World J Surg DOI 10.1007/s00268-014-2626-8
INVITED COMMENTARY
Prevention of Inguinodynia: The Need for Continuous Refinement and Quality Improvement in Inguinal Hernia Repair David C. Chen • Parviz K. Amid
Ó Socie´te´ Internationale de Chirurgie 2014
Dear Editors, It was with great interest that we read the manuscript Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing fibrin glue to tack fixation [1]. While there have been several studies, randomized controlled trials (RCTs), reviews, and meta-analyses comparing these fixation methods, the authors have provided a methodologically sound analysis of the available studies to date, commendably choosing to focus on the outcome of chronic pain. The success of modern herniorrhaphy techniques and the use of prosthetic materials have dramatically reduced recurrence rates, and chronic pain exceeds recurrence as the more frequent complication. Quality of life and avoidance of chronic pain have become important metrics of successful surgery. Inguinodynia has been a recognized complication with all techniques of hernia repair and long preceded meshbased techniques. [2, 3] While there is a statistical advantage of laparoscopic repair with regards to acute pain, direct comparisons between open and laparoscopic repair regarding chronic pain are difficult because the definitions and technique vary amongst studies. The wide variation is apparent, even within this meta-analysis of laparoscopic repairs where the five included trials report rates of chronic pain ranging from 0 to 24 % [1]. The recently published 2014 update to the European Hernia Society (EHS) guidelines reaffirms that there is no difference in the incidence of significant chronic pain between open and laparoscopic repair. [4] Remedial surgery for neuropathic
D. C. Chen P. K. Amid (&) Department of Surgery, Lichtenstein Amid Hernia Clinic at UCLA, UCLA David Geffen School of Medicine, Santa Monica, CA, USA e-mail: [email protected]
inguinodynia after preperitoneal repair is more challenging than with anterior repair and requires proximal access to these nerves via retroperitoneal neurectomy. [5–7] Proper technique and respect for neuroanatomy with each chosen method of repair is critical to improving outcomes and preventing inguinodynia. The important developments by Nyhus, Read, Stoppa, Wantz, Rives, Shumpelick, and others have helped to define and utilize the preperitoneal anatomy for effective hernia repairs. Laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches have made this compartmental anatomy ubiquitous for most hernia surgeons. However, in-depth understanding of the neuroanatomy of this compartment is needed to prevent neuralgia, orchialgia, dysejaculation, recurrence, and meshoma. [8] Causes of chronic pain can be nociceptive or neuropathic in origin and there is often overlap between the two, making diagnosis and treatment challenging. The most common causative mechanisms with laparoscopic inguinal hernia repair include neuropathy from direct contact with mesh, meshoma pain from folding of the mesh, and direct nerve injury (dissection, thermal injury, fixation). [5, 6] Read [9] and Mirilas et al. [10] have helped to delineate the surgical anatomy of the preperitoneal space, confirming the presence of two compartments behind the transversalis fascia separated by a membranous layer. [8–10] The visceral compartment medially contains the bladder, ureter, and prostate and laterally contains the vas deferens ensheathed by this membranous layer. The parietal compartment contains the genitofemoral trunk and its genital and femoral branches and the lateral femoral cutaneous nerve within the classically described ‘trapezoid of pain’. The ilioinguinal and iliohypogastric nerves travel in the retroperitoneum and exit cephalad and lateral to most preperitoneal repairs. [7, 10] Unlike the nerves in the
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inguinal canal that are protected by an investing fascia (investing fascia of the internal oblique for the ilioinguinal and iliohypogastric nerves; deep cremasteric fascia for the inguinal segment of the genital branch), the nerves in the preperitoneal compartment are naked. [7, 8, 10] Mesh placed in the parietal compartment during laparoscopic and open preperitoneal herniorrhaphy may produce chronic neuropathic inguinodynia or orchialgia. [6] Direct nerve injury from dissection or fixation is the more common causative mechanism during laparoscopic repair. [4, 11, 12] Careful lateral dissection of the preperitoneal space and inguinal canal will help to preserve the preperitoneal nerves. Refinements to technique and product development have been made with the goal of minimizing chronic pain, including no fixation, minimization of tacks, fibrin glue fixation, and the use of self-gripping meshes. [4, 12] From a neuroanatomic perspective, these techniques conceptually decrease the risk of nerve injury because only the genitofemoral and lateral femoral cutaneous nerves are at risk if no fixation is used. Tack fixation outside of Cooper’s ligament penetrates the transversalis fascia and transversus abdominous muscle and adds the risk of injury to the ilioinguinal and iliohypogastric nerves. The authors’ analysis of the benefit of fibrin glue reiterates these principles and is consistent with several similar RCTs, metaanalyses, Cochrane reviews, and guidelines documenting the benefit of minimal fixation. [4, 5, 12–15] The recently published 2014 update of the EHS guidelines on inguinal hernia repair thoughtfully reviewed this issue, stating that ‘‘penetrating fixating or traumatic devices like sutures, staples, and tacks cause local trauma that may result in nerve injury and chronic pain.’’ [4] In this update, a new chapter was added with analysis and recommendations on fixation techniques in both open and laparoscopic repairs. A level 1A conclusion was made that traumatic mesh fixation in TEP is unnecessary in most cases. Level 1B evidence cited a possible short-term benefit of a traumatic mesh fixation with no benefit in terms of chronic pain. Grade B recommendations were that traumatic mesh fixation in TEP endoscopic repair should be avoided in most cases and a traumatic mesh fixation can be used without increasing the recurrence rate. [4] The EHS committee thoroughly detailed the challenges in comparing the volume of source data on this topic due to the different factors and variables analyzed in each study. In this analysis, the authors have controlled for many of these limitations by including only five studies with similar quality, design, and studied outcomes. [1] While the numbers in the included five RCTs are limited (247 patients in each arm), the findings are valuable in reinforcing the benefits of limited fixation and methods to minimize nerve injury. Over the past 30 years, thousands of patients evaluated for inguinodynia at the Lichtenstein Amid Hernia Clinic
123
have presented after all methods and variations of hernia repair- anterior/posterior, tissue/prosthetic, open/laparoscopic. While well performed studies typically demonstrate lower rates of chronic pain, the true incidence of pain in general clinical practice remains disturbingly high. While there are clear technical considerations with each operation that can predispose patients to favorable or unfavorable outcomes, there is no definite superiority of one technique over another in the incidence and prevention of pain. [4] For the individual patient who develops chronic pain, the choice of any specific technique was the wrong one. Continued studies and reviews such as this analysis help to emphasize that all surgeons must make a concerted effort to continually refine their chosen preferred techniques. Thorough understanding of each technique and the specific risks associated with a specific operation is crucial. The commonality is that in-depth understanding of neuroanatomy and well designed technical refinements and products will help improve patient outcomes, as prevention is far more effective than treatment of chronic pain [5].
References 1. Shah NS, Fullwood C, Siriwardena AK, Sheen AJ (2014) Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing fibrin glue to tack fixation. World J Surg. doi:10.1007/ s00268-014-2547-6 2. Magee RK (1942) Genitofemoral causalgia: (a new syndrome). Can Med Assoc J 46(4):326–329 3. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1988) 0) Cause and prevention of postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg 155(6):786–790 4. Miserez M, Peeters E, Aufenacker T et al (2014) Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 18:151–163 5. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto GB (2011) International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 15(3):239–249 6. Amid PK, Hiatt JR (2007) New understanding of the causes and surgical treatment of postherniorrhaphy inguinodynia and orchalgia. J Am Coll Surg 205(2):381–385 7. Chen DC, Hiatt JR, Amid PK (2013) Operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach. JAMA Surg 48(10):962–967 8. Amid PK, Hiatt JR (2008) Surgical anatomy of the preperitoneal space. J Am Coll Surg 207(2):295 9. Read RC (1992) Cooper’s posterior lamina of the transversalis fascia. Surg Gynecol Obstet 174:426–434 10. Mirilas P, Mentessidou A, Skandalakis JE (2008) Secondary internal inguinal ring and associated surgical planes: Surgical anatomy, embryology, applications. J Am Coll Surg 206(3):561–570 11. Simons MP, Aufenacker T, Bay-Nielsen M et al (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13(4):343–403 12. Bittner R, Arregui ME, Bisgaard T et al (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal
World J Surg hernia [International Endohernia Society (IEHS)]. Surg Endosc 25(9):2773–2843 13. McCormack K, Scott NW, Go PM, Ross S, Grant AM, EU Hernia Trialists Collaboration (2003) Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev (1):CD001785 14. Kaul A, Hutfless S, Le H, Hamed SA et al (2012) Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of
inguinal hernia: a systematic review and meta-analysis. Surg Endosc 26(5):1269–1278 15. Campanelli G, Pascual MH, Hoeferlin A et al (2012) Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair. Ann Surg 255(4):650–657
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INVITED COMMENTARY
