This is the presentation on Inguinodynia where a complete definition has been formulated. It was presented in conference of Asia Pacific Hernia Society 2017 in Kaohsiung, Taiwan.

1. Inguinodynia: A Curse to
Inguinal Hernia Surgery
Dr. Avisak Bhattacharjee
MBBS,BCS(H), FCPS (Surgery)
MPH(Epidemiology),FMAS (AMASI,India)
Fellow, NCI (Bangkok,Thailand)
PhD Research Fellow (Surgical Oncology)
Consultant, NICRH,Dhaka,Bangladesh

2.  Inguinal hernia surgery is one of the commonest
operations practiced in global surgical field.
 The annual procedural rate in United States is 2,800
per million.
 In Bangladesh there is no well-documented statistics.
 But from the common perception we can surely claim
that the annual procedural rate will be more
outstanding than the first world countries.
INTRODUCTION:
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3.  The inguinodynia is incidence shows a wide range 0-
43 per cent.
 In a 13 years study done by Poobalan et al. from 1987 to
2000 the incidence was up to 53 per cent.
INCIDENCE:
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4.  Total patients: 227
 Inguinodynia:87 (39.4%) [at 6 months follow up]
 No preoperative pain: 29.6% of 87 cases of
inguinodynia.
 Neuropathic pain: 22 (25.28%)
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5. PAIN & CHRONIC PAIN:
International Association for Study of Pain (IASP)
defines –
“PAIN as an unpleasant sensory and emotional
experience associated with actual and potential tissue
damage, or described in terms of such damage.”
CHRONIC PAIN:
Any pain persists more than 3 months of healing
period may be recognized as chronic pain.
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6.  Inguinodynia may be severe and debilitating negative
effection individual in terms of lifestyle and work; also
on economy.
 Most of the definitions--- chronic pain in more than 3
months of surgery
INGUINODYNIA:
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7. INGUINODYNIA may be defined as chronic pain
persistantly lasts more than 3 months with
various intensities (mild, moderate,severe)
following inguinal hernia surgery which may be
due to tissue (nociceptive) or nerve injury
(neuropathic) during surgery.
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MY PROPOSED DEFINITION OF
INGUINODYNIA:

8. INGUINODYNIA TYPES:
INGUINODYNIA
NOCICEPTIVE
SOMATIC
(eg-Osteitis pubis)
VISCERAL
(eg; pain during
urination/ejaculation)
NEUROPATHIC
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9. •Dissection,
•Use of foreign material and
•Inflammation.
These steps may cause injury
•to tissue (nociceptive pain) and
•to nerve (neuropathic pain).
PATHOPHYSIOLOGY:
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10. It can be generated by Nociceptors/ Pain receptors:
•Non-encapsulated endings of peripheral nerve
•Sensitive to noxious stimulus.
In hernia surgery, it can be arise due to
•chronic inflammation,
•stretching of tissue, or
•pain from a lump of rolled-up mesh (meshoma)
pressing on its surroundings.
NOCICEPTIVE PAIN/
NON-NEUROPATHIC PAIN:
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11. INFLAMMATION
Prologed firing of
C fibres
Increased GLUTAMATE
production
Acts on NMDA R.
Central
sensitization & PAIN
Local inflammatory
response by noxious
stimuli
Release CYTOKININ
& MEDIATORS
Increased release of
Substance P and
BRADYKININ
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12. IASP defined as ‘Pain caused by a lesion or disease of
the somatosensary nervous system’.
•Suture fixation in open approach or
•Tacker fixation in laparoscopic approach is the root
cause of neuropathic pain.
•Besides, post operative scar formation in the presence
of prosthetic mesh is another cause of neuropathic
pain.
NEUROPATHIC PAIN:
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13. NEUROPATHIC INGUINODYNIA:
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14. PREOPERATIVE:
•Patient factors: Age, memory, mental status, activity
status as well as genetic status. Patients can experience
pain through combined effects of these factors.
•A clinically silent groin hernia.
Intraoperative Factors
•Anatomical variations of iliohypogastric and
ilioinguinal [Al-Dabbagh et al. claimed both nerves consistent
according to natural course in <50%]
•Surgeon’s experience specially in Lap.
FACTORS REPONSIBLE:
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15. Common victims of inguinal hernia surgery.
1) Iliohypogastric (IHN),
2) Ilioinguinal (IIN)and
3) Genital branch of genitofemoral nerves.
Ways of nerve injury:
• Neurectomy (transaction) during dissection,
• Neuroma formation after partial or complete
transaction or
• Entrapment during fixation or
• Healing is the commonest way of nerve injury.
Ilioinguinal nerve injury is the primary cause of all
neuropathic pain as it runs through the center of operation
field.
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16.  ANALGESIA:
 Pre-emptive analgesia
Prevents central sensitization
Prevents neuronal hyperexcitability
 L/A Field Block
 NSAIDS (-) NMDA receptors [N-Methyl-D-Aspartate]
 NMDA inhibitors
 Mx of severe pain:
 Physical (acupuncture)
 Drugs (analgesia, TCA)
 Nerve blocks
 Psychological support
 Refd to pain clinics
 If all fail  Removal of mesh
MANAGEMENT:
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17. 1) To use intraoperative nerve identifier as course of
nerve in majority cases show variations.
2) Frequent cadaveric dissection to develop expertise on
nerve identification.
RECOMMANDATIONS:
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18. References:
1. M. S. L. Liem, E. B. Van Duyn, Y. Van der Graaf, and
T. J. M. V. Van Vroonhoven, “Recurrences after
conventional anterior and laparoscopic inguinal
hernia repair: a randomized comparison,” Annals of
Surgery, vol. 237, no. 1, pp. 136–141, 2003.
2. S. Ross, N. Scott, A. S. Grant et al., “Laparoscopic
versus open repair of groin hernia: a randomised
comparison,” The Lancet, vol. 354, no. 9174, pp. 185–
190, 1999.
3. T. J. Coderre and J. Katz, “Peripheral and central
hyperexcitability: differential signs and symptoms
in persistent pain,” Behavioral and Brain Sciences,
vol. 20, no. 3, pp. 404–419, 1997.
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19. 4. P. K. Amid, “A 1-stage surgical treatment for
postherniorrhaphy neuropathic pain: triple
neurectomy and proximal end implantation
without mobilization of the cord,” Archives of
Surgery, vol. 137, no. 1, pp. 100–104, 2002.
5. R. E. Condon and L. M. Nyhus, “Complications of
groin hernia,” in Hernia, R. E. Condon and L. M.
Nyhus, Eds., pp. 269–282, Lippincott Williams &
Wilkins, Philadelphia, Pa, USA, 4th edition, 1995.
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20. 6. S. Alfieri, F. Rotondi, A. Di Giorgio et al., “Influence
of preservation versus division of ilioinguinal,
iliohypogastric, and genital nerves during open
mesh herniorrhaphy: prospective multicentric
study of chronic pain,” Annals of Surgery, vol. 243,
no. 4, pp. 553–558, 2006.
7. M. Tverskoy, C. Cozacov, M. Ayache, E. L. Bradley
Jr., and I. Kissin, “Postoperative pain after inguinal
herniorrhaphy with different types of anesthesia,”
Anesthesia & Analgesia, vol. 70, no. 1, pp. 29–35,
1990.
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21. THANK YOU
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