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Surgical Endoscopy
Erschienen in: Surgical Endoscopy 4/2018

Open Access 26.10.2017

What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry

verfasst von: H. Niebuhr, F. Wegner, M. Hukauf, M. Lechner, R. Fortelny, R. Bittner, C. Schug-Pass, F. Köckerling

Erschienen in: Surgical Endoscopy | Ausgabe 4/2018

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Abstract

Background

In inguinal hernia repair, chronic pain must be expected in 10–12% of cases. Around one-quarter of patients (2–4%) experience severe pain requiring treatment. The risk factors for chronic pain reported in the literature include young age, female gender, perioperative pain, postoperative pain, recurrent hernia, open hernia repair, perioperative complications, and penetrating mesh fixation. This present analysis of data from the Herniamed Hernia Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique.

Methods

In total, 20,004 patients from the Herniamed Hernia Registry were included in uni- and multivariable analyses. For all patients, 1-year follow-up data were available.

Results

Multivariable analysis revealed that onset of pain at rest, on exertion, and requiring treatment was highly significantly influenced, in each case, by younger age (p < 0.001), preoperative pain (p < 0.001), smaller hernia defect (p < 0.001), and higher BMI (p < 0.001). Other influencing factors were postoperative complications (pain at rest p = 0.004 and pain on exertion p = 0.023) and penetrating compared with glue mesh fixation techniques (pain on exertion p = 0.037).

Conclusions

The indication for inguinal hernia surgery should be very carefully considered in a young patient with a small hernia and preoperative pain.
Hinweise
H. Niebuhr and F. Wegner have contributed equally to this publication.
After mesh-based inguinal hernia repair 10–12% of patients experience at least a level of moderate pain that impacts daily activities [1‐6]. Chronic pain is defined as any pain reported by the patient at or beyond 3 months postoperatively [2]. More than one-quarter of these patients (2–4%) have moderate to severe pain [2, 5, 6]. Risk factors for chronic postoperative inguinal pain include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open hernia repair [1‐6].
In all statements in the guidelines of the international hernia societies, laparo-endoscopic techniques are associated with less chronic pain than the Lichtenstein repair [7‐11]. However, after laparo-endoscopic inguinal hernia repair, 2–5% of patients may still suffer from persistent pain influencing everyday activities, and about 0.4% are referred to pain clinics [12].
On the basis of three meta-analyses of randomized controlled trials [13‐15] mesh fixation in total extraperitoneal patch plasty (TEP) can only be recommended in large medial/direct (EHS MIII) hernias [10].
In the Guidelines of the International Endohernia Society, a recommendation is given for consideration of non-fixation of the mesh in transabdominal preperitoneal patch plasty (TAPP) inguinal hernia repair in types LI, II and MI, II (EHS classification) [9, 10]. For TAPP repair of larger defects (LIII, MIII), the mesh should be fixed [9, 10]. In TAPP inguinal hernia repair, mesh fixation is still used in 66.1% of all primary unilateral cases in men [16].
Considering the fact that five meta-analyses [17‐21] compared non-penetrating vs. mechanical mesh fixation, high-quality evidence could be expected. However, the meta-analyses can only conclude that the evidence is mostly of low or moderate quality, or that more high-quality multicenter studies are needed [22]. In view of the guidelines, fibrin glue should be considered for fixation to minimize the risk of postoperative acute and chronic pain [9, 10].
In a nationwide registry-based study, no differences were found in the frequency of recurrence and chronic pain between permanent and no/non-permanent fixation of the mesh in endoscopic inguinal hernia repair [23].
Another registry-based study from the Danish Hernia Database also found no difference in chronic pain after mesh fixation with fibrin glue vs. tacks in TAPP inguinal hernia repair [24].
The following analysis of data from the Herniamed Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique.

Methods

As of October 10, 2016, 577 participating hospitals and office-based surgeons mainly from Germany, Austria, and Switzerland had entered prospective data into the internet-based Herniamed Hernia Registry on their patients who had undergone routine hernia surgery and signed an informed consent agreeing to participate [25]. As part of the information provided to patients regarding participation in the Herniamed Quality Assurance Study and signing the informed consent declaration, all patients are informed that the treating hospital or medical practice would like to be informed about any problems occurring after the operation and that the patient has the opportunity to attend for clinical examination.
This present study analyzed the prospective data collected for all male patients who had been operated on with an endoscopic TAPP technique for repair of a primary unilateral inguinal hernia in the period September 01, 2009, up to and including September 01, 2015. On 1-year follow-up, the general practitioners and patients were asked through questionnaire about any pain at rest, pain on exertion, and chronic pain requiring treatment. If chronic pain is reported by the general practitioner or patient, patients can be requested to attend for clinical examination. A recent publication has provided impressive evidence of the role of patient-reported outcomes for the identification of chronic pain rates after groin hernia repair [26]. Only those patients for whom 1-year follow-up results were available were included in the analysis. Other inclusion criteria included age ≥ 16 years and only medial/lateral/combined types of inguinal hernia based on the EHS classification [27].
In total, 20,004 were included in uni- and multivariable analyses for investigation of the influencing factors for the development of chronic pain following TAPP inguinal hernia repair (Fig. 1).
All analyses were performed with the software SAS 9.4 (SAS Institute Inc. Cary, NC, USA) and intentionally calculated to a full significance level of 5%, i.e., they were not corrected in respect of multiple tests, and each p value ≤ 0.05 represents a significant result.
To first discern differences between the groups in unadjusted analyses, Fisher’s exact test was used for categorical outcome variables, and the robust t test (Satterthwaite) for continuous variables. For mesh size (cm2), a logarithmic transformation was applied and the re-transformed mean and range of dispersion are given.
To identify influence factors in multivariable analyses, binary logistic regression models for pain at rest, pain on exertion, and chronic pain requiring treatment were used. Potential influence factors were ASA score (I/II/III/IV), age (years), BMI (kg/m2), mesh size (cm2), defect size (I/II/III), risk factors (yes/no), preoperative pain (yes/no/unknown), EHS classification (lateral/medial/combined), postoperative complication (yes/no), and mesh fixation (no fixation/tacker/glue). Estimates for odds ratio (OR) and the corresponding 95% confidence interval based on the Wald test were given. For influence variables with more than two categories, pairwise odds ratios were given. For age (years) the 10-year OR estimate, for BMI (kg/m2) the five-point OR estimate, and for mesh size (cm2) the 10-point OR estimate were given. The results are presented in tabular form, sorted by descending impact.

