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Surgical Endoscopy

, Volume 32, Issue 4, pp 1971–1983 | Cite as

What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry

  • H. Niebuhr
  • F. Wegner
  • M. Hukauf
  • M. Lechner
  • R. Fortelny
  • R. Bittner
  • C. Schug-Pass
  • F. Köckerling
Open Access
Article

Abstract

Background

In inguinal hernia repair, chronic pain must be expected in 10–12% of cases. Around one-quarter of patients (2–4%) experience severe pain requiring treatment. The risk factors for chronic pain reported in the literature include young age, female gender, perioperative pain, postoperative pain, recurrent hernia, open hernia repair, perioperative complications, and penetrating mesh fixation. This present analysis of data from the Herniamed Hernia Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique.

Methods

In total, 20,004 patients from the Herniamed Hernia Registry were included in uni- and multivariable analyses. For all patients, 1-year follow-up data were available.

Results

Multivariable analysis revealed that onset of pain at rest, on exertion, and requiring treatment was highly significantly influenced, in each case, by younger age (p < 0.001), preoperative pain (p < 0.001), smaller hernia defect (p < 0.001), and higher BMI (p < 0.001). Other influencing factors were postoperative complications (pain at rest p = 0.004 and pain on exertion p = 0.023) and penetrating compared with glue mesh fixation techniques (pain on exertion p = 0.037).

Conclusions

The indication for inguinal hernia surgery should be very carefully considered in a young patient with a small hernia and preoperative pain.

Keywords

Inguinal hernia TAPP Chronic pain Complications Hernia registry 

After mesh-based inguinal hernia repair 10–12% of patients experience at least a level of moderate pain that impacts daily activities [1, 2, 3, 4, 5, 6]. Chronic pain is defined as any pain reported by the patient at or beyond 3 months postoperatively [2]. More than one-quarter of these patients (2–4%) have moderate to severe pain [2, 5, 6]. Risk factors for chronic postoperative inguinal pain include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open hernia repair [1, 2, 3, 4, 5, 6].

In all statements in the guidelines of the international hernia societies, laparo-endoscopic techniques are associated with less chronic pain than the Lichtenstein repair [7, 8, 9, 10, 11]. However, after laparo-endoscopic inguinal hernia repair, 2–5% of patients may still suffer from persistent pain influencing everyday activities, and about 0.4% are referred to pain clinics [12].

On the basis of three meta-analyses of randomized controlled trials [13, 14, 15] mesh fixation in total extraperitoneal patch plasty (TEP) can only be recommended in large medial/direct (EHS MIII) hernias [10].

In the Guidelines of the International Endohernia Society, a recommendation is given for consideration of non-fixation of the mesh in transabdominal preperitoneal patch plasty (TAPP) inguinal hernia repair in types LI, II and MI, II (EHS classification) [9, 10]. For TAPP repair of larger defects (LIII, MIII), the mesh should be fixed [9, 10]. In TAPP inguinal hernia repair, mesh fixation is still used in 66.1% of all primary unilateral cases in men [16].

Considering the fact that five meta-analyses [17, 18, 19, 20, 21] compared non-penetrating vs. mechanical mesh fixation, high-quality evidence could be expected. However, the meta-analyses can only conclude that the evidence is mostly of low or moderate quality, or that more high-quality multicenter studies are needed [22]. In view of the guidelines, fibrin glue should be considered for fixation to minimize the risk of postoperative acute and chronic pain [9, 10].

In a nationwide registry-based study, no differences were found in the frequency of recurrence and chronic pain between permanent and no/non-permanent fixation of the mesh in endoscopic inguinal hernia repair [23].

Another registry-based study from the Danish Hernia Database also found no difference in chronic pain after mesh fixation with fibrin glue vs. tacks in TAPP inguinal hernia repair [24].

The following analysis of data from the Herniamed Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique.

Methods

As of October 10, 2016, 577 participating hospitals and office-based surgeons mainly from Germany, Austria, and Switzerland had entered prospective data into the internet-based Herniamed Hernia Registry on their patients who had undergone routine hernia surgery and signed an informed consent agreeing to participate [25]. As part of the information provided to patients regarding participation in the Herniamed Quality Assurance Study and signing the informed consent declaration, all patients are informed that the treating hospital or medical practice would like to be informed about any problems occurring after the operation and that the patient has the opportunity to attend for clinical examination.

