Inguinal hernia

Epidemiology

• It is estimated that 3-4% of people will develop an inguinal hernia at one point
• 65% are indirect, 35% direct
  • Men - 2:1 indirect:direct
  • Women - almost all indirect
• M:W 25:1
• Strangulation occurs in 1-3%, more common at the extremes of life
  • Most strangulated hernias are indirect

Risk factors

• Advanced age
• Male
• Caucasian
• Smoking
• Increased abdominal pressure
• COPD
• Collagen disorders
• Family or personal history
• Heavy lifting is controversial
• Femoral herniae more common in women, and more likely to incarcerate

Pathophysiology/anatomy

• See section on inguinal region under 'anatomy'
• Three main weak points:
  • Internal ring - indirect herniae
  • Posterior floor of inguinal canal - direct. In Hesselbach's triangle, the only structure providing strength is transversalis fascia.
  • Femoral space
• Occur more commonly on the right - delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development
• Can be classified as congenital (incomplete closure of processus vaginalis) or acquired (weakness of tissues)

Presentation

• Groin mass accentuated by coughing, straining (urinating, defecating, lifting) or prolonged standing
• Urinary or gastrointestinal symptoms should lower threshold for repair ?intermittent incarceration
• One third are asymptomatic
• Can get paraesthesias related to compression or irritation of inguinal nerves
• Moderate to severe pain is unusual and raises suspicion for either complication, or alternative pathology

Examination

• Standing:
  • Visual inspection - asymmetry, scars
  • Visual inspection with cough/valsalva
  • Cough with finger over inguinal canal
  • Cough with invagination of external ring
  • If no bulge identified, but patient describes one, have them walk around, or bring them back another time
• Repeat exam supine
• Check testes
• Assess mass
  • Size
  • Degree of extension to scrotum
  • Location relative to inguinal ligament - femoral hernias normally felt inferior to inguinal ligament, in proximal thigh
• Look for other occult hernias elsewhere
  • Remember to discuss what to do for these if found in OT

Differential diagnosis

• Soft tissue lump
  • Inguinal/femoral lymphadenopathy
  • Soft tissue neoplasm
  • Lipoma
  • Haematoma
  • Sebaceous cyst
  • Hidradenitis
  • Lymphoma
  • Metastatic neoplasm
• Athletic pubalgia
• Scrotal pathology
  • Hydrocoele
  • Varicocoele
  • Ectopic testis
  • Epididymitis
  • Testicular torsion
  • Epididymal cyst
• Femoral hernia
• Femoral artery aneurysm or pseudoaneurysm
• Saphena varix

Workup of difficult cases

• When unable to confirm a hernia clinically, but pain is present, imaging is indicated
• USS is easiest, but hard to interpret images after the fact
• CT is easy and can effectively show an occult hernia
• MRI is best for athletic pubalgia

Littre's hernia (Meckel diverticulum)

Maydl's hernia (two loops of bowel)

Amyand's hernia (containing appendix - presentation mimics appendicitis)

Pantaloon hernia (both direct and indirect)

Sliding hernia (wall of sac is an organ)

Non-operative management

• Safe for asymptomatic or mildly symptomatic inguinal hernias - 0.3% risk of incarceration and no deaths at two years, with 68% eventually getting it repaired by 10 years, but same outcomes at this point (Fitzgibbon study - see below under 'specific situations').
• Sometimes get symptomatic improvement with a truss (30%)

Specific scenarios:

