The American Journal of Surgery (2016) 211, 637-643

Midwest Surgical Association

Reoperation for groin pain after inguinal

herniorrhaphy: does it really work?
Philip Sun, M.Sc., T. Kumar Pandian, M.D., M.P.H.,
Jad M. Abdelsattar, M.B.B.S., David R. Farley, M.D.*

Department of Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905,
USA

KEYWORDS: Abstract
Chronic groin pain; BACKGROUND: Chronic groin pain after inguinal hernia repair (IHR) is a vexing problem. Reopera-
Inguinal hernia; tion for groin pain (R4GP) has varied outcomes.
Inguinal neuralgia; METHODS: A retrospective review and telephone survey of adults who presented with groin pain
Neurectomy after IHR from 1995 to 2014.
RESULTS: Forty-four patients underwent R4GP; 23% had greater than 1 R4GP. Twenty-three (52%)
had hernia recurrence at the time of R4GP. Twenty (45%) underwent nerve resection, and 13 (30%) had
mesh removed. Twenty-eight patients completed a telephone survey. Of these, 26 (93%) respondents
indicated they experienced pain after their last R4GP for a median duration of 12.5 months. At study
completion, 5 patients continued to have debilitating chronic groin pain, 5 had moderate pain, 6 had
minimal discomfort, and 12 were pain-free. Twenty-four respondents (86%) would proceed with
reoperation(s) again if they could go back in time.
CONCLUSIONS: Although most patients do not experience immediate relief with R4GP, the majority
receive some benefit in long-term follow-up.
2016 Elsevier Inc. All rights reserved.

Chronic groin pain (CGP) after inguinal hernia repair
(IHR) can be a debilitating problem that may drastically
affect quality of life. Published literature suggests rates of
groin pain after IHR range from .9% to 30%.13 Some data
suggest that laparoscopic totally extraperitoneal or transab-
dominal preperitoneal (TAPP) repair of inguinal hernias
There were no relevant financial relationships or any sources of support
in the form of grants, equipment, or drugs.
The authors declare no conflicts of interest.
Presented at the meeting of the Midwest Surgical Association, July 26
29, 2015, Lake Geneva, WI.
* Corresponding author. Tel.: 11-507-284-2095; fax: 11-507-284-
5196.
E-mail address: farley.david@mayo.edu
Manuscript received July 13, 2015; revised manuscript November 25,
2015
result in a higher rate of CGP than open repair.1,3 Others
have found open repair to be associated with an increased
risk for postoperative pain and functional impairment.2
Such variability may be attributable to differing patient de-
mographics, varied methods of screening for pain, and
length of follow-up.
Similarly, conflicting data exist on the success of
reoperations for postherniorrhaphy CGP (reoperation for
groin pain [R4GP]) and the optimal timing for such an
intervention. A prospective study of 12 patients with
chronic neuralgia after a prior open IHR showed that a
reoperation consisting of combined laparoscopic and open
procedures (standard 3-trocar TAPP, groin exploration,
mesh removal, and nerve transection) resulted in at least
partial relief of groin pain in all patients without periop-
erative complications.4 Two case series have reported

0002-9610/$ - see front matter 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2015.11.013
638
moderate to complete pain reduction in 76% of patients af-
ter reoperation with selective neurectomy5 and in 88% of
patients treated with triple neurectomy.6 In a study with
longer follow-up, although two-thirds of patients showed
complete or partial relief of groin pain after ilioinguinal
neurectomy, 72% of patients had return of the original
pain, on average, within 35 months (range 3 to 108 months)
from surgery.7
Because of this conflicting outcome data, we aimed to
characterize our experience with patients undergoing
reoperation for CGP. Specifically, we assessed patient and
operative characteristics, as well as the long-term post-
operative outcome in these individuals.
Methods
With institutional review board approval, we retrospec-
tively identified adults (age R18 years) evaluated at our
institution (1995 to 2014) who experienced inguinal and/or
groin pain after IHR and subsequently underwent R4GP.