This present study analyzed the prospective data collected for all male patients who had been operated on with an endoscopic TAPP technique for repair of a primary unilateral inguinal hernia in the period September 01, 2009, up to and including September 01, 2015. On 1-year follow-up, the general practitioners and patients were asked through questionnaire about any pain at rest, pain on exertion, and chronic pain requiring treatment. If chronic pain is reported by the general practitioner or patient, patients can be requested to attend for clinical examination. A recent publication has provided impressive evidence of the role of patient-reported outcomes for the identification of chronic pain rates after groin hernia repair [26]. Only those patients for whom 1-year follow-up results were available were included in the analysis. Other inclusion criteria included age ≥ 16 years and only medial/lateral/combined types of inguinal hernia based on the EHS classification [27].

In total, 20,004 were included in uni- and multivariable analyses for investigation of the influencing factors for the development of chronic pain following TAPP inguinal hernia repair (Fig. 1).

Fig. 1

Flowchart of patient inclusion

All analyses were performed with the software SAS 9.4 (SAS Institute Inc. Cary, NC, USA) and intentionally calculated to a full significance level of 5%, i.e., they were not corrected in respect of multiple tests, and each p value ≤ 0.05 represents a significant result.

To first discern differences between the groups in unadjusted analyses, Fisher’s exact test was used for categorical outcome variables, and the robust t test (Satterthwaite) for continuous variables. For mesh size (cm2), a logarithmic transformation was applied and the re-transformed mean and range of dispersion are given.

To identify influence factors in multivariable analyses, binary logistic regression models for pain at rest, pain on exertion, and chronic pain requiring treatment were used. Potential influence factors were ASA score (I/II/III/IV), age (years), BMI (kg/m2), mesh size (cm2), defect size (I/II/III), risk factors (yes/no), preoperative pain (yes/no/unknown), EHS classification (lateral/medial/combined), postoperative complication (yes/no), and mesh fixation (no fixation/tacker/glue). Estimates for odds ratio (OR) and the corresponding 95% confidence interval based on the Wald test were given. For influence variables with more than two categories, pairwise odds ratios were given. For age (years) the 10-year OR estimate, for BMI (kg/m2) the five-point OR estimate, and for mesh size (cm2) the 10-point OR estimate were given. The results are presented in tabular form, sorted by descending impact.

Results

In total, 20,004 patients were included in the analysis exploring the influence exerted by the fixation technique as well as by other influencing variables on the rate of pain at rest, pain on exertion, and chronic pain requiring treatment (Fig. 1). Of these, 8799 patients had no fixation (44.0%), 6387 (31.9%) only tacker fixation, and 4818 patients (24.1%) only glue fixation.

The patient group in whom the mesh was fixed with a tacker was on average the oldest and had also the highest BMI (Table 1). While there were significant differences in age and BMI between the two groups due to the large patient number, these were not clinically relevant. The meshes in the patient group with no fixation were smaller (Table 1). Besides, meshes with glue fixation had the fewest (8.5%) and meshes with tacker fixation the most (14.1%) ASA III/IV patients (Table 2). The operations with no fixation were most commonly encountered for small hernia defect sizes (17.4%). As regards the defect localization, for lateral EHS classification no or only glue fixation was mainly used, whereas for medial EHS classification tacker fixation was most common (Table 2). Preoperative pain was less common among patients with tacker mesh fixation (59.4%) than in patients with glue mesh fixation (67.3%) or no mesh fixation (66.3%). Drain placement was most commonly used for patients with no mesh fixation (8.4%). In terms of the risk factors, mesh fixation with tackers or glue was more common in patients who continued to take platelet aggregation inhibitors (6.2 vs. 7.8% and 7.6%).

Table 1

Mean age, BMI, and mesh size in male patients with primary unilateral inguinal hernia repair in TAPP technique

 

Non-fixation

Tacker

Glue

p

Age (years)

Median ± STD

55.0 ± 15.6

58.8 ± 14.7

56.4 ± 15.0

< 0.001

BMI

Mean ± STD

25.9 ± 3.3

26.0 ± 3.4

25.8 ± 3.4

< 0.001

Mesh size (cm2)

MW

146.3 [145.2; 147.5]

149.9 [148.7; 151.1]

151.1 [150.1; 152.2]

< 0.001

Table 2

Patient and operative characteristics in relation to mesh fixation and unadjusted tests for significant differences