• Primary elective unilateral inguinal hernia repair in men
  • Can use open, TAPP or TEP depending on surgeon preference
  • Favour laparoscopic approaches in men <30yo
• Asymptomatic inguinal hernia in men (recommendations based on famous Fitzgibbons study)
  • >70% will become symptomatic within 10 years and require surgery
  • Only 2-3% will require emergency surgery in 10 years
  • Overall, safe to wait until it becomes symptomatic, but just involve the patient in discussion. Might give some patients an extra 10 years of life without chronic post-op hernia pain by delaying!
• Primary elective unilateral IHR in women
  • TAPP or TEP, to avoid missing a femoral hernia
• Femoral hernia
  • Should generally be repaired expeditiously due to risk of strangulation
• Primary bilateral IHR (men and women)
  • TAPP or TEP have better outcomes than open in terms of op time, recovery, complication rates
• Primary inguinoscrotal hernia
  • Open approach favoured, especially if skin resection required due to large scrotal hernia
• Previous lower midline incision
  • Open may be preferred due to adhesions/scarring
  • TAPP is still ok
  • TEP is difficult, worth trying, convert to open or maybe TAPP afterwards
• Previous pelvic or lower abdominal surgery
  • Open preferred
• Elderly patients/comorbid patients
  • Open Liechtenstein under LA for ASA III/IV
    • No difference in complication rates
• Recurrence
  • Try to use a different approach to last time - e.g. if primary repair was open, do TAPP or TEP, and vice versa
• Emergency for symptomatic incarcerated or strangulated
  • Any approach although it is preferable to visualise bowel to check for viability, meaning TAPP approach is ideal
  • Many surgeons would prefer open for large incarcerated hernias, even if a bowel resection is likely to be required, this can be done through the open inguinal approach
    • If the incarceration point is the external ring, then it will likely spontaneously reduce when the EO fibres are opened, so try to grasp it for later inspection before it does so.
    • Hernia sac contains only fat: resect anything of doubtful viability with meticulous haemostasis
    • Spontaneous reduction of hernia before the bowel can be inspected:

• • • 1. Unlikely strangulated (no radiologic or clinical features of strangulation pre-op, the sac contains clear or serous fluid): repair the hernia and forget about the bowel.
      2. Likely strangulated (pre-operative concern, or sac contains darker fluid): need to examine the bowel somehow, probably via laparoscopy, potentially via insertion of the scope through the hernia defect

• • • Bowel resection required - can be hard to replace in abdomen; try steep Trendelenburg and gentle compression. May need to open EO laterally to internal ring, then IO/transversalis in the same way. May even need laparoscopy for further traction. If the IO defect is large enough, the simplest way to perform bowel resection is externally through the inguinal repair, then push the anastomosis back in. If unable to do that, will need a lower midline laparotomy.
  • There is some (level 2a) evidence supporting nonabsorbable mesh in setting of bowel resection provided wound protectors are used along with saline lavage. However, standard practice is not to use mesh if resecting bowel or if tissues appear dusky/ischaemic.
    • If not doing it, perform Shouldice repair

Open techniques:

• The Bassini, Shouldice and McVey repairs are certainly not ideal for elective hernia repairs, but we should know about them for situations when you can't use mesh (contaminated fields). In that situation, Shouldice is best.
  • In emergency repair for incarceration hernia WITHOUT bowel resection: benefits of mesh repair outweigh risks of infection.
  • Unclear whether mesh is ok with bowel resection in these cases, but probably best to avoid it as things stand, and do a tissue repair instead.
• Open mesh repair (Liechtenstein) is best in elective setting, if going to do an open repair
• Plug-and-patch technique is not really recommended, due to increased foreign material and violation of more tissue planes. However it does have a very low recurrence rate.
• Recurrence rates:

Procedure	Recurrence rate
Liechtenstein	0.8%
Shouldice	3.6%
McVay/Bassini	6.9%

Shouldice repair:

• Modification of Bassini repair - probably the most enduring version
• Most extensively studied of open repairs, and generally recommended if non-mesh repair is taking place
• Essentially release the inguinal floor and then close it in four layers
• Method as per Gray's:
  • Need to expose more than for a mesh repair, especially EO. Often need to move iliohypogastric superiorly to avoid catching it.
  • Open inguinal floor (transversalis fascia opened between internal ring and pubic tubercle)
  • Option to use a 'scarf' of lateral cremaster muscle sutured up to to re-create the deep inguinal ring
  • Repair layers:
    • 1: Starting from medially, suture lateral edge of rectus abdominis down to bottom flap of TA/TF, and continue this laterally until lateral edge of rectus is reached.
    • 2: More laterally to rectus, fix free edge of upper flap of TA and IO to inguinal ligament to become the new medial wall of deep ring. Include the 'scarf' medial to internal ring, brought out behind the cord.
    • 3: moving back from deep ring towards pubic tubercle, bring conjoint tendon (IO and TA) together with the inguinal ligament. Tie back to the tail of the original suture.
    • Can stop there, or continue for another back and forth suture line.
    • 4: Suture from lateral medial, initially just mass closure of the previous suture line, then an imbricating suture back, tied to itself.

