Higher rate of chronic pain in young men after open mesh vs nonmesh repair of elective primary unilateral indirect inguinal hernia: A nationwide questionnaire study

Living a lifetime with chronic pain in the groin is a dire prospect. In inguinal hernia surgery, the risk of postoperative chronic pain is a non-negligible complication affecting up to 9%-15% of patients, depending on the definition of pain and the method of assessment. 1-3 In young adults, this issue is of particular interest as young age is a known risk factor for developing postoperative chronic pain after inguinal hernia surgery. 4-6 The surgical technique is an undeniable variable affecting surgical outcome, but in young men with inguinal hernia, the optimal surgical technique is still debatable. Inguinal hernia repair is one of the most frequently performed procedures worldwide with a lifetime risk of repair of 27% in males and 3% in females, 7 highlighting the importance of rigorous and ongoing effort s to optimize treatment. During the last decades, the use of mesh has gained particular focus as surgeons have worked on tackling the problem of recurrence. The introduction of mesh has lowered recurrence rates, as shown in a Cochrane review where one hernia recurrence was prevented for every 46 mesh repairs compared with nonmesh repairs. 8 Mesh repair has also reduced reoperation for recurrence compared with nonmesh repair in young men. 9 Today, mesh repair is recommended as first choice in all adults. 10 Having addressed the issue of recurrence to a seemingly acceptable degree, chronic pain is now the most important postoperative complication in modern inguinal hernia surgery. 11 For years, mesh has been a suspected risk factor for chronic pain, but evidence shows that mesh repair does not increase chronic pain in the general adult population. 12 However, there is sparse evidence comparing mesh and nonmesh repairs in young adults, though a questionnaire study showed no difference in pain between open mesh and nonmesh approaches. 13 Adult women of all ages should have a laparoscopic repair to exclude the existence of a femoral hernia as these are more prevalent in women and have a higher risk of incarceration than inguinal hernias. 10 , 14 However, in young men, the operative approach might be more nuanced. Direct and indirect inguinal hernias partly have different etiologies, 15 and a mesh -based repair should be used for direct hernias since these have a greater risk to recur than indirect hernias. 16 In contrast to this, to avoid living a lifetime with a foreign body in the groin, an open sutured repair in young men with small indirect European Hernia Society L1 and L2 hernias 17 might be acceptable if recurrence rates are acceptable and if a sutured repair decreases the risk of chronic pain. This approach is supported by a nationwide database study that assessed reoperation rates after sutured repairs in different age groups, which showed that young men had a lower cumulated reoperation risk compared with the other age groups. 18 The role of the mesh in postoperative chronic pain in young men therefore needs further investigation. The aim of this study was to compare chronic pain after elective primary unilateral open mesh versus nonmesh repair of indirect inguinal hernias in young men.