Editing Inguinal hernia (section)

=== '''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]]