Reoperation for Chronic Postoperative Inguinal Pain

Abstract

Importance: With a decrease in recurrence since modern hernia repair, chronic postoperative inguinal pain is the most important patient-centered outcome. Surgical intervention is often necessary in cases refractory to conservative measures but remains understudied.

Objective: To evaluate causes of refractory chronic postoperative inguinal pain and review the operative approaches used to treat patients who experience it.

Design, setting, and participants: This case series used electronic medical record data from a single-institution hernia center during the period August 1, 2009, to September 17, 2024. Participants were adult patients who underwent surgery for chronic postoperative inguinal pain; those who underwent surgeries during which the inguinal canal was not entered or involved were excluded. Patients were followed up from their remedial surgery date to their most recent surgeon follow-up visit date.

Exposures: Remedial surgical approach (laparoscopic, robotic, open, combined), use of mesh, nerve management, and mesh excision.

Main outcomes and measures: The primary outcome was subjective pain improvement after remedial surgery; other outcomes were postoperative complications and need for additional operations.

Results: A total of 818 adult patients underwent surgery for chronic postoperative inguinal pain (median [IQR] age, 53 [42-64] years; 193 [23.6%] were female and 625 [76.4%] male). Among them, 779 patients (95.2%) underwent previous inguinal repair with nearly half (49.3%) undergoing 2 or more surgeries. Of remedial surgeries, 221 (27.0%) were open alone, 113 (13.8%) were laparoscopic alone, 57 (7.0%) were robotic alone, 349 (42.7%) were hybrid open and laparoscopic, and 78 (9.5%) were hybrid open and robotic. Seven hundred thirty patients (89.2%) underwent a neurectomy, with triple neurectomies in 401 surgeries (54.9%). Mesh was removed in 559 patients (68.3%). Among patients with at least 5 days of postoperative follow-up, inguinal pain improved in 798 patients (98.5%), with 560 patients (70.2%) reporting more than a 50% reduction in inguinal pain and 226 (28.3%) reporting a 50% or smaller improvement. Twelve patients (1.5%) had no significant improvement in subjective pain. Forty-two patients (5.1%) experienced complications.

Conclusions and relevance: Chronic postoperative inguinal pain is a common, debilitating complication of inguinal hernia repair. Remedial surgery is complex, but tailored surgical approaches that consider neurectomy, mesh excision, and recurrent inguinal hernia repair can be safe and effective in experienced centers.