Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

18. Algorithmic Approach to the Workup and Management…
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Until recently no such algorithm has existed and current practices
were mainly guided by personal opinion and expertise. While it was
impossible to include every perspective and address every subtlety in
dealing with this complex diagnosis, the proposed algorithm involved
many dedicated inguinal hernia surgeons and addressed the general
issues that are important in the diagnosis and management. This algorithm
approach is not intended as a solid law or rigid guideline, but
hopefully will serve as a guide for practicing surgeons, pain physicians,
primary doctors and the multidisciplinary services that assist in treating
this important group of patients [ 14 ].
Timing
The algorithm starts with the two categories of patients after inguinal
hernia surgery requiring medical attention: patients with pain immediately
after surgery (acute pain) and patients who develop pain later during
the postoperative course. This second group is also subdivided in
two categories: patients who only complain in the early postoperative
phase and those who have persistent pain or develop pain after some
months. Acute, excruciating pain is considered an indication for early
re-exploration. If postoperative pain develops later during the postoperative
course, or if pain persists beyond the normal postoperative recovery
period, an expectative phase of 3 months is indicated. During this time,
analgesics and other conservative measures are recommended.
Diagnostics
If pain persists after 3 months, inguinal hernia recurrence should be
excluded based on physical examination. In case of clinical recurrence,
operative correction is indicated, with or without triple neurectomy,
depending on the type of pain (neuropathic or nociceptive). If physical
examination does not demonstrate recurrence, ultrasonography is recommended
as the initial diagnostic procedure to exclude occult recurrence
or meshoma. If ultrasonography is unrevealing, cross-sectional imaging
with MRI might detect recurrence, meshoma , or other pathologies.
If recurrence is identified and associated with pain, open anterior
repair is recommended in conjunction with triple neurectomy if accompanied
by neuropathic pain. From the perspective of pain management