What Defines ‘Chronic Pain’ After Hernia Surgery?

This question may seem like an easy one to answer, but developing a systematic scale and a formal survey to evaluate patients after any surgery can be difficult. For the sake of my hernia practice, I describe to patients chronic pain being pain that develops usually by 6 months, and which can last for years. Fortunately, this is a very, very rare occurrence!

Pain is not the only measure that we look at over the course of this time frame. Other important variables include:

• physical functioning
• role limitations due to physical health
• energy and fatigue
• emotional well being
• social functioning
• pain
• general health

What causes chronic pain?

Chronic pain is rarely caused by the hernia itself returning; instead, it is typically related to how the body interacts with the repair. The three primary causes are:

• Nerve Irritation or Entrapment: The groin is a “high-traffic” area for sensory nerves (the ilioinguinal, iliohypogastric, and genitofemoral nerves). If these nerves are handled roughly, entrapped by a suture, or irritated by the edge of a mesh, it can cause persistent neuralgia.
• The “Meshoma” Effect: In some cases, a mesh that is too heavy or improperly placed can wrinkle or ball up, creating a hard mass that tugs on surrounding tissue.
• Inflammatory Response: A patient’s unique biological response to prosthetic material or the surgical trauma itself can lead to localized inflammation.

What is the Chance This Will Happen to Me?

The “chance” of chronic pain is not a fixed number; it is highly dependent on the experience of the surgeon and the technique used. At our center, we mitigate your risk through three specific clinical pillars:

• Nerve-Sparing Technique: Dr. Todd Harris utilizes a meticulous “nerve-identifying” approach. By clearly visualizing and protecting the sensory nerves during every procedure, we significantly reduce the risk of accidental entrapment or injury.
• Specialized Material Selection: We use only lightweight, high-porosity “macroporous” mesh, which allows for better tissue integration and less “stiffness” than the heavy-weight meshes of the past. For qualified patients, we also offer the Shouldice (No-Mesh) repair, eliminating prosthetic materials entirely.
• Narcotic-Free Recovery (NCT05929937): Our research has shown that eliminating opioids and using Multimodal Analgesia reduces the “wind-up” of the nervous system. By controlling pain effectively in the first 72 hours without narcotics, we help prevent the brain from “mapping” a chronic pain response.

Timeline for Chronic Pain

• Surgery
• 3 weeks: most patients pain is 90-100% resolved
• 3 months: some patients have a delayed recovery with pain resolving at this point
• 6 months: definition for chronic pain

What Steps Do I Take to Minimize Chronic Pain?

One important concept to remember is that NO surgeon, of any type, can ensure that 100% of their patients are pain free years after surgery. This rule applies to myself as well. Also, in most instances, the root cause of a patient developing chronic pain isn’t clear. This means that despite our best efforts during surgery, we don’t always know what went ‘wrong’. Thus, there isn’t one technique, or one maneuver that will ensure that patients won’t develop pain. And again, this applies to my techniques and to my outcomes. However, applying some basic principles, there are some things that I try to do to help ensure that patients have the best outcomes.

1. I recognize that chronic pain is always a possibility, and to treat each surgery with absolute care. This may sound a bit unusual, but without the insight that something could go wrong, and the desire to avoid that outcome, having success will be impossible. Unfortunately there are plenty of professionals in all fields who don’t care, and are just going through the motions. This doesn’t apply to my medical practice or to any of the surgeries I perform each day. Hernia surgery is not an afterthought.

2. The use of lightweight meshes has dramatically improved patients outcomes. When we discuss lightweight meshes, we are referring to the thickness and density of the plastic mesh used in hernia repairs. Years ago, the thought was that the thicker and heavier the mesh, the better a job it would do repairing the hernia. Well, that was probably true, but we also realized that thick, heavyweight meshes cause an extensive amount of inflammation within the body. This often led to patients being able to feel the mesh and developing chronic pain. The use of the newest ‘lightweight’ meshes offer surgeons the ability to use a material that is just as strong as the older meshes, but with only about 1/3 of the actual mesh material. This results in significantly better outcomes for patients down the road by minimizing the scar tissue and inflammation that develops. Unfortunately, there are still a lot of surgeons who use the heavyweight mesh for their hernia repairs although this is decreasing every year.

3. Over many years and through 1000’s of hernia repairs, high volume surgeons develop an eye for issues that could possibly cause pain after surgery. Some of these may not be issues at all, but the only way to ensure the best outcomes is to try and make the entire surgery as smooth as possible. Avoiding nerves, preventing excess tension on the muscles around the hernia, minimizing the amount of dissecting of the normal healthy tissues can all lead to subtly better outcomes. Again, no surgeon can know exactly what step caused a complication, but by following a routine that works 99% of the time, high volume surgeons can provide a more reliable outcome over surgeons who only perform the procedure occasionally.

Incidence of Chronic Pain

Probably the most important part of this information is to discuss how often we see patients with chronic pain. I want to break up my answer into two different parts. First, I want to discuss the medically published statistics on chronic pain. This will give you a formal, unbiased vantage point into chronic post-operative hernia pain. Second, I will provide you with my personal experience in my practice. Keep in mind that there may be patients that have chronic pain after one of my surgeries who decide to see another surgeon, or a pain specialist without my knowledge. I would guess that if those patients are factored into my personal experience, the statistics are likely almost the same.

In my hernia practice, we perform roughly 500 hernia surgeries a year. At the end of every year I see about 3-5 patients back in my office after 3 months with pain that has not improved since surgery. Of these patients, about 3 of them see marked improvement by 6 months. Thus, we probably have about 0.5% of our patients each year who are experiencing severe or disabling pain 6 months or more after surgery.

For medically published data, there was a very good article which looked at chronic pain in July of 2016. The article appeared in the Journal of the American College of Surgeons and examined patients up to two years after hernia surgery. The surgery technique that the authors used is identical the technique that I perform in my practice today. In their research, the determined that about 1% of patients had moderate, severe or disabling pain at 1 year after surgery. 89% had no symptoms and 8% had mild and not bothersome symptoms. 2% had mild symptoms that were bothersome.

The article from the JACS can be viewed here.

Use of Lightweight Hernia Mesh

Over the last couple of years, hernia surgeons who specialize in hernia repair have adopted the newest types of mesh. Although prior hernia mesh was heavy, thick plastic, today’s newest mesh is ultra lightweight. This means that it is soft, and flexible like the muscles themselves. It causes much less scar tissue within the body which decreases the chances of acute and chronic pain after hernia surgery. Over time, the mesh remains soft and flexible minimizing the chances of chronic pain to almost zero.

Research Data on Chronic Pain

The following table demonstrates the results from a large medical study on chronic pain after hernia surgery. It indicates the responses from patients about their pain at one year after surgery.

Dr. Harris can discuss these items during your consultation to decide which method is best for you. Although basic open surgical hernia repair is still an important option for some patients, every patient should consider being seen by a surgeon who can perform advanced laparoscopic hernia surgery and who uses the newest lightweight mesh. Only a small handful of the hundreds of general surgeons in Orange County, Los Angeles, Riverside and San Diego have the experience to perform hernia surgeries using laparoscopic techniques and use cutting edge lightweight mesh.