Chronic Pain After Inguinal Repair

  • Nicholas H. Carter
  • David C. Chen


Chronic postherniorrhaphy inguinal pain (CPIP) has surpassed recurrence as the most common severe long-term complication of inguinal hernia surgery. The etiologies of CPIP are variable and incompletely understood, but evidence is emerging to guide the prevention and management of this debilitating syndrome. Meticulous attention to preoperative risk factors, intraoperative nerve identification, and postoperative analgesic care can help minimize risk for CPIP. If a patient develops signs and symptoms of CPIP, the clinician should apply a stepwise approach to diagnosis of the root cause of pain. Patients should be evaluated and treated by a multidisciplinary team including a pain specialist with pharmacologic, behavioral, and interventional modalities. Not all patients with severe pain following inguinal hernia repair are reasonable candidates for operative intervention. For patients with findings that suggest a lesion that would be amenable to surgical correction, open or laparoscopic triple neurectomy has been shown to be efficacious. Intimate familiarity with groin neuroanatomy is crucial to performing these operations successfully. Proper management of chronic inguinodynia following groin surgery can markedly improve ability to work, opiate dependence, and quality of life for patients who develop this complex and challenging syndrome.


  1. 1.
    Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239–49. Scholar
  2. 2.
    Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth. 2005;95(1):69–76. Scholar
  3. 3.
    Aasvang E, Kehlet H. Surgical management of chronic pain after inguinal hernia repair. Br J Surg. 2005;92(7):795–801. Scholar
  4. 4.
    Bjurstrom MF, Nicol AL, Amid PK, Chen DC. Pain control following inguinal herniorrhaphy: current perspectives. J Pain Res. 2014;7:277–90. Scholar
  5. 5.
    Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother. 2009;9(5):723–44. Scholar
  6. 6.
    Bjurstrom MF, Giron SE, Griffis CA. Cerebrospinal fluid cytokines and neurotrophic factors in human chronic pain populations: a comprehensive review. Pain Pract. 2016;16(2):183–203. Scholar
  7. 7.
    Kalliomaki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain. 2008;12(2):214–25. Scholar
  8. 8.
    Parsons B, Schaefer C, Mann R, Sadosky A, Daniel S, Nalamachu S, et al. Economic and humanistic burden of post-trauma and post-surgical neuropathic pain among adults in the United States. J Pain Res. 2013;6:459–69. Scholar
  9. 9.
    Dominguez CA, Kalliomaki M, Gunnarsson U, Moen A, Sandblom G, Kockum I, et al. The DQB1 *03:02 HLA haplotype is associated with increased risk of chronic pain after inguinal hernia surgery and lumbar disc herniation. Pain. 2013;154(3):427–33. Scholar
  10. 10.
    Belfer I, Dai F, Kehlet H, Finelli P, Qin L, Bittner R, et al. Association of functional variations in COMT and GCH1 genes with postherniotomy pain and related impairment. Pain. 2015;156(2):273–9. Scholar
  11. 11.
    Montes A, Roca G, Sabate S, Lao JI, Navarro A, Cantillo J, et al. Genetic and clinical factors associated with chronic postsurgical pain after hernia repair, hysterectomy, and thoracotomy: a two-year multicenter cohort study. Anesthesiology. 2015;122(5):1123–41. Scholar
  12. 12.
    Loos MJ, Roumen RM, Scheltinga MR. Classifying post-herniorrhaphy pain syndromes following elective inguinal hernia repair. World J Surg. 2007;31(9):1760–1765; discussion 6-7. Scholar
  13. 13.
    van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Investig Radiol. 1999;34(12):739–43.CrossRefGoogle Scholar
  14. 14.
    Aasvang EK, Jensen KE, Fiirgaard B, Kehlet H. MRI and pathology in persistent postherniotomy pain. J Am Coll Surg. 2009;208(6):1023–1028; discussion 8-9. Scholar
  15. 15.
    Bradley M, Morgan D, Pentlow B, Roe A. The groin hernia - an ultrasound diagnosis? Ann R Coll Surg Engl. 2003;85(3):178–80. Scholar
  16. 16.
    Knockaert DC, Boonen AL, Bruyninckx FL, Bobbaers HJ. Electromyographic findings in ilioinguinal-iliohypogastric nerve entrapment syndrome. Acta Clin Belg. 1996;51(3):156–60.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Filler A. Magnetic resonance neurography and diffusion tensor imaging: origins, history, and clinical impact of the first 50,000 cases with an assessment of efficacy and utility in a prospective 5000-patient study group. Neurosurgery. 2009;65(4 Suppl):A29–43. Scholar
  18. 18.
    Werner MU, Enggaard TP. Persistent pain following groin hernia repair: what is the best practice in pain management? Pain Manag. 2015;5(2):65–8. Scholar
  19. 19.
    Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237–51. Scholar
  20. 20.
    Attal N, Cruccu G, Haanpaa M, Hansson P, Jensen TS, Nurmikko T, et al. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol. 2006;13(11):1153–69. Scholar
  21. 21.
    Bischoff JM, Petersen M, Uceyler N, Sommer C, Kehlet H, Werner MU. Lidocaine patch (5%) in treatment of persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial. Anesthesiology. 2013;119(6):1444–52. Scholar
  22. 22.