We initially searched for all adults with documented
inguinal and/or groin pain, by querying our electronic
medical record (EMR) for the terms groin pain and
inguinal pain in clinical and operative notes during the
20-year study period. The search was conducted by using
an electronic search program (data discovery and query
builder). Within this cohort, we excluded all patients who
had no history of IHR. Of the remaining patients, we
identified those who suffered from CGP, which for the
purpose of this study, was defined as pain persisting 1 month
or longer. Of these patients, those who underwent reopera-
tion with the indication of groin and/or inguinal pain were
included. A chart review was performed to extract patient
demographics (ie, age, sex, race, and comorbidities),
operative characteristics (laterality, hernia type, surgery
type, operative time, anesthesia type, resected nerves, etc),
postoperative complications, and pain outcome. In addition,
a telephone survey was conducted to supplement informa-
tion on the postoperative outcome of R4GP. During this
survey, patients were asked regarding perception of pain
intensity before and after reoperation, improvement in their
pain while performing various activities (lying and/or
bending down, getting out of bed etc), pain intensity at
the time of survey, and willingness to have the reoperation
again if he and/or she had a choice. Descriptive statistical
analysis was performed using JMP version 10.0.0 (SAS
Institute Inc., 2012, Cary, NC).
Results
Overall results
Over a 20-year period (1995 to 2014), a total of 1,331
adults with groin pain were identified. From this group, 550
patients had documented CGP after IHR; we reoperated on
44 such patients (8%) in attempts to alleviate CGP.
The American Journal of Surgery, Vol 211, No 3, March 2016
Of the remaining 506 patients, 35.5% were observed
without any medication, 40.5% received nonsteroidal
anti-inflammatory drugs (NSAIDs), 2% narcotic pain
medication, 4.2% trigger point injection, 1% gabapentin,
.2% tricyclic antidepressants such as amitriptyline, 8.5%
any combination of the aforementioned treatments, and
8.1% had unclear or undocumented treatments. Patients
with low or minimal levels of pain were typically
observed with or without NSAIDs. Fifty-three (10.5%)
patients in this nonoperative group who visited a pain
clinic were refractory to NSAID or other medications, and
the majority (85%, 45 of 53) of these were noted to
undergo trigger point injection in our EMR.
Initial hernia operation
Of the 44 patients who underwent reoperation, 36 were
men and 8 women. Median age was 48 years (range, 18
to 80) at the time of their initial hernia operation (see
Table 1 for patient characteristics). Twenty-three (52%)
had their IHR performed at Mayo Clinic. Information on
the first operation (open mesh 5 19, laparoscopic 5 8,
and open tissue 5 8) was incomplete in 9 patients. Overall
for this first operation, we noted 1 patient undergoing open
mesh repair (of 19) had ilioinguinal neurectomy. A total
of 8 complications were identified in the study group:
4 wound infections, 1 hematoma, 1 seroma, 1 case of uri-
nary retention, and 1 patient with fat necrosis near the
incision.
Reoperation(s) for groin pain
The median age at the time of the first reoperation for
pain was 49 years (range 23 to 82). In total, 57 reoperations
were performed in the 44 patients. Ten (23%) underwent
more than one R4GP. Seventeen of 42 (40%) patients
(2 patients with unknown date of initial IHR) had their first
reoperation performed within 1 year of the most recent
IHR. Although not explicitly stated for every patient,
common indications for operation before 1 year found in
the medical record were pain of moderate to high intensity
refractory to conservative treatment and pain significantly
affecting quality of life. General anesthesia was adminis-
tered in 49 of 54 (88%) reoperations (3 unknown).
Fifty-two of 53 (98%) cases were performed in an elective
manner (4 unknown). The operative time was available in
56 of 57 cases; the mean duration was 105 6 48 minutes.