Results

In total, 20,004 patients were included in the analysis exploring the influence exerted by the fixation technique as well as by other influencing variables on the rate of pain at rest, pain on exertion, and chronic pain requiring treatment (Fig. 1). Of these, 8799 patients had no fixation (44.0%), 6387 (31.9%) only tacker fixation, and 4818 patients (24.1%) only glue fixation.
The patient group in whom the mesh was fixed with a tacker was on average the oldest and had also the highest BMI (Table 1). While there were significant differences in age and BMI between the two groups due to the large patient number, these were not clinically relevant. The meshes in the patient group with no fixation were smaller (Table 1). Besides, meshes with glue fixation had the fewest (8.5%) and meshes with tacker fixation the most (14.1%) ASA III/IV patients (Table 2). The operations with no fixation were most commonly encountered for small hernia defect sizes (17.4%). As regards the defect localization, for lateral EHS classification no or only glue fixation was mainly used, whereas for medial EHS classification tacker fixation was most common (Table 2). Preoperative pain was less common among patients with tacker mesh fixation (59.4%) than in patients with glue mesh fixation (67.3%) or no mesh fixation (66.3%). Drain placement was most commonly used for patients with no mesh fixation (8.4%). In terms of the risk factors, mesh fixation with tackers or glue was more common in patients who continued to take platelet aggregation inhibitors (6.2 vs. 7.8% and 7.6%).
Table 1
Mean age, BMI, and mesh size in male patients with primary unilateral inguinal hernia repair in TAPP technique
 
Non-fixation
Tacker
Glue
p
Age (years)
Median ± STD
55.0 ± 15.6
58.8 ± 14.7
56.4 ± 15.0
< 0.001
BMI
Mean ± STD
25.9 ± 3.3
26.0 ± 3.4
25.8 ± 3.4
< 0.001
Mesh size (cm2)
MW
146.3 [145.2; 147.5]
149.9 [148.7; 151.1]
151.1 [150.1; 152.2]
< 0.001
Table 2
Patient and operative characteristics in relation to mesh fixation and unadjusted tests for significant differences
 
Non-fixation
Tacker
Glue
p
n
%
n
%
n
%
ASA score
 I
3043
34.58
1864
29.18
1946
40.39
< 0.001
 II
4737
53.84
3621
56.69
2461
51.08
 III/IV
1019
11.58
902
14.12
411
8.53
Defect size
 I (< 1.5 cm)
1533
17.42
727
11.38
683
14.18
< 0.001
 II (1.5–3 cm)
6072
69.01
3939
61.67
3200
66.42
 III (> 3 cm)
1194
13.57
1721
26.95
935
19.41
EHS classification
 Combined
1128
12.82
633
9.91
394
8.18
< 0.001
 Lateral
5483
62.31
3718
58.21
3142
65.21
 Medial
2188
24.87
2036
31.88
1282
26.61
Drainage
 Yes
736
8.36
346
5.42
148
3.07
< 0.001
 No
8063
91.64
6041
94.58
4670
96.93
Risk factors
 Total
  Yes
2248
25.55
1665
26.07
1233
25.59
0.747
  No
6551
74.45
4722
73.93
3585
74.41
 COPD
  Yes
368
4.18
313
4.90
195
4.05
0.044
  No
8431
95.82
6074
95.10
4623
95.95
 Diabetes
  Yes
353
4.01
302
4.73
207
4.30
0.100
  No
8446
95.99
6085
95.27
4611
95.70
 Aortic aneurysm
  Yes
27
0.31
30
0.47
12
0.25
0.103
  No
8772
99.69
6357
99.53
4806
99.75
 Immunosuppression
  Yes
47
0.53
34
0.53
15
0.31
0.151
  No
8752
99.47
6353
99.47
4803
99.69
 Corticoid
  Yes
58
0.66
39
0.61
43
0.89
0.173
  No
8741
99.34
6348
99.39
4775
99.11
 Smoking
  Yes
1034
11.75
659
10.32
540
11.21
0.021
  No
7765
88.25
5728
89.68
4278
88.79
 Coagulopathy
  Yes
117
1.33
64
1.00
34
0.71
0.003
  No
8682
98.67
6323
99.00
4784
99.29
 Antiplatelet medication
  Yes
544
6.18
499
7.81
365
7.58
< 0.001
  No
8255
93.82
5888
92.19
4453
92.42
 Anticoagulation therapy
  Yes
133
1.51
118
1.85
68
1.41
0.134
  No
8666
98.49
6269
98.15
4750
98.59
Preoperative pain
 Yes
5829
66.25
3796
59.43
3241
67.27
< 0.001
 No
2515
28.58
2069
32.39
1210
25.11
 Unknown
455
5.17
522
8.17
367
7.62
Unadjusted analysis of the relationship between the fixation technique and the intra- and postoperative complications, recurrence rate as well as pain at rest, on exertion, and requiring treatment on 1-year follow-up is given in detail in Table 3. For postoperative complications, pain on exertion and pain requiring treatment differences are identified in relation to the fixation technique used. For postoperative complication these are largely due to an increased seroma rate (no fixation 0.7% vs. tacker fixation 2.1% vs. glue fixation 3.9%). For operations with no mesh fixation, the rate of pain on exertion (no fixation 10.1% vs. tacker fixation 9.4% vs. glue fixation 8.8%) and pain requiring treatment (no fixation 3.0% vs. tacker fixation 2.4% vs. glue fixation 2.3%) was somewhat higher than in the groups with tacker or glue mesh fixation.
Table 3
Outcome variables in relation to mesh fixation and unadjusted tests for significant differences
 
