Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Risk Factors of Chronic Postoperative Pain After Inguinal Hernia Repair and the Relationship Between Preoperative Depression-Anxiety: Observational Study
İnguinal Herni Onarımı Sonrası Kronik Postoperatif Ağrının Risk Faktörleri ve Preoperatif Depresyon-Anksiyete İlişkisi: Gözlemsel Çalışma
Derya BAYRAMa , Dostali ALİYEVb , İbrahim AŞIKc
aMardin Training and Research Hospital, Clinic of Neurology, Mardin, Türkiye
bTOBB University of Economics and Technology Faculty of Medicine Hospital, Department of Anesthesiology and Reanimation, Ankara, Türkiye
cAnkara University Faculty of Medicine İbn-i Sina Hospital, Department of Anesthesiology and Reanimation, Division of Algology, Ankara, Türkiye
Turkiye Klinikleri J Med Sci. 2024;44(4):149-57
doi: 10.5336/medsci.2024-102812
Article Language: EN
Full Text
ABSTRACT
 Objective: To determine the incidence and risk factors associated with chronic postoperative pain after inguinal hernia repair and to observe the relationship between preoperative depression/anxiety and chronic postoperative pain. Material and Methods: Between June 2021 and December 2022, two hundred and sixty patients who underwent inguinal hernia repair were enrolled in the study. Preoperative chronic pain and chronic postoperative pain were assessed with visual analogue scale, and the patients' results were recorded in the third and sixth months. Depression and anxiety assessments were made using the Beck Depression and Beck Anxiety Inventory before the operation. Preoperative, intraoperative, and postoperative details were recorded and the relationship with chronic postoperative pain was statistically analysed. Results: Pain persisted in 22.3% of the patients at the postoperative 3rd month and 12.3% of the patients at the 6th month. Preoperative pain was present in 56.53% of the patients, and chronic pain developed in 39.4%. A statistically significant relationship was found between preoperative chronic pain, postoperative analgesic use, duration of pain, female gender, reoperation, postoperative complication, and chronic postoperative pain (p<0.001). Chronic postoperative pain developed in 21 of 24 patients who underwent recurrent operations. The pain was in neuropathic character in 53.4% of the patients. A significant correlation was observed between preoperative anxiety/depression and chronic pain (p<0.001). Conclusion: Preoperative pain, the severity of postoperative acute pain, and reoperation should be questioned preoperatively, and adequate pain palliation should be provided to prevent chronic postoperative pain. In addition, the psychological state significantly affects the development of chronic postoperative pain.

Keywords: Hernia; inguinal; postoperative pain; depression; anxiety
ÖZET
 Amaç: Amaç, inguinal herni onarımı sonrası postoperatif kronik ağrı ile ilişkili insidans ve risk faktörlerini belirlemek ve preoperatif depresyon/anksiyete ile postoperatif kronik ağrı arasındaki ilişkiyi incelemekti. Gereç ve Yöntemler: Haziran 2021-Aralık 2022 tarihleri arasında inguinal herni onarımı yapılan 260 hasta çalışmaya alındı. Preoperatif kronik ağrı ve postoperatif kronik ağrı görsel analog skala skoru değerlendirildi ve hastaların operasyon sonrası 3 ve 6. aylardaki sonuçları kaydedildi. Ameliyat öncesi depresyon ve anksiyete değerlendirmeleri Beck Depresyon Envanteri ve Beck Anksiyete Envanteri kullanılarak yapıldı. Ameliyat öncesi, ameliyat sırası ve ameliyat sonrası detaylar kaydedildi ve kronik postoperatif ağrı ile ilişkisi istatistiksel olarak analiz edildi. Bulgular: Postoperatif 3. Ayda hastaların %22,3'ünde, 6. ayda ise hastaların %12,3'ünde ağrı devam etti. Hastaların %56,53'ünde preoperatif ağrı mevcuttu ve bu hastaların %39,4'ünde kronik ağrı gelişti. Preoperatif kronik ağrı, postoperatif analjezik kullanımı, ağrı süresi, kadın cinsiyet, reoperasyon, postoperatif komplikasyon ve postoperatif kronik ağrı arasında istatistiksel olarak anlamlı bir ilişki bulundu (p<0,001). Rekürren operasyon geçiren 24 hastanın 21'inde postoperatif kronik ağrı gelişti. Hastaların %53,4'ünde ağrı nöropatik karakterdeydi. Ameliyat öncesi anksiyete/depresyon ile kronik ağrı arasında anlamlı bir ilişki gözlendi (p<0,001). Sonuç: Preoperatif ağrı, postoperatif akut ağrının şiddeti ve reoperasyon preoperatif dönemde sorgulanmalı ve postoperatif kronik ağrıyı önlemek için yeterli ağrı palyasyonu sağlanmalıdır. Ek olarak, preoperatif psikolojik durum postoperatif kronik ağrı gelişiminde önemli bir etkiye sahiptir.

