on best-available clinical recommenda-
A 1988 landmark paper presented a treatment algorithm for tions. 147 The guidelines advised a 1-year expectant period
230
chronic pain after IH repair. The study authors con- before remedial surgical treatment to allow the mesh/tissue
cluded that pain persisting for 2–3 months required further interface inflammatory response to diminish. The guideli-
investigation and treatment, starting with an IIN block at nes further recommended a triple neurectomy if neurec-
the ASIS. If this reduced pain to some extent, a repeat tomy was done. After endoscopic repair, a transabdominal
nerve block could be done, since repeated injections may or retroperitoneal approach was urged to remove the
interrupt the pain cycle. If an IIN block is ineffective, an proximal parts of the nerves. They also concluded that the
anesthesiologist may be asked to perform a paravertebral intramuscular part of the IHN should be resected during an
block of the genitofemoral nerve. If transient pain reduc- open triple neurectomy.
tion is achieved, a repeat block or neurectomy of the IIN or More recently, others have proposed an algorithm for
GB of the GFN is the next recommended step. If a block CPIP using the Delphian consensus method. 233 They urge an
does not result in pain reduction, a course of pharmaco- expectant phase and—after recurrence has been excluded by
logical and adjunctive non-pharmacological therapy (i.e., imaging—referral to a multidisciplinary pain management
psychotherapy, hypnosis, behavioral therapy, biofeedback, team. If this approach fails, triple neurectomy and/or mesh
and acupuncture) is advocated. explantation by an expert hernia surgeon is advocated.
A systematic review of CPIP management was done in In 2014, two CPIP reviews were published. One
2005. 231 It concluded that neurectomy relieved chronic emphasized the complexity of, and the need for individu-
pain but also that studies demonstrating this finding suf- alization in, treatment schemes making definitive broadly
fered from methodological flaws. In particular, a clear applicable treatment algorithms difficult to compose. 152
pre, intra, and postoperative assessment was deemed The other concluded that while neurectomy provides the
necessary to provide a better understanding of therapeutic best results, improved studies with long-term outcome
options. measures should be initiated. 234
Another study group emphasized that there is a broad Most recently, data on 105 CPIP patients were pub-
differential diagnosis for chronic inguinal pain following lished. On the basis of history, physical examination, and
IH repair. 232 Examination with ultrasonography or mag- imaging, the 105 were partitioned into neuropathic (37) and
netic resonance imaging may provide useful information non-neuropathic (68) pain groups. Twenty-eight underwent
and may detect recurrence, meshoma, or non-hernia-related intervention with ultrasound-guided nerve blocks. Perma-
causes of pain. This group suggested an initial trial of nent pain reduction was achieved in 18 of the 28 (62%).
Implantable peripheral nerve stimulators were placed in 6

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