Non-fixation
Tacker
Glue
p
n
%
n
%
n
%
Intraoperative complication
 Total
  Yes
71
0.81
67
1.05
55
1.14
0.114
  No
8728
99.19
6320
98.95
4763
98.86
 Bleeding
  Yes
48
0.55
52
0.81
35
0.73
0.120
  No
8751
99.45
6335
99.19
4783
99.27
 Injury
  Total
   Yes
42
0.48
31
0.49
27
0.56
0.790
   No
8757
99.52
6356
99.51
4791
99.44
  Vascular
   Yes
23
0.26
17
0.27
11
0.23
0.914
   No
8776
99.74
6370
99.73
4807
99.77
  Bowel
   Yes
6
0.07
4
0.06
4
0.08
0.918
   No
8793
99.93
6383
99.94
4814
99.92
  Bladder
   Yes
4
0.05
6
0.09
5
0.10
0.394
   No
8795
99.95
6381
99.91
4813
99.90
  Nerve
   No
8799
100.0
6387
100.0
4818
100.0
1.000
Postoperative complications
 Total
  Yes
159
1.81
192
3.01
231
4.79
< 0.001
  No
8640
98.19
6195
96.99
4587
95.21
 Bleeding
  Yes
76
0.86
50
0.78
34
0.71
0.602
  No
8723
99.14
6337
99.22
4784
99.29
 Seroma
  Yes
61
0.69
133
2.08
189
3.92
< 0.001
  No
8738
99.31
6254
97.92
4629
96.08
 Infection
  Yes
6
0.07
7
0.11
2
0.04
0.407
  No
8793
99.93
6380
99.89
4816
99.96
 Bowel
  Yes
9
0.10
1
0.02
1
0.02
0.041
  No
8790
99.90
6386
99.98
4817
99.98
 Wound healing disorders
  Yes
7
0.08
5
0.08
8
0.17
0.250
  No
8792
99.92
6382
99.92
4810
99.83
 Ileus
  Yes
8
0.09
2
0.03
3
0.06
0.362
  No
8791
99.91
6385
99.97
4815
99.94
Complication-related reoperations
 Yes
89
1.01
55
0.86
35
0.73
0.226
 No
8710
98.99
6332
99.14
4783
99.27
Recurrence on 1-year follow-up
 Yes
91
1.03
56
0.88
41
0.85
0.467
 No
8708
98.97
6331
99.12
4777
99.15
Pain at rest on 1-year follow-up
 Yes
466
5.30
309
4.84
225
4.67
0.214
 No
8333
94.70
6078
95.16
4593
95.33
Pain on exertion on 1-year follow-up
 Yes
884
10.05
599
9.38
422
8.76
0.045
 No
7915
89.95
5788
90.62
4396
91.24
Pain requiring treatment on 1-year follow-up
 Yes
260
2.95
152
2.38
109
2.26
0.021
 No
8539
97.05
6235
97.62
4709
97.74
Tables 2 and 3 show, in some cases, significant differences in the influencing factors and thus also in outcomes in relation to fixation vs. non-fixation. Accordingly, the unadjusted analysis results permit only limited comparability and therefore call for multivariable analysis.

Multivariable analysis

Pain at rest on 1-year follow-up

The results of analysis of pain at rest on 1-year follow-up are summarized in Table 4 (model fitting: p < 0.001). Pain at rest was highly significantly influenced by the presence of preoperative pain, by age, BMI, and the hernia defect size (in each case p < 0.001). In higher age (10-year OR 0.880 [0.839; 0.924]; p < 0.001) the risk of pain at rest was lower, whereas for higher BMI (five-point OR 1.225 [1.124; 1.334]; p < 0.001), presence of preoperative pain (yes vs. no: OR 1.862 [1.574; 2.201]; p < 0.001), and smaller hernia defect (I vs. III: OR 1.619 [1.298; 2.021]; p < 0.001) it was higher. Additionally, postoperative complications led also to a higher risk of onset of pain at rest (OR 1.613 [1.162; 2.239]; p = 0.004). There was no evidence of the fixation technique having any influence on the risk of onset of pain at rest.
Table 4
Multivariable analysis of influencing factors for pain at rest on 1-year follow-up
Parameter
p Value
Category
p Value paired
OR estimate
95% CI
Preoperative pain
< 0.001
Yes vs. no
< 0.001
1.862
1.574
2.201
Yes vs. unknown
0.149
1.214
0.933
1.581
No vs. unknown
0.004
0.652
0.486
0.875
Age (10-year OR)
< 0.001
  
0.880
0.839
0.924
BMI (5-point OR)
< 0.001
  
1.225
1.124
1.334
Defect size
< 0.001
I (< 1.5 cm) vs. II (1.5–3 cm)
< 0.001
1.453
1.233
1.714
I (< 1.5 cm) vs. III (> 3 cm)
< 0.001
1.619
1.298
2.021
II (1.5–3 cm) vs. III (> 3 cm)
0.244
1.114
0.929
1.336
Postoperative complication
0.004
Yes vs. no
 
1.613
1.162
2.239
Fixation
0.354
Glue vs. tacks
0.184
0.886
0.741
1.059
Glue vs. non-fixation
0.210
0.899
0.761
1.062
Tacks vs. non-fixation
0.850
1.015
0.872
1.181
Risk factors
0.511
Yes vs. no
 
1.053
0.903
1.229
ASA score
0.513
I vs. II
0.248
0.913
0.783
1.065
I vs. III/IV
0.552
0.923
0.710
1.201
II vs. III/IV
0.924
1.011
0.806
1.269
Mesh size (10-point OR)
0.652
  
0.992
0.959
1.026
EHS classification
0.745
Combined vs. lateral
0.609
1.057
0.856
1.305
Combined vs. medial
0.449
1.094
0.867
1.379
Lateral vs. medial
0.649
1.035
0.892
1.201

