Hernia Repair

Chronic pain after Abdominal Wall Hernia Repair

What you need to know about causes and treatment options

This article discusses the issue of persistent pain after abdominal wall hernia repair and may not apply to all types of hernia repairs.  This discussion is focused on ventral, incisional, umbilical, and inguinal hernia repairs.  Consult a hernia specialist if you believe you have chronic pain from a hernia repair.  Tips on finding a specialist in your area are listed at the end of the article.

Background

Before discussing Hernia Repair and postoperative issues with pain, first it is important to clarify what a hernia is.  A hernia is a hole, or defect in a tissue layer through which other structures can protrude through.  Oftentimes, patients come to the office thinking that their hernia is the bulge, but in fact the hernia is the hole through which something is bulging through.  Therefore to fix the hernia, the surgeon must reconstruct the tissue layer or layers that have the hole.  Most often, repairing the hole requires a patch or mesh.  At a certain threshold size, hernia defects cannot be sewn together in an edge-to-edge fashion because the recurrence risk (or likelihood that the hernia will re-occur) is too high.  Whether or not your hernia repair will require mesh is something that can only be determined through consultation with a Hernia surgeon.

What is chronic pain after hernia repair?

Chronic pain is defined as persistent ongoing pain after hernia repair, specifically pain that has not resolved for 6 months or more after surgery.   The quality, or characteristic of the pain can be sharp, dull/aching, elicited by certain movements, or a burning-type pain.  Depending on the type of hernia repair that was performed, pain can often be categorized into two categories: trigger point pain, or nerve/nerve root distribution-type pain.

  • Trigger point pain: described as pain in one specific small area, not correlating to an area supplied by a nerve or nerve root.
  • Nerve distribution pain: pain that correlates to an anatomical dermatome or anatomical area supplied by a nerve.

Causes of chronic pain after Hernia repair

Hernia mesh is a highly engineered woven textile device, similar to netting.   Hernia meshes are continually being developed and improved as our technology and ability to manufacture them advances.  Depending on the type of hernia and type of repair chosen by the surgeon, the mesh can be placed in different anatomical layers, or planes in the body.  To accomplish a hernia repair, the mesh must be fixated in place so that in stays in position and covers the hernia defect as healing takes place.  Mesh can be fixated with sutures and/or tacks, the latter are similar to miniature barbed staples or mini-corkscrews.  Sutures are constructed of either permanent or absorbable material, and generally used to sew the mesh to the surrounding tissue.  In general, as healing takes place after a hernia repair, there is incorporation of the mesh into the tissue layers, eventually resulting in something similar to rebar in concrete, with the rebar representing the mesh fibrils and the concrete representing the surrounding tissue that has healed around the mesh.  Pain after hernia repair can originate from the fixation method(s) or from the mesh itself, and most often have to do with the nerves or nerve fibers in the soft tissue of the abdominal wall being affected by the mesh or mesh fixation devices.   Chronic pain can also be caused by a phenomenon called bridging fibrosis, which is a result of scar tissue causing the mesh to contract on itself over time.

Treatment Options

Treatment of chronic pain after Hernia repair is best addressed by a Hernia Repair specialist.  A treatment plan is best constructed with as much background information as possible, including the operative report from the initial operation, type of mesh and fixation used, history obtained from the patient regarding factors leading up to and after the hernia repair, and physical exam performed by the surgeon.  Treatment can involve conservative measures such as rest/ice, anti-inflammatory medications and multi-modal regimens, which can also include muscle relaxants, nerve pain medications, and nerve blocks.  For severe pain that does not respond to these measures, a neurectomy procedure can be an option.   In certain cases, mesh excision or partial mesh excision can help.  Your local Hernia Expert can help you determine the right treatment plan for you.  If possible, bring to your consultation visit all original operative report(s) and any recent CT scans with images on disk.

What is a Hernia Specialist?

Hernia repair is quickly becoming a sub-specialty area of General Surgery.  It is a vastly different field than it was even 10 years ago due primarily to advances in minimally invasive technology, materials science, surgical techniques, and introduction of enhanced recovery protocols.  There are currently several hundred types of meshes currently available on the market, and our understanding of hernias and how to best repair them remains a rapidly expanding field.  A Hernia Specialist is a surgeon with extra training and/or expertise in the Hernia Repair Techniques and knows how to best match these advanced techniques with the appropriate mesh for each patient.

How to find a Hernia Specialist in your area

In addition to referral recommendations from one’s current medical provider(s), internet search engines have greatly extended the ability of patients to do their own research on surgeons and to identify local experts from the comfort of their own homes.  In addition to identifying a surgeon with a special interest and expertise in training, here a couple of other things to look for and/or ask your surgeon about during your consultation:

  1. Surgeons who use ERAS/Fast-Track protocols – ERAS (Enhanced Recovery After Surgery), aka Fast-Track Surgery is a methodology to help patients recover from surgery faster with less risk of complications and leads to overall improved outcomes.  It affords patients less pain with recovery, faster return to full activity, and fewer days of missed work.  The main tenets of ERAS for Hernia surgery consist of pre-surgery optimization, reduction in narcotic use through multi-modal therapy and regional nerve blocks, fluid optimization, early mobilization, and early return to normal diet after surgery.
  2. Surgeons with specialized training in Hernia Repair and a history of publications and invited talks in the field of Hernia Surgery – Seek out a surgeon/surgical group who have completed formal training in complex hernia repair, and who keep up to date from the leaders in the field of Hernia Surgery.  Surgeons who have published extensively in the literature on hernia repair and hernia repair materials are also considered experts in the field.  Only the surgeons who are considered to be the world’s leading experts are invited to give talks at international meetings.  You can search for published articles on pubmed.gov by typing in the surgeon’s last name and first initial

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