Anahtar Kelimeler: Herni; inguinal; postoperatif ağrı; depresyon; anksiyete
REFERENCES:
  1. Merskey H, Bogduk N. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms, 2nd ed. Seattle: IASP Press; 1994.
  2. Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, et al. Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial. J Am Coll Surg. 2014;218(1):102-7. [Crossref]  [PubMed] 
  3. Nienhuijs SW, Rosman C. Long-term outcome after randomizing prolene hernia system, mesh plug repair and Lichtenstein for inguinal hernia repair. Hernia. 2015;19(1):77-81. [Crossref]  [PubMed] 
  4. Karaman Y, Özkarakaş H, Karaman S, Turan M, Gönüllü M, Uyar M, et al. İnguinal herni onarımı sonrası kronik ağrı insidansı [Incidence of chronic pain after ingunial hernia repair]. Agri. 2015;27(2):97-103. Turkish. [PubMed] 
  5. Wilder-Smith OH. Changes in sensory processing after surgical nociception. Curr Rev Pain. 2000;4(3):234-41. [Crossref]  [PubMed] 
  6. Gu D, Zhou M, Han C, Lei D, Xie S, Yuan Y, et al. Preoperative anxiety induces chronic postoperative pain by activating astrocytes in the anterior cingulate cortex region. Rev Assoc Med Bras (1992). 2019;65(9):1174-80. [Crossref]  [PubMed] 
  7. Woo AK. Depression and anxiety in pain. Rev Pain. 2010;4(1):8-12. [Crossref]  [PubMed]  [PMC] 
  8. Tuğlu C, Türe M, Dağdeviren HN, Aktürk Z. The reliability and validity analysis of the Turkish version of Beck Depression Inventory for primary care. J Fam Pract. 2007;9:117-22. [Link] 
  9. Ulusoy M, Sahin NH, Erkmen H. The Beck anxiety inventory: psychometric properties. J Cogn Psychother. 1998;12(2):163-72. [Link] 
  10. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1-2):29-36. [Crossref]  [PubMed] 
  11. Forester B, Attaar M, Chirayil S, Kuchta K, Denham W, Linn JG, et al. Predictors of chronic pain after laparoscopic inguinal hernia repair. Surgery. 2021;169(3):586-94. [Crossref]  [PubMed] 
  12. Manangi M, Shivashankar S, Vijayakumar A. Chronic pain after inguinal hernia repair. Int Sch Res Notices. 2014;2014. [Crossref]  [PubMed]  [PMC] 
  13. Perkins KA, Gerlach D, Broge M, Sanders M, Grobe J, Fonte C, et al. Quitting cigarette smoking produces minimal loss of chronic tolerance to nicotine. Psychopharmacology (Berl). 2001;158(1):7-17. [Crossref]  [PubMed] 
  14. Sipilä R, Estlander AM, Tasmuth T, Kataja M, Kalso E. Development of a screening instrument for risk factors of persistent pain after breast cancer surgery. Br J Cancer. 2012;107(9):1459-66. [Crossref]  [PubMed]  [PMC] 
  15. Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19(1):48-54. [Crossref]  [PubMed] 
  16. Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, et al; International Endohernia Society. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc. 2015;29(2):289-321. Erratum in: Surg Endosc. 2015;29(6):1655-6. Koeckerling, F [corrected to Köckerling, F]. [Crossref]  [PubMed]  [PMC] 
  17. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, et al; Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350(18):1819-27. [Crossref]  [PubMed]  [PMC] 
  18. Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth. 2005;95(1):69-76. [Crossref]  [PubMed] 
  19. Lopes A, Seligman Menezes M, Antonio Moreira de Barros G. Chronic postoperative pain: ubiquitous and scarcely appraised: narrative review. Braz J Anesthesiol. 2021;71(6):649-55. [Crossref]  [PubMed]  [PMC] 
  20. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):50-5. [Crossref]  [PubMed] 
  21. O'Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers B, Horeyseck G. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg. 2005;92(2):166-70. [Crossref]  [PubMed] 
  22. Uzzaman MM, Ratnasingham K, Ashraf N. Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. Hernia. 2012;16(5):505-18. [Crossref]  [PubMed] 
  23. Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. Br J Surg. 2012;99(1):29-37. [Crossref]  [PubMed] 
  24. Klinge U, Klosterhalfen B, Birkenhauer V, Junge K, Conze J, Schumpelick V. Impact of polymer pore size on the interface scar formation in a rat model. J Surg Res. 2002;103(2):208-14. [Crossref]  [PubMed] 
  25. Joshi GP, Rawal N, Kehlet H; PROSPECT collaboration; Bonnet F, Camu F, Fischer HB, Neugebauer EA, Schug SA, Simanski CJ. Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery. Br J Surg. 2012;99(2):168-85. [Crossref]  [PubMed] 
  26. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H, Wijsmuller AR, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239-49. [Crossref]  [PubMed] 
  27. Campanelli G, Bertocchi V, Cavalli M, Bombini G, Biondi A, Tentorio T, et al. Surgical treatment of chronic pain after inguinal hernia repair. Hernia. 2013;17(3):347-53. [Crossref]  [PubMed] 
  28. Ghoneim MM, O'Hara MW. Depression and postoperative complications: an overview. BMC Surg. 2016;16:5. [Crossref]  [PubMed]  [PMC] 

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