Pain on exertion on 1-year follow-up

Pain on exertion on 1-year follow-up, whose analysis results are summarized in Table 5 (model fitting: p < 0.001), was significantly influenced by age, preoperative pain, hernia defect size, BMI (in each case p < 0.001), mesh size (p = 0.031), postoperative complications (p = 0.023), and the fixation technique (p = 0.037). A higher age (10-year OR 0.796 [0.768; 0.825]; p < 0.001) led to a lower risk and preoperative pain (yes vs. no: OR 1.516 [1.349; 1.705]; p < 0.001) to a higher risk of onset of pain on exertion. Small defect sizes (I vs. III: OR 1.605 [1.354; 1.902]; p < 0.001), higher BMI (five-point OR 1.180 [1.104; 1.260]; p < 0.001), and onset of postoperative complications (yes vs. no: OR 1.364 [1.045; 1.780]; p = 0.023) increased the risk of pain on exertion.
Table 5
Multivariable analysis of influencing factors for pain on exertion on 1-year follow-up
Parameter
p Value
Category
p Value paired
OR estimate
95% CI
Age (10-year OR)
< 0.001
  
0.796
0.768
0.825
Preoperative pain
< 0.001
Yes vs. no
< 0.001
1.516
1.349
1.705
Yes vs. unknown
0.040
1.236
1.010
1.513
No vs. unknown
0.067
0.815
0.655
1.015
Defect size
< 0.001
I (< 1.5 cm) vs. II (1.5–3 cm)
< 0.001
1.317
1.163
1.492
I (< 1.5 cm) vs. III (> 3 cm)
< 0.001
1.605
1.354
1.902
II (1.5–3 cm) vs. III (> 3 cm)
0.006
1.218
1.060
1.401
BMI (5-point OR)
< 0.001
  
1.180
1.104
1.260
Postoperative complication
0.023
Yes vs. no
 
1.364
1.045
1.780
Mesh size (10-point OR)
0.031
  
0.971
0.946
0.997
Fixation
0.037
Glue vs. tacks
0.010
0.839
0.734
0.959
Glue vs. non-fixation
0.123
0.906
0.800
1.027
Tacks vs. non-fixation
0.183
1.080
0.964
1.209
ASA score
0.088
I vs. II
0.031
0.882
0.787
0.988
I vs. III/IV
0.496
0.932
0.760
1.142
II vs. III/IV
0.548
1.056
0.883
1.263
Risk factors
0.416
Yes vs. no
 
1.049
0.934
1.179
EHS classification
0.518
Combined vs. lateral
0.727
1.029
0.875
1.210
Combined vs. medial
0.701
0.966
0.811
1.151
Lateral vs. medial
0.254
0.939
0.842
1.046
The use of a larger mesh reduced the risk of pain on exertion (10-point OR 0.971 [0.946; 0.997]; p = 0.031). There was also evidence of the influence of the fixation technique, (p = 0.037), revealing that tacker compared with glue fixation led to a higher rate of pain on exertion (OR 1.192 [1.043; 1.362]; p = 0.010).

Chronic pain requiring treatment on 1-year follow-up

The results of analysis of the influencing factors for pain requiring treatment are shown in Table 6 (model fitting: p < 0.001). Here, too, the risk of onset of chronic pain requiring treatment was highly significantly affected by the hernia defect size, age, BMI, and preoperative pain (in each case p < 0.001). The rate of chronic pain requiring treatment was, in particular, negatively influenced by small defect sizes (I vs. III: OR 1.996 [1.482; 2.688]; p < 0.001), higher BMI (five-point OR 1.319 [1.181; 1.473]; p < 0.001) as well as by preoperative pain (yes vs. no: OR 1.819 [1.441; 2.296]; p < 0.001). On the other hand, higher age (10-year OR 0.842 [0.788; 0.899]; p < 0.001) resulted in a lower risk of chronic pain requiring treatment.
Table 6
Multivariable analysis of influencing factors for chronic pain requiring treatment
Parameter
p Value
Category
p Value paired
OR estimate
95% CI
Defect size
< 0.001
I (< 1.5 cm) vs. II (1.5–3 cm)
< 0.001
1.853
1.500
2.289
I (< 1.5 cm) vs. III (> 3 cm)
< 0.001
1.996
1.482
2.688
II (1.5–3 cm) vs. III (> 3 cm)
0.572
1.077
0.832
1.394
Age (10-year OR)
< 0.001
  
0.842
0.788
0.899
BMI (5-point OR)
< 0.001
  
1.319
1.181
1.473
Preoperative pain
< 0.001
Yes vs. no
< 0.001
1.819
1.441
2.296
Yes vs. unknown
0.794
1.048
0.739
1.486
No vs. unknown
0.006
0.576
0.388
0.854
Risk factors
0.079
Yes vs. no
 
1.203
0.979
1.478
Mesh size (10-point OR)
0.167
  
0.966
0.921
1.014
Fixation
0.202
Glue vs. tacks
0.280
0.870
0.675
1.120
Glue vs. non-fixation
0.074
0.810
0.642
1.021
Tacks vs. non-fixation
0.501
0.931
0.755
1.147
ASA score
0.462
I vs. II
0.405
0.914
0.740
1.129
I vs. III/IV
0.223
0.803
0.565
1.142
II vs. III/IV
0.403
0.879
0.649
1.189
EHS classification
0.591
Combined vs. lateral
0.618
1.076
0.807
1.436
Combined vs. medial
0.341
1.167
0.849
1.605
Lateral vs. medial
0.436
1.085
0.884
1.331
Postoperative complication
0.729
Yes vs. no
 
0.902
0.504
1.615

Additional analysis

An additional analysis was included to show, not only qualitatively but also quantitatively, the results for the impact of age and BMI on chronic pain. This revealed that age ≤ 40 years was associated with the highest rates of pain at rest (6.4%), pain on exertion (13.7%), and pain requiring treatment (3.6%) on 1-year follow-up. Patients between > 40 and 60 years had mean pain rates (5.5, 11.6, and 3.1%, respectively) and patients > 60 years had the lowest pain rates (3.9, 6.0, and 1.8%, respectively). Patients with BMI of 18.5–24.9 (WHO classification: normal weight) had the lowest pain rates (4.2, 8.5, and 2.1%, respectively), those with BMI between 25.0 and 29.0 (WHO classification: overweight) had average rates (5.5, 10.0, and 2.7%, respectively) and those with BMI ≥ 30 (WHO classification: obesity) the highest pain rates (6.3, 11.5 , and 4.1%, respectively).

