Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Hernia
Published in: Hernia 3/2011

01-06-2011 | Editorial

International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery

Authors: S. Alfieri, P. K. Amid, G. Campanelli, G. Izard, H. Kehlet, A. R. Wijsmuller, D. Di Miceli, G. B. Doglietto

Published in: Hernia | Issue 3/2011

Login to get access

Abstract

Purpose

To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain.

Methods

A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question.

Results

A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair.
Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy.

Conclusion

The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain.
Literature
1.
Aasvang EK, Bay-Nielsen M, Kehlet H (2006) Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia 10:316–321PubMedCrossRef
2.
Aasvang EK, Brandsborg B, Christensen B, Jensen TS, Kehlet H (2008) Neurophysiological characterization of postherniorrhaphy pain. Pain 137:173–181PubMedCrossRef
3.
Aasvang EK, Hansen JB, Kehlet H (2009) Pre-operative pain and sensory function in groin hernia. Eur J Pain 13:1018–1022PubMedCrossRef
4.
Aasvang EK, Kehlet H (2010) Persistent sensory dysfunction in pain-free herniotomy patients. Acta Anaesthesiol Scand 54:291–298
5.
Aasvang E, Kehlet H (2005) Surgical management of chronic pain after inguinal hernia repair. Br J Surg 92:795–801PubMedCrossRef
6.
Aasvang EK, Kehlet H (2009) The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg 249:327–334PubMedCrossRef
7.
Aasvang EK, Mohl B, Bay-Nielsen M, Kehlet H (2006) Pain related sexual dysfunction after inguinale herniorrhaphy. Pain 122:258–263PubMedCrossRef
8.
Akita K, Niga S, Yamato Y, Muneta T, Sato T (1999) Anatomic basis of chronic groin pain with special reference to sports hernia. Surg Radiol Anat 21(1):1–5
9.
Al-dabbagh AK (2002) Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat 24(2):102–107
10.
Alfieri S (2008) A met-analytic approach to ilioinguinal nerve. Excision or preservation during open inguinal hernia repair. Ann Surg 247(6):1078–1080CrossRef
11.
Alfieri S, Di Miceli D, Doglietto GB (2007) Prophylactic ilioinguinal neurectomy in open inguinal hernia repair. Ann Surg 245(4):663PubMedCrossRef
12.
Alfieri S, Di Miceli D, Doglietto GB (2007) Re: nerve management during open hernia repair. Br J Surg 94(7):914PubMedCrossRef
13.
Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, Di Miceli D, Ridolfini MP, Sgagari A, Doglietto G, Group Groin Pain Trial (2006) Groin pain trial group. Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg 243(4):553–558PubMedCrossRef
14.
Amid PK (2002) A 1-stage surgical treatment for postherniorrhaphy neuropatic pain: triple neurectomy and proximal end implantation with mobilization of the cord. Arch Surg 137:100–104PubMedCrossRef
15.
Amid PK (2004) Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia: triple nerurectomy with proximal end implantation. Hernia 8(4):343–349PubMedCrossRef
16.
Amid PK, Hiatt JR (2008) Surgical anatomy of the preperitoneal space. J Am Coll Surg 207(2):295 (author reply 295–296)
17.
Amid PK, Hiatt JR (2007) New understanding of the causes and surgical treatment of postherniorrhaphy inguinodynia and orchalgia. J Am Coll Surg 205(2):381–385PubMedCrossRef
18.
Amid PK (2004) Lichtenstein tension-free hernioplasty: its inception, evolution, and principles. Hernia 8(1):1–7PubMedCrossRef
19.
Anson BJ, Morgan EH, Mc VC (1960) Surgical anatomy of the inguinal region based upon a study of 500 body-halves. Surg Gynecol Obstet 111:707–725PubMed
20.
Bay-Nielsen M, Perkins FM, Kehlet H (2001) Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg 233:1–7PubMedCrossRef
21.
Boyer (2004) Oral presentation at 26th Congress of the EHS in 2004
22.
Brennan TJ, Kehlet H (2005) Preventive analgesia to reduce wound hyperalgesia and persistent postsurgical pain: not an easy path. Anesthesiology 103:681–683PubMedCrossRef
23.
Callesen T, Bech K, Kehlet H (1999) Prospective study of chronic pain after groin hernia repair. Br J Surg 86:1528–1531PubMedCrossRef
24.