    Bischoff JM, Ringsted TK, Petersen M, Sommer C, Uceyler N, Werner MU. A capsaicin (8%) patch in the treatment of severe persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled trial. PLoS One. 2014;9(10):e109144. Scholar
  23. 23.
    Voorbrood CE, Burgmans JP, Van Dalen T, Breel J, Clevers GJ, Wille F, et al. An algorithm for assessment and treatment of postherniorrhaphy pain. Hernia. 2015;19(4):571–7. Scholar
  24. 24.
    Bischoff JM, Koscielniak-Nielsen ZJ, Kehlet H, Werner MU. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial. Anesth Analg. 2012;114(6):1323–9. Scholar
  25. 25.
    Bjurstrom MF, Alvarez R, Nicol AL, Olmstead R, Amid PK, Chen DC. Quantitative validation of sensory mapping in persistent postherniorrhaphy inguinal pain patients undergoing triple neurectomy. Hernia. 2017;21:207. Scholar
  26. 26.
    Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg. 2009;249(2):327–34. Scholar
  27. 27.
    Loos MJ, Scheltinga MR, Roumen RM. Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia. Surgery. 2010;147(2):275–81. Scholar
  28. 28.
    Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioinguinal neurectomy for chronic pain. J Neurosurg. 2010;112(4):784–9. Scholar
  29. 29.
    Zwaans WA, Perquin CW, Loos MJ, Roumen RM, Scheltinga MR. Mesh removal and selective neurectomy for persistent groin pain following Lichtenstein repair. World J Surg. 2017;41(3):701–12. Scholar
  30. 30.
    Klaassen Z, Marshall E, Tubbs RS, Louis RG Jr, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat. 2011;24(4):454–61. Scholar
  31. 31.
    Lange JF, Kaufmann R, Wijsmuller AR, Pierie JP, Ploeg RJ, Chen DC, et al. An international consensus algorithm for management of chronic postoperative inguinal pain. Hernia. 2015;19(1):33–43. Scholar
  32. 32.
    Chen DC, Hiatt JR, Amid PK. Operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach. JAMA Surg. 2013;148(10):962–7. Scholar
  33. 33.
    Kehlet H, Aasvang E. Groin hernia repair: anesthesia. World J Surg. 2005;29(8):1058–61. Scholar
  34. 34.
    Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003;362(9387):853–8. Scholar
  35. 35.
    Bay-Nielsen M, Kehlet H. Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Acta Anaesthesiol Scand. 2008;52(2):169–74. Scholar
  36. 36.
    Amid PK, Hiatt JR. New understanding of the causes and surgical treatment of postherniorrhaphy inguinodynia and orchalgia. J Am Coll Surg. 2007;205(2):381–5. Scholar
  37. 37.
    Lange JF, Wijsmuller AR, van Geldere D, Simons MP, Swart R, Oomen J, et al. Feasibility study of three-nerve-recognizing Lichtenstein procedure for inguinal hernia. Br J Surg. 2009;96(10):1210–4. Scholar
  38. 38.
    Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, Di Miceli D, et al. Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg. 2006;243(4):553–8. Scholar
  39. 39.
    Wijsmuller AR, van Veen RN, Bosch JL, Lange JF, Kleinrensink GJ, Jeekel J, et al. Nerve management during open hernia repair. Br J Surg. 2007;94(1):17–22. Scholar
  40. 40.
    Hsu W, Chen CS, Lee HC, Liang HH, Kuo LJ, Wei PL, et al. Preservation versus division of ilioinguinal nerve on open mesh repair of inguinal hernia: a meta-analysis of randomized controlled trials. World J Surg. 2012;36(10):2311–9. Scholar
  41. 41.
    Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. Br J Surg. 2012;99(1):29–37. Scholar
  42. 42.
    Sajid MS, Kalra L, Parampalli U, Sains PS, Baig MK. A systematic review and meta-analysis evaluating the effectiveness of lightweight mesh against heavyweight mesh in influencing the incidence of chronic groin pain following laparoscopic inguinal hernia repair. Am J Surg. 2013;205(6):726–36. Scholar
  43. 43.
    Colvin HS, Rao A, Cavali M, Campanelli G, Amin AI. Glue versus suture fixation of mesh during open repair of inguinal hernias: a systematic review and meta-analysis. World J Surg. 2013;37(10):2282–92. Scholar
  44. 44.
    Sanders DL, Waydia S. A systematic review of randomised control trials assessing mesh fixation in open inguinal hernia repair. Hernia. 2014;18(2):165–76. Scholar
  45. 45.
    Ladwa N, Sajid MS, Sains P, Baig MK. Suture mesh fixation versus glue mesh fixation in open inguinal hernia repair: a systematic review and meta-analysis. Int J Surg. 2013;11(2):128–35. Scholar
  46. 46.
    Zhang C, Li F, Zhang H, Zhong W, Shi D, Zhao Y. Self-gripping versus sutured mesh for inguinal hernia repair: a systematic review and meta-analysis of current literature. J Surg Res. 2013;185(2):653–60. Scholar
  47. 47.
    Amid PK, Chen DC. Surgical treatment of chronic groin and testicular pain after laparoscopic and open preperitoneal inguinal hernia repair. J Am Coll Surg. 2011;213(4):531–6. Scholar
  48. 48.
    Bjurstrom MF, Nicol AL, Amid PK, Lee CH, Ferrante FM, Chen DC. Neurophysiological and clinical effects of laparoscopic retroperitoneal triple neurectomy in patients with refractory postherniorrhaphy neuropathic inguinodynia. Pain Pract. 2016;17:447. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Residency in General SurgeryVanderbilt University Medical CenterNashvilleUSA
  2. 2.Lichtenstein Amid Hernia Clinic at UCLASanta MonicaUSA
  3. 3.Department of SurgeryDavid Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations