Wednesday, March 20, 2013

Gabapentin in post hernia pain

A 50 year old gentleman came to us with right sided indirect inguinal hernia.The hernia was big and complete .The mesh hernioplasty with biological(cook) mesh was carried out.
The surgery was open surgery.Post operative the patient started complaining of continuous pain in i the testis was also tender to touch but as such there were no signs of inflammation.
We ruled out epididymo-orchitis ,conservative measures like tramadol painkillers and tight undergarments were subscribed to the patient but without any relief.
Hernia repair, one of the most common surgical procedures, carries a risk many patients don't consider: chronic pain after surgery.
More than 30% of patients may suffer from long-term chronic pain and restricted movement after hernioplasty  Damage to nerves and muscles from the hernia may cause lingering discomfort. New synthetic mesh devices, though better than traditional sutures at reinforcing the abdominal wall, can irritate nerves and carry a slightly higher risk of infection.In this case we used biological porcine mesh-supposed to be the least irritating but still the nagging pain was present.

The pain if distributed towards the distribution of genitofemoral nerve or ilioinguinal nerve can give us an idea about possible neural injury ... nerve entrapment.This pain was only in the testicle. We follow a policy of meticulous dissection round the nerves and in case it is necessary we rather cut the nerve sharply with the scissors than getting entrapped in the sutures and causing chronic neuralgia.

Over a period of time this pain becomes lighter and remains persistent only in 9% of the  cases. So proper counselling of the patient is needed.It is essential for all surgeons to apprise the patient before the surgery of possibility of chronic pain.The informed consent should be taken.
In literature we get many strategies to treat such pains like injection of steroid in the site of scar,ilioinguinal nerve block, Gabapentin or amityptiline. In persistent cases even exploration and mesh removal has been resorted to.

There has been a nice study by Sen et al about preoperative single-dose gabapentin ( 1.2 gm orally)decreases the intensity of acute postoperative pain, tramadol consumption and the incidence and intensity of pain in the first 6 months after inguinal herniorrhaphy.
We started the patient on gabapentin and the pain gradually subsided.We are considering seriously to start pre-operative gabapentin (especially in patient having pre-operative pain disproportionate to the hernia size).

1 comment:

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