DISCUSSION
In our series, a total of 206 patients having 243 surgical interventions enrolled but 20 patients
with 23 interventions were excluded with dropout ratio of 10%. Finally 186 patients with 220
patient interventions were included for analysis.
• The study of Koch et al [151] had 4% and Callesen et al have 7% of drop out
ratio. [130]
International Society for Study of Pain (ISSP) defines chronic pain is the pain persisting for 3
months, International Consensus Conference on hernia had added the rider ‘who did not have
groin pain before their original hernia operation’, or, ‘if they did, the post-operative pain
differs from the pre-operative pain”.[104] Jaiswal had studied for minimum period of 6
months. [19] Alfien had studied for 6 months. [15] Other study had studied it 3 months to 3
years. [114]
The main objective o f the study is to found incidence ofpain its relation to various factors
When we analyze the data for early postoperative pain on day 3 & 7 almost all the patients
have pain and around 20% patients had moderate to severe pain required analgesics on day 7.
So the data for various factors were analyzed with pain data on 30th day and for chrome pam
at 90*day and 180th day.
I our study age group we have divided the patient’s age m three groups young age (0-39 yrs.),
middle age (40-60 yrs.) and old age (>61 yrs.). Poobalan et al and Bay- Nielsen et al had
similar age grouping division in their study except the old age group, where it was > 60 years
and >65 years respectively.[13,117]
•
In our study 98(44.5%) had pam on 30th day and it was 35(61.4%) young, 38(37.3%)
middle and 25(41%) old age group patients. Analysis on day 90 showed chrome pam
in 30(13.6%) patients and it was 13(22.8%), 14(12.7%) and 4(6.6%) in respective age
groups. On 180* day, chronic pam was present m 14(6.4%), it was 5(8.8%) young
patients in compare to middle 7(6.9%) and 2(3.1%) old age group. The moderate pam
group both 2(0.9%) were from young group.
The analysis using X2 test, we found that there was significant relation between age o f the
patients’ age and pain. Pain and the severity o f pain decrease with advancing age On
extended follow up the overall pain incidence was only (6.6%) and so such relation was
difficult to established (P-0,15)
105
•
Poobalan et al had reported 30% chronic pam at 3months with 11(58%), 33(40%) and
169(14%) in similar age groups and had concluded the same. They also concluded
that M l time employment were more likely to have chronic pain then retired. [117]
•
Bay-Nielsen et al. chrome pain incidence was 28 7% and the relation of chrome pam
to age groups were 39.7%, 33.2% and 17.6% respectively with functional impairment
rate of 11.2% and 6.1% in young and old age groups [13], but m our study the
functional impairment was not observed. In further study they conclude that pain was
more common in patients younger than 40 years o f age [116]
In our study there were 102(46.4%) hernia on left side and 118(53.6%) on right side. In study
of Alfien et al also 45% on left side and 55% on right side [15]
•
No study had analyzed the chrome pain relationship with right or left side hernia.
•
We analysed the data on the 30th day, suggest 46(45.1%) left sided and 52(46.1%)
right sided hernia had pam, which was 9(8.8%) and 21(17.8%) on the 90th day and
4(3.9%) and 10(8.4%) on extended follow up of 180th day respectively.
•
The analysis suggest that there is association between right side hernia and chronic
pain (P= 0 05) at 9(fh day, but with Spearman‘s correlation test itfound there is weak
relation between side hernia and chronic pain ( r - 0.122; P -0.070) at 9(fh day.
In our study there were 152(81.7%) patients presented as unilateral hernia and 34 (18.3%) as
bilateral hennas. Fitzgibbon study 86.5% unilateral and 13 5% bilateral hernias,[53] Alfien
study had 90% and 10% respectively.[15]
•
In our study mild pam was in 13.2% unilateral and 10.3% bilateral hernia on 90th day,
which turned 5.3% and 5.9% respectively on 180th day. Moderate pam was 2.9% in
both 90th and 180th day.
•
The analysis was (p=0 366) on 9(fh day and (p=0.299) on 18(fhday, suggest that there
was no significant relation between unilateral or bilateral hernia and pam,
•
Alfieri et al had reported moderate to severe pain at 6 months m 2.0% (16/797)
unilateral and 2 8% (5/176) bilateral hernia repairs (P=0.16)
In our study 12.7% hernias presented within Imonth and 28 6% between 1-2 months. Over
all 85.5% patients presented within 6 months of hernia with mean duration of 4.3 months.