Nerve resection was performed in 20 (45%) of the 44
patients. Among the 57 total reoperations in these 20
patients, neurectomy (n 5 22, 39%) of the ilioinguinal
nerve (n 5 19), genitofemoral nerve (n 5 6), iliohypogas-
tric nerve (n 5 11), and lateral cutaneous nerve of the thigh
(n 5 1), was carried out. Minor complications included
1 wound infection, 1 hematoma, 1 seroma, and 2 cases of
urinary retention.
P. Sun et al. Reoperation for groin pain 639

Table 1 Patient and reoperation characteristics Table 1 (continued )

Characteristic N % Characteristic N %
Total 44 Mesh excision (by case)
Patient characteristics Yes 13 23
Sex No 44 77
Male 36 82 Transected/resected nerve (by patient)
Female 8 18 Yes 20 45
Race No 24 55
White 39 89 Nerve transected/resected (by patient)
Unknown 5 11 Ilioinguinal nerve 19 43
Comorbidity Genitofemoral nerve 6 14
Pain syndrome (ie fibromyalgia) 0 0 Iliohypogastric nerve 11 25
Diabetes 3 7 Lateral cutaneous nerve of thigh 1 2
Hypertension 10 23 Anesthesia (by case)
Coronary artery disease 4 9 General 49 86
Chronic kidney disease 0 0 MAC/attended local 3 5
Chronic steroid use 1 2 Local only 2 3
COPD 4 9 Spinal 2 3
Chronic narcotic use 1 2 Unknown 2 3
R4GP COPD 5 chronic obstructive pulmonary disease; MAC 5 monitored
Number of R4GP cases 57 anesthesia care; R4GP 5 reoperation for postherniorrhaphy CGP; TAPP
Number of R4GPs (by patient) 5 transabdominal preperitoneal; TEP 5 totally extraperitoneal.
1 34 77
2 8 18
3 1 2 Twenty-three (52%) patients had an inguinal her-
4 1 2 nia recurrence (7 direct, 13 indirect, and 3 pantaloon)
R4GP side (initial reoperation) documented and repaired at the time of their reoperation.
Left 17 39
The hernia repairs consisted of 11 open mesh, 9 la-
Right 25 57
Bilateral 2 4
paroscopic (totally extraperitoneal 5 3, TAPP 5 6), and
R4GP side (all cases) 3 open tissue repairs. From this group of 23 patients with
Left 21 37 CGP found to have recurrent hernia at the time
Right 31 54 of reexploration, nerve transection and/or resection was
Bilateral 5 9 performed in 4 patients, all of whom underwent ilioinguinal
Elective vs emergent (by case) neurectomy. Mesh removal occurred in 4 (17%). Post-
Elective 52 91 operative complications included 1 wound infection, 1 se-
Emergency 1 2 roma, and 1 case of urinary retention.
Unknown 4 7 In the 21 patients without recurrent IHR at the time of
First R4GP within 1 year of most recent hernia repair reoperation, nerve transection and/or resection was per-
Yes 16 36
formed in 16 cases: ilioinguinal nerve 5 15, iliohypogastric
No 26 59
Unknown 2 5
nerve 5 11, genitofemoral nerve 5 6. Unfortunately, we
Hernia recurrence at R4GP were unable to determine the specific rationale by the
Yes 23 52 surgeon to forego neurectomy in 5 of these 21 patients. In
No 21 48 addition, we were not able to elucidate why selective
Type of recurrence at R4GP neurectomy was performed instead of triple neurectomy.
Direct 7 30 Mesh removal occurred in 7 (33%) of these patients.
Indirect 13 57 Postoperative complications included 1 hematoma and
Pantaloon 3 13 1 case of urinary retention.
Treatment for recurrent hernia at R4GP Overall, mesh was removed in 13 of 44 (30%) patients.