 

Non-fixation

Tacker

Glue

p

n

%

n

%

n

%

ASA score

 I

3043

34.58

1864

29.18

1946

40.39

< 0.001

 II

4737

53.84

3621

56.69

2461

51.08

 III/IV

1019

11.58

902

14.12

411

8.53

Defect size

 I (< 1.5 cm)

1533

17.42

727

11.38

683

14.18

< 0.001

 II (1.5–3 cm)

6072

69.01

3939

61.67

3200

66.42

 III (> 3 cm)

1194

13.57

1721

26.95

935

19.41

EHS classification

 Combined

1128

12.82

633

9.91

394

8.18

< 0.001

 Lateral

5483

62.31

3718

58.21

3142

65.21

 Medial

2188

24.87

2036

31.88

1282

26.61

Drainage

 Yes

736

8.36

346

5.42

148

3.07

< 0.001

 No

8063

91.64

6041

94.58

4670

96.93

Risk factors

 Total

  Yes

2248

25.55

1665

26.07

1233

25.59

0.747

  No

6551

74.45

4722

73.93

3585

74.41

 COPD

  Yes

368

4.18

313

4.90

195

4.05

0.044

  No

8431

95.82

6074

95.10

4623

95.95

 Diabetes

  Yes

353

4.01

302

4.73

207

4.30

0.100

  No

8446

95.99

6085

95.27

4611

95.70

 Aortic aneurysm

  Yes

27

0.31

30

0.47

12

0.25

0.103

  No

8772

99.69

6357

99.53

4806

99.75

 Immunosuppression

  Yes

47

0.53

34

0.53

15

0.31

0.151

  No

8752

99.47

6353

99.47

4803

99.69

 Corticoid

  Yes

58

0.66

39

0.61

43

0.89

0.173

  No

8741

99.34

6348

99.39

4775

99.11

 Smoking

  Yes

1034

11.75

659

10.32

540

11.21

0.021

  No

7765

88.25

5728

89.68

4278

88.79

 Coagulopathy

  Yes

117

1.33

64

1.00

34

0.71

0.003

  No

8682

98.67

6323

99.00

4784

99.29

 Antiplatelet medication

  Yes

544

6.18

499

7.81

365

7.58

< 0.001

  No

8255

93.82

5888

92.19

4453

92.42

 Anticoagulation therapy

  Yes

133

1.51

118

1.85

68

1.41

0.134

  No

8666

98.49

6269

98.15

4750

98.59

Preoperative pain

 Yes

5829

66.25

3796

59.43

3241

67.27

< 0.001

 No

2515

28.58

2069

32.39

1210

25.11

 Unknown

455

5.17

522

8.17

367

7.62

Unadjusted analysis of the relationship between the fixation technique and the intra- and postoperative complications, recurrence rate as well as pain at rest, on exertion, and requiring treatment on 1-year follow-up is given in detail in Table 3. For postoperative complications, pain on exertion and pain requiring treatment differences are identified in relation to the fixation technique used. For postoperative complication these are largely due to an increased seroma rate (no fixation 0.7% vs. tacker fixation 2.1% vs. glue fixation 3.9%). For operations with no mesh fixation, the rate of pain on exertion (no fixation 10.1% vs. tacker fixation 9.4% vs. glue fixation 8.8%) and pain requiring treatment (no fixation 3.0% vs. tacker fixation 2.4% vs. glue fixation 2.3%) was somewhat higher than in the groups with tacker or glue mesh fixation.

Table 3

Outcome variables in relation to mesh fixation and unadjusted tests for significant differences

 