Discussion

The present analysis of data from the Herniamed Hernia Registry for 20,004 male patients with elective primary, unilateral inguinal hernia repair in TAPP technique and with 1-year follow-up results has once again confirmed that, as reported in the literature, a pain at rest rate of 4–5%, pain on exertion of 8–10%, and pain requiring treatment of 2–3% must be expected [1‐6]. In this selected patient group with laparoscopic inguinal hernia repair of exclusively male patients with primary unilateral inguinal hernia, it was also demonstrated that, as in the literature [1‐6], young age (≤ 40 years) and preoperative pain are important influencing factors for onset of chronic pain. The present multivariable analysis has revealed that pain at rest, pain on exertion, and chronic pain requiring treatment was highly affected by preoperative pain and young age. But that was also true for small hernia defects. For a small hernia defect the risk of pain at rest, on exertion, and requiring treatment appeared to be highly significantly greater than for a large hernia defect. One explanation for this could be that a patient who is willing to undergo surgery for even a smaller inguinal hernia is more sensitive to pain [1], and already experiences preoperative pain. But the issue of the indication for surgery must also be addressed. Was the inguinal pain really related to a small inguinal hernia or was this due to other causes that also persisted after inguinal hernia repair? Other causes of inguinal pain must be effectively ruled out.
This clearly demonstrates that young patients with a small inguinal hernia (EHS I: < 1.5 cm) and inguinal pain are at highest risk for onset of chronic pain following laparoscopic inguinal hernia repair. Accordingly, a well-founded indication for surgery is of strictly crucial importance for these patients. The patient should definitely be made aware of this before signing the declaration of informed consent form for surgery. If the indication is correct, the operation should be performed in accordance with the evidence-based guidelines for the TAPP technique [9, 10].
Likewise, patients with higher BMI value (≥ 25.0) had a highly significant influence on the risk of pain at rest, on exertion, and chronic pain requiring treatment after TAPP operation. Overweight or obesity, in particular in male patients makes additional demands on the surgeon during conduct of TAPP. Therefore commensurate caution must be exercised when performing surgery for overweight patients.
In addition to the most important influencing factors for onset of chronic pain after laparoscopic inguinal hernia surgery (young age, preoperative pain, small hernia defect, and higher BMI), there are other factors affecting onset of chronic pain. These include postoperative complications and the use of penetrating tackers for mesh fixation. As demonstrated in five meta-analyses, the use of penetrating mesh fixation compared with glue fixation led to significantly more chronic inguinal pain [17‐21], but the evidence is mostly of low or moderate quality. Unlike the aforementioned meta-analyses, on comparing tack mesh fixation vs. non-fixation Sajid et al. [15] did not find any difference in the chronic pain rates. Likewise, a registry-based Danish study did not find any difference in chronic pain rates after TAPP operation on comparing mesh fixation with fibrin glue vs. tacks [24]. In our study, the influence of penetrating tacks on chronic pain was only confirmed for pain on exertion on comparing non-fixation vs. tack fixation. In their systematic review, Lederhuber et al. [22] concluded that there is still a lack of high-quality evidence for differences between the assessed mesh fixation techniques. Therefore, more high-quality multicenter studies are needed [22]. The findings of our study at least suggest that other factors, such as a small hernia, preoperative pain, younger age, and higher BMI, have a greater impact on the development of chronic pain than does the fixation technique.
Likewise, postoperative complications can trigger inguinal pain. Therefore, an appropriate response must be taken to any development of postoperative complications after TAPP operation to prevent the onset of chronic inguinal pain.
The potential weakness of this study is its non-randomization and the voluntary participation in the internet-based registration. These could lead to selection bias, which can be balanced by the large case number of the study. Furthermore, the registry does not contain any data on how the peritoneum was closed.
In summary, it can be stated that there are several influencing factors for pain at rest, on exertion, and chronic pain requiring treatment following primary unilateral inguinal hernia repair in male patients in TAPP technique. Younger patient age, preoperative pain, smaller hernia defect size, and higher BMI value have a highly significant influence. Other potentially influencing factors are penetrating mesh fixation and development of postoperative complications. Through a well-founded indication, and observance of the technical guidelines for evidence-based conduct of TAPP, it may be possible to prevent chronic pain after TAPP operation.

Acknowledgements

Ferdinand Köckerling received grants to fund the Herniamed Registry from Johnson & Johnson, Norderstedt; Karl Storz, Tuttlingen; PFM medical, Cologne; Dahlhausen, Cologne; B Braun, Tuttlingen; MenkeMed, Munich; and Bard, Karlsruhe.

Compliance with ethical standards

Disclosures

H. Niebuhr, F. Wegner, M. Hukauf, M. Lechner, R. Fortelny, R. Bittner, C. Schug-Pass have no conflicts of interest or financial ties to disclose.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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Appendix

Herniamed Study Group

Scientific board

Köckerling, Ferdinand (Chairman) (Berlin); Bittner, Reinhard (Rottenburg); Fortelny, René (Wien); Jacob, Dietmar (Berlin); Koch, Andreas (Cottbus); Kraft, Barbara (Stuttgart); Kuthe, Andreas (Hannover); Lammers, Bernhard (Neuss); Lippert, Hans (Magdeburg): Lorenz, Ralph (Berlin); Mayer, Franz (Salzburg); Niebuhr, Henning (Hamburg); Peiper, Christian (Hamm); Pross, Matthias (Berlin); Reinpold, Wolfgang (Hamburg); Simon, Thomas (Weinheim); Stechemesser, Bernd (Köln); Unger, Solveig (Chemnitz); Weyhe, Dirk (Oldenburg); Zarras, Konstantinos (Düsseldorf).