•
Bay-Nielsen had found that around 16% of the patients had < 6 wks of hernia where
as 72% had >= 6wks hemia.[13]
•
In our series, size of hernia was A (<4cm) m 66(30%), B (4-8 cm) in (56.8%) and
C(>8cm) in 29(13.2%) of patients. The extent of hernia was 1 (within inguinal canal)
106
in 88(40%), 2 (Beyond external ring but not in scrotum) m 125(56.8%) and 3 (in the
scrotum) in 7(3.2%).
•
We studied the relation of size o f hernia to extent of hernia usmg cross tabulation with
X2 test and Spearman analysis, we found significant relation between them (P<0.001).
•
Small hernias correlate well with confinement within the inguinal canal but large
hernias not always reach to scrotum. Our study show that most of the hernias
presented to us are around the inguinal region with variable size but only 3.2% of the
hernia extent in the scrotum.
•
In other study also only 6.9% hernias were found to be mgumoscrotal.[15].
In our study, as per Nyhus classification 53.6% hernia were indirect (25.9% type I, 25.9%
type II, 1.8% type III B) and 45% were direct III A in our series.
•
The study of Fitzgibbon had indirect inguinal hernias comprised 53% of hernias (type
1=12%, type 2=29%, type 3b=12%) and 41% (type 3a) direct inguinal hernias. [53]
•
In our study, analysis between the size o f hernia and direct or indirect hernia found
no significant relation (P -0 268) and there is no association between extent o f hernia
with direct or indirect hernia (P = 0.06)
In our series hernia size C (> 8cm) showed 27.6% had chronic pam in compare size A
(12.1%) and B (11.2%) on 90th day.
•
The analysis suggest that chronic pam had weak association with large hernias
(p=0.054) but such association was not present with extent o f hernia (p--0.766)
•
No study had reported size and extentfo r pain.
In our senes pre operative pam was present in 80(36.4%) patients and the character of pain
was dragging in 47(58.8%) and 33(41.3%) had dullache.
•
The analysis suggests that there was no significant relation between preoperative
hernia pain and post operative early pain (P -0.067) and chronic pain (P—0 289).
•
Liem also found no significant relation between them (P=0.2).[l 19]
•
The study of Poobalan stated significant predictive value (P<0.005) between
preoperative and chrome pain.[117] In contrast, Page showed that hernia surgery
reduced the preoperative pain, but some of the patients develop pam at the operative
site which was not preoperatively present. In contrast, other study had found that 30%
of the patients reported no change in pain from before surgery and 5% had worse pain
than before surgery. [14, 120]
In our series, the content of sac was bowel in 164(75%) and omentum in 56(25%).
107
•
The analysis suggests no relation of content of the sac with chronic pain (p=0.690).
•
No study had reported this type of analysis.
In our senes, general anesthesia was given in 3(1.4%) patients, local anesthesia in 24 (10.9%)
patients and spinal anesthesia in 193 (87.7%) patients.
•
The analysis suggests that there was no relation between type o f anesthesia and post
operative pain (p=0.967).
•
In Fitzgibbons study general anesthesia (GA) was used in 51%, spinal anesthesia (SA)
in 10%, and local anesthesia (LA) in 37% and found no difference on post operative
pain.[53]
•
Marre found that the open inguinal hernia repair was performed under local in 73% (n
= 316), epidural in 21% (n = 94), or general in 6% (n = 25) anesthesia. [68]
•
Despite sufficient scientific data to support the local anesthesia, large epidemiologic
and nationwide information from databases show high use of spinal anesthesia and
low use of local infiltration anesthesia.[69]
•
Alfieri et al had reported moderate to severe pam at 6 months around 2.0% in each
form of local, general and spinal/ epidural anesthesia (P=0.89) [15].
In our series, associated risk factors presents with hernia includes, COPD (n=39), DiabetesDM (n=17), Hypertension-HT (n=38), Ischemic heart diseases-IHD (n=17), Smoking (n=53),
Prostatism (n=34), Tuberculosis-TB (n=l), Phymosis (n=3) and Hydrocele (n=4).
