Melanie Cole:  Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we examine chronic pain after hernia repair. Joining me is Dr. Abhisek Parmar. He's a minimally invasive general surgeon and an assistant professor at UAB Medicine. Dr. Parmar, it's a pleasure to have you join us today. After hernia repair and since pain is somewhat subjective, how do you measure it?

Dr. Abhisek Parmar: Well, first of all, thanks so much for having me, Melanie. That's a really good question at the gates. I think one of the things I see a lot with patients after this operation is we really have to just believe patients and take them at their word. What's so interesting to me about hernia disease kind of globally, but specifically inguinal hernia disease, is that it's such a common problem that I think so many providers in the medical community think that it's something that's pretty straightforward and it's really easy to manage.

And post-herniorrhaphy pain is actually quite common. If you look at the literature, up to 30% of patients after inguinal hernia repair can have fairly disabling pain, that can be very uncomfortable. And one of the main reasons I wanted to come and talk to you about this issue is that this is something that unfortunately is all too common. I see patients that are sent to a psychiatrist that are kind of written off as somehow trying to get some secondary gain and all sorts of things because folks think that you're supposed to do really well after inguinal hernia surgery. And that's just not the case.

So I think step one is really believing patients when they have some pain that lasts more than three months. And that's the definition of post-herniorrhaphy pain three months after surgery.

Melanie Cole: Three months. And I did read the literature, so your 30% is right on and it is interesting how under-reported or under-understood this really is. So how do you work with a patient when it's at that three-month mark? And tell us a little bit about the multimodal approach that you might use for the chronic pain that can come with hernia repair.

Dr. Abhisek Parmar: Right. So there are at least a handful of reasons why folks can still have pain after the operation. And the first step really is again going back to the patient, getting a very thorough history and trying to understand their pain that could be related to a nerve injury after surgery. Is this a recurrent hernia?

Many times I see patients who had a hernia repair and they still have pain after the operation. And it turns out their pain never was really even related to their hernia in the first place. And they have, you know, a hip problem or a back problem or something like that. So the first step is really sort of delineating, you know, where they fall into those categories. And from there, I kind of move on to the next step, which is doing a nerve block.

Melanie Cole: Oh, so you use a nerve block first. Okay. So then speak about the levels of pain management that you would use. And I would like you to touch, Dr. Parmar, on parameters or guidelines for opioids in this situation. As we know, this is an epidemic and stewardship and physicians are trying to really look at this big picture and prescribe fewer of them if that's something they can do, but it's not always. So speak a little bit about those guidelines and kind of the tiers that you would use after the nerve block or with it.

Dr. Abhisek Parmar: Right. So, you know, actually, we don't really advocate for opiates much in this setting. For most of these patients again, I guess there's three sort of categories. So if the hernia has come back, then the treatment sort of tree goes to reoperation to fix the hernia.

And if it's a nerve injury, I first we'll start with a nerve block. And if the patient had a response to the nerve block, that's really pretty suggestive of a nerve injury. And so in that case, you know, I really don't try to use any multimodal pain agents at all. Those are the patients that I would take back to surgery and actually do something called a triple neurectomy and actually remove their mesh or explant their mesh.

So, I guess I really have to kind of tailor the treatment to the problem itself. So, I agree with you, multimodal pain therapy and kind of a tiered approach is the standard of care for a lot of chronic pain patients. But for this problem, there are actual sort of, real diagnoses we can usually find in these patients and correct surgically.

Melanie Cole: And then what happens after that? So if you take them back to surgery, then is this something that now is repaired? Tell us a little bit about what happens after that.

Dr. Abhisek Parmar: Sure. So the subset of patients whose pain after inguinal hernia repair is due to nerve injury. So those patients, if they truly have an injury to one of the nerves and taking a step back, just to reiterate, these people can be in exquisite pain postoperatively.

I mean, I have seen so many unfortunate patients in my clinic who have been living in the community and, like you've said, kind of been taking opiates because it's the only sort of thing that can help them. And I really hate to say it, they've actually contemplated suicide at some point because this pain can be quite severe.

So what's so satisfying to me about treating these patients is that surgery has about a 90% to 95% percent success rate in addressing this chronic pain problem. So by going back and removing the mesh and removing the nerves that are involved, we can actually make a really remarkable impact on these patients.

That operation is not without risk. There aren't a lot of surgeons that do this operation after hernia repair, because it's extremely high risk. There's risks of testicular loss, there's risk of major bleeding and all those things. But if the payoff is relief of pain, I've never had a patient not want to pursue the operation.

Melanie Cole: It's so interesting. So now, tell us how has COVID, how has this pandemic affected your practice? And for patients that did need hernia repair, have you seen any change? Tell us how you've been dealing with your practice.

Dr. Abhisek Parmar: I think globally something that we're starting to learn about COVID is that there are a lot of patients out in the community who really do need medical care, but they were so afraid to seek it that they've kind of just had to stay at home. And, if you look at some of the science behind it, there's some literature that folks are having more heart attacks at home instead of going to see their doctor or they're afraid to go to the emergency department.

For some reason, I've started to see the exact same phenomenon with hernia pain. Just in the past month, I think I've seen four patients in my clinic with hernia pain. So I think people are kind of forced to stay at home. And what's really worrisome to me is that patients, there's this element of defeatism to the whole problem and they feel like there's no solution and that there's no hope to the pain and this is just how their life has to be. And that's really the kind of fallacy I wanted to correct with this interview.

Melanie Cole: That is certainly true. And thank you so much for that. So why don't you let other providers know what you'd like them to take away from this interview about dealing with chronic pain after inguinal hernia repair, what you're doing with your patients, and when you feel it's important they refer. If they have a patient that's gone through a hernia repair and they are still suffering chronic pain, when would you like them referred?

Dr. Abhisek Parmar: That's a great question. So I think anyone who's been dealing with pain after their inguinal hernia operation for more than three months, you know, really needs to see a hernia specialist to understand what's going on. And because these patients are so miserable, I have a very low threshold for seeing them in my clinic, because like I've been saying, usually there's a handful of treatable reasons for why they're still having pain.

Now granted it's an extremely complicated issue and not a lot of surgeons sort of tackle it. But, if any provider sees a patient who has a history of inguinal hernia repair and who's still having discomfort more than three months after, those patients really need to be seen by a hernia specialists.

Melanie Cole: Thank you so much, Dr. Parmar. You are such a great guest as always. Thank you again and come back on with us and share some updates as you learn more about really anything. Thank you again.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.

That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, you can always visit our website at UABMedicine.org/physician. Please also remember to download, subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.