Non-fixation

Tacker

Glue

p

n

%

n

%

n

%

Intraoperative complication

 Total

  Yes

71

0.81

67

1.05

55

1.14

0.114

  No

8728

99.19

6320

98.95

4763

98.86

 Bleeding

  Yes

48

0.55

52

0.81

35

0.73

0.120

  No

8751

99.45

6335

99.19

4783

99.27

 Injury

  Total

   Yes

42

0.48

31

0.49

27

0.56

0.790

   No

8757

99.52

6356

99.51

4791

99.44

  Vascular

   Yes

23

0.26

17

0.27

11

0.23

0.914

   No

8776

99.74

6370

99.73

4807

99.77

  Bowel

   Yes

6

0.07

4

0.06

4

0.08

0.918

   No

8793

99.93

6383

99.94

4814

99.92

  Bladder

   Yes

4

0.05

6

0.09

5

0.10

0.394

   No

8795

99.95

6381

99.91

4813

99.90

  Nerve

   No

8799

100.0

6387

100.0

4818

100.0

1.000

Postoperative complications

 Total

  Yes

159

1.81

192

3.01

231

4.79

< 0.001

  No

8640

98.19

6195

96.99

4587

95.21

 Bleeding

  Yes

76

0.86

50

0.78

34

0.71

0.602

  No

8723

99.14

6337

99.22

4784

99.29

 Seroma

  Yes

61

0.69

133

2.08

189

3.92

< 0.001

  No

8738

99.31

6254

97.92

4629

96.08

 Infection

  Yes

6

0.07

7

0.11

2

0.04

0.407

  No

8793

99.93

6380

99.89

4816

99.96

 Bowel

  Yes

9

0.10

1

0.02

1

0.02

0.041

  No

8790

99.90

6386

99.98

4817

99.98

 Wound healing disorders

  Yes

7

0.08

5

0.08

8

0.17

0.250

  No

8792

99.92

6382

99.92

4810

99.83

 Ileus

  Yes

8

0.09

2

0.03

3

0.06

0.362

  No

8791

99.91

6385

99.97

4815

99.94

Complication-related reoperations

 Yes

89

1.01

55

0.86

35

0.73

0.226

 No

8710

98.99

6332

99.14

4783

99.27

Recurrence on 1-year follow-up

 Yes

91

1.03

56

0.88

41

0.85

0.467

 No

8708

98.97

6331

99.12

4777

99.15

Pain at rest on 1-year follow-up

 Yes

466

5.30

309

4.84

225

4.67

0.214

 No

8333

94.70

6078

95.16

4593

95.33

Pain on exertion on 1-year follow-up

 Yes

884

10.05

599

9.38

422

8.76

0.045

 No

7915

89.95

5788

90.62

4396

91.24

Pain requiring treatment on 1-year follow-up

 Yes

260

2.95

152

2.38

109

2.26

0.021

 No

8539

97.05

6235

97.62

4709

97.74

Tables 2 and 3 show, in some cases, significant differences in the influencing factors and thus also in outcomes in relation to fixation vs. non-fixation. Accordingly, the unadjusted analysis results permit only limited comparability and therefore call for multivariable analysis.

Multivariable analysis

Pain at rest on 1-year follow-up

The results of analysis of pain at rest on 1-year follow-up are summarized in Table 4 (model fitting: p < 0.001). Pain at rest was highly significantly influenced by the presence of preoperative pain, by age, BMI, and the hernia defect size (in each case p < 0.001). In higher age (10-year OR 0.880 [0.839; 0.924]; p < 0.001) the risk of pain at rest was lower, whereas for higher BMI (five-point OR 1.225 [1.124; 1.334]; p < 0.001), presence of preoperative pain (yes vs. no: OR 1.862 [1.574; 2.201]; p < 0.001), and smaller hernia defect (I vs. III: OR 1.619 [1.298; 2.021]; p < 0.001) it was higher. Additionally, postoperative complications led also to a higher risk of onset of pain at rest (OR 1.613 [1.162; 2.239]; p = 0.004). There was no evidence of the fixation technique having any influence on the risk of onset of pain at rest.

Table 4

Multivariable analysis of influencing factors for pain at rest on 1-year follow-up

Parameter

p Value

Category

p Value paired

OR estimate

95% CI

Preoperative pain

< 0.001

Yes vs. no

< 0.001

1.862

1.574

2.201

Yes vs. unknown

0.149

1.214

0.933

1.581

No vs. unknown

0.004

0.652

0.486

0.875

Age (10-year OR)

< 0.001

  

0.880

0.839

0.924

BMI (5-point OR)

< 0.001

  

1.225

1.124

1.334

Defect size

< 0.001

I (< 1.5 cm) vs. II (1.5–3 cm)

< 0.001

1.453

1.233

1.714

I (< 1.5 cm) vs. III (> 3 cm)

< 0.001

1.619

1.298

2.021

II (1.5–3 cm) vs. III (> 3 cm)

0.244

1.114

0.929

1.336

Postoperative complication

0.004

Yes vs. no

 

1.613

1.162

2.239

Fixation

0.354

Glue vs. tacks

0.184

0.886

0.741

1.059

Glue vs. non-fixation

0.210

0.899

0.761

1.062

Tacks vs. non-fixation

0.850

1.015

0.872

1.181

Risk factors

0.511

Yes vs. no

 

1.053

0.903

1.229

ASA score

0.513

I vs. II

0.248

0.913

0.783

1.065

I vs. III/IV

0.552

0.923

0.710

1.201

II vs. III/IV

0.924

1.011

0.806

1.269

Mesh size (10-point OR)

0.652

  

0.992

0.959

1.026

EHS classification

0.745

Combined vs. lateral

0.609

1.057

0.856

1.305

Combined vs. medial

0.449

1.094

0.867

1.379

Lateral vs. medial

0.649

1.035

0.892

1.201

Pain on exertion on 1-year follow-up

Pain on exertion on 1-year follow-up, whose analysis results are summarized in Table 5 (model fitting: p < 0.001), was significantly influenced by age, preoperative pain, hernia defect size, BMI (in each case p < 0.001), mesh size (p = 0.031), postoperative complications (p = 0.023), and the fixation technique (p = 0.037). A higher age (10-year OR 0.796 [0.768; 0.825]; p < 0.001) led to a lower risk and preoperative pain (yes vs. no: OR 1.516 [1.349; 1.705]; p < 0.001) to a higher risk of onset of pain on exertion. Small defect sizes (I vs. III: OR 1.605 [1.354; 1.902]; p < 0.001), higher BMI (five-point OR 1.180 [1.104; 1.260]; p < 0.001), and onset of postoperative complications (yes vs. no: OR 1.364 [1.045; 1.780]; p = 0.023) increased the risk of pain on exertion.

Table 5

Multivariable analysis of influencing factors for pain on exertion on 1-year follow-up

Parameter

p Value

Category

p Value paired

OR estimate

95% CI

Age (10-year OR)

< 0.001

  

0.796

0.768

0.825

Preoperative pain

< 0.001

Yes vs. no

< 0.001

1.516

1.349

1.705

Yes vs. unknown

0.040

1.236

1.010

1.513

No vs. unknown

0.067

0.815

0.655

1.015

Defect size

< 0.001

I (< 1.5 cm) vs. II (1.5–3 cm)

< 0.001

1.317

1.163

1.492

I (< 1.5 cm) vs. III (> 3 cm)

< 0.001

1.605

1.354

1.902

II (1.5–3 cm) vs. III (> 3 cm)

0.006

1.218

1.060

1.401

BMI (5-point OR)

< 0.001

  

1.180

1.104

1.260

Postoperative complication

0.023

Yes vs. no

 

1.364

1.045

1.780

Mesh size (10-point OR)

0.031

  

0.971

0.946

0.997

Fixation

0.037

Glue vs. tacks

0.010

0.839

0.734

0.959

Glue vs. non-fixation

0.123

0.906

0.800

1.027

Tacks vs. non-fixation

0.183

1.080

0.964

1.209

ASA score

0.088

I vs. II

0.031

0.882

0.787

0.988

I vs. III/IV

0.496

0.932

0.760

1.142

II vs. III/IV

0.548

1.056

0.883

1.263

Risk factors

0.416

Yes vs. no

 

1.049

0.934

1.179

EHS classification

0.518

Combined vs. lateral

0.727

1.029

0.875

1.210

Combined vs. medial

0.701

0.966

0.811

1.151

Lateral vs. medial

0.254

0.939

0.842

1.046

The use of a larger mesh reduced the risk of pain on exertion (10-point OR 0.971 [0.946; 0.997]; p = 0.031). There was also evidence of the influence of the fixation technique, (p = 0.037), revealing that tacker compared with glue fixation led to a higher rate of pain on exertion (OR 1.192 [1.043; 1.362]; p = 0.010).

Chronic pain requiring treatment on 1-year follow-up

The results of analysis of the influencing factors for pain requiring treatment are shown in Table 6 (model fitting: p < 0.001). Here, too, the risk of onset of chronic pain requiring treatment was highly significantly affected by the hernia defect size, age, BMI, and preoperative pain (in each case p < 0.001). The rate of chronic pain requiring treatment was, in particular, negatively influenced by small defect sizes (I vs. III: OR 1.996 [1.482; 2.688]; p < 0.001), higher BMI (five-point OR 1.319 [1.181; 1.473]; p < 0.001) as well as by preoperative pain (yes vs. no: OR 1.819 [1.441; 2.296]; p < 0.001). On the other hand, higher age (10-year OR 0.842 [0.788; 0.899]; p < 0.001) resulted in a lower risk of chronic pain requiring treatment.

