Editing Inguinal hernia (section)

== '''Complications''' ==

* Surgical site infection
** Superficial - open the incision, local wound care, heal by secondary intention
** Deep - involving mesh should be explanted
* Post-op pain
** Consider recurrence, infection, seroma, mesh pain (dull mild ache, often worse with sitting/bending), nerve impingement/entrapment (could be relieved with nerve block)
** If obvious recurrence, just repair it
** If exam is unrevealing, suggest CT with Valsalva to exclude collection, occult femoral hernia, or recurrence
*** Fluid deep to the mesh is suspicious for mesh infection - trial Abx and drainage. Removal may be necessary.
*** Fluid anterior to the mesh is usually a seroma
* Chronic pain/nerve injuries
** See below
** Injury can result from traction, electrocautery, transection and entrapment
** Usually worse with local pressure, or hyperextension of the hip, and relieved by flexion of the thigh
* Ischaemic orchitis/testicular atrophy
** Usually occurs from thrombosis of the small veins of the pampiniform plexus within the spermatic cord, resulting in venous congestion. Testicle becomes swollen and tender 2-5 days post-op, which can continue for 6-12 weeks and eventually result in testicular atrophy.
** Can also be caused by ligation of testicular artery.
** Treat with analgaesia and anti-inflammatories


=== '''Recurrence''' ===

* Anatomy
** Usually involves the floor of the inguinal canal near the pubic tubercle, where tension is greatest
** Can also be recurrent indirect hernias
* Risk factors
** Technical issues
*** Inadequate dissection and reduction of the indirect sac
*** Failure to identify a direct or indirect hernia in either open or laparoscopic repair
*** Repair under tension
*** Incorrect mesh placement
*** Inadequate overlap of mesh in the inferomedial side of inguinal canal near the pubic tubercle (medial recurrence)
*** Failure to close a patulous internal ring
*** Surgeon's overall caseload and experience
*** Procedure under LA
** Factors contributing to healing
*** Malnutrition
*** Immunosuppression
*** Diabetes
*** Infection
*** Obesity
*** Smoking - double recurrence rate
** Genetics
*** Collagen synthesis disorders
** Notably no clear increased recurrence with post-op haematoma or emergency case
** Main reasons for failure of non-mesh repair:
*** Medially - tension
*** Medially or laterally with unzippering of suture line if not anchored properly
* Workup
** Cameron's says MRI with Valsalva is best for studying planes looking for recurrence
* Treatment
** Reinforce lifestyle advice and counsel patient that risk of another recurrence is higher
** Operate again through a different tissue plane
** Keep in mind that risk of strangulation through a recurrent hernia is generally considered to be low

=== '''Chronic pain''' ===

* Estimated 10-12% total, 0.5% debilitating
* Most get better with time - 14% at 4 months, 4% at 2 years
* Attempt to differentiate between neuropathic and nociceptive pain
* Patient factors:
** Young age
** High pain intensity level prior to repair
** Lower preoperative optimism
** Impairment of daily activities
** Genetic predisposition (HLA haplotype)
* Surgeon factors:
** Less experience
** Dissection of nerves
** Dissection/fixation lateral to internal ring
** Use of tacks/sutures rather than glue, where possible
** TEP/TAPP has better postop acute and chronic pain
* Strategies to help avoid
** Good postop pain control - paracetamol + NSAIDs, only adding opioids if necessary. Long acting bupivicaine in wound.
* You can use the 'Alvarez' classification to describe neuropathic-type pain, but this is quite high-level and more good for chronic pain teams than surgical
**
* Indicators for early referral to chronic pain:
** Catastrophisation
** High-dose opioids
** Multiple other sites of pain
*
* Early (<6 months)
** REASSURE AND CONSIDER NSAID SUCH AS MELOXICAM 15MG DAILY +/- PPI, AND REVIEW IN TWO WEEKS IF
*** No neuropathic features (not confined to specific nerve territory)
*** Mild to moderate pain
*** No adverse psychological features
** Start first-line anti-neuropathic + NSAID/COX2 and consider referral to pain clinic/specialist IF
*** Neuropathic features
**** Could mesh be causing inflammation and irritation to nerves?
* Late (>6 months)
** Once mesh organisation has occurred, different problem
** Neuropathic features -> trial of antineuropathic, role of diagnostic blocks vs triple neurectomy, suggest share burden with pain clinic
** No neuropathic features -> refer to pain clinic
* Good anti-neuropathics
**
** Amitryptilline especially good with sleep disturbance
** Have to try one of top two before pregabalin as per PBS

[[Category:Abdo wall and retroperitoneum]]