•
In Fitzgibbon study factors were hypertension (55%), IHD (2%), COPD (9.1%), DM
(9.2%), Prostatism (21.4%), Cigarette smoking (37%) and alcohol (24.1%) of the
patients. [53]
•
At Shouldice Hospital, the study of 7159 patients reported associated cardiovascular
factors were anticoagulation therapy (aspirin, ticlopidine, warfarin 12%), history of
myocardial infarction (15%), history of angina (15%), therapy for congestive heart
failure (17%), hypertension (20%), and cardiac arrhythmias (50%),[6]
In our series, size of incision for operation was around 7 cm in l3 1 and 8 cm m 56 patients.
•
The analyses suggest that there was no significant association and relation between
sizes o f incision to post operative pain (p=0.993)
•
No previous reports had studied this.
In our series, cremasteric skeletanization done in 145(73%) and not done in 75(27%). 85% of
the mdirect hernia and 40% of the direct hernia required cremasteric skeletanization.
108
•
The analyses suggest that there was significant association (p=0.012) between
skeletonization and chronic pain on 9(fh day but with spearman correlation it showed
(r--0 .079; P~0 241) weak correlation between cremasteric skeletamzation and post
operative chronic pain
•
No past studies had studied this factor.
•
Experimental study found that preserved cremasteric muscle fibers protected the
structures of the spermatic cord.[152]
In our series, in 165(75%) patients the nerves were isolated and in 55(25%) they were not
isolated.
•
The findings suggest that isolation o f nerve had no significant association with early
post operative pain at 3(fh day (p=0.686) or pain at 9(fh day (p~0.249), but have
definite association with long standing post operative pain and its severity at 18(fh
day (p—0.037). I f nerves were not isolated than patients have more likely to have long
standing post operative pain
•
Ravindran survey in UK for inguinal nerves during open hernia repair showed that
IIN was routinely identified by 88% of surgeons, IHN by 58% and GFN by
54%.[121]
•
These nerves are considered to be one of the culprit for post hermoplasty chronic
pain, m particular ilioinguinal and/ or gemtofemoral nerve.[42]
•
Identifica:ion and preservation of these nerves during open inguinal hernia surgery
reduce chronic pain,[43] and it is easily feasible and not time consuming if there is
knowledge of anatomy.[38]
In our series, 11(5%) patients had accidental or iatrogenic injury to either of nerve branches
of ilioinguinal, iliohypogastric or genitofemoral nerve. The pain was present in 26(13.4%) of
the non injury group and 4(44.4%) in the injury group at 90* day, 11(5.3%) and 3(33.3%) at
180* day.
•
The analysis suggest that injury to the nerve branches shows significant association
with chronic postoperative pain at 9(fh day (p -0 .017) and definite association with
long standing postoperative pain and its seventy at 18(fh day (p-0.003). Two patients
had iatrogenic division o f genital branch o f the genitorfemoral nerve and they do not
show any association with pain.
•
The individual nerves were routinely divided by 5 to 7% of surgeons in hernia
surgery.[121]
109
•
The common nerve likely to get injured is gemtofemoral nerve, the incidence of
chronic pam reduced by preserving it, and if necessary elective division to reduces
chance of entrapment syndromes.[126]
•
Alfieri reported the risk of developing inguinal pam increasing with the number of
nerves concomitantly not detected and the division of nerves was strongly correlated
with the presence of chronic pam, thus they strongly stress the importance of always
identifying and preserving all 3 nerves of the inguinal canal, during hemia.[43]
International Consensus Conference on hernia had recommendation to identify and preserve
all three inguinal nerves during open inguinal hernia repair to reduce the risk o f chronic
groin pain. Likewise, elective resection o f a suspected injured nerve was recommended [104]
In our series, the hernia defect size was < 1.5 cm in 49(22.3%), between 1.5 to 3 cm in
124(56.4%) and > 3 cm size in 47(21.4%). Direct hernias had usually more than 1.5 cm and
few indirect hernia had more than 3 cm.
The posterior wall defect repair was performed m 125(56.8%) patients m the form of ring
closure or posterior wall placation.