Open mesh 11 48 The major indication for removing mesh was not
TEP 3 13
elucidated clearly in the operative or clinical reports. We
TAPP 6 26
Open tissue 3 13
suspect this was based on the surgeons discretion intra-
Mesh excision (by patient) operatively, and likely was based on whether the mesh
Yes 13 30 appeared to cause any irritation and/or inflammation,
No 31 70 necrosis, adhesions to surrounding tissue, or nerve entrap-
ment. In these 13 patients, mesh was not replaced in
(continued)
any case. Two of these patients underwent exploration
640 The American Journal of Surgery, Vol 211, No 3, March 2016

laparoscopically with mesh excision and tack removal.

Table 2 Postoperative complications and pain after R4GP
The type of mesh was mentioned in the operative reports
of 7 of the 13 patients with mesh removal. This included 2 Operation
patients with explicitly stated polypropylene mesh, 4 with R4GP R4GP
plug and patch mesh (not further specified), and 1 patient with hernia without hernia
with GoreTex mesh. Initial IHR recurrence recurrence
In the 10 patients who underwent multiple reoperations for Complication n 5 44 n 5 23 n 5 21
groin pain, we subsequently found 2 patients with hernia Infection 4 1 0
recurrence and interventions included resection of the following Hematoma 1 0 1
nerves: ilioinguinal 5 7, iliohypogastric 5 5, genitofemoral Seroma 1 1 0
nerve 5 5. Postoperative complications included: 1 hematoma Urinary retention 1 1 1
and 1 case of urinary retention. Table 1 summarizes R4GP; Fat necrosis 1 0 0
Table 2 summarizes complications. Total 8 3 2
Pain N %
Clear documentation on 20
Assessment of pain after R4GP follow-up surgical visits in EMR
Duration of at least some pain after 1st R4GP?
In the overall cohort of 44 patients, we had follow-up ,1 wk 0 0
documentation (physician visits or extensive survey re- 1 wk,3 mo 2 10
sponses) for 36 patients with a median follow-up of 3,6 mo 3 15
6.5 years (interquartile range [IQR] 24.7 months to 9 years). 6 mo,1 y 1 5
Twenty had clear documentation of surgical visits in our R1 y 9 45
EMR with a median follow-up of 15 months (IQR 4 months No pain reported 5 25
Telephone survey 28*
to 5 years). Fifteen patients (75%) reported at least some
At least some benefit after reoperation(s) while
persistent pain after their first R4GP, with 13 (87%) having
Lying down 15/19 79
pain lasting at least 3 months. Sitting up 15/20 75
Twenty-eight of 33 eligible patients completed the Getting of bed, bathing, walking 19/23 83
telephone survey (4 refused to respond and 1 could not be up stairs, getting dressed
reached). The median follow-up was 7 years (IQR Coughing/deep breathing 18/22 82
3.5 years to 8.5 years). Pain intensity before R4GP was Jogging/running/exercising 17/23 74
7.0 6 2.4 of 10, and the pain score immediately after Having sex 8/15 53
reoperation(s) (including surgical pain) was 4.9 6 3.5 of How would you classify the end result of surgery?
10. Twenty-six (93%) reported having pain after their last Pain-free 12 43
R4GP for a median duration of 12.5 months (IQR 1 month Almost pain-free 6 21
Some pain reduction 5 18
to 5 years). Seventeen (65%) patients had pain lasting
No effect on the pain 4 14
at least 3 months post-R4GP. In longer follow-up, most
Worsened the pain 1 4
patients experienced at least some benefit from the Would you have the reoperation again if you had a choice?