Table 6

Multivariable analysis of influencing factors for chronic pain requiring treatment

Parameter

p Value

Category

p Value paired

OR estimate

95% CI

Defect size

< 0.001

I (< 1.5 cm) vs. II (1.5–3 cm)

< 0.001

1.853

1.500

2.289

I (< 1.5 cm) vs. III (> 3 cm)

< 0.001

1.996

1.482

2.688

II (1.5–3 cm) vs. III (> 3 cm)

0.572

1.077

0.832

1.394

Age (10-year OR)

< 0.001

  

0.842

0.788

0.899

BMI (5-point OR)

< 0.001

  

1.319

1.181

1.473

Preoperative pain

< 0.001

Yes vs. no

< 0.001

1.819

1.441

2.296

Yes vs. unknown

0.794

1.048

0.739

1.486

No vs. unknown

0.006

0.576

0.388

0.854

Risk factors

0.079

Yes vs. no

 

1.203

0.979

1.478

Mesh size (10-point OR)

0.167

  

0.966

0.921

1.014

Fixation

0.202

Glue vs. tacks

0.280

0.870

0.675

1.120

Glue vs. non-fixation

0.074

0.810

0.642

1.021

Tacks vs. non-fixation

0.501

0.931

0.755

1.147

ASA score

0.462

I vs. II

0.405

0.914

0.740

1.129

I vs. III/IV

0.223

0.803

0.565

1.142

II vs. III/IV

0.403

0.879

0.649

1.189

EHS classification

0.591

Combined vs. lateral

0.618

1.076

0.807

1.436

Combined vs. medial

0.341

1.167

0.849

1.605

Lateral vs. medial

0.436

1.085

0.884

1.331

Postoperative complication

0.729

Yes vs. no

 

0.902

0.504

1.615

Additional analysis

An additional analysis was included to show, not only qualitatively but also quantitatively, the results for the impact of age and BMI on chronic pain. This revealed that age ≤ 40 years was associated with the highest rates of pain at rest (6.4%), pain on exertion (13.7%), and pain requiring treatment (3.6%) on 1-year follow-up. Patients between > 40 and 60 years had mean pain rates (5.5, 11.6, and 3.1%, respectively) and patients > 60 years had the lowest pain rates (3.9, 6.0, and 1.8%, respectively). Patients with BMI of 18.5–24.9 (WHO classification: normal weight) had the lowest pain rates (4.2, 8.5, and 2.1%, respectively), those with BMI between 25.0 and 29.0 (WHO classification: overweight) had average rates (5.5, 10.0, and 2.7%, respectively) and those with BMI ≥ 30 (WHO classification: obesity) the highest pain rates (6.3, 11.5 , and 4.1%, respectively).

Discussion

The present analysis of data from the Herniamed Hernia Registry for 20,004 male patients with elective primary, unilateral inguinal hernia repair in TAPP technique and with 1-year follow-up results has once again confirmed that, as reported in the literature, a pain at rest rate of 4–5%, pain on exertion of 8–10%, and pain requiring treatment of 2–3% must be expected [1, 2, 3, 4, 5, 6]. In this selected patient group with laparoscopic inguinal hernia repair of exclusively male patients with primary unilateral inguinal hernia, it was also demonstrated that, as in the literature [1, 2, 3, 4, 5, 6], young age (≤ 40 years) and preoperative pain are important influencing factors for onset of chronic pain. The present multivariable analysis has revealed that pain at rest, pain on exertion, and chronic pain requiring treatment was highly affected by preoperative pain and young age. But that was also true for small hernia defects. For a small hernia defect the risk of pain at rest, on exertion, and requiring treatment appeared to be highly significantly greater than for a large hernia defect. One explanation for this could be that a patient who is willing to undergo surgery for even a smaller inguinal hernia is more sensitive to pain [1], and already experiences preoperative pain. But the issue of the indication for surgery must also be addressed. Was the inguinal pain really related to a small inguinal hernia or was this due to other causes that also persisted after inguinal hernia repair? Other causes of inguinal pain must be effectively ruled out.