Participants

Ahmetov, Azat (Saint-Petersburg); Alapatt, Terence Francis (Frankfurt/Main); Albayrak, Nurretin (Herne); Amann, Stefan (Neuendettelsau); Anders, Stefan (Berlin); Anderson, Jürina (Würzburg); Antoine, Dirk (Leverkusen); Apfelstedt, Heinrich (Solingen); Arndt, Anatoli (Elmshorn); Aschenbrenner, Michael (Spittal/Drau); Asperger, Walter (Halle); Avram, Iulian (Saarbrücken); Baikoglu-Endres, Corc (Weißenburg i. Bay.); Bandowsky, Boris (Damme); Barkus; Jörg (Velbert); Becker, Matthias (Freital); Behrend, Matthias (Deggendorf); Berkhoff, Christian (Fulda); Beuleke, Andrea (Burgwedel); Birk, Dieter (Bietigheim-Bissingen); Bittner, Reinhard (Rottenburg); Blaha, Pavel (Zwiesel); Blumberg, Claus (Lübeck); Böckmann, Ulrich (Papenburg); Böhle, Arnd Steffen (Bremen); Bolle, Ludger (Berlin); Borchert, Erika (Grevenbroich); Born, Henry (Leipzig); Brabender, Jan (Köln); Breitenbuch von, Philipp (Radebeul); Brož, Miroslav (Ebersbach); Brückner, Torsten (Gießen); Brütting, Alfred (Erlangen); Buchert, Annette (Mallersdorf-Pfaffenberg); Buchholz, Torsten (Aurich); Budzier, Eckhard (Meldorf); Burchett, Bert (Teterow); Burghardt, Jens (Rüdersdorf); Cejnar, Stephan-Alexander (München); Chirikov, Ruslan (Dorsten); Claußnitzer, Christian (Ulm); Comman, Andreas (Bogen); Crescenti, Fabio (Verden/Aller); Daniels, Thies (Hamburg); Dapunt, Emanuela (Bruneck); Decker, Georg (Berlin); Demmel, Michael (Arnsberg); Descloux, Alexandre (Baden); Deusch, Klaus-Peter (Wiesbaden); Dick, Marcus (Neumünster); Dieterich, Klaus (Ditzingen); Dietz, Harald (Landshut); Dittmann, Michael (Northeim); Drummer, Bernhard (Forchheim); Eckermann, Oliver (Luckenwalde); Eckhoff (Jörn /Hamburg); Ehmann, Frank (Grünstadt); Eisenkrein, Alexander (Düren); Elger, Karlheinz (Germersheim); Engelhardt, Thomas (Erfurt); Erichsen, Axel (Friedrichshafen); Eucker, Dietmar (Bruderholz); Fackeldey, Volker (Kitzingen); Faddah, Yousif (Kamenz); Farke, Stefan (Delmenhorst); Faust, Hendrik (Emden); Federmann, Georg (Seehausen); Fiedler, Michael (Eisenberg); Fikatas, Panagiotis (Berlin); Firl, Michaela (Perleberg); Fischer, Ines (Wiener Neustadt); Fleischer, Sabine (Dinslaken); Fortelny, René H. (Wien); Franczak, Andreas (Wien); Franke, Claus (Düsseldorf); Frankenberg von, Moritz (Salem); Frehner, Wolfgang (Ottobeuren); Friedhoff, Klaus (Andernach); Friedrich, Jürgen (Essen); Frings, Wolfram (Bonn); Fritsche, Ralf (Darmstadt); Frommhold, Klaus (Coesfeld); Frunder, Albrecht (Tübingen); Fuhrer, Günther (Reutlingen); Garlipp, Ulrich (Bitterfeld-Wolfen); Gassler, Harald (Villach); Gawad, Karim A. (Frankfurt/Main); Gehrig, Tobias (Sinsheim); Gerdes, Martin (Ostercappeln); Germanov, German (Halberstadt); Gilg, Kai-Uwe (Hartmannsdorf); Glaubitz, Martin (Neumünster); Glauner-Goldschmidt, Kerstin (Werne); Glutig, Holger (Meissen); Gmeiner, Dietmar (Bad Dürrnberg); Göring, Herbert (München); Grebe, Werner (Rheda-Wiedenbrück); Grothe, Dirk (Melle); Günther, Thomas (Dresden); Gürtler, Thomas (Zürich); Hache, Helmer (Löbau); Hämmerle, Alexander (Bad Pyrmont); Haffner, Eugen (Hamm); Hain, Hans-Jürgen (Gross-Umstadt); Halter, Christian Jörn (Recklinghausen); Hammans, Sebastian (Lingen); Hampe, Carsten (Garbsen); Hanke, Stefan (Halle); Harrer, Petra (Starnberg); Hartung, Peter (Werne); Heinzmann, Bernd (Magdeburg); Heise, Joachim Wilfried (Stolberg); Heitland, Tim (München); Helbling, Christian (Uznach/Schweiz); Hellinger, Achim (Fulda); Hempen, Hans-Günther (Cloppenburg); Henneking, Klaus-Wilhelm (Bayreuth); Hennes, Norbert (Duisburg); Herdter, Christian (Gelsenkirchen); Hermes, Wolfgang (Weyhe); Herzing, Holger (Höchstadt); Hessler, Christian (Bingen); Heuer, Matthias (Herten); Hildebrand, Christiaan (Langenfeld); Höferlin, Andreas (Mainz); Hoffmann, Henry (Basel); Hoffmann, Michael (Kassel); Hofmann, Eva M. (Frankfurt/Main); Horbach, Thomas (Fürth); Hornung, Frederic (Wolfratshausen); Hudak, Attila (Suhl); Hübel-Abe, Jan (Ilmenau); Hügel, Omar (Hannover); Hüttemann, Martin (Oberhausen); Hüttenhain, Thomas (Mosbach); Hunkeler, Rolf (Zürich); Imdahl, Andreas (Heidenheim); Iseke, Udo (Duderstadt); Isemer, Friedrich-Eckart (Wiesbaden); Jablonski, Herbert Gustav (Sögel); Jacob, Dietmar (Berlin); Jansen-Winkeln, Boris (Leipzig); Jantschulev, Methodi (Waren); Jenert, Burghard (Lichtenstein); Jugenheimer, Michael (Herrenberg); Junge, Karsten (Aachen); Kaaden, Stephan (Neustadt am Rübenberge); Käs, Stephan (Weiden); Kahraman, Orhan (Hamburg); Kaiser, Christian (Westerstede); Kaiser, Gernot Maximilian (Kamp-Lintfort); Kaiser, Stefan (Kleinmachnow); Karch, Matthias (Eichstätt); Kasparek, Michael S. (München); Kastl, Sigrid (Braunau am Inn); Keck, Heinrich (Wolfenbüttel); Keller, Hans W. (Bonn); Kewer, Jans Ludolf (Tuttlingen); Kienzle, Ulrich (Karlsruhe); Kipfmüller, Brigitte (Köthen); Kirsch, Ulrike (Oranienburg); Klammer, Frank (Ahlen); Klatt, Richard (Hagen); Klein, Karl-Hermann (Burbach); Kleist, Sven (Berlin); Klobusicky, Pavol (Bad Kissingen); Kneifel, Thomas (Datteln); Knolle, Winfried (Pritzwalk); Knoop, Michael (Frankfurt/Oder); Knotter, Bianca (Mannheim); Koch, Andreas (Cottbus); Koch, Andreas (Münster); Köckerling, Ferdinand (Berlin); Köhler, Gernot (Linz); König, Oliver (Buchholz); Kornblum, Hans (Tübingen); Krämer, Dirk (Bad Zwischenahn); Kraft, Barbara (Stuttgart); Kratsch, Barthel (Dierdorf/Selters); Krausbeck, Matthias (Schwerin); Kreissl, Peter (Ebersberg); Krones, Carsten Johannes (Aachen); Kronhardt, Heinrich (Neustadt am Rübenberge); Kruse, Christinan (Aschaffenburg); Kube, Rainer (Cottbus); Kühlberg, Thomas (Berlin); Kühn, Gert (Freiberg); Kuhn, Roger (Gifhorn); Kusch, Eduard (Gütersloh); Kuthe, Andreas (Hannover); Ladberg, Ralf (Bremen); Ladra, Jürgen (Düren); Lahr-Eigen, Rolf (Potsdam); Lainka, Martin (Wattenscheid); Lalla, Thomas (Oschersleben); Lammers, Bernhard J. (Neuss); Lancee, Steffen (Alsfeld); Lange, Claas (Berlin); Langer, Claus (Göttingen); Laps, Rainer (Ehringshausen); Larusson, Hannes Jon (Pinneberg); Lauschke, Holger (Duisburg); Lechner-Puschnig, Marina (Klagenfurt am Wörthersee/Österreich); Leher, Markus (Schärding); Leidl, Stefan (Waidhofen/Ybbs); Leisten, Edith (Köln); Lenz, Stefan (Berlin); Liedke, Marc Olaf (Heide); Lienert, Mark (Duisburg); Limberger, Andreas (Schrobenhausen); Limmer, Stefan (Würzburg); Locher, Martin (Kiel); Loghmanieh, Siawasch (Viersen); Lorenz, Ralph (Berlin); Luedtke, Clinton (Kusel); Luther, Stefan (Wipperfürth); Luyken, Walter (Sulzbach-Rosenberg); Mallmann, Bernhard (Krefeld); Manger, Regina (Schwabmünchen); Maurer, Stephan (Münster); May, Jens Peter (Schönebeck); Mayer, Franz (Salzburg); Mayer, Jens (Schwäbisch Gmünd); Mellert, Joachim (Höxter); Menzel, Ingo (Weimar); Meurer, Kirsten (Bochum); Meyer, Moritz (Ahaus); Mirow, Lutz (Zwickau); Mittag-Bonsch, Martina (Crailsheim); Möbius, Ekkehard (Braunschweig); Mörder-Köttgen, Anja (Freiburg); Moesta, Kurt Thomas (Hannover); Mugomba, Gilbert (Dannenberg); Moldenhauer, Ingolf (Braunschweig); Morkramer, Rolf (Radevormwald); Mosa, Tawfik (Merseburg); Müller, Hannes (Schlanders); Müller, Volker (Nürnberg); Münzberg, Gregor (Berlin); Murr, Alfons (Vilshofen); Mussack, Thomas (St. Gallen); Nartschik, Peter (Quedlinburg); Nasifoglu, Bernd (Ehingen); Neumann, Jürgen (Haan); Neumeuer, Kai (Paderborn); Niebuhr, Henning (Hamburg); Nix, Carsten (Walsrode); Nölling, Anke (Burbach); Nostitz, Friedrich Zoltán (Mühlhausen); Obermaier (Straubing); Öz-Schmidt, Meryem (Hanau); Oldorf, Peter (Usingen); Olivieri, Manuel (Pforzheim); Passon, Marius (Freudenberg); Pawelzik, Marek (Hamburg); Pein, Tobias (Hameln); Peiper, Christian (Hamm); Peiper, Matthias (Essen); Pertl, Alexander (Spittal/Drau); Philipp, Mark (Rostock); Pickart, Lutz (Bad Langensalza); Pizzera, Christian (Graz); Pöllath, Martin (Sulzbach-Rosenberg); Pöschmann, Enrico (Thalwil); Possin, Ulrich (Laatzen); Prenzel, Klaus (Bad Neuenahr-Ahrweiler); Pröve, Florian (Goslar); Pronnet, Thomas (Fürstenfeldbruck); Pross, Matthias (Berlin); Puff, Johannes (Dinkelsbühl); Rabl, Anton (Passau); Raggi, Matthias Claudius (Stuttgart); Rapp, Martin (Neunkirchen); Reck, Thomas (Püttlingen); Reinpold, Wolfgang (Hamburg); Renter, Marc Alexander (Moers); Reuter, Christoph (Quakenbrück); Radke, Alexander (Thun/Zweisimmen); Richter, Jörg (Winnenden); Riemann, Kerstin (Alzenau-Wasserlos); Riesener, Klaus-Peter (Marl); Rodehorst, Anette (Otterndorf); Roehr, Thomas (Rödental); Rössler, Michael (Rüdesheim