How to manage incapacitating pain in the medial thigh 10 days post open Lichtenstein repair of inguinal hernia in a patient with a history of ventral hernia repair with mesh?

Management of Incapacitating Medial Thigh Pain After Inguinal Hernia Repair

The most effective approach for managing incapacitating medial thigh pain 10 days after open Lichtenstein repair is to administer a genitofemoral nerve block, as this nerve distribution is most commonly affected in post-herniorrhaphy pain and targeted nerve blocks have shown 77% complete pain resolution in affected patients. 1

Evaluation of Pain Source

• Pain in the medial thigh 10 days after Lichtenstein repair most likely represents neuropathic pain involving the genitofemoral nerve, which commonly presents as sharp shooting pain along the distribution of inguinal nerves 2
• Clinical examination should focus on identifying the point of maximal tenderness, particularly over the genitofemoral nerve distribution, medial end of the scar, pubic tubercle, or ilioinguinal nerve distribution 1
• Chronic post-herniorrhaphy pain is defined as pain lasting >6 months, but early intervention for acute severe pain can prevent progression to chronic pain 3

First-Line Treatment

• Genitofemoral nerve block with local anesthetic (such as Chirocaine) and corticosteroid (such as Methylprednisolone acetate) at the point of maximal tenderness 1
• For pain management, use oxycodone 5-15 mg every 4-6 hours as needed, titrating to the lowest effective dose that achieves adequate analgesia while monitoring for respiratory depression 4
• Local infiltration at the medial end of the scar or pubic tubercle with anesthetic and corticosteroid if examination reveals these as points of maximal tenderness 1

Second-Line Options

• If nerve blocks are ineffective, consider amitriptyline for neuropathic pain management 1
• For persistent severe pain, surgical exploration may be necessary to address potential mesh-related issues, with re-suturing of the mesh if it appears to be the source of pain 1
• MRI can be safely performed even with the presence of surgical mesh to evaluate for other potential causes of pain, as mesh is not a contraindication to MRI 5

Prevention of Chronic Pain

• Early aggressive pain management is crucial, as early postoperative pain is a significant predictor of chronic pain development 3
• Identification and preservation of all three inguinal nerves (ilioinguinal, iliohypogastric, and genitofemoral) during the initial surgery is critical for preventing chronic pain 2, 3
• Lightweight meshes are generally preferred due to lesser foreign body reaction and better tolerance by patients 2

Prognosis

• With appropriate treatment targeting the specific cause of pain, approximately 77% of patients can become completely pain-free, 15% may have mild residual pain, and only about 8% may continue to experience significant persistent pain 1
• The success of treatment depends on accurate identification of the pain source and appropriate targeted intervention 1, 2

Clinical Pitfalls to Avoid

• Failure to identify the exact nerve involved can lead to ineffective treatment and progression to chronic pain 2, 3
• Delaying treatment of acute severe post-operative pain increases the risk of developing chronic pain syndrome 3
• Using only systemic analgesics without addressing the specific nerve involvement is less effective than targeted nerve blocks 1