2. Henry Kissinger, 17 Jun 2006 “ Soccer is a game that hides great complexity in an appearance of simplicity.”

3. GROIN PAIN INCIDENCE * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986;3 (suppl): 1–226. Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years 34.3% >1year 210 E. K. Aasvang 2006 Mild 4.1% > 1yr Severe 0.5% > 1yr 2.1 %> 6 mo 9.7% > 6 mo 973 Sergio Alfieri 2006 31% >24 to 36 mo 2456 Ulf Fra¨nneby 2006 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo 208 Jrg Kninger 2004 1.8% > 5 yrs 9.7%>1 yr 928 A. M. Grant 2004 6%>1 yr 25% > 1 yr 593 Marcello Picchio 2004 > 2.5 yrs 71% have pain Severe in 22% Mild in 45% 3% > 3 mo 4062 C. A. Courtney 2002 30% >21 mo 454 S. Kumar 2002 3% 28.7% > year 1166 Morten Bay-Nielsen 2001 30% > 3 mo 226 A. S. Poobalan 2001 Pain Severe Outcome of Pain Pain * # of Pts Author

4. QUALITY OF LIFE 6% 2456 Ulf Fra¨nneby 2006 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) 208 Jrg Kninger 2004 11.3% to 14.2% 973 Sergio Alfieri, 2006 24.8% 6% after 6.5 years 210 Nb E K Aasvang 2006 18.1% 454 S Kumar 2002 16.6% 1166 Morten Bay-Nielsen 2001 Pain affects the Quality of life Pts Author

5. What Causes Groin Pain Like soccer affects our lives, groin pain also effects the quality of life… How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n.

6. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation

8. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n.

9. GENITOFEMORAL NERVE INNERVATION (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve

10. NERVE INNERVATION - FEMORAL BR. GENITOFEMORAL NERVE (L1,2) The femoral branch supplies sensory innervation to the anterolateral thigh.

11. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n.

13. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Femoral n.

15. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n.

16. RISK FACTORS: MESH REPAIR The presence of the prosthetic mesh was not associated with significant postoperative complaints Jrg Kninger 2004 There was no association between severe or very severe pain following operation and operation type (mesh or non-mesh) C. A. Courtney 2002 Patients who underwent mesh repair reported more chronic pain than those who had suture repair, but this was not significant (P = 0.08) A. S. Poobalan 2001 Mesh repairs are less likely to cause CGP than non-mesh repairs Scott N 2000 The behaviour of the prosthetic mesh as a foreign body, with all its implications such as shrinkage and scarring, might be a risk factor for the development of chronic pain itself Heise CP, Starling JR (1998)

19. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age

20. RISK FACTORS: AGE P < 0.001 345 (33.6%) 205 (21.0%) < 59 > 59 1026 976 Ulf Fra¨nneby, 2006 NS 30.2% 36.5% 31.7% 18-40 41-65 >65 43 126 41 E K Aasvang 2006 P 0.000 47 134 66 72 < 50 > 50 309 Simon Willem Nienhuijs 2005 P < 0.001 8 (42%) 49 (60%) 102 (86%) 11 (58%) 33 (40%) 16 (14%) < 40 40-60 >60 226 19 82 118 7 ? A S Poobalan 2001 Statistical Significance No Pain Pain Age # of Pts Author

21. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Pre-op pain

22. RISK FACTORS: PREOPERATIVE PAIN * Lower than “Affects concentration on daily activities” ** “Affects concentration on daily activities” or higher Statistical significance No Chronic Pain Chronic Pain # of Pts Preop Pain Author No pain* 966 Pain** 1036 No pain Pain 176 (18.2%) 374 (36.1%) 7 (13%) 50 (35%) 47(87%) 95(65%) P <0.001 Ulf Fra¨nneby2006 0.005 A.S. Poobalan 2001 No correlation was found between the presence of preoperative pain and the occurrence of postoperative pain Marcello Picchio, 2004 Patients who go on to suffer chronic pain are more likely to have complained of pain from the hernia before operation than those who have no postoperative pain and they are more likely to suffer from other chronic pain conditions compared with the normal population. C. A. Courtney 2002

23. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age BMI Pre-op pain

24. RISK FACTORS: BMI *The authors of this study considered the association of the BMI with chronic pain a coincidence. The elderly, for the most part, had a higher body mass index. Statistical Significance No Chronic Pain Chronic Pain # Pts BMI Author < 25 282 >25 Normal 66 Overweight 109 Obese 40 76 (27%) 45 (16% 16 (24%) 31 (28%) 15 (38%) 85 (30%) 76 (27%) 50 (76%) 78 (72%) 25 (62%) P 0.059 Simon Willem Nienhuijs * 2005 P 0.341 A S Poobalan 2001

25. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk Pre-op pain BMI

26. RISK FACTORS: POST OP COMPLICATIONS Postoperative complications were found to be linked to an increased risk for longterm pain. (OR, 1.8; 95% CI, 1.2–2.5; P 0.003) Risk Factors for Long-term Pain After Hernia Surgery Ulf Fra¨nneby, MD, ( Ann Surg 2006;244: 212–219) P < 0.003 Post Op Complications 52/137 (38.0%) Registered 498/1865 (26.7%) Not registered

27. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Recurrent hernia

28. RISK FACTORS: RECURRENT HERNIA *In this study no variables were identified that significantly correlated to pain or functional impairment 6.5 years after surgery. Statistical Significance No Chronic Pain Chronic Pain # Pts Recurrent Hernia Author Recurrent Initial Recurrent Initial 27.8% 35.6% 10 (59%) 39 (24%) 7 (41%) 124 (76%) NS E. K. Aasvang 2006* 0.005 A. S. Poobalan 2001

29. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Day case surgery Technique Insurance status Recurrent hernia

31. RISK FACTORS: LAPAROSCOPY vs. OPEN P< 0.01 54 (22.5%) 82 (38.3%) TEP Open mesh repair 240 214 S. Kumar 2002 532 (27.9%) 18 (18.9%) Anterior approach Posterior approach 1907 95 Ulf Fra¨nneby, 2006 P 0.019 108 (27.7%) 129 (35.6%) TEP Open 390 362 A. M. Grant 2004 P< 0.01 Slight Moderate Severe 12 (14.8%) 1 (1.2%) - 18 (23.7%) 4 (5.3%) 3 (3.9%) 16 (21.6%) 10 (13.3%) 2 (2.7%) TAPP Lichetenstein Shouldice 81 76 74 Jrg Kninger 2004 Statistical Significance Pain Procedure # Pts Author

32. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Day case surgery Technique Insurance status Recurrent hernia Non-surgical management Neurolysis

35. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Lat. femoral cutaneous n. Femoral n.

36. SURGICAL MANAGEMENT: NEURECTOMY 3% 25% 72% 100 James A. Madura 2005 5% 15% 80% 225 Amid PK 2004 10% 11% 17% 25% 68% II 78% IH 83% GF 50% 54 Cathy H Lee 2000 83% 30 Starling 1987 100% 5 Magee 1945 83% 6 Lyon 1942 Poor result Partial relief Excellent relief # of Pts Author

37. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Lat. femoral cutaneous n. Femoral n.

40. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Lat. femoral cutaneous n. Femoral n.

42. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Lat. femoral cutaneous n. Femoral n.

43. WATCHFUL WAITING The rate of acute incarceration and strangulation is very low. The risk of this complication should not be the sole indication for repair of the hernia. Patients who have pain benefit from repair; however, many patients experience pain after hernia repair; and in some patients, this is new or worse pain than before their operation. Preoperative discussions with patients should include disclosure of this risk. Delaying repair appears safe, although major life-threatening complications can occur in any patient undergoing even a simple operation. Leigh Neumayer, 2006 Repair of an asymptomatic inguinal hernia does not affect the rate of long-term chronic pain and may be beneficial to patients in improving overall health and reducing potentially serious morbidity. Patrick J. O’Dwyer, 2006 A strategy of watchful waiting is a safe and acceptable option for men with asymptomatic or minimally symptomatic inguinal hernias. Acute hernia incarcerations occur rarely (1.8 per 1000 patient years), and patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic hernia repair Fitzgibbons RJ Jr 2006

44. PREVENTION: WATCHFUL WAITING 20% by 1 year 23% by 2years Conversion P 0.11 P 0.34 P 0.036 P 0.39 P 0.99 P 0.93 P 0.20 Statistical significance 1% 0.3% Acute incarceration Pain in Observation Gp Pain in Repair Gp # of Pts Mean (SD) At rest 6 mo: 8.0 (14.0) At rest 12 mo: 3.7 (8.2) At movement 6 mo: 10.9 (16.0) At movement 12 mo: 7.6 (15.0) Mean (SD) At rest 6 mo: 4.8 (10.7) At rest 12 mo: 5.2 (12.3) At movement 6 mo: 6.1 (11.9) At movement 12 mo: 5.7 (11.5) 160 Repair 75 Observe 78 Patrick J. O’Dwyer, 2006 At rest: 8.2 (15.6) Nl activities: 10.4 (14.9) Work/Exercice:14.6 (20.7) At rest: 8.2 (13.1) Nl activities: 10.3 (14.9) Work/Exercice: 17.1 (24.6) 720 Repair 356 Observe 364 Fitzgibbons RJ Jr 2006

45. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Prophylactic neurectomy Lat. femoral cutaneous n. Femoral n.

46. PROPHYLACTIC NEURECTOMY 42 vs 42.9 (P 0.931) 8% vs 28.6% (p 0.008) 50 vs 50 Wilfred Lik-Man Mui 2006 18% vs. 4% (p 0.10) 13% vs. 5% (p 0.32) 6 mos.3% vs 26% (p 0.001) 1 yr 3% vs 25% (p 0.003) 66 vs 24 George W Dittrick 2004 Numbness 6.28% Sensory Loss 1.04% 0 191 DE Tsakayannis 2004 Numbness 4% vs 6% p 0.39 Loss of touch sensation 11% vs 4% p 0.002 Loss of pain sensation 9% vs 8% p 0.89 Mild: 21% vs 18% Moderate: 3% vs 4% Severe: 3% vs 2% p 0.55 408 vs 405 Marcello Picchio 2004 10% vs 0% 0% vs 5% 20 bilateral Ravichandran 2000 Paresthesia Pain (Neurectomy vs Non-neurectomy) # of Pts Author

47. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Nerve identification Prophylactic neurectomy Lat. femoral cutaneous n. Femoral n.