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

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K.A. Seymour and J.S. Yoo
reproducible pain. The operative report from the previous surgery
should be reviewed, including the type of repair, size of the defect, size
and type of mesh, handling of nerves, and type of fixation. Diagnostic
imaging—ultrasound, computed tomography scan, or magnetic resonance
imaging—supplements the management, excludes recurrence or
meshoma, and assists in the diagnosis [ 4 ].
Supportive Treatment
Treatment of postoperative pain involves a multidisciplinary approach,
including medications, behavior modification, and therapeutic intervention.
Courtney et al. found that 30 % of patients have resolution of postoperative
inguinal hernia repair pain, 45 % have reduced pain, and 25 %
continue to have chronic pain [ 12 ]. A period of watchful waiting with
symptomatic treatment with a multimodal therapy that includes behavior
modification, NSAIDs, and opioid medications is recommended.
Additionally, a multidisciplinary group approach that consists of the
primary care provider and a dedicated pain specialist (anesthesiologist,
neurologist, psychiatrist) is recommended. Adjunctive modalities such
as nerve stimulators, steroid injections, or nerve blocks can be both diagnostic
and therapeutic. Specific to this subgroup of patients with pain in
the presence of a known recurrence, it is important to characterize the
potential etiologies of pain so that all contributing factors can be
addressed at the time of remedial surgery for both recurrence and pain.
Surgical Options
Reoperation for a recurrent inguinal hernia is considered at the time
of identification either by physical exam or imaging studies. A trial of
conservative measures, careful diagnostic evaluation, and treatment for
the pain component is prudent to help delineate if the pain is primarily
due to the recurrence or if neuropathy, meshoma, or other anatomic
issues are causative. At the time of repair of a recurrent inguinal hernia,
surgery for pain management may include an operative neurectomy or
possible removal of mesh, depending on the presentation and suspected
etiology of pain.
Neuropathic pain refractory to conservative measures identified from
history, physical examination, and adjunctive testing may not improve
with recurrent hernia repair alone, and the inguinal and preperitoneal