FRESH MESH Almost all hernias are best repaired with surgical mesh.

The medical literature contains a wealth of research on the pathways of pain, particularly visceral pain, but it's clear even without a clinical study that every surgery hurts, and hernia repairs are no exception. Here are 4 tips for managing post-op hernia pain.

1. Set expectations
Whether the hernia is inguinal or the more complex ventral, there is always pain: from the underlying condition as well as from the surgical remedy, which by necessity causes trauma to the tissue. Most patients suffer a certain degree of post-op discomfort — swelling, bruising and muscle aches are common — in the days and weeks of recovery. Every patient experience is different, but the amount of tissue dissection required in their surgery plays a role in post-op pain.

The time to make patients aware of these facts is not at bedside, shortly after they've emerged from anesthesia, say surgical and pain management experts. Effective post-op pain management demands patient education during the pre-surgical office visit. This discussion should cover what they might experience following surgery, and what can be done about it. Patients should know that if during recovery they feel the prescribed pain management regimen isn't sufficiently effective, they should speak up. When post-op patients understand what's expected, and are empowered to communicate their conditions, that's a real source of comfort to them and a solid foundation for their recovery.

Many general surgeons also note the importance of talking with patients about their expectations to tailor post-op care to each individual case. The loss of control that surgical patients feel can create fear, anxiety and stress, which amplifies pain. But effective pain management doesn't have to be a complicated arrangement, especially if you act early enough to prevent pain from dominating recovery in the first place.

SUTURE SOLUTION Suturing mesh is said to result in less pain than stapling or tacking, but fastening devices are convenient for laparoscopic access.

2. Treat preemptively
Every surgery hurts, but every patient feels different levels of pain, and responds differently to it. Still, some physicians make a point of administering the same pain management regimen to each patient, under the logic that pain response cannot be predicted. Why should a patient's orders be limited to oral meds instead of IV analgesics, for example, just because their history and physical or other observations suggest they'll tolerate a procedure better than another patient?

The best opportunity to control a patient's post-op discomfort comes not after they begin to feel pain, but before it is triggered. This is where pre-emptive pain management comes in. Anesthesia providers who administer IV ketorolac or acetaminophen before surgery starts can in 20 or 30 minutes' time ensure a good response to block the patient's pain pathways before they've been activated. This works alongside the anesthesia and any abdominal wall nerve block they've delivered for the surgery itself.

The smaller incisions of minimally invasive hernia repair techniques reduce the amount of trauma on tissue and result in less abdominal wall pain. Without question, less tissue handling is better, surgeons say, but even with experience and caution, there is still pulling, tugging and dissecting. That's why they also advise delivering a local anesthetic injection into the area of the incision shortly before it's made, to numb the pain of the work that's about to be undertaken.

DELAY-FREE DISCHARGE
Are Pumps Part of Your Pain Plan?

PUMP IT UP Continuous local anesthetic infusion can smooth patients' recovery in PACU as well as at home.

Following hernia surgery, it's standard procedure to give patients acetaminophen, ketorolac or another non-steroidal anti-inflammatory medication, either intravenously or orally. But your post-op pain management regimen can still be actively working for days after patients arrive home.

Many abdominal surgeons swear by continuous local anesthetic infusion pumps, strategically placing their catheters beneath the skin at the end of the case. The pump's elastomeric reservoir begins infusing long-lasting bupivacaine or ropivacaine into the surgical site or over the abdominal nerves on its own and counteracts the effects of surgical pain before the patient even leaves the room.

The take-home, disposable pain pumps, available in different sizes and with a range of dosing features and settings, make a surgery that once required 2 or 3 days of recovery in the hospital into one that involves discharging patients within a day and letting them get back to normal sooner.

"I can't overstate the value they offer," says Rita Hadley, MD, PhD, FACS, a general surgeon at Miami Valley Hospital in Dayton, Ohio. "Fear is a terrible negative motivator. 'I'm in pain' can easily lead to 'I won't be able to take care of myself,' and that step can make for a difficult recovery. Pain pumps lend patients in recovery an enormous amount of confidence."

— David Bernard

GRASP AND GO Laparoscopic devices are available to assist in positioning mesh at the defect.

3. Place mesh carefully
Hernia repair is synonymous with surgical mesh usage. Almost all hernias are best repaired with mesh, and surgeons say their choice of mesh depends as much on the type of case they're doing as on the surgical facility's purchasing patterns.

Synthetic, non-absorbable, permanent meshes made from polypropylene, polyester and PTFE are commonly used. Some are coated with additives to provide a measure of protection against adhesion or infection. Alternatively, meshes made from biological materials can be used when an infection is present in the repair site, since antibiotics are able to infiltrate the material. Laparoscopic devices are available to assist learners and experienced hands alike in insertion, positioning and placing mesh faster, more accurately and more efficiently with minimal tissue handling.

If mesh is incorrectly implanted, it can cause foreign body reactions or other complications, and some implanted meshes may feel less flexible than others, but there is no correlation between the specific type of mesh used and the incidence of post-hernia-surgery pain.

On the other hand, the extent of the surgery and the manner in which the mesh is fixed to surrounding tissue can often be correlated to post-op pain. A large hernia will require a large mesh placement, and some methods of attachment may result in more pain than others. For example, tacks, staples and other permanent or absorbable mesh fasteners have been known to cause more post-op pain than sutures do, but it's a trade-off. The fasteners are quicker and more convenient to use than sutures during laparoscopic cases, which results in less post-op pain and accelerated recoveries, as compared with open hernia repairs. During open repairs, there's plenty of access for suturing, although fastening devices are still often used, due to their efficiency.

4. Avoid complications
There is a growing consensus that patients' exposure to narcotics should be limited in favor of multimodal pain management regimens, even after hernia repairs.

Multimodal's proponents urge providers not to let their own patient care complicate recoveries. A nurse who doses a post-surgical patients with IV hydromorphone may have quelled their pain, they argue, but has also likely lowered their blood pressure, made them groggy or dizzy, potentially nauseated them and prolonged their stay in PACU.

Narcotics are good for managing deep abdominal pain, but they're not that good at controlling incisional pain. Injections at the incision site or pain pumps are better. Try administering a bolus from a pain pump before resorting to IV narcotics, experts say. If that's successful in blocking the pain signals to the brain, patients may not need narcotics at all. If they do, however, they'll likely need less and suffer fewer side effects.

A recent survey says that, given the choice, most surgical patients would opt against narcotics to manage post-op pain if they knew there was an alternative. Give them that choice and improve your outcomes.