http://repub.eur.nl/res/aut/27089/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/23805/ 2011-03-02T00:00:00Z Purpose: To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain. Methods: A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question. Results: A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair. Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy. Conclusion: The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain. http://repub.eur.nl/res/pub/21815/ 2010-12-08T00:00:00Z In the Netherlands approximately 31,000 inguinal hernias are corrected yearly, making it one of the most frequently performed operations in surgery. The majority of inguinal hernia repairs is conducted in male patients older than 50 years. Since recurrence rates have been reduced to a few per cent after mesh repair, nowadays morbidity associated with open inguinal hernia repair is mainly related to chronic pain. The incidence of chronic pain has been reported to be up to 53%, however reported incidences are variable due to different defnitions of chronic pain. A working group that recently developed the European Hernia Society (EHS) guidelines for treatment of inguinal hernia estimated the overall incidence of moderate to severe chronic pain after hernia surgery to be around 10-12%. The primary endpoint in studies regarding inguinal hernia repair has been recurrence up to now. Currently, such studies have also focused on chronic pain. The choice for surgical treatment of an inguinal hernia is based on dissolving pain and discomfort associated with the hernia. Additionally, this prevents an emergency operation necessary in case of incarceration and/or strangulation of the previous harmless hernia that is associated with higher morbidity and mortality compared to elective surgery. However, the indication for elective surgery should not only depend on consideration of mortality rates that are associated with emergency and elective repair. The rate of incarceration and/or strangulation of a conservatively treated hernia, the rate of recurrence of a hernia postoperatively, contra-indications, preoperative pain and discomfort associated with the hernia, the natural course of pain and the incidence of chronic postoperative pain should also be taken into account. http://repub.eur.nl/res/pub/24073/ 2009-10-01T00:00:00Z Background: Inguinal nerve identification during open inguinal hernia repair is associated with less chronic postoperative pain.However,most Dutch surgeons do not identify all three inguinal nerves when carrying out this procedure. The aim of this study was to evaluate the feasibility of a nerve-recognizing Lichtenstein hernia repair and to measure the extra time required for surgery Methods: Forty patients with primary inguinal hernia were operated on following the nerve-recognizing Lichtenstein hernia repair by four experienced hernia surgeons from four different Dutch teaching hospitals. The additional time needed to identify each individual nerve was recorded, and iatrogenic nerve injuries and anatomical characteristics were registered. Results: Identification of the iliohypogastric and ilioinguinal nerves was each performed within 1 min. Identification of the genital branch of the genitofemoral nerve was notably more difficult but could usually be performed within 2 min. Identification of the cremasteric vein, running parallel to the genital branch, was less comprehensive. The incidence of major anatomical variations was low. Twenty-five per cent of ilioinguinal nerves, however, could not be identified. In five patients inguinal nerves were damaged iatrogenically during standard manoeuvres of the Lichtenstein hernia repair. Conclusion: Three-nerve-recognizing Lichtenstein hernia repair is feasible and non-time consuming if the surgeon has appropriate anatomical knowledge. In view of the low incidence of major anatomical variations, knowledge of standard inguinal nervous anatomy should be adequate. This procedure could enable the surgeon to prevent or recognize iatrogenic nerve damage and offer an opportunity to perform deliberate neurectomy as an alternative to accidental nerve injury. Copyright http://repub.eur.nl/res/pub/35119/ 2007-11-01T00:00:00Z Background: Open mesh or non-mesh inguinal hernia repair may influence the incidence of chronic postoperative pain differently. Methods: A total of 300 patients scheduled for repair of a primary unilateral inguinal hernia were randomized to non-mesh or mesh repair. The primary outcome measure was clinical outcome including persistent pain and discomfort interfering with daily activity. Long-term results at 3 years of follow-up have been published. Included here are 10-year follow-up results with respect to pain. Results: Of the 300 patients, 87 patients (30%) died and 49 patients (17%) were lost to follow-up. A total of 153 were physically examined in the outpatient clinic after a median long-term follow-up of 129 months (range, 109 to 148 months). None of the patients in the non-mesh or mesh group suffered from persistent pain and discomfort interfering with daily activity. Conclusions: Our 10-year follow-up study provides evidence that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity. An important new finding from the patient's perspective is that chronic postoperative pain seems to dissipate over time. http://repub.eur.nl/res/pub/35332/ 2007-07-01T00:00:00Z