Surgical Endoscopy

, Volume 34, Issue 2, pp 946–953 | Cite as

Chronic pain after two laparoendoscopic inguinal hernia repairs compared with laparoendoscopic repair followed by the Lichtenstein repair: an international questionnaire study

  • Stina ÖbergEmail author
  • Kristoffer Andresen
  • Hanna Nilsson
  • Eva Angenete
  • Jacob Rosenberg



The best repair of a recurrent inguinal hernia after primary laparoendoscopic repair is debatable. The aim was to assess chronic pain after two laparoendoscopic repairs in the same groin compared with Lichtenstein reoperation preceded by a laparoendoscopic repair.


This cohort study included adult patients who had received two laparoendoscopic repairs (Lap–Lap) or a laparoendoscopic repair followed by the Lichtenstein repair (Lap–Lich). Eligible patients were identified in the Danish and the Swedish hernia databases. Lap–Lap was matched 1:3 with Lap–Lich, and patients were sent validated questionnaires. The primary outcome was the proportion with chronic pain-related functional impairment, compared between the two groups. Secondary outcomes included chronic pain during various activities.


In total, 74% (546 patients) responded to the questionnaires with a median follow-up since the second repair of 4.9 years (0.9–21.9 years). Regarding the primary outcome, 21% in Lap–Lap and Lap–Lich had chronic pain-related functional impairment of daily activities (p = 0.94). More patients in Lap–Lap compared with Lap–Lich reported pain ≥ 20 mm measured by the visual analog scale, 11% versus 5%, p = 0.04. However, there was no difference in the median VAS score or in the vast majority of the remaining secondary outcomes.


There was no overall difference in chronic pain between patients who had received Lap–Lap compared with Lap–Lich. Choice of operative strategy for the second repair should, therefore, not be based on risk of chronic pain.


Chronic pain Questionnaires Inguinal hernia recurrence Reoperation Laparoendoscopic repair Lichtenstein repair 



The A.P. Møller Foundation for the Advancement of Medical Science contributed with financial support to cover the operational expenses of questionnaires, postal stamps, and envelopes. The contribution was solely financial without influence on the study process.

Compliance with ethical standards


Jacob Rosenberg reports personal fees from Bard and Merck, outside the submitted work. Stina Öberg, Kristoffer Andresen, Hanna Nilsson, Eva Angenete reports no potential conflicts of interest and financial ties to disclose.