Iliopubic tract repair:

• Approximates transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures
• Begin at pubic tubercle and extend laterally past the internal ring
• Initially described using a relaxing incision, but not seen as necessary any more

Bassini repair:

• Developed 1887
• Reapproximation of layers of inguinal canal en masse to shelving edge of inguinal ligament
• Basically bring TA down to inguinal ligament (makes sense since IO doesn't give any strength at this level; have to use TA)
• Modified many times since then
• Version described in Gray's:
  • Reduce the indirect hernia
  • Expose the aponeurosis of TA, which is sutured to the inguinal ligament using non-absorbable sutures - proceed from medial to lateral until the internal ring does not gape. Sometimes needs a few sutures lateral the cord to tighten adequately.
  • Sometimes need to make a relaxing incision in anterior rectus sheath to bring TA and inguinal ligament together without tension.
  • Close EO.

McVay repair:

• Similar to Bassini, but first few sutures placed between conjoint tendon/transversus abdominis arch and Cooper's ligament, transitioning to inguinal ligament when femoral vein encountered

Desarda repair:

• External oblique transposed under spermatic cord to cover inguinal floor, then incised and sutured to conjoint tendon (tension-free)
• Lacks long-term follow-up

Liechtenstein repair - open, tension-free, mesh

• Overview
  • Dissect down to identify inferior edge of inguinal ligament
  • Expose external ring
  • Open external oblique
  • Delineate anatomy - isolate cord structures
    • Reduce direct hernia
    • Dissect free and ligate indirect hernia
  • Place mesh
  • Plicate external oblique
  • Close
• Developed by Irvin Liechtenstein
• Supine, GA, IV Abx (although technically not evidence-based for low-risk patients), TT, TEDs, prep+drape
• Palpate inguinal ligament, pubic tubercle, and ASIS
• Incision a few centimetres superior to, and parallel with, the inguinal canal
  • Some surgeons do a transverse incision at the medial half of the IL
• Divide subcutaneous layer. Ligate superficial epigastric vein (found around level of internal ring) and superficial circumflex iliac vein (found laterally), and superficial external pudendal (medially). May also encounter superficial epigastric artery and superficial external pudendal artery. Dissect down to external oblique aponeurosis, then dissect subcutaneous tissue free from it to expose external ring.
• Incise the aponeurosis with metz scissors a few centimetres superior to inguinal ligament, moving laterally (protect ilioinguinal nerve, which is often adherent to the inner surface of EO) as far as the internal ring
  • Expose internal oblique fibres and identify ilioinguinal nerve.
  • Some surgeons suggest always dividing ilioinguinal nerve - which seems to reduce incidence of chronic pain in systematic reviews
• Men: dissect spermatic cord free from underlying transversalis fascia in region of Hesselbach's triangle (medially), and put the hernia ring forceps around it. Doing this laterally can injure the posterior wall.
• Identify the hernia
  • Indirect herniae will be anterior and medial to cord (look for a whitish membranous layer, which is normally sharply demarcated from the cord). These should be dissected out to the level of the internal ring by putting artery forceps on the sac and pushing other structures away using gauze, and diathermy as needed. Note that they will be contained within the cremasteric muscle, which needs to be opened parallel to its fibres to get directly onto the sac. Large indirect sacs will need to be opened to check for visceral contents. Sacs can then either be mobilised and returned to the pre-peritoneal space, or ligated and divided. The easiest thing to do is open, divide, suture ligate
  • Examine the floor of canal even if an indirect hernia is present (can have a pantaloon hernia). If a direct hernia is present, do a purse-string around it, invert it, and tie. May need to incise the transversalis fascia to facilitate return of a direct sac to pre-peritoneal space.
  • In women, division of round ligament may facilitate the hernia repair (ligate it as high and then as low as possible)
• Don't routinely skeletonise the cord (risk of ischaemic orchitis) beyond the level of pubic tubercle, but do explore it and check whether a hernia is present. Close the peritoneum at level of inguinal ring.
• Liechtenstein repair: polypropylene mesh covers inguinal region, cut to fit, anchor at pubic tubercle, with the mesh overlapping the pubic tubercle to cover 15mm medially too. Suture from medial to lateral to the inguinal ligament (with small bits of both mesh and ligament to stop bunching). Suture the two mesh tails together lateral to internal ring. Superiorly suture to internal oblique/transversus abdominis (the IO is muscular fibres at this level and not useful in holding - need to go deeper to get to aponeurosis of TA, which is actually strong at this level).
  • Careful not to make rings too tight - risk of ischaemic orchitis
  • Women - don't need to create an opening in the mesh, if the round ligament was divided.
  • VARIATION - plug and patch repair ('Rutkow and Robbins') - never been shown definitively to reduce recurrence rates. The plug may lead to complications such as chronic pain or issues with the intra-abdominal component of it. So plug and patch is not recommended by Cameron's. Polypropylene mesh plug is sutured into internal ring, in the pre-peritoneal space.
  • Prolene Hernia System - anterior oval polypropylene mesh (similar to Liechtenstein) connected to a smaller circular component which is deployed into a bluntly created preperitoneal space. Good early results.
  • Stoppa repair - posterior preperitoneal placement of mesh covering both groins.
• Make a neo-inguinal ring, which should be placed just medial to the true inguinal ring, to create obliquity of the cord in the canal.
• Close external oblique (vicryl)
• Close Scarpa's fascia (vicryl)
• Close skin (monocryl)

