Inguinodynia after hernioplasty with video laparoscopic techniques: predictive risk factors

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Introduction

The laparoscopic approach to the treatment of inguinal hernia (IH) was first proposed by R. Ger et al. in 1982 [1]. A decade later, M.E. Arregui et al. (1992) presented preliminary results on the benefits of transabdominal preperitoneal repair (TAPP) in 52 patients [2], while J.L. Dulucq (1992), G.S. Ferzli et al. (1992), J.B. McKernan, H.L. Laws (1993), E.H. Phillips et al. (1993) recommended total extraperitoneal repair (eTEP), which would avoid complications due to disruption of the integrity of the peritoneal cavity [3–6]. Thus, the introduction of these two methods into practice has opened a new chapter in IH surgery.

Minimally invasive techniques IH repair versus open repair, and then the comparison of these two methods with each other, became a hot topic of debate about the advantages of one or another method in abdominal surgery [7]. However, even at present, the choice of videolaparoscopic technique remains an unresolved issue in terms of reducing postoperative inguinal pain (inguinodynia), the overall prevalence of which after IH repair is from 10 to 12 % [8]. In addition, current international recommendations do not provide specific algorithms regarding the preference of the TAPP or TEP method [9; 10]. We believe that both of these methods require additional study of the risk factors that determine the formation of inguinodynia in the postoperative period in patients with IH, in connection with which this study was conducted.

The aim of the study is to determine the predicted risk factors for inguinodynia after hernioplasty using various videolaparoscopic techniques.

Materials and Methods

The prospective study included 460 patients aged 18–85 years who underwent surgical treatment for IH at Davydovsky City Clinical Hospital between January 2019 and May 2022. Depending on the type of hernioplasty performed, the patients were divided into two groups. Group I included 348 patients who underwent videolaparoscopic transabdominal preperitoneal repair (TAPP). Group II included 112 patients who underwent videolaparoscopic total extraperitoneal repair with improved visibility (eTEP). To analyze the factors of development of inguinodynia after hernioplasty, each study participant was questioned about pain sensation using Visual Analogue Scale (VAS) on the first day and six months after surgery. Statistical analysis of the obtained data was performed in the IBM SPSS Statistics software environment, version 28.0.1.

Results and Discussion

Statistically significant differences (p < 0.05) were obtained between the severity of inguinodynia on the first day after surgery: the average VAS score in Group I (TAPP) was 5.5 ± 1.4, while in Group II (eTEP) it was 3.4 ± 0.8 points. Six months after surgery, the VAS scores in the compared groups also had statistically significant differences (2.1 ± 0.24 and 1.4 ± 0.17 points, respectively, p < 0.05). That is, when performing hernioplasty using the TAPP method, the pain syndrome remained more pronounced than after eTEP.

Analyzing the nature of ingvinodynia in the postoperative period, we also identified such a factor as the method of positioning the implant (p < 0.05). The most pronounced pain sensations on the first day after surgery were observed in patients whose implant was fixed with a herniostapler (6.3 ± 0.4 points). The least pronounced pain sensations were observed in patients with adhesive fixation of the implant (3.3 ± 0.21 points). A similar trend was observed six months after the operation (Table 1).

 

Table 1. Severity of inguinodynia after hernioplasty using TAPP and eTEP methods, points on a visual analogue scale

Observation period after surgery	Hernio-stapler	adhesive	Combined method	р
For the first day	6.3 ± 0.4	3.3 ± 0.21	5.4 ± 0.7	p < 0.05
In six months	2.2 ± 0.24	0.7 ± 0.15	1.9 ± 0.3	p < 0.05

 

Comparative assessment of the intensity of inguinodynia in the postoperative period depending on the surgical intervention technique, the type of implant fixation and the observation period is graphically presented in Fig. 1.

 

Fig. 1. Intensity of inguinodynia in the early postoperative period depending on the method of surgical intervention and the type of implant fixation, the number of points on the visual analogue scale

 

Further analysis of factors potentially influencing the development of inguinodynia in the postoperative period was performed, such as age, body mass index (BMI), type of hernia, diabetes mellitus, bronchial asthma, hypertension, connective tissue diseases, chronic venous insufficiency, hemorrhoids, the degree of anesthetic risks according to the ASA scale, type of hernioplasty, history of surgical intervention, history of herniotomy, duration of surgery, and method of mesh fixation. It was established that the main risk factors for inguinodynia are BMI, hypertension, type of hernioplasty, as well as previous intervention on the lower floor of the abdominal cavity (Table 2).

 

Table 2. Identification of predicted risk factors for inguinodynia after videolaparoscopic inguinal hernia repair

Variable	Regression equation coefficient (B)	Standard error of the coefficient В	Wald test	Number of degrees of freedom	Significance	B Exponent	95 % CI for Exp (B)
Age	0.55	0.054	1.043	1	0.307	1.057	0.950	1.176
BMI	1.541	0.668	5.329	1	0.021	4.671	1.262	17.291
Hernia type	–0.930	1.300	0.512	1	0.474	0.394	0.031	5.042
Diabetes mellitus	3.486	2.247	2.406	1	0.121	32.647	0.399	2671.791
Bronchial asthma	–1.277	2.340	0.298	1	0.585	0.279	0.003	27.399
Hypertension	3.196	1.548	4.264	1	0.039	24.429	1.176	507.357
Connective tissue diseases	20.762	20404.213	0.000	1	0.999	1039814623	0.000	.
CVD	2.897	2.198	1.737	1	0.188	18.126	0.244	1347.471
Hemorrhoids	–20: 295	22035.757	0.000	1	0.999	0.000	0.000	.
The degree of anesthetic risks according to the ASA scale	4.034	2.668	2.286	1	0.131	56.483	0.303	10537.533
Type of hernioplasty	6.063	2.868	4.470	1	0.034	429.833	1.557	118693.460
History of surgical intervention	–3.389	1.595	4.511	1	0.034	0.034	0.001	0.770
History of hernia repair	2. 669	1.654	2.603	1	0.107	14.419	0.564	368.712
Duration of operation	0.005	0.020	0.076	1	0.783	1.006	0.967	1.046
Mesh fixation method	–0.586	1.764	0.110	1	0.740	0.556	0.018	17.674

Note: BMI – body mass index, CVD – chronic venous disorder.

