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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tistical analysis. Experience and common sense have therefore regained
their importance for determining optimal surgical techniques.
This chapter describes strategies for optimizing the laparoscopic
repair of inguinal hernias to prevent postoperative pain, based on review
of the relevant literature, our own experience, and the experience of
leading surgeons in the field.
General Aspects of Preventing Pain After
TEP and TAPP Hernia Repair
Surgeons should master the laparoscopic anatomy of the inguinal
region before performing laparoscopic inguinal hernia repair and should
be particularly aware of the anatomy of the inguinal nerves.
Surgeons should be appropriately trained in all techniques for laparoscopic
hernia repair, including the totally extraperitoneal (TEP),
enhanced or extended view TEP (eTEP), transabdominal preperitoneal
(TAPP), and intraperitoneal onlay mesh (IPOM) techniques, in addition
to primary closure of defects. Comprehensive training allows surgeons
to offer the appropriate procedure according to individual patient characteristics
and to convert from one procedure to another if necessary.
One of the best ways to avoid pain after inguinal hernia repair is to
avoid operating on patients with unusual preoperative inguinal pain or
inguinal pain that is disproportionate to the hernia. Pain is usually not a
remarkable symptom of inguinal hernias, except in complex cases.
Many patients with disproportionate preoperative pain have a different
cause for their pain and develop chronic pain after hernia repair.
We recommend administration of a first-generation cephalosporin
during the induction of anesthesia. We do not routinely use prophylactic antithrombotic
medication, but use pneumatic compression devices in all patients.
Patients should be reexamined while standing immediately before
surgery, and the physical examination findings should be compared with
the laparoscopic findings. This is an excellent method for ensuring that
hernias are not missed.
We prepare the skin, drape the patient, and set up the equipment while
the patient is still awake (but sedated) so that surgery starts almost immediately
after the induction of anesthesia, thereby reducing costs and facilitating
a faster recovery. Optimal muscle relaxation is important to ensure a
fast and easy procedure, and the anesthesiologist should be asked to provide
a short period of full relaxation before the start of the operation.