How Long Does The Pain Last After A Ventral Hernia Repair
JSLS. 2008 Apr-Jun; 12(2): 113–116.
Postoperative Pain After Laparoscopic Ventral Hernia Repair: a Prospective Comparison of Sutures Versus Tacks
Scott Q. Nguyen, MD, Celia M. Divino, Medico, 
Kerri E. Buch, FNP, Jessica Schnur, MD, Kaare J. Weber, Doc, L. Brian Katz, Dr., Marking A. Reiner, MD, Robert A. Aldoroty, MD, and Daniel M. Herron, Doc
Abstract
Background and Objectives:
Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods.
Methods:
Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Heart were prospectively enrolled in the study. They were sorted into 2 groups (ane) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were non randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-upwardly at 1 week, 1 calendar month, and ii months postoperatively.
Results:
From 2004 through 2005, fifty patients were enrolled in the study. Twenty-9 had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had like average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, ane month, and two months were similar. Both groups also had similar times to return to work and need for narcotic pain medication.
Conclusions:
Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.
Keywords: Laparoscopic ventral hernia repair, Incisional hernia, Mesh, Fixation
INTRODUCTION
Laparoscopic ventral hernia repair has grown in popularity since it was outset reported in the early 1990s. Numerous studies take found information technology to accept many advantages over traditional open repair.1–3 Lower recurrence rates, fewer complications, and shorter infirmary stays have led some to believe that it sets the new standard of care for ventral hernia repair.one,2 Controversy exists regarding the optimal method to ready the prosthetic mesh to the anterior intestinal wall. Currently, the 2 nearly popular methods of mesh fixation are via transabdominal sutures and laparoscopic tacks. Sutures pass through all layers of the fascia and muscle of the anterior abdominal wall, while tacks secure the mesh to the innermost millimeters of the peritoneal crenel.
Nigh controversy in laparoscopic repair centers on the tensile forcefulness of the mesh fixation method. Recurrence is idea to exist the issue of inadequate or failed fixation. Postoperative pain produced by the securing methods is some other consideration in deciding between sutures and tacks. Sutures are felt to crusade worse and more persistent pain.3,4 However, no comparative studies investigate which method truly causes more discomfort. This written report compares these ii methods and examines the consequential pain that occurs after each type of fixation.
METHODS
From 2004 through 2006, patients undergoing laparoscopic ventral hernia repair by 8 different surgeons at the Mountain Sinai Medical Center were prospectively enrolled in the study. Patients undergoing other simultaneous procedures were excluded. The patients were sorted into 2 groupsone: those undergoing hernia repairs primarily with transabdominal sutures (Sutures Group) and2 those undergoing hernia repairs primarily with tacks (Tacks Group). Patients in the Sutures Group had repairs with transabdominal sutures placed circumferentially approximately 2 cm to three cm apart. These patients typically had 10 to 20 sutures placed, depending on the size of hernia. Patients in the Tacks Group included those with hernias completely repaired with simply tacks and repairs that may have involved 4 stay sutures with the rest of the mesh secured to the inductive abdominal wall with tacks. The patients were non randomized into these groups. Selection of repair was made by surgeon preference, including blazon of mesh and type of tacks.
Patients' demographics and clinical data were prospectively recorded. Telephone follow-up was used to determine verbal hurting scores at 1 calendar week, one month, and 2 to iii months postoperatively (0=hurting free, 10=excruciating pain/worse pain e'er). In addition, patients were asked regarding time to return to work and need for narcotic hurting medications. Informed consent was obtained, and this study was approved past the institutional review board. We needed to enroll 50 patients into the report to detect a 50% difference in pain scores (Power 80%, Level of significance P=0.05).
RESULTS
Fifty patients were enrolled in this study. Twenty-nine were in the Sutures Grouping and 21 in the Tacks Grouping. Demographics and clinical characteristics of the 2 groups are outlined in Tabular array 1 . Both groups were of similar historic period and body mass index (BMI). More females were in the Sutures Group. No pregnant difference was plant between the groups in terms of proportion of patients with recurrent hernias, multiple hernia defects, and total defect size. The type of mesh used was surgeon dependant and was variable across both groups.
Table 1.
Demographics and Hernia Characteristics
| Sutures (north = 29) | Tacks (northward = 21) | |
|---|---|---|
| Age | 52 | 57 |
| Thousand/F | 11/18 | iv/17 |
| BMI (kg/m2) | 31.iii | 27.iv |
| Recurrent | v (17%) | 5 (24%) |
| Multiple Defects | 8 (28%) | half-dozen (29%) |
| Mean Defect Size (cmtwo) | 106 | 81 |
| Mesh Type | 12 Composix EX | 15 Composix EX |
| fifteen Dualmesh | five Parietex | |
| 1 Dulex | 1 Dualmesh | |
| 1 Parietex |
Table ii shows the operative and postoperative characteristics of the ii groups. Both groups were like in operative fourth dimension. The Tacks Group had a longer length of postoperative infirmary stay (ii.4 vs 1.7 days); however, this difference was non statistically significant. There was no early recurrence during the follow-up catamenia. The Tacks Group had a higher morbidity rate (19% vs 4%). The well-nigh common complications between the two groups were pneumonia and urinary retention.
Table ii.