Laparoscopic repairs

• Comparison to open
  • Quicker recovery
  • Less pain
  • Better visualisation of anatomy
  • Ease of fixing all hernias
  • Longer operative times
  • Technical challenges
  • Increased risk of recurrence
  • Increased cost
  • 0.3% risk of visceral or vascular injury
• TAPP vs TEP
  • Although TEP has demonstrated slightly lower recurrence rates, on the whole, there isn't any evidence to prefer one over the other definitively
  • Both suitable choices
  • TEP has a longer learning curve but doesn't violate as many tissue planes
  • TAPP allows visualisation of both sides, and intra-peritoneal structures
  • Liechtenstein and TAPP and TEP are thought to have similar recurrence rates overall
  • rTAPP has shown reasonably similar recurrence rates to TAPP/TEP although no clear data
• Critical view of myopectineal orifice
  • Dissect 2cm across midline
  • Display direct hernia space
  • Dissect 2cm posterior pectineal ligament
  • Display femoral hernia space
  • Dissect indirect sac
  • Reduce all cord lipomas
  • Posterior lateral dissection to expose psoas (why?)
  • Mesh coverage and fixation
  • Minimum mesh size 10 x 15cm

TAPP

• First performed 1990 by Schultz
• Supine, GA, prep, drape, Abx
• Hasson entry at umbilicus with 10mm port, then two 5mm ports bilaterally in a horizontal plane with the umbilicus
• Landmarks - umbilical ligaments, bladder, inferior epigastrics, vas def, spermatic cord, iliac vessels, hernia defects.
• Incise peritoneum from lateral edge of median umbilical ligament (at level of ASIS bilaterally) and extend 8-10cm laterally, to about 2cm medial to ASIS. Allow enough room above hernia for mesh placement! Need 2-3cm!
• Zone 1: First work laterally to IEVs, pushing transversalis and fat away from the peritoneum, which allows nerves to retain their fascial coverings (thin peritoneal flap)
• Zone 2: Then move medially to IEVs, and dissect directly on the posterior rectus sheath, with fat being pushed down with the peritoneum, which avoids damage to bladder or peri-vesical structures (thick peritoneal flap). Continue the dissection 2cm below pubic symphysis, and 2cm across midline to the contralateral side.
• Zone 3: Then dissect out around the IEVs, and triangle of doom
• Continue dissection until 'critical view of safety' is obtained
• Reduce hernia with gentle traction
• Insert mesh (e.g. Bard 3D Max ideally large) to cover the entire myopectineal orifice and fix in place with sutures/tacks (don’t use self-fixating mesh). 5-6 tacks is usually enough to fix it. Don't tack to bone. Often use fibrin glue on posterior aspect of mesh in triangles of doom and pain.
• Close peritoneum
• Close fascia, skin
  • The 'inverted Y': inferior epigastrics (red), vas deferens (white), spermatic vessels (blue).
  • Iliopubic tract in blue