This clearly demonstrates that young patients with a small inguinal hernia (EHS I: < 1.5 cm) and inguinal pain are at highest risk for onset of chronic pain following laparoscopic inguinal hernia repair. Accordingly, a well-founded indication for surgery is of strictly crucial importance for these patients. The patient should definitely be made aware of this before signing the declaration of informed consent form for surgery. If the indication is correct, the operation should be performed in accordance with the evidence-based guidelines for the TAPP technique [9, 10].

Likewise, patients with higher BMI value (≥ 25.0) had a highly significant influence on the risk of pain at rest, on exertion, and chronic pain requiring treatment after TAPP operation. Overweight or obesity, in particular in male patients makes additional demands on the surgeon during conduct of TAPP. Therefore commensurate caution must be exercised when performing surgery for overweight patients.

In addition to the most important influencing factors for onset of chronic pain after laparoscopic inguinal hernia surgery (young age, preoperative pain, small hernia defect, and higher BMI), there are other factors affecting onset of chronic pain. These include postoperative complications and the use of penetrating tackers for mesh fixation. As demonstrated in five meta-analyses, the use of penetrating mesh fixation compared with glue fixation led to significantly more chronic inguinal pain [17, 18, 19, 20, 21], but the evidence is mostly of low or moderate quality. Unlike the aforementioned meta-analyses, on comparing tack mesh fixation vs. non-fixation Sajid et al. [15] did not find any difference in the chronic pain rates. Likewise, a registry-based Danish study did not find any difference in chronic pain rates after TAPP operation on comparing mesh fixation with fibrin glue vs. tacks [24]. In our study, the influence of penetrating tacks on chronic pain was only confirmed for pain on exertion on comparing non-fixation vs. tack fixation. In their systematic review, Lederhuber et al. [22] concluded that there is still a lack of high-quality evidence for differences between the assessed mesh fixation techniques. Therefore, more high-quality multicenter studies are needed [22]. The findings of our study at least suggest that other factors, such as a small hernia, preoperative pain, younger age, and higher BMI, have a greater impact on the development of chronic pain than does the fixation technique.

Likewise, postoperative complications can trigger inguinal pain. Therefore, an appropriate response must be taken to any development of postoperative complications after TAPP operation to prevent the onset of chronic inguinal pain.

The potential weakness of this study is its non-randomization and the voluntary participation in the internet-based registration. These could lead to selection bias, which can be balanced by the large case number of the study. Furthermore, the registry does not contain any data on how the peritoneum was closed.

In summary, it can be stated that there are several influencing factors for pain at rest, on exertion, and chronic pain requiring treatment following primary unilateral inguinal hernia repair in male patients in TAPP technique. Younger patient age, preoperative pain, smaller hernia defect size, and higher BMI value have a highly significant influence. Other potentially influencing factors are penetrating mesh fixation and development of postoperative complications. Through a well-founded indication, and observance of the technical guidelines for evidence-based conduct of TAPP, it may be possible to prevent chronic pain after TAPP operation.

Notes

Acknowledgements

Ferdinand Köckerling received grants to fund the Herniamed Registry from Johnson & Johnson, Norderstedt; Karl Storz, Tuttlingen; PFM medical, Cologne; Dahlhausen, Cologne; B Braun, Tuttlingen; MenkeMed, Munich; and Bard, Karlsruhe.

Compliance with ethical standards

Disclosures

H. Niebuhr, F. Wegner, M. Hukauf, M. Lechner, R. Fortelny, R. Bittner, C. Schug-Pass have no conflicts of interest or financial ties to disclose.

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Copyright information

© The Author(s) 2017

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • H. Niebuhr
    • 1
  • F. Wegner
    • 1
  • M. Hukauf
    • 2
  • M. Lechner
    • 3
  • R. Fortelny
    • 4
  • R. Bittner
    • 5
  • C. Schug-Pass
    • 6
  • F. Köckerling
    • 6
  1. 1.Hanse-Hernia CenterHamburgGermany
  2. 2.StatConsult GmbHMagdeburgGermany
  3. 3.Department of SurgeryParacelsus Medical UniversitySalzburgAustria
  4. 4.Department of General, Visceral and Oncologic SurgeryWilhelminen HospitalViennaAustria
  5. 5.Winghofer MedicumHernia CenterRottenburg am NeckarGermany
  6. 6.Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical SchoolVivantes HospitalBerlinGermany

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