Professor Michael O’Rourke - PowerPoint Presentation

1. Professor Michael O’RourkeGeneral SurgeonThe New Pain Complications of Mesh Inguinal HerniaASIEQ Quarterly Meeting Wednesday 10 May 2017

2. ComplicationsPost Hernia Repair Pain or CPSP.Recurrence. Wound Infections.

3. Reference: 1986 International Assoc for Pain Study, 2011 Alfieri et alia.CPSP: Chronic post surgical pain.Pain that has been present continuously for longer than 3 months.And longer than 6 months.Definitions

4. Reference: Bendavid et alia Hernia 2015 Pain has supplemented recurrence as a complication of surgery. The increased incidence of pain mirrors a parallel increase in the use of polythene meshes.Incidence (1)

5. O’Rourke & O’Rourke 6-54% - (6 Studies) ANZ J .of. S 2012.Langeveld Rotterdam 27% - Hernia 2015.Westin et alia Laparoscopic 20% Open 33% Annals of Surg 2016.Incidence (2)

6. Most pain resolves in the first 12 months, generally CPSP is treatment resistant, it eventually dissipates with time, it is impossible to prognosticate when.Reference: Sanblom (K) J.Pain Res 2015 Geticis J.Am Coll Surg 2015 Natural History (1)

7. Neuropathic pain or 2. Nociceptive pain or pain due to tissue injury or inflammation.Natural History (2)

8.  May be burning, tingling or electric shock like pain, may be associated with paraesthesia, anaesthesia, hyperaesthesia or allodynia. This is more typical of neuropathic pain.Pain due to other pathology or nociceptive pain is usually less severe.V.V difficult to differentiate.Reference: Voorbrood Hernia 2015Symptoms CPSP

9.  Exclude other pathology e.g. hip, back, adductor muscles.MRI / CT is of little value in diagnosis of CPSP.History probably best for differentiating neuropathic from other pathology but it is unreliable.Use of algorithm e.g. history, physical signs, past and family history, psychiatric history, previous environments e.g. work and insurance status.Reference: Voorbrood Hernia 2015Diagnosis CPSP

10. Prevention. Neuropathic pain refer to a pain clinic for at least 12 months.Treatment of non-neuropathic pathology.Wait for late resolution.Surgery for persistent pain!!Treatment

11. Instead of mesh therapy being the sole surgical technique:With young males and females with indirect Hernia – excise the sac and tissue repair.Patients with severe pain and a reducible lump – allow the pain to settle pre-op +/- temporary truss.No lump no hernia – groin pain and ultrasound diagnosis of hernia is no indication for surgery.It is the duty of every surgeon to avoid iatrogenic complications.Prevention

12.

13. Triple neurectomy.Mesh removal, re-innervation or neo innervation.Treatment of recurrence.Many patients want surgery – think something went wrong.Rationale for repeat surgery

14. Wantz – no nerve no pain.Prospective randomized trials – no benefit dividing nor preserving the 3 nerves.Post-mesh implant – Marked fibrosis and difficulty finding 3 nerves.Invalid claims by a few.Reference: Amid Hernia 2011Triple Neurectomy

15. Sun et Alia Mayo clinic 43% >12 months Multiple procedures Am J. of Surg 2016Calleson et Alia Hernia recurrence and pain High post op neuropathic pain B.J of Surg 1999ValvekensOne In three pain free Hernia 2015 Amid 90% Cure with triple neurectomy Surgical Reports

16. Yes it is an iatrogenic complication.Excuses: All from correspondenceNot due to surgery. Never had this before. Just take analgesics and it will go away.Referred back to General Practitioner to cope.Referred to sports medicine doctor.Need to re-explore.Surgical Negligence

17. CPSP is iatrogenic.The incidence is high 20-30%.There is a high incidence of spontaneous resolution.Treatment is difficult. The role of interventional procedures is still unknown.Summary

18. GEPIThe Queensland Workers’ Compensation Scheme Guidelines for Evaluation of Permanent Impairment, 2nd Edition, Chapter 16, Page 94.16.2 AMA5, p 136: section 6.6 hernias. Occasionally in regard to inguinal hernias there is damage to the ilio-inguinal nerve following surgical repair. Where there is loss of sensation in the distribution of the ilio- inguinal nerve involving the upper anterior medial aspect of the thigh, a one percent Whole Person Impairment should be assessed as per Table 5.1 of this Guide. This assessment should not be made unless the symptoms have persisted for twelve months.

19. Table 6-9 Criteria for Rating Permanent Impairment Due to HerniationClass 10% - 9% Impairment of the Whole PersonClass 2 10% - 19% Impairment of the Whole PersonClass 3 20% - 30% Impairment of the Whole Person Palpable defect in supporting structures of abdominal wallandSlight protrusion at site of defect with increased abdominal pressure, readily reducibleorOccasional mild discomfort at site of defect but not precluding most activities of daily living.Palpable defect in supporting structures of abdominal wallandFrequent or persistent protrusion at site of defect with increased abdominal pressure, manually reducibleorFrequent discomfort, precluding heavy lifting but not hampering some activities of daily living.Palpable defect in supporting structures of abdominal wallandPersistent, irreducible, or irreparable protrusion at site of defectandLimitation in activities of daily living.AMA5The American Medical Association’s Guides to the Evaluation of Permanent Impairment, 5th Edition, Chapter 6, Page 136.

20. Professor Michael G.E. O’Rourke AM.M.B., B.S., F.R.C.S., F.R.C.S.Ed., F.R.A.C.S., F.A.C.S. F.Q.I.M.R.General Surgeon