Canonico S, Santoriello A, Campitiello F, Fattopace A, Corte AD, Sordelli I, Benevento R (2005) Mesh fixation with human fibrin glue (Tissucol) in open tension-free inguinal hernia repair: a preliminary report. Hernia 9:330–333PubMedCrossRef
25.
Castaldi M (2004) The use of fibrin glue in open inguinal hernia, abstract of the 26th congress of the EHS in 2004
26.
Classification of chronic pain (1986) Description of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the study of pain Subcommitte on Taxonomy. Pain Suppl 3:S1–S226
27.
Diop M, Dia A, Ndiaye A, Lo EA, Sow ML, Ndiaye PD (2000) Emergence and course of the ilioinguinal nerve of the groin. Morphologie 84(266):29–32PubMed
28.
Dittrick GW, Ridl K, Kuhn JA, McCarty TM (2004) Routine ilioinguinal nerve excision in inhuinal hernia repairs. Am J Surg 188(6):736–740PubMedCrossRef
29.
Ferzli GS, Edwards ED, Khoury GE (2007) Chronic pain after inguinal herniorrhaphy. J Am Coll Surg 205:333–341PubMedCrossRef
30.
Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH (2005) Algorithm for neuropathic pain treatment: an evidence based proposal. Pain 118:289–305PubMedCrossRef
31.
Franneby U, Gunnarsson U, Andresson M, Heuman R, Nordin P, Nyrén O, Sandblom G (2008) Validation of an inguinal pain questionnaire for assessment of chronic pain after groin hernia repair. Br J Surg 95:488–493PubMedCrossRef
32.
Haapaniemi S, Nilsson E (2002) Recurrence and pain three years after groin hernia repair. Validation of postal questionnaire and selective physical examination as a method of follow-up. Eur J Surg 168:22–28PubMedCrossRef
33.
Helbling C, Schlumpf R (2003) Sutureless Lichtenstein: first results of a prospective randomised clinical trial. Hernia 7(2):80–84PubMedCrossRef
34.
Hidalgo M, Castillo MJ, Eymar JL, Hidalgo A (2005) Lichtenstein inguinal hernioplasty: sutures versus glue. Hernia 9(3):242–244PubMedCrossRef
35.
Izard G, Gailleton R, Randrianasolo S, Houry R (1996) Treatment of inguinal hernia by McVay’s technique. A propos of 1332 cases. Ann Chir 50:775–776
36.
37.
Kehlet H, Jensen TS, Woolf CJ (2006) Persistent postsurgical pain: risk factors and prevention. Lancet 367:1618–1625PubMedCrossRef
38.
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1998) Causes and prevention of postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Sur 155:786–790
39.
Liu WC, Chen TH, Shyu JF, Chen CH, Shih C, Wang JJ, Kung SP, Lui WY, Wu CW, Liu JC (2002) Applied anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy. Eur J Surg 168(3):145–149PubMedCrossRef
40.
Loos MJ, Roumen RM, Scheltinga MR (2007) Classifying postherniorrhaphy pain syndromes following elective inguinal hernia repair. World J Surg 31:1760–1765PubMedCrossRef
41.
Madura JA, Madura JA 2nd, Copper CM, Worth RM (2005) Inguinal neurectomy for inguinal nerve entrapment; an experience with 100 patients. Am J Surg 189:283–287
42.
Mandelkow H, Loeweneck H (1988) The iliohypogastric and ilioinguinal nerves. Distribution in the abdominal wall, danger areas in surgical incisions in the inguinal and pubic regions and reflected visceral pain in their dermatomes. Surg Radiol Anat 10(2):145–149PubMedCrossRef
43.
McCarthy M Jr, Jonasson O, Chang CH, Pickard AS, Giobbie-Hurder A, Gibbs J, Edelman P, Fitzgibbons R, Neumayer L (2005) Assessment of patient functional status after surgery. J Am Coll Surg 201:171–178PubMedCrossRef
44.
Mirilas P, Mentessidov A, Shandalakis JE (2008) Secondary internal inguinal ring and associates surgical planes: surgical anatomy, embryology, applications. J Am Coll Surg 2006:561–570CrossRef
45.
Moosman DA, Oelrich TM (1977) Prevention of accidental trauma to the iloinguinal nerve during inguinal hernoirrhaphy. Am J Surg 133(2):146–148PubMedCrossRef
46.
Mui WL, Ng CS, Fung TM, Cheung FK, Wong CM, Ma TH, Bn MY, Ng EK (2006) Prophylactic ilioinguinal neurectomy in open ilioinguinal repair: a double-blind randomized controlled trial. Ann Surg 244(1):27–33PubMedCrossRef
47.
Ndiaye A, Diop M, Ndoye JM, Konaté I, Ndiaye AI, Mané L, Nazarian S, Dia A (2007) Anatomical basis of neuropathies and damage to the ilioinguinal nerve during repairs of groin hernias (about 100 dissections). Surg Radiol Anat 29(8):675–681PubMedCrossRef
48.
Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R (2007) Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg 194:394–400PubMedCrossRef
