HARDLY RISK-FREE Hernia repair carries a risk many surgeons and facility managers may not fully consider: chronic post-operative pain. About 1 in 3 patients may suffer from long-term chronic pain and restricted movement after surgery to repair a hernia. Find out what you can do to prevent pain and long-term complications.

When it comes to reducing the pain of hernia repairs, plenty of gains have been made in recent years. Laparoscopic refinements, innovations in mesh and fixation devices, and a new drug-delivery system can all minimize discomfort and increase patient satisfaction. Here are 4 factors to consider in the quest to minimize, or virtually eliminate, the pain that traditionally accompanies hernia surgery.

1. Open or laparoscopic?
There's no question that laparoscopic procedures offer several advantages with inguinal hernias, but there are several variables to consider, one of the biggest being who's doing the surgery. "You have to look at the ability of the surgeon," says Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Health Science Center in Memphis and past president of the American Hernia Association. "Laps are more technically demanding. If you're not well-versed, you should probably stick with open."

But if you are, one of the benefits is likely to be less discomfort for patients.

"There's less acute pain, a quicker recovery and, when done properly, less chronic pain," says Dr. Voeller. "Of course you also have to consider the patient. If you're dealing with someone with a lot of other illnesses, or if the patient has comorbidities that make him high-risk with general anesthesia, you probably want to do open."

It depends on the type of hernia, too, says laparoscopic surgeon Sharona B. Ross, MD, of Tampa, Fla. "For large ventral hernias, I almost exclusively use an open approach, which results in a nice, flat abdominal wall. However, since laparoscopic surgeries do produce less pain and discomfort, there's less peritoneal trauma. Virtually all my inguinal and hiatal hernias I repair laparoscopically. The only time I use an open approach (with hiatal hernia) is when there's an especially hostile abdomen due to previous operations."

Dr. Voeller agrees. "With inguinal hernias, if there have been previous surgeries in the area, or if there's a lot of scarring, it probably should be an open surgery unless the surgeon is very experienced at laparoscopy," he says.

2. Mesh
The trend in recent years has been toward using less-dense material, and as little of it as possible, since, as noted above, the less foreign material you introduce to the body, the less pain there tends to be. The downside: Using less and lighter material makes it harder to handle and position the mesh. And heavier patients may still require heavier material.

In some cases, you may be able to get away with absorbable mesh, or even no mesh at all. "I'm able to repair the majority of the hiatal hernias without mesh in a tension-free manner," says Dr. Ross. "When I need mesh for reinforcement, depending on the size of the defect, I use an absorbable biosynthetic mesh composed partly of porcine small intestine submucosa.

"Sometimes I use ePFTE (expanded polytetrafluoroethylene) impregnated mesh with an antiseptic for diaphragmatic hernias that can't be approximated," says Dr. Ross. "It's more expensive and the operative times are longer, but studies have shown it results in significantly lower numbers of recurrences."

When dealing with hiatal hernias that require mesh reinforcement, Dr. Voeller prefers the biosynthetic mesh BIO-A.

With incisional hernias, different situations call for different approaches, as Dr. Ross notes. "If the abdominal wall is thin, or especially if it's denervated, devascularized and attenuated, I use non-crosslinked bovine pericardium biologic mesh to reinforce it," she explains. "This type of mesh lowers the propensity to develop adhesions, while also eliciting a cascade of events leading to new healthy tissue deposition and prosthesis remodeling. Occasionally, I use this same mesh with smaller abdominal wall hernias."

3. Fixation
The question of which of the many fixation devices is best for reducing pain is, to say the least, an open one. "Mesh fixation in laparoscopic inguinal hernias is highly variable by surgeon," sums up Dr. Ross.

Or as another surgeon once put it: "Nations have gone to war with less passion than manufacturers who argue about who makes the best hernia tack."

It may come down to personal preference, but Dr. Ross cites a study showing no difference in pain scores with and without fixation. "Some people worry that fixation has more trauma and can injure the nerves and vasculature in the area," she says. "The study demonstrates that this shouldn't be a concern."

Her favorite approach is suturing and tacking, although she acknowledges that fibrin glue adhesive can also be used effectively.

