From the Journals

Underlay mesh for hernia repair yields better postop pain outcomes


Key clinical point: Patients receiving underlay mesh procedures for hernia repair had less postop pain than did those receiving overlay mesh procedures.

Major finding: Mild pain at rest and with movement were both significantly lower in patients who received TAPP than in those who received one of three other surgical procedures.

Data source: Retrospective analysis of 334 primary inguinal hernia patients with 378 lesions undergoing TAPP or Lichtenstein procedures.

Disclosures: The authors did not report any relevant financial disclosures.


Chronic pain that typically follows primary inguinal hernia repair can be significantly reduced by adopting procedures that use underlay mesh rather than overlay mesh, according to a new study published in the Journal of Surgical Research.

“Although chronic pain and discomfort is still one of the greatest problems after inguinal hernia repair due to the fact that it interferes with patients’ quality of life, there are very little data available from previous studies concerning presentation, diagnosis, and modes of treatment of this issue. In particular, the data in the literature concerning the cause of chronic pain are very limited,” wrote the authors, led by Hideyuki Takata, MD, of Nippon Medical School, Tokyo.

Dr. Takata and his coinvestigators looked at patients who underwent a mesh repair operation for primary inguinal hernia at a single institution – Nippon Medical School – between May 2011 and May 2014. All patients were aged 40 years or older, and the overwhelming majority were male. A total of 334 patients were identified, with 378 lesions among them; all patients’ operations were performed via the Lichtenstein (onlay mesh only), Ultrapro Plug (onlay and plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (underlay mesh only, TAPP) surgical routes.

Forty-four patients had bilateral lesions, 152 had lesions on the right, and 138 on the left; 76 patients received Lichtenstein operations, 85 received Ultrapro Plug, 156 received modified Kugel Patch, and 61 received TAPP. (J Surg Res 2016 Aug 11. doi: 10.1016/j.jss.2016.08.027).

Patients received questionnaires at 2-3 weeks, 3 months, and 6 months after the operation to determine their pain and discomfort levels. Responses for all 378 lesions (100%) were received at the first follow-up, with questionnaires received for 229 lesions (60.5%) at the 3-month follow-up and 249 lesions (65.9%) at the 6-month follow-up. Of those who responded at the 6-month follow-up, 46 received Lichtenstein, 59 received Ultrapro Plug, 101 received modified Kugel Patch, and 61 received TAPP.

No patients reported moderate or severe pain while at rest. Mild pain was reported by 11 (4.4%) of all respondents; 0 of those who received Lichtenstein, 4 (6.8%) of those who received Ultrapro Plug, 7 (6.9%) of those who received modified Kugel Patch, and 0 of those who received TAPP (P less than .01).

Pain with movement was reported in 35 (14.1%) of respondents: 6 (13.0%) of those who received Lichtenstein, 7 (11.9%) of those who received Ultrapro Plug, 20 (19.8%) of those who received modified Kugel Patch, and 2 (4.7%) of those who received TAPP (P less than .05). One respondent reported experiencing moderate pain with movement, and that individual received Ultrapro Plug (1.7%). No patients reported experiencing severe pain with movement.

“We conclude that the sensory nerves in the inguinal region should be kept away from the mesh to prevent the development of chronic pain and discomfort,” the investigators concluded. “Further study is required to determine the mechanism involved in the generation of chronic pain and discomfort to improve the patient’s quality of life after primary inguinal hernia repair.”

No funding source was disclosed for this study. Dr. Takata and his coauthors did not report any relevant financial disclosures.

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