What is the best course of action for a patient with a history of bilateral inguinal hernia with mesh placement, presenting with intermittent pain in the right groin region, radiating to the inner thigh, eased by rest and exacerbated by activity, over the past 2 years?

Chronic Post-Herniorrhaphy Groin Pain: Diagnostic and Management Approach

This patient most likely has chronic post-herniorrhaphy inguinal pain (CPIP), and the best course of action is to begin with conservative management including NSAIDs, physical therapy, and nerve blocks, followed by surgical exploration with mesh removal and neurectomy if conservative measures fail after 3-6 months. 1, 2

Initial Diagnostic Assessment

This clinical presentation is highly consistent with CPIP rather than hernia recurrence or other pathology:

• Pain characteristics favor CPIP: Intermittent groin pain radiating to inner thigh, relieved by rest and sitting, worsened by activity, without sensory/motor deficits—this pattern strongly suggests nerve involvement rather than recurrent hernia 3, 4
• Timeline supports CPIP diagnosis: Pain persisting for 2 years post-mesh repair falls within the typical presentation window for late-onset chronic pain, which can appear months to years after surgery 5
• Absence of red flags: No weakness, no sensory loss, and no mention of a palpable bulge makes recurrent hernia or other acute pathology less likely 3

Key diagnostic steps:

• Physical examination should specifically assess for nerve tenderness along ilioinguinal, iliohypogastric, and genitofemoral nerve distributions 4
• Ultrasound or MRI can help rule out recurrent hernia if there is diagnostic uncertainty 3
• Consider imaging to evaluate mesh position and potential nerve entrapment 5

Understanding CPIP Epidemiology and Risk Factors

CPIP affects 10-12% of patients overall, with debilitating pain affecting daily activities in 0.5-6% of cases 4. This patient's 2-year history places them in the clinically significant chronic pain category.

Risk factors present in this case:

• Previous mesh repair (inherent risk factor) 4
• The bilateral nature of the original repair may increase complexity 4

Conservative Management Algorithm (First-Line)

Begin with a stepwise conservative approach for 3-6 months before considering surgical intervention 1, 4:

1. Pharmacological management:

   • NSAIDs as first-line analgesics (when not contraindicated) 6
   • Consider neuropathic pain medications (gabapentin, pregabalin) for nerve-related symptoms 4
   • Acetaminophen as adjunct therapy 6

2. Physical therapy:

   • Targeted exercises to reduce nerve irritation and improve core stability 6
   • Manual therapy techniques for groin pain 4

3. Interventional pain management:

   • Diagnostic and therapeutic nerve blocks (ilioinguinal, iliohypogastric, genitofemoral) 4, 2
   • If nerve blocks provide temporary relief, this confirms nerve involvement and guides surgical planning 2

Critical pitfall to avoid: Do not rush to surgery without attempting conservative measures, as many patients improve with non-operative management 4

Surgical Management (When Conservative Fails)

If conservative management fails after 3-6 months, surgical exploration is indicated 1, 4, 2:

Recommended Surgical Approach

A combined laparoscopic and open approach yields excellent outcomes with 95% patient satisfaction (20/21 patients reporting significant improvement) 2:

1. Laparoscopic exploration first:

   • Assess mesh position and identify potential nerve entrapment from the posterior approach 2
   • Evaluate for mesh displacement or fixation issues 5, 7

2. Open anterior exploration:

   • Direct visualization of ilioinguinal, iliohypogastric, and genitofemoral nerves 2, 5
   • Identify specific pathology (nerve entrapment in mesh, staple fixation on pubic tubercle) 5

3. Definitive surgical treatment:

   • Mesh removal if nerve is entrapped or indistinguishable from mesh 2, 5
   • Triple neurectomy (ilioinguinal, iliohypogastric, genitofemoral nerves) in selected cases 1, 4
   • Removal of problematic fixation devices (staples on periosteum of pubic tubercle are a known cause of late-onset pain) 5
   • Mesh replacement in the opposite anatomical plane (if original was anterior/open, place posterior/laparoscopic mesh and vice versa) 2

Specific Technical Considerations

Two main pathological findings account for late-onset severe chronic pain 5:

• Ilioinguinal nerve entrapment (found in 4/6 patients in one series): Mesh becomes indistinguishable from nerve, requiring en-bloc removal 5
• Mesh fixation on pubic tubercle periosteum (found in 2/6 patients): Staple removal from periosteum provides relief 5

Mesh displacement is minimal with modern techniques: Mean displacement is only 1.8-1.9 cm at 30 days, even without fixation, making this an unlikely cause of chronic pain 7

Multidisciplinary Pain Management

CPIP should be managed by multidisciplinary teams combining pharmacological and interventional measures 1, 4:

• Pain medicine specialists for nerve blocks and medication optimization 4
• Physical therapy throughout conservative and post-operative phases 4
• Surgical expertise in hernia and nerve surgery for definitive management 1, 4

Expected Outcomes

Surgical outcomes for CPIP are favorable when properly selected 2, 5:

• 95% significant improvement or resolution with combined approach 2
• No hernia recurrences reported in surgical series for CPIP 2, 5
• Minimal morbidity with modern techniques 2
• Follow-up of 6-44 months shows sustained pain relief 5

Critical Pitfalls to Avoid

• Do not dismiss chronic pain as "normal": CPIP lasting >3 months and affecting daily activities requires active management 4
• Do not operate without attempting conservative measures first: Nerve blocks and physical therapy should precede surgery 4, 2
• Do not perform isolated neurectomy without mesh evaluation: Combined approach addressing both mesh and nerves yields better outcomes 2
• Do not replace mesh in the same anatomical plane: If mesh removal is necessary, replacement should be in the opposite plane (anterior vs. posterior) 2