That's the best choice for inguinal hernias, as far as Dr. Voeller is concerned. "Some clinical studies show that adhesives can cause less pain, while others show no difference," he says. His own experience, however, suggests there is a difference.

"I switched to adhesive fixation in 2003, and anecdotally, it definitely seems to me as if there's less pain with it," he says. "I've heard others say the same thing — the majority of people don't even have to take narcotics afterward. I also like the fact that with adhesives, you can get fixation into areas where you can't use mechanical fixation."

A recent trend toward absorbable devices has also found favor with some surgeons, but the efficacy jury is still out. "You'd think that there'd be less pain with absorbable tacks than permanent ones," says Dr. Voeller, "but there's no data that says absorbable tacks cause less pain."

What about using no fixation? "With laparoscopic surgery, people have looked into it," says Dr. Voeller. "The recurrence rate when you're looking at hernias that are less than 2 centimeters in size is probably no different with or without fixation, and some people believe there's less pain with no fixation. But without fixation the mesh will definitely migrate, so it's an approach you'd only want to take with incisions of 2 centimeters or less."

Concerned about migration, Dr. Ross prefers the cautious approach. "Studies have shown that there is no difference in pain if you do or do not use a fixation device," she says. "So I think to prevent movement of the mesh or possible recurrence, fixation is good practice."

4. Post-op pain management
It used to be a given that once the hernia patient got home, he was in for a couple of very painful days. Not anymore.

"We use bupivacaine solution to irrigate the diaphragm in all of our laparoscopic procedures to minimize post-operative pain," says Dr. Ross.

Bupivacaine is the active ingredient in the drug Exparel, which now incorporates a time-release delivery platform that dramatically extends the period of post-op pain relief (see "Pain, Pain, Go Away — For Several Days" on page 35).

"I'm a huge proponent of Exparel," says Dr. Ross.

So is Dr. Voeller. "We have used it for the last year or so," he says, "Now that they've put it in liposomes to make it time-released, instead of 3 hours of pain relief, it provides more like 2 or 3 days. Patients simply don't hurt afterward."

SUSTAINED RELIEF
Pain, Pain, Go Away — For Several Days

NO NARCOTICS NEEDED In an independent study, patients who were given Exparel experienced only minimal pain for 72 hours after surgery.

When Dennis Feierman, PhD, MD, talks about post-operative pain with hernia repair, he can relate. He underwent his first hernia surgery more than 25 years ago and the agonizing memory is still vivid.

"Normally, a good block can provide 6 to 8 hours of pain relief," says Dr. Feierman, vice chairman of academic affairs in the division of anesthesiology at Maimonides Medical Center in Brooklyn, N.Y. After that, of course, the painful reality of invasive surgery sets in. And managing it typically requires a significant dose of narcotics.

That's changed, thanks to recent advances with the analgesic Exparel. The injectable drug encapsulates bupivacaine in DepoFoam lipid membranes, which erode and reorganize over time. The result: Bupivacaine is released at various intervals over a period of days.

Dr. Feierman, the lead investigator of an independent hernia pain control study of the drug's efficacy, was extremely impressed by what he saw.

"In our study, patients who were given Exparel were asked to rate the pain on a 0-10 scale with 0 being no pain at all, and 10 being the worst imaginable pain," he says. "After 72 hours, the average rating was 1.6. When it finally wears off, after about 72 hours, most people don't feel too bad anymore."

As part of the study, post-operative pain scores were also assessed after 2, 4, 8, 12, 24 and 48 hours. The highest average came at the 2-hour mark — a mere 2.3. Compare that to what Dr. Feierman experienced in 1985. "I probably would have rated the pain in the high 8s," he says.

And sustained pain relief isn't Ex-parel's only benefit.

"One of the good things about the drug is that it's not an intense block like novocaine," says Dr. Feierman. "You can get the area really anesthetized, but not completely numb. You also eliminate a lot of the side effects you get with narcotics. More and more patients are morbidly obese or may have sleep apnea or other comorbidities. You worry about sending those people home with narcotics. The same is true with the large elderly population. When you can give people a local anesthetic that works for 3 days, you eliminate most of those problems.

Incidentally, Dr. Feierman recently needed another small hernia repair. "I asked for Exparel," he says. "And I went back to work the next morning."

— Jim Burger