  1. 1.
    Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J, Fortelny R, Heikkinen T, Jorgensen LN, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Simons MP (2014) Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 18:151–163CrossRefGoogle Scholar
  2. 2.
    Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13:343–403CrossRefGoogle Scholar
  3. 3.
    Rosenberg J, Bisgaard T, Kehlet H, Wara P, Asmussen T, Juul P, Strand L, Andersen FH, Bay-Nielsen M (2011) Danish hernia database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 58:C4243PubMedGoogle Scholar
  4. 4.
    HerniaSurge Group (2018) International guidelines for groin hernia management. Hernia 22:1–165CrossRefGoogle Scholar
  5. 5.
    Poelman MM, van den Heuvel B, Deelder JD, Abis GS, Beudeker N, Bittner RR, Campanelli G, van Dam D, Dwars BJ, Eker HH, Fingerhut A, Khatkov I, Koeckerling F, Kukleta JF, Miserez M, Montgomery A, Munoz Brands RM, Morales Conde S, Muysoms FE, Soltes M, Tromp W, Yavuz Y, Bonjer HJ (2013) EAES consensus development conference on endoscopic repair of groin hernias. Surg Endosc 27:3505–3519CrossRefGoogle Scholar
  6. 6.
    Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, Chowbey P (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 25:2773–2843CrossRefGoogle Scholar
  7. 7.
    Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, Buhck H, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Grimes KL, Klinge U, Köckerling F, Kumar S, Kukleta J, Lomanto D, Misra MC, Morales-Conde S, Reinpold W, Rosenberg J, Singh K, Timoney M, Weyhe D, Chowbey P (2015) Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc 29:289–321CrossRefGoogle Scholar
  8. 8.
    Burcharth J, Pommergaard HC, Bisgaard T, Rosenberg J (2015) Patient-related risk factors for recurrence after inguinal hernia repair: a systematic review and meta-analysis of observational studies. Surg Innov 22:303–317CrossRefGoogle Scholar
  9. 9.
    Aasvang E, Kehlet H (2005) Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth 95:69–76CrossRefGoogle Scholar
  10. 10.
    Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA (2003) A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 19:48–54CrossRefGoogle Scholar
  11. 11.
    Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M (2014) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Int J Surg 12:1500–1524CrossRefGoogle Scholar
  12. 12.
    Friis-Andersen H, Bisgaard T (2016) The Danish Inguinal Hernia database. Clin Epidemiol 8:521–524CrossRefGoogle Scholar
  13. 13.
    Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto GB (2011) International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 15:239–249CrossRefGoogle Scholar
  14. 14.
    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 201:171–178CrossRefGoogle Scholar
  15. 15.
    Heniford BT, Walters AL, Lincourt AE, Novitsky YW, Hope WW, Kercher KW (2008) Comparison of generic versus specific quality-of-life scales for mesh hernia repairs. J Am Coll Surg 206:638–644CrossRefGoogle Scholar
  16. 16.
    Fränneby U, Gunnarsson U, Andersson 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 95:488–493CrossRefGoogle Scholar
  17. 17.
    Carlsson AM (1983) Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 16:87–101CrossRefGoogle Scholar
  18. 18.
    Aasvang EK, Mohl B, Bay-Nielsen M, Kehlet H (2006) Pain related sexual dysfunction after inguinal herniorrhaphy. Pain 122:258–263CrossRefGoogle Scholar
  19. 19.
    Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J, Bittner R, Kehlet H (2010) Predictive risk factors for persistent postherniotomy pain. Anesthesiology 112:957–969CrossRefGoogle Scholar
  20. 20.
    Andresen K, Burcharth J, Fonnes S, Hupfeld L, Rothman JP, Deigaard S, Winther D, Errebo MB, Therkildsen R, Hauge D, Sørensen FS, Bjerg J, Rosenberg J (2017) Chronic pain after inguinal hernia repair with the ONSTEP versus the Lichtenstein technique, results of a double-blinded multicenter randomized clinical trial. Langenbecks Arch Surg 402:213–218CrossRefGoogle Scholar
  21. 21.
    Andresen K, Burcharth J, Fonnes S, Hupfeld L, Rothman JP, Deigaard S, Winther D, Errebo MB, Therkildsen R, Hauge D, Sørensen FS, Bjerg J, Rosenberg J (2017) Sexual dysfunction after inguinal hernia repair with the Onstep versus Lichtenstein technique: a randomized clinical trial. Surgery 161:1690–1695CrossRefGoogle Scholar
  22. 22.
    Danielsen AK, Pommergaard HC, Burcharth J, Angenete E, Rosenberg J (2015) Translation of questionnaires measuring health related quality of life is not standardized: a literature based research study. PLoS ONE 10:e0127050CrossRefGoogle Scholar
  23. 23.
    Belyansky I, Tsirline VB, Klima DA, Walters AL, Lincourt AE, Heniford TB (2011) Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs. Ann Surg 254:709–714 (discussion 714–715) CrossRefGoogle Scholar
  24. 24.
    Lund I, Lundeberg T, Sandberg L, Budh CN, Kowalski J, Svensson E (2005) Lack of interchangeability between visual analogue and verbal rating pain scales: a cross sectional description of pain etiology groups. BMC Med Res Methodol 5:31CrossRefGoogle Scholar
  25. 25.
    Collins SL, Moore RA, McQuay HJ (1997) The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 72:95–97CrossRefGoogle Scholar
  26. 26.
    Loos MJ, Houterman S, Scheltinga MR, Roumen RM (2008) Evaluating postherniorrhaphy groin pain: visual analogue or verbal rating scale? Hernia 12:147–151CrossRefGoogle Scholar
  27. 27.
    Fletcher R, Fletcher S, Fletcher G (2014) Risk: from disease to exposure. In Clinical epidemiology: the essentials, 5th edn. Wolters Kluwer Health/Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  28. 28.
    Livingston EH, Wislar JS (2012) Minimum response rates for survey research. Arch Surg 147:110CrossRefGoogle Scholar
  29. 29.
    Sevonius D, Sandblom G, Agger E, Smedberg S, Montgomery A (2015) The impact of type of mesh repair on 2nd recurrence after recurrent groin hernia surgery. World J Surg 39:315–322 (discussion 323–324) CrossRefGoogle Scholar
  30. 30.
    Sevonius D, Gunnarsson U, Nordin P, Nilsson E, Sandblom G (2011) Recurrent groin hernia surgery. Br J Surg 98:1489–1494CrossRefGoogle Scholar
  31. 31.
    Öberg S, Andresen K, Rosenberg J (2016) Surgical approach for recurrent inguinal hernias: a nationwide cohort study. Hernia 20:777–782CrossRefGoogle Scholar
  32. 32.
    Köckerling F, Bittner R, Kuthe A, Stechemesser B, Lorenz R, Koch A, Reinpold W, Niebuhr H, Hukauf M, Schug-Pass C (2017) Laparo-endoscopic versus open recurrent inguinal hernia repair: should we follow the guidelines? Surg Endosc 31:3168–3185CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Center for Perioperative Optimization, Department of Surgery, Herlev HospitalUniversity of CopenhagenCopenhagenDenmark
  2. 2.Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research GroupSahlgrenska University Hospital ÖstraGothenburgSweden

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