Review Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark Correspondence to: Dr E. Aasvang (e-mail: eske.aasvang@rh.dk) Background: Chronic pain after inguinal hernia repair is an adverse outcome that affects about 12 per cent of patients. Principles of treatment have not been defined. This review examines neurectomy and mesh or staple removal as possible treatments. Method: A literature search was carried out using the Medline and Ovid databases. Keywords were ‘pain; chronic’, ‘herniorrhaphy; inguinal’, ‘neurectomy’ and similar words. Article references were cross- checked for additional references. Articles were reviewed for data on surgical treatment of chronic pain after hernia repair. Results: Neurectomy of the ilioinguinal, iliohypogastric, genitofemoral or lateral femoral cutaneous nerve was described in 14 papers. Overall, a favourable outcome was reported. However, the methodological quality was poor in all studies in respect of preoperative diagnostic criteria and treatment, intraoperative success in identifying a pathological lesion or nerve and quality of follow-up; this hindered interpretation of the data. Insufficient information is available at present on the effect of removal of mesh or staples. Conclusion: Chronic pain after hernia repair is a significant problem and there is a need for a definitive assessment of its surgical treatment Paper accepted 26 April 2005 Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5103 Introduction Chronic pain is a frequent and sometimes debilitating consequence of various types of surgery, including repair of inguinal hernia 1–3 . The precise incidence of chronic pain after hernia repair is unknown, but well conducted, large, unselected epidemiological studies suggest that about 20 per cent of patients are affected and that in about 12 per cent the intensity of pain is sufficient to impair some aspects of daily activity 4–7 . Patients are classified as having chronic pain if postoperative pain lasts for more than 3 months 8 . The underlying pathogenesis is poorly understood and, although a nerve lesion may be a prerequisite, it is not the only factor as many patients have postoperative sensory abnormalities but no pain 2,9 . An inflammatory response due to mesh repair may also cause chronic pain, but no method exists to distinguish between the various causes of chronic discomfort. Concomitant with the increased awareness of the problem an increasing number of studies have suggested that surgical management might be an option. This review assessed the role of surgery in management of chronic pain after inguinal hernia repair. Methods Studies of surgical treatment of chronic pain after inguinal hernia repair were identified using the Pubmed and Ovid search engines. Both databases were searched in July 2004. The term ‘pain’ was combined with the term ‘hernia, inguinal’ and ‘treatment’ or ‘division’ or ‘neurectomy’. Other words associated with pain were explored, such as ‘neuropathic’, ‘neuropathy’ and ‘neuralgia’, and ‘groin’ was used instead of ‘hernia’ in a cross-search. Articles on meralgia paraesthetica were checked for inclusion of patients with a previous inguinal hernia repair. In addition, papers published during the writing process were included, as were those known by the authors but not found in the databases. References were cross- checked for literature not found in the database search. Reviews were not included, but were checked for additional Copyright  2005 British Journal of Surgery Society Ltd British Journal of Surgery 2005; 92: 795–801 Published by John Wiley & Sons Ltd