Inguinal hernia: pain and chronic pain

Inguinal hernia and pain

Some inguinal hernias may present with little or no pain symptoms even if they are large or have been present for a long time.

In other cases we can find hernias that have only just begun, very small or even not yet visible, but very painful.

It is evident that there is not a direct correlation between pain and danger of a hernia. On the contrary, sometimes hernias that are not very painful work to the disadvantage of the patient, giving him the impression of being able to live with the problem indefinitely.

However, it is not uncommon in these cases, which are not very symptomatic, to witness the complication of the pathology without warning.

Three sensory nerves per side pass through the inguinal region: Ileo-hypogastric, Ileo-inguinal, and genito-femoral.

These three nerves run in the inguinal region and when compressed by the hernia can signal pain. Nerve compression occurs at the level of the inguinal region but pain can also be felt in other areas such as the inner thigh, the testicle rather than the lower abdominal quadrants, which are all territories pertaining to the three inguinal nerves.

Therefore, it is not uncommon for an inguinal hernia to cause pain in seemingly distant areas such as the inner thigh.

In general, if a hernial repair is adequately performed, the pain symptoms will regress on their own, as the nerve compression disappears.

Inguinal hernia and chronic postoperative pain

Depending on the type of technique used for hernial repair there may be a low percentage of risk that it is the surgery itself that generates pain. If the pain persists beyond a certain number of months we can speak of chronic pain.

This phenomenon occurs especially in techniques with surgical incision and prosthesis inserted inside the inguinal canal. Such reconstructions in fact (in a modest percentage of cases), may involve the risk that one of the three sensory nerves of the groin (ileo-hypograft, ileo-inguinal and genito-femoral) may come into contact and conflict with the mesh or its fixation points. There are also cases where more than one of the three nerves are involved in suchneuroprosthetic conflicts.

This rare but distressing complication can lead up to reintervention with removal of the prosthesis and the triple inguinal neurectomy. Even in laparoscopy there is a certain percentage of development of chronic postoperative pain due to the fact that the mesh is usually fixed with rather traumatic anchoring means (called tucks). This prosthetic fixation solution sometimes defeats the laparoscopic mini-invasiveness by irritating or injuring the nerves.

In our clinical practice we prefer robotic techniques with access R-TAPP because thanks to the dexterity and characteristics of the instrumentation it is possible to use different materials, very light and self-fixing, which therefore do not require tucks.

The fact that the prostheses are no longer anchored with tucks but simply attached to the tissues and are located in a region outside the inguinal canal minimizes the risk of neuroprosthetic conflict and therefore of chronic post-operative pain..

We also frequently use this reconstructive solution in conjunction with neurolysis or neurectomy in those patients already suffering from chronic pain as a result of previous surgery.

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