http://repub.eur.nl/res/pub/35341/ 2007-07-01T00:00:00Z http://repub.eur.nl/res/pub/36076/ 2007-07-01T00:00:00Z Ilioinguinal nerve entrapment presents with a clinical triad of pain in the iliac fossa and inguinal region, sensory abnormalities in the cutaneous distribution of the nerve and tenderness on palpation 2-3 cm medial and below the anterior superior iliac spine. The syndrome poses diagnostic difficulties, as genitofemoral nerve entrapment and non-neurological conditions of the lower abdomen may cause similar pain. We report on a patient with acute groin pain radiating towards the scrotum, caused by ilioinguinal nerve entrapment. The clinical diagnosis was strongly suggested by electromyographic examination, using the monopolar needle as a deep stimulating electrode. Subsequent nerve blockade caused complete relief of symptoms. The technique is described. Future applications for treatment of post-surgical pain are discussed. http://repub.eur.nl/res/pub/35482/ 2007-04-01T00:00:00Z Background: Prospective studies and meta-analyses have indicated that non-mesh repair is inferior to mesh repair based on recurrence rates in inguinal hernia. The only reliable way to evaluate recurrence rates after hernia surgery is by long-term follow-up. Methods: Between September 1993 and January 1996, a multicentre clinical trial was performed, in which 300 patients with unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. Long-term follow-up was carried out from June 2005 to January 2006. Results: Median follow-up was 128 months for non-mesh and 129 months for mesh repair. The 10-year cumulative hernia recurrence rates were 17 and 1 per cent respectively (P = 0-005). Half of the recurrences developed after 3 years' follow-up. There was no significant correlation between hernia recurrence and age, level of expertise of the surgeon, contralateral hernia, obesity, history of pulmonary disease, constipation or prostate disease. Conclusion: After 10 years mesh repair is still superior to non-mesh hernia repair. Recurrence rates may be underestimated as recurrences continue to develop for up to 10 years after surgery. Copyright http://repub.eur.nl/res/pub/35491/ 2007-04-01T00:00:00Z http://repub.eur.nl/res/pub/36745/ 2007-04-01T00:00:00Z Background: Morbidity associated with open inguinal hernia repair (IH repair) mainly consists of chronic pain. The aim of this study was to identify possible disparities between state-of-the-art Lichtenstein repair, and its application in general practice. Methods: A questionnaire was mailed to all surgeons and surgical residents (n = 1,374) in the Netherlands in February 2005. The objective was to determine the state of general practice with respect to technical steps during the Lichtenstein repair that are suggested to be involved in the development of chronic pain, as recently updated by Lichtenstein's successor, Amid. Results: More than half of the respondents do not act according to the Lichtenstein guidelines with respect to surgical steps that are suggested to be involved with the origin of chronic pain of somatic origin. Compliance with Amid's guidelines with respect to the handling of the nerves is variable. Surgeons conducting high numbers of IH repair are more likely to operate according to the key principles of the state-of-the-art Lichtenstein repair. Conclusion: There is a substantial disparity between the state-of-the-art Lichtenstein repair and its application in general practice with respect to steps that are suggested to play a role in the origin of chronic groin pain. http://repub.eur.nl/res/pub/36130/ 2007-02-01T00:00:00Z Background: Pain syndromes of somatic and neuropathic origin are considered to be the main causes of chronic pain after open inguinal hernia repair. Nerve-identification during open hernia repair is suggested to be associated with less postoperative chronic pain. The aim of this study was to define clinically relevant surgical anatomical zones facilitating efficient identification of the three inguinal nerves during open herniorrhaphy. Method: Through dissection of 18 inguinal areas of embalmed and unembalmed human cadavers, identification zones were developed for the inguinal nerves (in particular for the genital branch of the genitofemoral nerve). Results: The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5-5.5 cm) cranially from the external ring. When present, the ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. Identification of the genital branch of the genitofemoral nerve was more comprehensive. The course of the genital branch is laterocaudal at the level of the internal inguinal ring. Conclusion: Based on the newly defined identification zones, peroperative identification of all inguinal nerves is possible. Further research is warranted to assess clinical feasibility of these zones and to evaluate the influence of (facultative) division, preservation or omittance of the identification of inguinal nerves on the incidence of chronic pain. http://repub.eur.nl/res/pub/35642/ 2007-01-01T00:00:00Z Background: Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain. Methods: A systematic literature review was performed to identify studies investigating the influence of different types of nerve management. Results: Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all. Conclusion: The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results. Copyright