Pedersen et al reported an algorithm for the management of a patient with chronic pain after inguinal hernia. The authors are from Zealand University Hospital, University of California Los Angeles, and the University of Copenhagen.
Patient selection: chronic pain after inguinal hernia repair, which may be neuropathic or nocioceptive in nature
Indication for surgery: moderate or severe pain lasting >= 6 months and failure of multi-modal analgesic therapy tried for at least 3 months
Exclusion: recurrent hernia, alternative cause for pain, poor compliance, drug or alcohol abuse
Types of inguinal repair performed:
(1) Lichenstein (tension-free mesh repair)
(2) TAPP (transabdominal preoperitoneal patch)
TEP (totally extra-peritoneal) repair was not performed in population.
A diagnosis of neuropathic inguinodynia was supported by dermatosensory mapping to identify involved nerves in the groin.
If persistent pain is present after the Lichtenstein procedure, then:
(1) 3-neuroectomy and open mesh removal was performed
(2) if no improvement then perform laparoscopic extraperitoneal 3-neurectomy
(3) if no improvement then refer the patient to a multidisciplinary pain team
If persistent pain is present after the TAPP procedure, then:
(1) if dermatosensory mapping is positive, then perform laparoscopic extraperitoneal 3-neurectomy
(2) If the dermatosensory mapping was negative, then total mesh removal without neurectomy was performed.
(3) if no improvement then refer the patient to a multidisciplinary pain team
