Monday, January 8, 2018

Is chronic pain after inguinal hernia repair a big problem?

Yesterday one of my twitter followers posted this:
He was referring to a paper in the British Journal of Surgery that said 15.2% of patients who had inguinal herniorrhaphies complained of severe chronic pain one year after the surgery. Open hernia repairs caused significantly more chronic pain than did endoscopic total extraperitoneal [TEP] repairs, but the reoperation rate was significantly higher for TEP procedures.

The study included almost 23,000 patients and was based on data from the Swedish Hernia Registry and a questionnaire sent to the patients one year after their initial hernia operation. Pain was rated on a scale of 1 to 7 and was considered chronic if it was present for more than 3 months and interfered with daily activities.

The recurrence rate for the 18,000 patients who had open anterior mesh repair was 3.4% compared to 23.3% for the 2688 who had TEP repairs.

The authors concluded that the trade-off for less pain was an increased recurrence rate. Only 232 [1.39%] of the 1666 patients with recurrent hernias had undergone repeat herniorrhaphy.

Some of the comments on Twitter were as follows:

When I was in private practice in the early 1980s, I invited all of my post-op hernia patients to return to my office for yearly follow-up at no charge.

One day, a nice elderly gentleman was sitting in the exam room when I walked in. After an exchange of pleasantries, I asked him how his hernia repair was doing. He said he had no problems and was quite happy.

I had him stand up and when he lifted his gown, I saw a softball-sized recurrent hernia. Ever since then, I have not trusted any studies in which follow-up was not done in person.

Based on my experience, the recurrence rate after groin hernia repairs could even be higher than the Swedish study reported.

The incidence of chronic pain after inguinal herniorrhaphy may depend on how surgeons follow their patients.


artiger said...

Happy New Year Scalpel.

Is it just me, or does it seem to you that a lot of us in surgery confuse anecdotal evidence with research ("I never see that in my practice, so the paper must be wrong.")?

The more alarming thing to me is 23% recurrence rate with TEPP. Who is doing these operations? Whoever it is needs to stop.

I don't do TEPP as much as I used to, but I liked it when I did it more. I still prefer it for recurrent and bilateral hernias. A slightly off topic question for you...if someone has a recurrence from a TEPP, would you prefer an open, anterior repair for the redo?

Rugger said...

Just cut the ileoinguinal nerve. Problem solved. I cut it on everyone and place a hernia prolene system. Never had a single complaint after cutting the nerve, and I ask everyone at 3 weeks follow up. Some of us were told that this is malpractice, but it is not, and many do it, especially with an anterior approach and with putting mesh.

Anonymous said...

The recurrence rates mentioned is wrong, in the paper it says 1.5 % for open anterior mesh and 2.3 for TEP.

Skeptical Scalpel said...

Rugger, I know some surgeons advocate doing what you do. I think it's OK as long as you warn the patients that they may have some numbness postop.

Anon, I'm not sure where you read that. Please take a look at Table 2 of the paper. Clearly stated is a recurrence rate of 3.4% for open anterior mesh with a reoperation rate of 1.3% compared to a recurrence rate of 23.3% and a reop rate of 2.5% for TEP

Anonymous said...

Just don't get how they diagnosed recurrence of hernia through a questionnaire. In the Swedish national hernia registry recurrence only counts as a reoperation since we don't offer follow up. Is not the recurrent hernia stated in table 2 the proportion operations for recurremt hernias as index operations? They included recurrent hernias as index operation also.

Skeptical Scalpel said...

I see what you are saying. You may be right. But then why there is a listing for both "recurrent hernia" and "operation for recurrence" as baseline characteristics. For example if 615 patients in the OAM group had surgery for a recurrent hernia, then what does the category "Reoperation for recurrence" mean?

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