TEP

• First performed 1993 by McKernan
• Contraindications
  • Obliteration of retroperitoneal plane from previous surgery (prostate) or radiotherapy
• Pitfalls
  • Missed hernia/inadequate mesh fixation
  • Injury to bladder
  • Nerve or major vessel injury
• Setup
  • Both arms tucked
  • May need Trendelenburg
  • Monitor at foot of table
  • Surgeon on side opposite to hernia
• Technique
  • Transverse para-umbilical incision (give yourself more room, if there is a short lower abdomen)
    • Can also do infra-umbilical
    • Generally orient the incision on the ipsilateral side, to give better access to that rectus sheath
  • Dissect through fat with scissors to get straight down to linea alba (don't need to stay close to cicatrix). Expose 2cm of ipsilateral anterior sheath to the hernia. Make a transverse 1cm incision in the anterior sheath. Elevate and lateralise ipsilateral rectus abdominis to expose posterior rectus sheath, using blunt dissection.
  • Use the S retractor to keep muscle elevated, and slide the dilating balloon in, aiming directly for symphysis pubis. Under vision (often use straight scope), inflate the dilating balloon manually with the white end (no specific number of pumps - use judgment) and hold inflated for 1-2 minutes, then deflate with the black end and swap to the structural balloon. Pump up the sealing balloon, which is the button closest to symphysis. Then attach gas, pressure 12mmHg, straight to high flow.
    • If using a regular Hasson port instead of the dissecting balloon, use the camera itself to push in and dissect down to symphysis pubis
  • Two additional 5mm ports just off midline. Top one as high as possible whilst not interfering with the balloon on the camera port, the other one halfway between umbilicus and symphysis pubis. The lower one should be slightly contralateral to the hernia, but it doesn't really matter.
  • Need to dissect peritoneum off transversalis fascia (same plane as TAPP)
    • Start with pubic tubercle
    • Look for the plane just above the peritoneal reflection, using both hands in an up-down chopsticks motion
    • Expose inferior epigastric vessels (key landmark), and expose ipsilateral pubic tubercle, Cooper's ligament, and the iliopubic tract (avoid going below iliopubic tract)
    • Expose as far laterally as ASIS
    • Look for the whitish hernia sac
    • Be wary of femoral vein/artery
  • Hernia reduced (may require some cord skeletonization)
    • Small indirect sacs should reduce easily
    • Larger chronic sacs may have adhesions distally - may need to divide the sac just distal to the internal ring, by entering from the opposite side to the cord structures. If so, may need to close the proximal sac with clips or EndoLoop to prevent pneumoperitoneum from occurring.
    • Direct hernias should be able to be easily reduced with gentle traction
  • Mesh placed over direct, indirect and femoral spaces
    • Can use a polypropylene mesh such as Bard 3D, or just any 12x14cm polypropylene
    • Need to cover entire myopectineal orifice - direct, indirect and femoral spaces, and resting over cord structures
    • No need to cut a slit for the cord (Chassin), but need to ensure peritoneum has been dissected at least 4cm off cord structures, to prevent subsequent encroachment and recurrence under mesh.
  • Secure mesh with tacks - avoid triangle of doom and pain
    • Single tack medially to soft tissue above pubic tubercle
    • Medial inferior border fastened just above Cooper's ligament
    • Don't tack directly into the pubic symphysis - although many surgeons do
    • Also secure mesh along the superior border to the posterior rectus sheath and transversalis fascia, at least 2cm above the hernia defect, and laterally to iliopubic tract
    • Respect the triangles of doom (medial) and pain (lateral)
      • If the tacking device cannot be palpated on the anterior abdominal wall, assume it is below the iliopubic tract
      • Can only tack below the iliopubic tract if you are medial to external iliac vessels
      • See below
  • Allow space to close under vision to ensure sac stays on top of the mesh and doesn't slip under the edge
  • Close fascia with single figure-of-eight
    • If peritoneum was opened, release pneumoperitoneum with a cutdown
• Problems
  • Pneumoperitoneum
    • Insert a 5mm optical port in LUQ with tap open to decompress
    • If still unable to get space, convert to TAPP or open

Fixation in laparoscopic repairs

• Controversial topic
• Tacks (absorbable and permanent), suture, adhesives
• If used, limit to the region of Cooper's ligament, medial to femoral space and anterior abdominal wall
• Do not place tacks posterior to ASIS
• Triangles: apex is internal ring, with doom medially and pain laterally
  • Triangle of pain - femoral and lateral femoral cutaneous nerves and femoral branch of genitofemoral nerve.
  • Triangle of doom - medial - femoral vessels, vas def medially, spermatic vessels laterally

Mesh

• Commonly polypropylene or polyester
• Does not need to be coated if being placed in preperitoneal plane
• Primary variable is weight - 'lightweight' meshes MAY reduce chronic inflammation

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