Skip to main content

Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography

Abstract

Background

Chronic post-operative inguinal pain (CPIP) is the most significant complication following inguinal hernia repair. Patients without a palpable hernia prior to surgery seemed to report more CPIP. Our aim was to evaluate the effects of surgery on patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography.

Methods

A total of 179 hernia repairs in patients with a positive ultrasonography but negative physical examination were analysed retrospectively. Patients with recurrent hernias, femoral hernias or previous surgery to the inguinal canal were excluded. The primary outcome was the presence of chronic postoperative inguinal pain (pain > 3 months postoperatively). Data on preoperative complaints, surgical technique and findings during ultrasonography and surgery were also studied in relation to the development of CPIP.

Results

A quarter (25.1%) of the patients reported chronic postoperative pain. Female gender (p = 0.03), high BMI (p = 0.04) and atypical symptoms prior to surgery (p < 0.001) were significant univariate risk factors for developing CPIP. Logistic regression showed a significant association between atypical symptoms and CPIP [OR = 6.31, p < 0.001, 95% CI (2.32, 17.16)], which was still present after correction for the significant univariate variables [OR = 4.23, p = 0.02, 95% CI (1.26, 14.21)].

Conclusion

Patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography report a high incidence of CPIP after elective hernia repair. Patients with atypical groin pain prior to surgery are especially prone to CPIP. It is questionable whether these hernias should be classified and treated as symptomatic inguinal hernias. The results advocate taking other causes of groin pain into consideration before choosing surgical treatment.

This is a preview of subscription content, access via your institution.

References

  1. Gooszen HG, Blankensteijn JD, Borel Rinkes IHM, Dejong CHC, Gouma DJ, Heineman E et al (2012) Leerboek chirurgie, 2nd edn. Bohn Stafleu van Loghum, Houten

    Book  Google Scholar 

  2. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J et al (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13(4):343–403

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R (2007) Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg 194(3):394–400

    Article  PubMed  Google Scholar 

  4. Koning GG, Keus F, Koeslag L, Cheung CL, Avci M, van Laarhoven CJ et al (2012) Randomized clinical trial of chronic pain after the transinguinal preperitoneal technique compared with Lichtenstein’s method for inguinal hernia repair. Br J Surg 99(10):1365–1373

    Article  PubMed  CAS  Google Scholar 

  5. Grant AM, Scott NW, O’Dwyer PJ, MRC Laparoscopic Groin Hernia Trial Group (2004) Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia. Br J Surg 91(12):1570–1574

    Article  PubMed  CAS  Google Scholar 

  6. van der Pool AE, Harlaar JJ, den Hoed PT, Weidema WF, van Veen RN (2010) Long-term follow-up evaluation of chronic pain after endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia. Surg Endosc 24(7):1707–1711

    Article  PubMed  PubMed Central  Google Scholar 

  7. Koning GG, Adang EM, Stalmeier PF, Keus F, Vriens PW, van Laarhoven CJ (2013) TIPP and Lichtenstein modalities for inguinal hernia repair: a cost minimisation analysis alongside a randomised trial. Eur J Health Econ 14(6):1027–1034

    Article  PubMed  CAS  Google Scholar 

  8. van Rijckevorsel DC, de Vries M, Schreuder LT, Wilder-Smith OH, van Goor H (2015) Risk factors for chronic postsurgical abdominal and pelvic pain. Pain Manag 5(2):107–116

    Article  PubMed  Google Scholar 

  9. Katz J, Jackson M, Kavanagh BP, Sandler AN (1996) Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 12(1):50–55

    Article  PubMed  CAS  Google Scholar 

  10. Nikolajsen L, Ilkjaer S, Kroner K, Christensen JH, Jensen TS (1997) The influence of preamputation pain on postamputation stump and phantom pain. Pain 72(3):393–405

    Article  PubMed  CAS  Google Scholar 

  11. Katz J, Seltzer Z (2009) Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother 9(5):723–744

    Article  PubMed  Google Scholar 

  12. Hanley MA, Jensen MP, Smith DG, Ehde DM, Edwards WT, Robinson LR (2007) Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain 8(2):102–109