R4GP(s): 79% had improvement in symptoms when lying Yes 24 86
down; 75% when sitting up; 83% while getting of bed or No 4 14
bathing or walking up stairs, or getting dressed, 82%
EMR 5 electronic medical record; IHR 5 inguinal hernia repair;
when coughing or deep breathing, 74% while R4GP 5 reoperation for postherniorrhaphy CGP.
jogging, running or exercising; and 53% during sexual *Of the 44 patients eligible for the study, 4 patients died according
activities. Eighteen (64%) respondents stated they were to the EMR and 7 had phone numbers that were disconnected at the
either completely (n 5 12) or almost pain-free (n 5 6) at time of survey collection. Of the 33 eligible patients, 28 patients
completed the survey (4 patients explicitly refused to participate in
the time of the survey. Comparison of pain improvement
the survey and 1 patient could not be reached).
with these activities between patients undergoing re-
operation within 1 year of CGP onset vs patients
greater than 1 year after CGP onset revealed greater 1st IHR operation) and subsequent operative interventions
improvement in the latter group. Twenty-four (86%) for CGP (mesh removal and/or neurectomy) did not predict
respondents stated they would proceed with reoperation(s) success or failure in the group overall. Table 2 summarizes
again if they could go back in time. post-R4GP pain.
Two of 15 general surgeons performed the R4GP in 27
patients, whereas 10 other surgeons performed the remain-
ing 17 reexplorations; long-term pain relief and symptom Comments
improvement was better for patients being explored by the
2 higher volume general surgeons (P , .05). Preoperative CGP after IHR remains a difficult and vexing problem.
factors (age, gender, body mass index, and technique of This study, with numerous limitations evident, highlights
P. Sun et al. Reoperation for groin pain
several key concepts for surgeons treating patients with
post-IHR CGP: (1) CGP occurs after all types of IHR in all
types of patients, (2) an underlying inguinal hernia
recurrence is common in patients explored for CGP, (3) a
knee-jerk response for operative reintervention in
patients with CGP should be avoided, and (4) most
patients with CGP eventually garner pain relief in long-
term follow-up.
CGP after IHR may occur with open or laparoscopic
techniques, with or without mesh placement, in men or
women, and in obese, normal, or thin patients.13 Even our
small study had patients developing CGP after IHR within
each subgroup. Regardless of whether a patient is obese or
thin, man or woman, or repaired via x, y, or z technique,
no one seems immune to potential postoperative groin
pain.111 Given that surgeons cannot change patients size,
gender, or type of hernia, we are left to focus on: (1) operative
technique and (2) patient selection as variables that might
help alleviate this problem. Operative techniques that repair
hernias likely should remain tension-free with placement of
mesh, suture, glue, and/or tacks away from sensory nerves
in addition to avoiding trauma or constriction of the sper-
matic cord.3,8 Patients have been found to have sutures or
tacks impaling sensory nerves, mesh wadded into palpable
balls (meshoma), or mesh and tissue repairs visibly con-
stricting the spermatic cord.8 The vast majority of patients
in this study and others,10,11 however, reveal that those who
have CGP after IHR have no obvious signs of errors or struc-
tural abnormalities. The truth seems that we remain naive to
the causes of post-IHR CGP.
Careful patient selection may be more critical than
operative technique in lowering rates of post-IHR CGP.10,11
Although our selected group of patients showed no obvious
predictors for who developed CGP after IHR, another
study2 has shown a greater propensity for postoperative
CGP in young men. Often, such patients have asymptom-
atic hernias or unusual preoperative pain complaints.
Greater scrutiny of patients preoperatively, especially
young males and anyone with unusual groin discomfort
or asymptomatic inguinal hernias, may allow us to provide
education preemptively, which better informs our patients
of potential postoperative discomfort. Surgeons are good
at fixing hernias, but relief from groin pain is only likely
if the discomfort is directly related to the hernia.5
Anecdotally, we believe that documenting the types of
pain and unusual complaints preoperatively and setting
patient expectations for postoperative discomfort may
render less postoperative disappointment than any change
in surgical technique.
Although our 44 patients with CGP for greater than
1-month duration were selected for reexploration to
alleviate persistent pain, over half had evidence of an
unsuspected recurrent hernia at the time of the operation.