am Rhein); Roncossek (Bremerhaven); Rosniatowski, Rolland (Marburg); Roth Hartmut (Nürnberg); Sardoschau, Nihad (Saarbrücken); Sauer, Gottfried (Rüsselsheim); Sauer, Jörg (Arnsberg); Seekamp, Axel (Freiburg); Seelig, Matthias (Bad Soden); Seidel, Hanka (Eschweiler); Seiler, Christoph Michael (Warendorf); Seltmann, Cornelia (Hachenburg); Senkal, Metin (Witten); Shamiyeh, Andreas (Linz); Shang, Edward (München); Siemssen, Björn (Berlin); Sievers, Dörte (Hamburg); Silbernik, Daniel (Bonn); Simon, Thomas (Weinheim); Sinn, Daniel (Olpe); Sinner, Guy (Merzig); Sinning, Frank (Nürnberg); Smaxwil, Constatin Aurel (Stuttgart); Sörensen, Björn (Lauf an der Pegnitz): Sucke, Jochen Markus (Gießen); Syga, Günter (Bayreuth); Schabel, Volker (Kirchheim/Teck); Schadd, Peter (Euskirchen); Schassen von, Christian (Hamburg); Schattenhofer, Thomas (Vilshofen); Scheibel, Mike (Krefeld); Schelp, Lothar (Wuppertal); Scherf, Alexander (Pforzheim); Scheuerlein, Hubert (Paderborn); Scheyer, Mathias (Bludenz); Schilling, André (Kamen); Schimmelpenning, Hendrik (Neustadt in Holstein); Schinkel, Svenja (Kempten); Schmid, Michael (Gera); Schmid, Thomas (Innsbruck); Schmidt, Ulf (Mechernich); Schmitz, Heiner (Jena); Schmitz, Ronald (Altenburg); Schöche, Jan (Borna); Schoenen, Detlef (Schwandorf); Schrittwieser, Rudolf (Bruck an der Mur); Schroll, Andreas (München); Schubert, Daniel (Saarbrücken); Schüder, Gerhard (Wertheim); Schürmann, Rainer (Steinfurt); Schultz, Christian (Bremen-Lesum); Schultz, Harald (Landstuhl); Schulze, Frank P. (Mülheim an der Ruhr); Schulze, Thomas (Dessau-Roßlau); Schumacher, Franz-Josef (Oberhausen); Schwab, Robert (Koblenz); Schwandner, Thilo (Lich); Schwarz, Jochen Günter (Rottenburg); Schymatzek, Ulrich (Eitorf); Spangenberger, Wolfgang (Bergisch-Gladbach); Sperling, Peter (Montabaur); Staade, Katja (Düsseldorf); Staib, Ludger (Esslingen); Staikov, Plamen (Frankfurt am Main); Stamm, Ingrid (Heppenheim); Stark, Wolfgang (Roth); Stechemesser, Bernd (Köln); Steinhilper, Uz (München); Stengl, Wolfgang (Nürnberg); Stern, Oliver (Hamburg); Stöltzing, Oliver (Meißen); Stolte, Thomas (Mannheim); Stopinski, Jürgen (Schwalmstadt); Stratmann, Gerald (Goch); Straßburger, Harald (Alfeld); Stubbe, Hendrik (Güstrow/); Stülzebach, Carsten (Friedrichroda); Tepel, Jürgen (Osnabrück); Terzić, Alexander (Wildeshausen); Teske, Ulrich (Essen); Thasler, Wolfgang (München); Tichomirow, Alexej (Brühl); Tillenburg, Wolfgang (Marktheidenfeld); Timmermann, Wolfgang (Hagen); Tomov, Tsvetomir (Koblenz); Train, Stefan H. (Gronau); Trauzettel, Uwe (Plettenberg); Triechelt, Uwe (Langenhagen); Ulbricht, Wolfgang (Breitenbrunn); Ulcar, Heimo (Schwarzach im Pongau); Ungeheuer, Andreas (München); Unger, Solveig (Chemnitz); Utech, Markus (Gelsenkirchen); Verweel, Rainer (Hürth); Vogel, Ulrike (Berlin); Voigt, Rigo (Altenburg); Voit, Gerhard (Fürth); Volkers, Hans-Uwe (Norden); Volmer, Ulla (Berlin); Vossough, Alexander (Neuss); Wallasch, Andreas (Menden); Wallner, Axel (Lüdinghausen); Warscher, Manfred (Lienz); Warwas, Markus (Bonn); Weber, Jörg (Köln); Weber, Uwe (Eggenfelden); Weihrauch, Thomas (Ilmenau); Weiß, Heiko (Aue); Weiß, Johannes (Schwetzingen); Weißenbach, Peter (Neunkirchen); Werner, Uwe (Lübbecke-Rahden); Wessel, Ina (Duisburg); Weyhe, Dirk (Oldenburg); Wicht, Sebastian (Bützow); Wieber, Isabell (Köln); Wiens, Matthias (Affoltern); Wiesmann, Aloys (Rheine); Wiesner, Ingo (Halle); Withöft, Detlef (Neutraubling); Woehe, Fritz (Sangerhausen); Wolf, Claudio (Neuwied); Wolkersdörfer, Toralf (Pößneck); Yaksan, Arif (Wermelskirchen); Yildirim, Can (Lilienthal); Yildirim, Selcuk (Berlin); Zarras, Konstantinos (Düsseldorf); Zeller, Johannes (Waldshut-Tiengen); Zhorzel, Sven (Agatharied); Zuz, Gerhard (Leipzig).
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Metadaten
Titel
What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry
verfasst von
H. Niebuhr
F. Wegner
M. Hukauf
M. Lechner
R. Fortelny
R. Bittner
C. Schug-Pass
F. Köckerling
Publikationsdatum
26.10.2017
Verlag
Springer US
Erschienen in
Surgical Endoscopy / Ausgabe 4/2018
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-017-5893-2

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