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need for analgesics. It was noted in this series that the
vast majority of the patients did not consider early post-
operative pain to be a major factor. The use of post-oper-
ative analgesics was: 14% needed no painkillers, 18% u s ed
pain killers for 1day, and th e majority for just a few days
to a week. Even those who felt post-operative pain to be
an issue did not develop significant chronic pain. Those
patients who did complain of post-operative pain at one
week were kept under review until the pain resolved.
The low incidence of significant early post-operative
pain or perceived pain and the minimal need for analge-
sia in many patients, may be of significance. The LA may
contribute to this early low level of pain and may be a
significant factor, particularly as pre-emptive, peri-opera-
tive and post-operative analgesia considered under the
title “multimodal analg esia” are being assessed as factors
in preventing chronic pain [16].
Furthermore with LA many of the early side effects of
general anaesthesia such as nausea, vomiting, and acute
retention of urine are reduced. Less intensive post-opera-
tive nursing, including airway care is required. The major-
ity of patients go home within 3 hours of surgery. The lo n g
acting LA lasts from 4 - 10 hours and many patients do
not need further analgesia. Many patients preferred the LA
because of previous problems with general anaesthesia.
Many of the studies of the Lichtenstein method have
not used local anaesthesia as described by Lichtenstein.
This may diminish the benefits of the original repair, and
account for a higher incidence of chronic pain found in
some studies [8].
Similarly the role of surgeon experience has been dis-
cussed previously, but not yet explored [17].
4.1. The Nerves
The management of the 3 major nerves of the inguinal
canal has been considered to be a factor in chronic pain
[18]. This study showed a low incidence of chronic pain
despite the IIN and IHN not being formally identified or
damaged and removed in more than 20% of cases.
Extensive studies concluded that identification and of
all 3 nerves of the inguinal canal could influence the in-
cidence of chronic groi n pai n [19,2 0] .
4.2. Mesh, Staples
Mesh and staples have also been widely implicated as
signi ficant fac tors in the d evelopmen t of chronic p ain l e ad -
ing to a variety of new lighter weight meshes, staples and
glues [16]. This series with its low incidence of significant
chronic pain using a standard Polypropylene mesh and
non-absorbable staples raises the question as to their role.
4.3. Positive Results
The positive results identified in this series may be due to
the following factors.
LA infiltration allowing simpler dissection of the tis-
sues with less trauma. Diathermy is not used, possibly
reducing the inflammatory response around the nerve end-
ings, a possible cause of nocioceptive pain. Iden tification
and management of the nerves [12]. The use of the open
skin stapler to fix the mesh (appose ulc 35 w auto suture).
The early supervised management of post-operative pain,
including contact by telephone con tact by the surg eon for
all patients, the day following surgery to adjust analgesia
and give support as necessary.
If the results vary so much, is it possible to attribute
chronic pain to the mesh/fixation alone? The results in
this study, suggest that mesh and staples may not be the
main factors in determining the incidence of chronic pain,
and could it just be the way the materials are used? Does
it depend on the technique and the surgeon?
5. Conclusions
There is strong evidence from this series, using a vali-
dated inguinal pain questionnaire, that a Lichtenstein re-
pair with local anaesthesia can result in a low incidence
of moderate or severe significant chronic post-operative
pain. Those few patients who did report pain requiring
analgesia, did not have any associated significant mor-
bidity or impairment of activities of daily living. Thus
there appeared to be no reason to alter the type of mesh
used or its method of fixation. As well the approach t aken
to the identification and management of the nerves ap-
peared to achieve satisfactory results.
The validated IPQ provides a more detailed apprecia-
tion of the pain. This will be useful in the future to help
in assessing the role of surgical risk factors, surgical ma-
terials, management of the nerves and even the skill of
the surgeon as a cause of chronic pain.
6. Acknowledgements
Prof. Avni Sali, Prof. Steven Chan, Prof. Julian Smith,
Mrs. Di Bloore.
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