The Harald Breivik lecture 2022. Pathophysiology in persistent severe pain after groin hernia repair

Abstract

The transition from a healthy to a persistent severe pain state following otherwise successful elective surgery is a feared complication. Groin hernia repair, previously considered minor surgery, is a standard surgical procedure annually performed on 2,000 individuals per one million residents. A trajectory into persistent severe pain is, unfortunately, seen in 2–4%, severely impeding physical and psychosocial daily functions.

Quantitative somatosensory assessments in patients with persistent pain following groin hernia repair: A systematic review with a meta-analytical approach

“…It is important to consider the stimulation area, since differences in probe area size could influence results due to differences in stimulation of superficial and deeper situated nociceptors (skin vs . fascia) [ 1 , 57 ]. If the same force was to be applied with a 0.18 cm 2 probe and a 1 cm 2 probe, the pressure would be reduced by a factor 5.6.…”

“…The surgical procedure and the type of mesh implant could also have an impact on the transition to chronic pain. Minimally invasive repair seems to be linked to a lower incidence of postoperative complications, e.g., hematoma, wound infection, a lower prevalence of persistent pain, and an earlier return to work/daily activities [ 1 ]. Further research is, however, needed to minimize confounding variables obscuring the results [ 1 , 2 ].…”

“…Minimally invasive repair seems to be linked to a lower incidence of postoperative complications, e.g., hematoma, wound infection, a lower prevalence of persistent pain, and an earlier return to work/daily activities [ 1 ]. Further research is, however, needed to minimize confounding variables obscuring the results [ 1 , 2 ]. In addition to groin hernia repair, other surgical procedures such as breast implants, vascular grafts, and joint prosthetic material are also known to be associated with pathophysiologic events related to mesh implants [ 3 ].…”

“…The opening in the abdominal wall is associated with several important anatomical structures, including the vas deferens, vascular supply to the testicles, the ilioinguinal nerve, and the genital branch of the genitofemoral nerve [ 7 ]. When performing blunt pressure algometry, pressure is applied to the superficial ring, compressing these deeper structures, including part of the implanted mesh [ 1 ]. A severely inflamed mesh may develop into a pathological ‘ʻmeshoma” [ 6 ].…”

“…The condition can significantly impair the physical and psychosocial functions of the individual, and a conservative estimate is that 2% of patients undergoing groin hernia repair will be affected by PPSP [ 6 , 7 ]. The prevalence of PPSP is primarily contingent on the respective surgical procedure, whilst patient-related pre-surgical factors also affect the frequency and severity of PPSP [ 1 , 8 , 9 ].…”