Originally published by our sister publication General Surgery News

LONG BEACH, Calif.—Avoiding chronic pain after inguinal hernia repair can be achieved by following a few fundamental tenets, according to Kaela Blake, MD. Presenting at the 2025 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Dr. Blake offered a series of tips and tricks on how to prevent this sometimes devastating by-product of surgery.

“Let’s talk about what approaches to inguinal hernia repair to have the lowest rates of chronic pain,” began Dr. Blake, an assistant professor of surgery at the University of Tennessee Graduate School of Medicine, in Knoxville.

The 2023 update to the HerniaSurge guidelines for groin hernia management (BJS Open 2023;7[5]:zrad080) offers several recommendations that Dr. Blake highlighted:

• Mesh-based repair reduces the risk for recurrence without increasing the risk for chronic pain.
• Open preperitoneal mesh techniques can achieve favorable results in terms of operating time, acute and chronic postoperative pain, and return to work compared with the Lichtenstein repair.
• Laparo-endoscopic techniques have less chronic pain and faster recovery than the Lichtenstein repair.

“Their final, strong recommendation is that for all patients and all sexes undergoing a primary unilateral inguinal hernia repair, a lap-endo or MIS [minimally invasive surgical] approach is recommended because of lower postoperative pain and a reduction in chronic pain, as long as expertise and resources are available for that,” Dr. Blake said.

If a Lichtenstein repair is warranted, the guidelines offer several insights into reducing or preventing pain. For one, they state that self-gripping mesh does not provide any benefit in terms of short- and medium-term outcomes. They also state that despite comparable surgical results, 3D implants such as plugs and bilayer mesh systems are not recommended due to the excessive use of foreign material, the need to enter both the anterior and posterior planes, and additional cost.

“The final strong recommendation is to use a standard flat sheet of mesh for the Lichtenstein technique,” Dr. Blake said. The guidelines also recommend lightweight mesh (<50 g/m²) in Lichtenstein repairs, preferably with large pore sizes.

Identifying and protecting the nerves in Lichtenstein repairs is another way to avoid the potential for chronic pain. Here it is recommended that surgeons perform pragmatic resection of the ilioinguinal nerve and/or iliohypogastric nerve if iatrogenic nerve injury occurs or if the nerves interfere with mesh position.

“Remember that when you open up the external oblique aponeurosis, your iliohypogastric and ilioinguinal nerves are going to be right there,” Dr. Blake explained. “Take a second and slow down. Protect those nerves instead of just bear pawing your way through that space and causing unnecessary iatrogenic nerve injury.”

A 2016 meta-analysis of 16 studies explored the issue of ilioinguinal nerve neurectomy and preservation in the Lichtenstein repair (World J Surg 2021;45[6]:1750-1760). The research found reduced pain at six months after surgery with automatic neurectomy of the ilioinguinal nerve (8.9% vs. 25.1%; P<0.00001), without a concomitant increase in paresthesia at the same time point.

Dr. Blake then turned her attention to chronic pain after MIS approaches to inguinal hernia. In the 2023 guidelines update, HerniaSurge states that chronic pain in MIS repair is not affected by mesh weight. “They actually recommend a heavyweight mesh [>70 g/m²] for MIS repairs,” she noted.

In regard to the association between tacking or suture fixation and chronic pain after MIS repair, there is little evidence. Indeed, Dr. Blake said only one study has explored the topic (Surg Endosc 2023;37[1]:723-728). “That study found no difference in chronic pain at one and two years,” Dr. Blake explained. “There was also a systematic review and meta-analysis comparing laparoscopic and robotic inguinal hernia repair, which found no difference in pain at one year as well.”

As Dr. Blake concluded, when it comes to preventing chronic pain after inguinal hernia repair, approach matters. “MIS and open preperitoneal repairs have less chronic groin pain than Lichtenstein,” she noted. “And if you’re doing a Lichtenstein, the guidelines tell us to use flat, lightweight mesh, large pores, avoid 3D plugs and patches, and perform pragmatic nerve resection.

“Finally, when it comes to MIS, use minimal fixation, although there’s no difference between tacks and sutures. And as always, avoid the triangle of pain.”

David Earle, MD, offered his insights on the topic, explaining that while chronic pain after hernia repair is rare, it can be devastating nonetheless.

“Even though the incidence is low, the consequences are high,” said Dr. Earle, the director of the New England Hernia Center, in North Chelmsford, Mass. “It can ruin somebody’s life.”

As Dr. Earle said, chronic pain is multifactorial and has complex interactions with the mind and body. Compounding that problem is the fact that chronic pain patients often have clinicians from multiple specialties telling them they’re perfectly fine.

“That’s when the patient can actually begin to think they’re crazy,” he explained. “Every doctor they’ve seen has told them there’s nothing wrong, but meanwhile they’re in constant pain.”

With this in mind, Dr. Earle said choosing the proper technique for every situation is crucial.

“There are many ways to fix a hernia, but you want the one that is most likely to meet the patient’s goals and least likely to cause a problem,” he told General Surgery News. “The way I see it, a laparoscopic repair has the lowest risk of causing chronic pain and an equally low recurrence rate. But because not all patients are candidates for this approach, the surgeon must be able to use anterior technique such as a Lichtenstein repair or refer the patient to a surgeon with sufficient expertise.”