Others have found unsuspecting recurrent inguinal or
femoral hernias as a source of CGP.5 Unfortunately, repair-
ing recurrences in some patients may make no difference or
potentially worsen the problem with more mesh, suture,
641
and trauma. Subgroup analysis of our 23 patients undergo-
ing IHR with neurectomy (n 5 4), mesh removal (n 5 4),
or simply having just the recurrent hernia fixed showed no
greater relief of CGP than in 21 patients without evidence
of recurrence. Although inguinal hernia recurrence may
be a leading cause of intermittent postoperative CGP,
hernias rarely generate 24/7 pain.5
Our study offered a variety of techniques attempting to
correct CGP after IHR in 44 varied patients treated by 12
different general and urologic surgeons. Disappointingly,
analysis of our results does not offer an obvious algorithm
in caring for patients with CGP after IHR. Although 18 of
33 carefully followed study patients are pain-free or nearly
pain-free, their treatment was similar to 15 other patients
who continue to harbor groin discomfort; some without any
improvement over time. Others suggest that triple neurec-
tomy, mesh removal, and careful intraoperative and post-
operative analgesia lead to high rates of success.4,6
Invariably, follow-up with many of these studies, as with
ours, is incomplete, and patients often move on to another
surgical team for evaluation and intervention.10 Surgeons
have a tendency to intervene sooner rather than later
when patients are in pain; most literature suggests that re-
exploration for CGP after IHR should be held off until at
least 12 months have passed and no evidence of improve-
ment exists.2,8,9 Our collective group waited at least 1
year in only 60% of study patients. Indeed, most hernia sur-
geons are good at holding off reexploration of their own
patients but offer a lower threshold for referred CGP pa-
tients. Indeed, numerous patients end up having 1, 2, 3,
or more reoperations in less than 12 months from their
initial IHR. Our own algorithm would suggest avoiding re-
operation if possible until 1 year passes. Of the 550 patients
we evaluated with post-IHR CGP, 506 did not undergo re-
exploration, and anecdotally, we suspect that most of these
were considerably better in less than 12 months. We under-
stand that there are numerous factors that determine surgi-
cal candidacy, including a patients overall medical
condition, pain intensity at the time of consultation, and
other quality of life concerns. Our chart review indicates
that there was no fixed algorithm to determine which pa-
tients to take to the operating room. In general, we observed
that patients with low or minimal levels of pain were typi-
cally observed with NSAIDs, whereas those suffering from
intense pain that severely compromised their quality of life
and was refractory to conservative options (eg, NSAID,
trigger point injection), were more likely to undergo oper-
ative management. In addition, although not clear from the
medical records, it may be because these patients had no
signs to suggest recurrence.
Encouragingly, in follow-up of 28 patients in this study,
most were markedly better off at a median of 7 years after
our intervention; 12 were pain-free. One could argue that
these outcomes may have been achieved by simply
following patients for 7 years and withholding R4GP. The
human body and brain may alter the perception of pain over
time along with softening of scar tissue, atrophy of nerves,
642
or any combination of better blood flow and collateral
nerve distribution.12 When it comes to CGP, like back pain,
headaches, sciatica, and other human conditions, time may
be a key factor in patient perception of pain and discomfort.
Specific factors have been suggested that are predictive of
R4GP after IHR. These include younger age, surgery for
recurrence, and preoperative pain.2 Similar factors may also
predict failure of R4GP. Although our study is underpowered
to capture statistical significance, looking at the 4 survey re-
spondents who regret having undergone R4GP indicate the
median age at the time of IHR was 43 years (overall
median 5 49), 4 of 4 were male, 3 of 4 underwent multiple
R4GP, all underwent neurectomy, and none had postopera-
tive complications. Anecdotally, our 2 senior surgeons with
the most experience with R4GP tend to opt for triple neurec-
tomy and mesh removal in younger men with CGP after IHR;
believing such patients are the most difficult to treat.
This study has numerous and important limitations.
Forty-four selected patients from 550 having undergone
previous IHR, generates bias. Retrospective analysis is
fraught with limitations, and follow-up on 8 patients could
not be completed by EMR or survey. Fewer than half of our
cohort had clear documentations from postsurgical visits,
and only 64% were reached with a telephone survey.