 

ROC analysis (Fig. 2) revealed that patients with previous surgical interventions on the lower floor of the abdominal cavity experienced less pain discomfort in the postoperative period.

 

Fig. 2. ROC curves for assessing risk factors influencing the occurrence of inguinodynia in the postoperative period

 

Most patients were discharged on the first day after surgery (n = 398; 86.5 %). On the second day, 44 (9.5 %) patients were discharged, which was due to the need for dynamic monitoring in the postoperative period. In addition, 18 (4 %) patients were discharged on the third day after surgery due to the peculiarities of hospital administration.

According to the definition of the International Association for the Study of Pain (IASP), pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described by a person in terms of such damage. Chronic pain is any pain that persists beyond an uncomplicated healing period of 12 weeks. Post-hernia groin pain is pain that lasts longer than three months after surgery and is one of the most serious complications that occurs after IH removal; it is more common than previously thought [11].

Although hernioplasty is a relatively safe operation, it is associated with a number of potential complications, such as inguinodynia, the incidence of which, according to published data, varies widely (0 to 62.9 %) and averages from 10 to 12% [8]. However, 2–4 % of patients after IH repair experience chronic inguinodynia for many years, and this prevalence rate of inguinal pain is quite high given the volume of procedures performed worldwide [12].

Laparoendoscopic repair has been shown to be superior in terms of reducing the risk of inguinodynia compared to open methods of IH correction such as the Lichtenstein operation [9; 13]. However, sporadic results of comparison of various videolaparoscopic techniques of IH plastic surgery in terms of studying the incidence and risk of inguinodynia have been published. In this study, we found that both early postoperative pain and chronic inguinodynia develop significantly more often after TAPP, and this, in our opinion, may be associated with the features of this method, namely, dissection of the parietal peritoneum.

No statistical differences were found in the study by A. Elhadidi et al. [8] in the incidence of inguinodynia depending on the type of fixation, whereas in our study, when studying risk factors, it was found that the least pronounced pain was observed in patients with adhesive fixation of the implant compared to fixation with a stapler or the use of a combined method.

According to the results of a systematic review and meta-analysis [14], the factors for inguinodynia are young age, the presence of other postoperative complications, a hernial sac defect of less than 3 cm, female gender, pre- and early postoperative pain. In our study, we did not receive confirmation of these prognostic factors. Our multivariant analysis showed that statistically significant predictors increasing the risk of developing inguinodynia after IH plastic surgery using videolaparoscopic methods were BMI, hypertension, and the type of plastic surgery, while a history of lower abdominal surgery, on the contrary, reduced the risk of inguinodynia.

Conclusions

The incidence of ingvinodynia after IH plastic surgery in modern clinical practice remains at a fairly high level. Despite the fact that videolaparoscopic methods of hernioplasty are the least traumatic, it is necessary to take into account individual risk factors for ingvinodynia in order to improve the quality of life of patients in the postoperative period.

About the authors

E. A. Galliamov

I.M. Sechenov First Moscow State Medical University (Sechenov University); MEDSI Clinical Hospital

Author for correspondence.
Email: eduardgal62@gail.cоm
ORCID iD: 0000-0002-6359-0998

DSc (Medicine), Head of the Department of General Surgery, Surgeon

Russian Federation, Moscow; Krasnogorsk

S. N. Perekhodov

MEDSI Clinical Hospital

Email: eduardgal62@gail.cоm
ORCID iD: 0000-0001-7166-0290

DSc (Medicine), Professor, Corresponding Member of the Russian Academy of Sciences, Director of the Clinical Hospital

Russian Federation, Krasnogorsk

M. I. Vasilchenko

MEDSI Clinical Hospital

Email: eduardgal62@gail.cоm
ORCID iD: 0000-0002-7942-5145

DSc (Medicine), Professor, Deputy Chief Physician for Surgical Care

Russian Federation, Krasnogorsk

Yu. B. Busyrev

“New World Surgery” Medical Clinic

Email: eduardgal62@gail.cоm
ORCID iD: 0000-0002-5475-4284

PhD (Medicine), Chief Physician

Russian Federation, Zhukovsky

S. A. Kuliev

Yusupovskaya Hospital (“Neuro-Clinic” LLC)

Email: eduardgal62@gail.cоm
ORCID iD: 0000-0002-7220-7292

DSc (Medicine), Surgeon

Russian Federation, Moscow

G. S. Gadlevskiy

I.M. Sechenov First Moscow State Medical University (Sechenov University); MEDSI Clinical Hospital

Email: eduardgal62@gail.cоm
ORCID iD: 0000-0003-0547-2085

Assistant of the Department of General Surgery, Surgeon

Russian Federation, Moscow; Krasnogorsk

References

Supplementary files