154(70%) of the patients required 8*7 cm size mesh, where as 38(17.3%) had 7*6 and
28(12.7%) had 9*7 cm size mesh.
•
The analysis suggests that posterior wall defect itself is not associated with post
operative pain (p~0 325)
•
When posterior wall repair performed fo r defect closure, the early post operative was
noted (p =0 046) but not reflected in later on follow up o f 9(fh day (p=0.829) and
180th day (p=0,868)
No study had studied defect size and closure m relation to chrome pam.
•
The analysis fo r mesh size (p=0.307), types o f suture material (prolene or Vicryl) and
size (0 or 00) o f suture material (p—0 939), and method o f suturing either continuous
or intermittent stitches (p=0198) had no association with post operative chronic
pain.
•
Paajanen studied fixation of mesh with absorbable and polypropylene sutures m
Lichtenstein operation and found no significant difference in pam and other outcome
of measures.[140]
In our series, 208(95%) surgeries had been completed within 60 minutes and 12(5%) more
than 60 minutes.
no
•
The analysis suggest that operative time is more than 60 minutes was associated with
post operative pain (p -0 042) but Spearman correlation did not found the relation
between them
•
I f surgery lasted > 90 minutes than wound infection rate was 9,9% [88]
In our series, mean period of postoperative analgesia required by patients was 1.75 days of
injectable drugs and 6 days of oral analgesics.
•
The analysis suggests that analgesics requirement is having direct relation with the
severity o f the pain (p-0.001).
•
There is no data in the literature to assess the role o f specific analgesic therapies in
reducing the development o f a chronic pain state after inguinal herniorrhaphy. [14]
In present study patients had resume their routine work ranging from 1 day to 20 days with
average of 11.7 days. We have 12 (5.5%) wound infection. We so we to analyze the data of
return work, wound infection and pain together.
•
The analysis using Spearman correlation test and found the values (r= 0127,
P-0.059) suggest that there was a weak relation between wound infection and return
to routine work.
•
The analysis o f wound infection and pain at 30, 90 and 180 days the value were
(p<0 001) and (r=0.127; p=0.061), (r=0.268; p<0 001) and (r=0.344; p<0.001). It
suggests that there was strong relation between wound infection and chronic pain.
•
Cochrane Database (2007) found minor bruise or erythema in 3%, wound infection
3% and wound hematoma 1% in hospital records. If surgery lasted > 90 minutes than
wound infection rate was 9 9%.[88]
•
Verstraete reported mean social inactivity period was 3.2 weeks, the time to work
resumption 5.4 weeks. [114]
•
Koch had reported lightweight mesh patients returned to work after 4 days, compared
with 6.5 days for the standard mesh (P = 0.040). The lightweight group returned to
normal activity after 7 days, versus 10 days for the standard group (P = 0.005). There
was no difference in postoperative pain or recurrence at the 1-year follow-up.[151]
Our study had shown that, pain incidence m early post operative period was 207(94.1%) on
7th day and 98(45.5%) on 30th day. The incidence of post operative chronic para was
30(13.6%) on 90th day and 14(6.4%) on 180th day. Detail study of chrome pain had shown
that 24 (10.9%) had mild pain, 3(1.4%) had mild pain but occasional taking drugs and
ill
3(1.4%) had moderate pain but not taking any drug on 90th day. On 180* day, 14 (6.4%) had
chronic pain of which 12 (5.5%) had mild pain while 2(0.9%) patients had moderate pain but
none of the patients were taking any analgesics.
•
The analysis suggests that there was strong relation between early post operative pain
on 3(fh day and chronic pain (r=0.622; P<0.001) 90th day and (r~0.445; P<0.001)
on 180th day.
•
Over all analysis suggest that early post operative pain and its seventy had strong
relation with post operative chronic pain.
•
Callesen et al found that the nsk of chronic pain was significantly higher (P<0.05) in
patients with a high early postoperative pain score compared with those with a lower
postoperative pain score after 1 and 4 weeks.[130]
In our senes no patient had recurrence of hernia up to six months of follow up.
•
The use of meshes had dramatically reduced the mcidence of hernia recurrence and m
nearly all case it occurs at the edges of meshes. Two-thirds of recurrences occur after
3 years (median, 26 months), early recurrence may be because of technical
failure. [82]
112