Scientific classification and objective analysis of groin
pain is suboptimal, nerve distributions are varied, and
mesh placement and suture, tacking, or glue techniques
are numerous. In addition, patient follow-up (survey or
physical examination) and interpretation of pain varies, and
much of it is based on memory from nearly 7 years prior.
Our philosophy in treating groin pain has historically
involved: attempting to wait 12 months for post-IHR CGP
patients, confirming physical findings of localized and
consistent and/or repeatable groin pain, and offering mesh
removal and/or neurectomy as indicated by operative
findings. If no abnormalities are identified, then the
treatment is guided by preoperative discussions with the
patient and often utilizes neurectomy. Moving forward, we
plan to prospectively follow IHR patients in attempts to
identify who experiences CGP after IHR and why. Treating
such patients effectively remains to be elucidated with a
heavy emphasis on better patient selection for IHR initially,
more accurate documentation and follow-up in the medical
record, and if CGP does develop postoperatively, reliance
on a heavy tincture of time.
References
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Discussion
Discussant
Dr. Nicholas J. Zyromski (Indianapolis, IN): I have 2
questions. One is, can you give us a little more insight into
how exactly you searched your EMR for inguinal pain.
That would be a challenge using our own medical record
in Indiana. Did you also use some modalities? For example,
is there a Current Procedural Terminology code, for reoper-
ation in the groin? My 2nd question is whether you can give
us some insight in how you selected these 44 patients of
550 patients with groin pain? What were the indications
to operate on these patients? And as a corollary, what
sort of therapy did you provide for the nonoperative group?
Did you use trigger point injection, nonsteroidal anti-
inflammatory medications, narcotics, and so forth?
Dr. Sun: Regarding patient selection, we did a retro-
spective chart review by searching for patients with
inguinal pain or groin pain. So we used those 2 terms to
get a list of patients. And then, we looked into whether
they had IHR done, and if they had it done, whether the
pain came about after their IHR and whether they persisted
for at least 1 month.
Regarding the selection of 44 patients of 550, as a 3rd-
year medical student, it is difficult for me to base my
answers on extensive experience. But some conversations I
had with Dr. Farley, my mentor, who conducted nearly half
of reoperations on this cohort, tells me that the 2 things that
we look into most closely are, firstly, the pain intensity and
the nature of the pain. So regarding pain intensity, if the
patients continue to suffer from unbearable high-intensity
pain that is not responsive to conservative management
such as NSAID, narcotics, or nerve block, then he would be
P. Sun et al. Reoperation for groin pain
more inclined to conduct a reoperation as opposed to
continuing conservative management.
And regarding the nature of pain, from this cohort of
patients there is a high proportion of patients with hernia
recurrence, although there is not a clear line between hernia
recurrence associated pain or CGP after IHR that is not
related to hernia. We could see that if the patients usually
have sharp pain, that is persistent not related to bulging of
the hernia from activities such as lifting up objects, then
Dr. Farley would believe that those patients are good
candidates for operative treatments appropriate for CGP,
such as neurectomy, or if the patient complains heavily
about mesh causing pain, then he would be more inclined to
remove the mesh and consider using techniques that would
not rely on using mesh such as Basini technique.
643
Dr. Jeffrey A. Claridge (Cleveland, OH): You stated,
I believe, that approximately half of your patients had
hernia recurrence. Did you have a chance to look at and
examine which patients got better because they had a
hernia recurrence repaired and those that got better with
just a nerve transaction?
Dr. Sun: It is difficult for us to first see whether
the hernia is the underlying cause of the pain. And
about the treatments for the hernia, we have not been
able to look into what type of surgical repair resulted
in better outcome of the pain. As a study being primar-
ily descriptive with the low sample size, we are not
able to conduct statistical analysis on this small
subset of patients. So we do not have the answer to that,
sorry.