Prevention of Inguinodynia: The Need for Continuous Refinement and Quality Improvement in Inguinal Hernia Repair David C. Chen • Parviz K. Amid
Ó Socie´te´ Internationale de Chirurgie 2014
Dear Editors, It was with great interest that we read the manuscript Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing fibrin glue to tack fixation [1]. While there have been several studies, randomized controlled trials (RCTs), reviews, and meta-analyses comparing these fixation methods, the authors have provided a methodologically sound analysis of the available studies to date, commendably choosing to focus on the outcome of chronic pain. The success of modern herniorrhaphy techniques and the use of prosthetic materials have dramatically reduced recurrence rates, and chronic pain exceeds recurrence as the more frequent complication. Quality of life and avoidance of chronic pain have become important metrics of successful surgery. Inguinodynia has been a recognized complication with all techniques of hernia repair and long preceded meshbased techniques. [2, 3] While there is a statistical advantage of laparoscopic repair with regards to acute pain, direct comparisons between open and laparoscopic repair regarding chronic pain are difficult because the definitions and technique vary amongst studies. The wide variation is apparent, even within this meta-analysis of laparoscopic repairs where the five included trials report rates of chronic pain ranging from 0 to 24 % [1]. The recently published 2014 update to the European Hernia Society (EHS) guidelines reaffirms that there is no difference in the incidence of significant chronic pain between open and laparoscopic repair. [4] Remedial surgery for neuropathic
D. C. Chen P. K. Amid (&) Department of Surgery, Lichtenstein Amid Hernia Clinic at UCLA, UCLA David Geffen School of Medicine, Santa Monica, CA, USA e-mail: [email protected]
inguinodynia after preperitoneal repair is more challenging than with anterior repair and requires proximal access to these nerves via retroperitoneal neurectomy. [5–7] Proper technique and respect for neuroanatomy with each chosen method of repair is critical to improving outcomes and preventing inguinodynia. The important developments by Nyhus, Read, Stoppa, Wantz, Rives, Shumpelick, and others have helped to define and utilize the preperitoneal anatomy for effective hernia repairs. Laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches have made this compartmental anatomy ubiquitous for most hernia surgeons. However, in-depth understanding of the neuroanatomy of this compartment is needed to prevent neuralgia, orchialgia, dysejaculation, recurrence, and meshoma. [8] Causes of chronic pain can be nociceptive or neuropathic in origin and there is often overlap between the two, making diagnosis and treatment challenging. The most common causative mechanisms with laparoscopic inguinal hernia repair include neuropathy from direct contact with mesh, meshoma pain from folding of the mesh, and direct nerve injury (dissection, thermal injury, fixation). [5, 6] Read [9] and Mirilas et al. [10] have helped to delineate the surgical anatomy of the preperitoneal space, confirming the presence of two compartments behind the transversalis fascia separated by a membranous layer. [8–10] The visceral compartment medially contains the bladder, ureter, and prostate and laterally contains the vas deferens ensheathed by this membranous layer. The parietal compartment contains the genitofemoral trunk and its genital and femoral branches and the lateral femoral cutaneous nerve within the classically described ‘trapezoid of pain’. The ilioinguinal and iliohypogastric nerves travel in the retroperitoneum and exit cephalad and lateral to most preperitoneal repairs. [7, 10] Unlike the nerves in the
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inguinal canal that are protected by an investing fascia (investing fascia of the internal oblique for the ilioinguinal and iliohypogastric nerves; deep cremasteric fascia for the inguinal segment of the genital branch), the nerves in the preperitoneal compartment are naked. [7, 8, 10] Mesh placed in the parietal compartment during laparoscopic and open preperitoneal herniorrhaphy may produce chronic neuropathic inguinodynia or orchialgia. [6] Direct nerve injury from dissection or fixation is the more common causative mechanism during laparoscopic repair. [4, 11, 12] Careful lateral dissection of the preperitoneal space and inguinal canal will help to preserve the preperitoneal nerves. Refinements to technique and product development have been made with the goal of minimizing chronic pain, including no fixation, minimization of tacks, fibrin glue fixation, and the use of self-gripping meshes. [4, 12] From a neuroanatomic perspective, these techniques conceptually decrease the risk of nerve injury because only the genitofemoral and lateral femoral cutaneous nerves are at risk if no fixation is used. Tack fixation outside of Cooper’s ligament penetrates the transversalis fascia and transversus abdominous muscle and adds the risk of injury to the ilioinguinal and iliohypogastric nerves. The authors’ analysis of the benefit of fibrin glue reiterates these principles and is consistent with several similar RCTs, metaanalyses, Cochrane reviews, and guidelines documenting the benefit of minimal fixation. [4, 5, 12–15] The recently published 2014 update of the EHS guidelines on inguinal hernia repair thoughtfully reviewed this issue, stating that ‘‘penetrating fixating or traumatic devices like sutures, staples, and tacks cause local trauma that may result in nerve injury and chronic pain.’’ [4] In this update, a new chapter was added with analysis and recommendations on fixation techniques in both open and laparoscopic repairs. A level 1A conclusion was made that traumatic mesh fixation in TEP is unnecessary in most cases. Level 1B evidence cited a possible short-term benefit of a traumatic mesh fixation with no benefit in terms of chronic pain. Grade B recommendations were that traumatic mesh fixation in TEP endoscopic repair should be avoided in most cases and a traumatic mesh fixation can be used without increasing the recurrence rate. [4] The EHS committee thoroughly detailed the challenges in comparing the volume of source data on this topic due to the different factors and variables analyzed in each study. In this analysis, the authors have controlled for many of these limitations by including only five studies with similar quality, design, and studied outcomes. [1] While the numbers in the included five RCTs are limited (247 patients in each arm), the findings are valuable in reinforcing the benefits of limited fixation and methods to minimize nerve injury. Over the past 30 years, thousands of patients evaluated for inguinodynia at the Lichtenstein Amid Hernia Clinic
123
have presented after all methods and variations of hernia repair- anterior/posterior, tissue/prosthetic, open/laparoscopic. While well performed studies typically demonstrate lower rates of chronic pain, the true incidence of pain in general clinical practice remains disturbingly high. While there are clear technical considerations with each operation that can predispose patients to favorable or unfavorable outcomes, there is no definite superiority of one technique over another in the incidence and prevention of pain. [4] For the individual patient who develops chronic pain, the choice of any specific technique was the wrong one. Continued studies and reviews such as this analysis help to emphasize that all surgeons must make a concerted effort to continually refine their chosen preferred techniques. Thorough understanding of each technique and the specific risks associated with a specific operation is crucial. The commonality is that in-depth understanding of neuroanatomy and well designed technical refinements and products will help improve patient outcomes, as prevention is far more effective than treatment of chronic pain [5].
References 1. Shah NS, Fullwood C, Siriwardena AK, Sheen AJ (2014) Mesh fixation at laparoscopic inguinal hernia repair: a meta-analysis comparing fibrin glue to tack fixation. World J Surg. doi:10.1007/ s00268-014-2547-6 2. Magee RK (1942) Genitofemoral causalgia: (a new syndrome). Can Med Assoc J 46(4):326–329 3. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1988) 0) Cause and prevention of postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg 155(6):786–790 4. Miserez M, Peeters E, Aufenacker T et al (2014) Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 18:151–163 5. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto GB (2011) International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 15(3):239–249 6. Amid PK, Hiatt JR (2007) New understanding of the causes and surgical treatment of postherniorrhaphy inguinodynia and orchalgia. J Am Coll Surg 205(2):381–385 7. Chen DC, Hiatt JR, Amid PK (2013) Operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach. JAMA Surg 48(10):962–967 8. Amid PK, Hiatt JR (2008) Surgical anatomy of the preperitoneal space. J Am Coll Surg 207(2):295 9. Read RC (1992) Cooper’s posterior lamina of the transversalis fascia. Surg Gynecol Obstet 174:426–434 10. Mirilas P, Mentessidou A, Skandalakis JE (2008) Secondary internal inguinal ring and associated surgical planes: Surgical anatomy, embryology, applications. J Am Coll Surg 206(3):561–570 11. Simons MP, Aufenacker T, Bay-Nielsen M et al (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13(4):343–403 12. Bittner R, Arregui ME, Bisgaard T et al (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal
World J Surg hernia [International Endohernia Society (IEHS)]. Surg Endosc 25(9):2773–2843 13. McCormack K, Scott NW, Go PM, Ross S, Grant AM, EU Hernia Trialists Collaboration (2003) Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev (1):CD001785 14. Kaul A, Hutfless S, Le H, Hamed SA et al (2012) Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of
inguinal hernia: a systematic review and meta-analysis. Surg Endosc 26(5):1269–1278 15. Campanelli G, Pascual MH, Hoeferlin A et al (2012) Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair. Ann Surg 255(4):650–657
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