    Article  PubMed  Google Scholar 

  13. Kehlet H, Jensen TS, Woolf CJ (2006) Persistent postsurgical pain: risk factors and prevention. Lancet 367(9522):1618–1625

    Article  PubMed  Google Scholar 

  14. Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J et al (2010) Predictive risk factors for persistent postherniotomy pain. Anesthesiology 112(4):957–969

    Article  PubMed  Google Scholar 

  15. Aasvang E, Kehlet H (2005) Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth 95(1):69–76

    Article  PubMed  CAS  Google Scholar 

  16. Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA (2003) A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 19(1):48–54

    Article  PubMed  Google Scholar 

  17. Nienhuijs SW, Boelens OB, Strobbe LJ (2005) Pain after anterior mesh hernia repair. J Am Coll Surg 200(6):885–889

    Article  PubMed  Google Scholar 

  18. Langeveld HR, Klitsie P, Smedinga H, Eker H, Van’t Riet M, Weidema W et al (2015) Prognostic value of age for chronic postoperative inguinal pain. Hernia 19(4):549–555

    Article  PubMed  CAS  Google Scholar 

  19. Pierides GA, Paajanen HE, Vironen JH (2016) Factors predicting chronic pain after open mesh based inguinal hernia repair: a prospective cohort study. Int J Surg 29:165–170

    Article  PubMed  Google Scholar 

  20. van den Heuvel B, Beudeker N, van den Broek J, Bogte A, Dwars BJ (2013) The incidence and natural course of occult inguinal hernias during TAPP repair: repair is beneficial. Surg Endosc 27(11):4142–4146

    Article  PubMed  Google Scholar 

  21. Bochkarev V, Ringley C, Vitamvas M, Oleynikov D (2007) Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects. Surg Endosc 21(5):734–736

    Article  PubMed  CAS  Google Scholar 

  22. van Wessem KJ, Simons MP, Plaisier PW, Lange JF (2003) The etiology of indirect inguinal hernias: congenital and/or acquired? Hernia 7(2):76–79

    Article  PubMed  Google Scholar 

  23. Paajanen H, Ojala S, Virkkunen A (2006) Incidence of occult inguinal and Spigelian hernias during laparoscopy of other reasons. Surgery 140(1):9–12 (discussion 12–3)

    Article  PubMed  Google Scholar 

  24. Campanelli G (2010) Pubic inguinal pain syndrome: the so-called sports hernia. Hernia 14(1):1–4

    Article  PubMed  CAS  Google Scholar 

  25. Farber AJ, Wilckens JH (2007) Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg 15(8):507–514

    Article  PubMed  Google Scholar 

  26. Garvey JF, Hazard H (2014) Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia 18(6):815–823

    Article  PubMed  CAS  Google Scholar 

  27. Sayad P, Abdo Z, Cacchione R, Ferzli G (2000) Incidence of incipient contralateral hernia during laparoscopic hernia repair. Surg Endosc 14(6):543–545

    Article  PubMed  CAS  Google Scholar 

  28. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ et al (2008) What is “quality of evidence” and why is it important to clinicians? BMJ 336(7651):995–998

    Article  PubMed  PubMed Central  Google Scholar 

  29. Classification of chronic pain (1986) Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 3:S1–S226

    Google Scholar 

  30. Robinson A, Light D, Nice C (2013) Meta-analysis of sonography in the diagnosis of inguinal hernias. J Ultrasound Med 32(2):339–346

    Article  PubMed  Google Scholar 

Download references

Funding

No funding or (financial) support.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to L. van Hout.

Ethics declarations

Conflict of interest

LvH declares no conflict of interest. WB declares no conflict of interest. MI declares no conflict of interest. JH declares no conflict of interest. PV declares no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

van Hout, L., Bökkerink, W.J.V., Ibelings, M.S. et al. Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography. Hernia 22, 525–531 (2018). https://doi.org/10.1007/s10029-018-1744-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10029-018-1744-x

Keywords

  • Inguinal hernia
  • Chronic postoperative inguinal pain
  • Ultrasound
  • Clinically inapparent