49.
O’Dwyer PJ, Alani A, McConnachie A (2005) Groin hernia repair: postherniorrhaphy pain. World J Surg 29:1062–1065PubMedCrossRef
50.
Oelrich TM, Moosman DA (1977) The aberrant course of the cutaneous component of the ilioinguinal nerve. Anat Rec 189(2):233–236PubMedCrossRef
51.
Papadopoulos NJ, Katritsis ED (1981) Some observations on the course and relations of the iliohypogastric and ilioinguinal nerves (based on 348 specimens). Anat Anz 149(4):357–364PubMed
52.
Pappalardo G, Frattaroli FM, Mongardini M, Salvi PF, Lombardi A, Conte AM, Arezzo MF (2007) Neurectomy to prevent persistent pain after inguinal herniorraphy: a prospective study using objective criteria to assess pain. World J Surg 31(5):1081–1086PubMedCrossRef
53.
Peschaud F, Malafosse R, Floch-Prigent PL, Coste-See C, Nordlinger B, Delmas V (2006) Anatomical bases of prolonged ilio-inguinal-hypogastric regional anesthesia. Surg Radiol Anat 28(5):511–517PubMedCrossRef
54.
Picchio M, Palimento D, Attanasio U, Matarazzo PF, Bambini C, Caliendo A (2004) Randomized controller trial of preservation or elective division of ilioinguinal nerve on open inguinal hernia repair with polypropylene mesh. Arch Surg 139(7):755–758PubMedCrossRef
55.
Rab M, Ebmer J, Dellon AL (2001) Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg 108(6):1618–1623PubMedCrossRef
56.
Rasmussen PV, Sindrup SH, Jensen TS, Bach FW (2004) Symptoms and signs in patients with suspected neuropathic pain. Pain 110:461–469PubMedCrossRef
57.
Ravichandran D, Kalambe BG, Pain JA (2000) Pilot randomized controlled study of preservation or division of ilioinguinal nerve in open mesh repair of inguinal hernia. Br J Surg 87(9):1166–1167PubMedCrossRef
58.
Staal E, Nienhuijs SW, Keemers-Gels ME, Rosman C, Strobbe LJ (2008) The impact of pain on daily activities following open mesh inguinal hernia repair. Hernia 12:153–157PubMedCrossRef
59.
Starling JR, Harms BA (1994) Ilioinguinal, iliohypogastric, and genitofemoral neuralgia. In: Bendavid R (eds) Prostheses and abdominal wall hernia. Landes, Austin, pp 3351–3567
60.
Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J (2008) Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology 70:1630–1635PubMedCrossRef
61.
van Hanswijck de JP, Lloyd A, Hrsfall L, Tan R, O’Dwyer PJ (2008) The measurement of chronic pain and health-related quality of life following inguinal hernia repair: a review of the literature. Hernia 12:561–569CrossRef
62.
Whiteside JL, Barber MD, Walters MD, Falcone T (2003) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol 189(6):1574–1578 (discussion 1578)
63.
Wijsmuller AR, Lange JF, Kleinrensink GJ, van Geldere D, Simons MP, Huygen FJ, Jeekel J, Lange JF (2007) Nerve-identifying inguinal hernia repair: a surgical anatomical study. World J Surg 31(2):414–420 (discussion 421–422)
64.
Wijsmuller AR, Lange JF, van Geldere D, Simons MP, Kleinrensink GJ, Hop WC, Jeekel J, Lange JF (2007) Surgical techniques preventing chronic pain after Lichtenstein hernia repair: state-of-the-art vs daily practice in the Netherlands. Hernia 11(2):147–151
Metadata
Title
International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery
Authors
S. Alfieri
P. K. Amid
G. Campanelli
G. Izard
H. Kehlet
A. R. Wijsmuller
D. Di Miceli
G. B. Doglietto
Publication date
01-06-2011
Publisher
Springer-Verlag
Published in
Hernia / Issue 3/2011
Print ISSN: 1265-4906
Electronic ISSN: 1248-9204
DOI
https://doi.org/10.1007/s10029-011-0798-9

Other articles of this Issue 3/2011

Hernia 3/2011 Go to the issue

Original Article

Comparison of Permacol™ and Strattice™ for the repair of abdominal wall defects

Case Report

Small bowel obstruction due to broad ligament hernia: computed tomography findings

Original Article

Risk factors for wound complications in midline abdominal incisions related to the size of stitches

Case Report

Concomitant management of a large abdominal aortic aneurysm and a giant incarcerated inguinal hernia

Original Article

Prospective randomized evaluation of prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty

Original Article

The use of mesh in acute hernia: frequency and outcome in 99 cases