Inguinal hernia surgery recovery: what happened after 540 mesh repairs?

How common is day surgery for inguinal hernia in Australia?

About 42,000 inguinal hernia repairs are performed in Australia each year, yet at the time of this study only 22% were done as day or short-stay procedures, compared with up to 92% in some other countries. Evidence-based guidelines support day surgery for most patients, and the authors point to funding incentives, surgical habit and the growth of keyhole repairs, most of which still involve an overnight stay, as reasons for the gap.

Pain is the most common reason a planned day-surgery patient ends up staying overnight, with single-centre studies reporting significant pain in anywhere from 8% to 81% of patients. Better pain control is therefore the key to making same-day discharge routine, and this study built its whole pathway around it.

How was the open mesh repair performed?

Every patient had a modified Lichtenstein repair through a 4 to 5 cm groin incision, smaller than the classic approach. Local anaesthetic (ropivacaine) was injected into the skin before the incision and around the nerves during the operation. The ilioinguinal nerve, a common source of long-term pain after hernia surgery, was identified and preserved in 98% of one-sided repairs.

After the mesh was placed, a fine soaker catheter was laid beside the preserved nerves and connected to a small elastic pump that delivered local anaesthetic into the wound at 2 mL per hour for 48 hours. Patients removed the catheter themselves at home on the second day.

The operation was done under local anaesthetic with sedation or under general anaesthetic, depending on patient preference and fitness. About one third of patients had local anaesthetic, which the authors note suits people with heart or lung conditions. Each patient received one dose of antibiotic, and people taking blood thinners such as clopidogrel or warfarin had them managed around surgery, with aspirin continued throughout.

How much pain is there after inguinal hernia surgery?

Patients scored their pain on the evening of surgery, on days one and two, and at four weeks. Pain stayed at a similar level for the first two days and then fell sharply, and by four weeks two thirds of patients had none at all.

Most people who reported pain in the first 48 hours had skipped the regular paracetamol and anti-inflammatory tablets they were advised to take, so taking them on schedule for four to five days is the simplest way to stay comfortable. Only 20% of patients needed anything stronger at any point, and 12% needed no tablets at all beyond the anaesthetic delivered by the catheter. Five patients (0.9%) had severe pain at four weeks, and all five were pain-free with no limit on exercise at long-term follow-up.

When can you go home after hernia surgery, and what are the risks?

Patients went home once they could walk freely, pass urine and were comfortable, with a pack of paracetamol and an anti-inflammatory. After a one-sided repair, 88% were home within four hours, and most of those who stayed longer did so for social reasons such as living alone. Bilateral repairs stayed one night by design, and 84% of those patients were home within 24 hours. Eight patients (1.5%) were readmitted early, for pain, wound infection, haematoma or difficulty passing urine.

The overall complication rate was 7.4%. There were no deep wound or mesh infections, no seromas, no injuries to bowel, bladder or blood vessels, and no deaths. Many patients were on blood-thinning medication, yet only about 2% developed a clinically relevant bruise or blood collection.

Does the type of hernia mesh affect recovery?

From 2007 to 2010, 299 patients had standard polypropylene mesh fixed with permanent stitches. From 2010 to 2012, 241 patients had Parietex ProGrip, a lightweight polyester mesh with tiny grips on one side, fixed with dissolving stitches because the grips hold well on muscle and fat and less well on tendon.

Pain scores were the same with both meshes. The self-gripping mesh shortened the operation and brought people back to normal activities four days sooner after a one-sided repair. The authors noticed less tenderness and firmness of the wound at four weeks with the self-gripping mesh and suggest it may provoke less inflammation.

Is open or keyhole inguinal hernia repair better?

Both approaches are safe in experienced hands. Reviews suggest keyhole repair causes less early pain, although the authors point out that many trials compared it with older tension repairs and reported pain relief and nerve handling inconsistently. The type of pain also differs: open repair causes local groin soreness, while keyhole repair more often causes shoulder-tip or deep abdominal discomfort, with one study finding half of keyhole patients had moderate to severe pain on the first day.

In this series, pain and recovery after open repair matched or bettered recent keyhole results, and the 10-day return to normal activities with self-gripping mesh is similar to published keyhole series. The authors estimated a keyhole repair cost about AU$2,000 more than a day-only open repair at their hospital. They also note that keyhole repair carries a higher risk of rare serious complications, and that mesh placed behind the abdominal wall can make later prostate surgery harder, which patients should hear about when choosing.

What are the limits of this study?

The two mesh types were used in consecutive periods and were never randomised, and pain was measured only after surgery. Pain before surgery is a known risk factor for chronic groin pain, although the study's main finding concerned return to activity, which is less affected by that gap. Long-term follow-up of the cohort was ongoing at publication.