Operative and Postoperative Characteristics
| Sutures (due north = 29) | Tacks (n = 21) | P | |
|---|---|---|---|
| Operative Fourth dimension (min) | 132 | 122 | p > 0.05* |
| Length of Stay (days) | i.seven | 2.4 | p > 0.05* |
| Early Recurrence | 0 | 0 | |
| Morbidity | 1 (iii%) Pneumonia | iv (19%) | |
| Urinary Retention: 2 | |||
| Pulmonary Embolism: 1 | |||
| Pneumonia: 1 |
Exact pain scores every bit reported via phone interview are shown in Figure ane . No difference was reported in mean pain scores between the ii groups at 1 calendar week, 1 month, and iii months (P>0.05). On a scale of 0 to ten, patients from both groups had moderate pain i week later on the functioning. Pain scores in both groups decreased at 1 month and were minimal by 2 to three months. In add-on, use of narcotic pain medications during the postoperative period was similar in both groups (Table 3). A similar proportion of both groups required such pain medications at 1 week. Time to render to work was besides similar between the groups. No patients required local anesthetic injection for chronic, persistent hurting in either group.
Mean postoperative pain scores at 1 week, 1 month, and ii to iii months after laparoscopic ventral hernia repair. No difference in pain score existed between groups (P>0.05, 2-tailed Student t test).
Table 3.
Postoperative Pain Assessment
| Sutures (due north = 29) | Tacks (n = 21) | |
|---|---|---|
| Narcotic Pain Meds > one wk | 12 (41%) | 8 (38%) |
| Return to Piece of work by ane wk | 10/xx (50%) | 5/12 (42%) |
Give-and-take
The preferred method of mesh fixation during laparoscopic ventral hernia is controversial. Many proponents of the use of transabdominal sutures cite lower recurrence rates due to higher tensile property strengths of sutures in comparison to tacks.5,6 Other authorsvi–viii argue that the use of tacks reduces surgical time considerably while maintaining similar recurrence rates. These authors besides contend that the use of tacks significantly reduces postoperative pain. To date, nearly studies of mesh fixation during laparoscopic ventral hernia repair focus on the risk of recurrence. Nevertheless, this is the but written report that compares postoperative pain after hernia repair with sutures versus tacks.
Anecdotally, pain is generally worse after repair with sutures than with tacks. Sutures penetrate through the total thickness of intestinal wall musculature and fascia. This has been theorized to crusade local muscle ischemia resulting in severe pain postoperatively.7 In addition, numerous sutures are typically needed effectually the perimeter of the hernia defect. Because mesh overlap on normal muscular fascia is usually aimed for around 3 cm to five cm, the circumference effectually which sutures must be secured becomes quite big. Nosotros found no difference in postoperative pain in patients undergoing hernia repair with sutures or tacks. Both groups had moderate pain at one calendar week and minimal hurting on further follow-up. It is possible that early pain caused by multiple tacks penetrating the parietal peritoneum is equivalent to the pain caused past transfascial sutures. In the long-term, both repairs seem to level off in terms of discomfort.
Cobb et al12 has besides proposed that intercostal nerves may become entrapped within the transabdominal sutures causing chronic, persistent neuropathic pain. Series of repairs using transfascial sutures written report persistent pain and discomfort in 1% to half-dozen% of patients.1–iii,8,9 Most authors feel oral anti-inflammatory medications or injections of a local anesthetic can convalesce the symptoms in the bulk of cases.i,3,10,11 Others have reported re-explorations for persistent pain, finding immediate relief later on the release of a suture from the site of symptoms.12 None of the patients in our study had persistent pain severe enough to undergo local anesthetic injection or reoperation. The reports of persistent cases of pain seem to be isolated at i detail suture site, supporting the nerve entrapment theory. Hurting from muscle ischemia would seem to be more generalized at all of the suture sites. Our data suggest that both methods of mesh fixation are generally not different in terms of their resultant postoperative hurting. Still, because our study only included l patients, occasional episodes of chronic persistent pain due to nerve entrapment are certainly possible if more patients were followed. Our findings are somewhat consistent with those of LeBlanc et al,17 whose written report noted that patients in the earlier half of their series had more hurting. These patients had fewer sutures used, suggesting the use of these sutures was unrelated to postoperative hurting.
Though the apply of laparoscopic tackers may seem to be simpler and faster, nosotros did not notice a significant difference in operative time between the two fixation methods. This is reverse to the general opinion that the employ of tacks reduces surgical fourth dimension.1,4 Operative time during laparoscopic ventral hernia repair significantly involves extensive adhesiolysis and dissection of peritoneal contents from the anterior abdominal wall. Conceivably, surgeons may misinterpret the amount of time spent on the unlike phases of the operation and focus on fourth dimension spent on mesh fixation. In our study, we did not specifically look at operative time during different components of the functioning. Moreover, no other prospective studies compare operative time in laparoscopic ventral hernia repair. Therefore, the assumption that repair with transabdominal sutures takes longer than tack repair remains largely unproven.
The limitations of this study center on the sample size. 50 patients were followed, and comparisons were fabricated between the 2 groups. Small differences in hurting calibration between the groups may exist hard to assess. Still, big differences should be found. Considering that most anecdotal evidence suggests a large difference in pain experience, we experience our conclusions are still valid. In add-on, although information were prospectively recorded, the patients in this study were not randomized to treatment artillery. The blazon of repair was based on surgeon preference, as each had his or her ain stiff feeling regarding the best method of fixation. Larger controlled trials may be necessary to optimally determine which method contributes to the most hurting.
CONCLUSION
Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar overall postoperative pain. Symptoms are moderate by the end of the first postoperative calendar week and mild by i month. Occasional episodes of chronic, persistent suture site hurting are possible and take been reported. Postoperative hurting should exist a minor factor when deciding between repair with sutures or tacks in laparoscopic ventral hernia repair.
Acknowledgments
The authors wish to thank Anthony J. Vine, Doctor, Brian P. Jacob, MD, Subhash Kini, MD, and David Pertsemlidis, Doctor, at the Mount Sinai School of Medicine for assisting in recruiting their patients for this study.
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How Long Does The Pain Last After A Ventral Hernia Repair,
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016187/
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