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.

More on activity restrictions after surgery

In early January, I blogged about the dearth of evidence about activity restrictions after surgery.

A number of people commented and most agreed that there is little basis for most of the activity restrictions surgeons currently use.

An anonymous reader told me about a 2008 study from Creighton University that generated some interesting data about intra-abdominal pressures associated with some common activities. Here’s a summary of the paper.

What about activity restrictions after surgery?

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology service's description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.



I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I can't think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to 'forever' [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.

Discrediting the paper about discredited practices

According to a study in the August 2013 issue of the Mayo Clinic Proceedings, 146 papers appearing in the New England Journal of Medicine over the first decade of this century contradicted medical practices previously thought to be effective.

The paper's findings were widely publicized. There was talk in the New York Times of inertia hindering change and allowing ineffective treatments to continue for years.

The full text of the paper and a supplement containing a brief summary of all 146 discredited practices are available on line.

I decided to see for myself if any practices relating to general surgery were included in the paper and found 11.

Two of them seemed somewhat debatable to me.

Number 43 on the list was a comparison of open mesh to laparoscopic mesh inguinal hernia repair that appeared in NEJM on 4/29/04. This was the critique:

"A laparoscopic approach to repair inguinal hernias with mesh was thought to have lower hernia recurrence rates and less post-operative pain. This multicenter, randomized trial in a VA population found that the laparoscopic approach led to a higher rate of complications and a higher rate of recurrences when repairing primary inguinal hernias."

It definitively closed the door on laparoscopic inguinal hernia repair. Or did it?

In the 4/30/04 issue of NEJM, letters to the editor pointed out that the laparoscopic recurrence rate of 10% in the VA study was much higher than in other reported series, and the size of the mesh (~8.0 cm) used in the laparoscopic cohort was much smaller than the 10 cm x 15 cm that most experts recommended.

How has the VA paper affected surgeons' choice of technique for hernia repair?

A report from the American Journal of Surgery in 2012 found that as of 2008 at the Mayo Clinic, 41% of inguinal herniorrhaphies were performed laparoscopically.

Looking at national resident case logs data for 2012 from the ACGME, 35% of all groin hernia repairs were done laparoscopically.

Despite having been "discredited" in NEJM, laparoscopic inguinal hernia repair is quite alive and well.

The Mayo Clinic Proceedings paper also stated that preoperative biliary drainage for patients with cancer of the head of the pancreas was discredited by another NEJM paper for 1/14/10. Here is what they said about number 131 on their list:

"Jaundice in surgical patients is postulated to increase the rate of postoperative complications. Many surgical centers have employed biliary drainage prior to surgical intervention for cancer of the head of the pancreas, but there is conflicting evidence regarding its effect on morbidity and mortality. This multicenter, randomized trial found that routine preoperative biliary drainage increases the rate of serious complications without a mortality benefit."

Subsequent letters in the 4/8/10 issue criticized the study because patients were drained for 6 weeks prior to surgery which was not the norm of 2 weeks, patients with bilirubin levels above 14.6 gm/dL who were most likely to benefit from preop drainage had been excluded, the wrong type of stent was used and prophylactic antibiotics for ERCP were not uniformly administered.

Is preop biliary drainage still being used?

A randomized trial from South Korea in the July 2013 American Journal of Surgery showed that preoperative biliary drainage for longer than 2 weeks resulted in twice as many complications as drainage for less than 2 weeks, 25.9% vs. 9.1% respectively. This compares favorably to the 74% complication rate of 6 weeks of drainage found in the 2010 NEJM study.

In the July 2013 American Journal of Gastroenterology, a group from Memorial Sloan Kettering Cancer Center published a retrospective review of over 500 pancreaticoduodenectomy patients, 220 of whom had preop stents. The overall complication rates did not differ whether a stent was used or not.

Again despite being "discredited," the use of preoperative biliary drainage continues to be very common.

So what happened here?

The only surgeon among the authors of the 146 discredited practices paper is a third-year general surgery resident. Maybe he did not have enough experience to evaluate these papers and their impact.

Or maybe one should not necessarily base an opinion about whether a practice has been discredited or not on a single paper in one journal.

The findings about these two topics, hernia repair and biliary drainage, lead me to question just how many of the other discredited practices are really no longer indicated or used.