At the 2021 annual meeting of the American Hernia Society, Brian P. Jacob, MD, FACS, an associate professor of surgery at Mount Sinai Icahn School of Medicine and a partner at the Laparoscopic Surgical Center of New York, both in New York City, gave a presentation on chronic groin pain, titled “What Did I Miss and What Can I Do Now.” To find out more about the presentation and how surgeons can better treat patients with pain, General Surgery News interviewed Dr. Jacob.
GSN: What spurred this presentation?
Dr. Jacob: My career has become super-specialized in treating patients who are suffering from chronic pain and chronic groin pain, and I soon realized that there was so much more needed to help people suffering from chronic pain than just my surgical skill set.
GSN: It looked like your presentation focused on nonsurgical approaches to hernia pain. Can you elaborate?
Dr. Jacob: In 2021, we published a study in Surgical Endoscopy designed to study the outcomes following hernia mesh removal with robotic technology [2021 Nov 1. doi:10.1007/s00464-021-08835-x]. Even though we do a great surgery to get the mesh out, we are only curing somewhere between 60% and 70% of the patients fully. This means there is a small cohort of patients still suffering chronic pain symptoms that despite mesh going in and then coming out, they still have pain. This cohort of patients is often challenging to manage for a variety of reasons. Those patients are sometimes angry, and very quick to blame the mesh, the mesh companies and the surgeons, but there is always more to their suffering. So, I tried to set up a unique session to address this small cohort of patients.
GSN: You mentioned in your talk that surgeons can contribute to the problem of chronic pain after a hernia. Can you explain?
Dr. Jacob: One common reason patients get post-op hernia pain is because the surgeon may have repaired a hernia that wasn’t the only cause of the pain. Missing parts of the full history and failing to thoroughly work up the patient before surgery can often be the reason chronic pain continues.
The second most common reason patients get post-op hernia pain may also, innocently, be our fault. This involves unrecognized intraoperative or postoperative issues, dismissing the patient’s early postoperative complaints; not knowing how to, or having time to, properly and thoroughly work up or treat the patient’s postoperative pain complaints; not believing the surgery could be the source of the pain, when in reality, it probably has to be related. In some cases, patients subjected to that cycle are then experiencing gaslighting. They know the surgery must be related to the new pain, but the doctors keep denying it is possible. When that patient finally gets relief, for example with mesh removal, that patient can then develop new post-traumatic stress disorder from that experience. This can then continue to prolong their pain cycle if not managed with proper interventions or even therapy.
There are also people in this unique cohort of chronic pain sufferers who come to the surgical table with preexisting, undiagnosed trauma before they have surgery, and then they can have two hits: 1) trauma from the gaslighting after the most recent surgery, and 2) older trauma from something else that is causing them longstanding, unconscious pain.
As surgeons, we may be doing our job really well, but we may not be acknowledging or treating all the ingredients that have gone into that patient’s suffering. The surgery sometimes cures only a piece of the person’s journey toward healing. So, I wanted to introduce some alternative therapies besides surgery.
GSN: What are some of these alternative approaches that can benefit patients with chronic groin pain?
Dr. Jacob: The first thing, before you get into any of these alternative therapies, is to make sure that you have really truly eliminated all the things that you can cure with surgery. You have to eliminate back, hip and pubic bone sources of pain as well. Finally, you have to eliminate musculoskeletal injuries. But once that is all eliminated, then treatment options include nonmedical and medicine therapy, such as meditation and mindfulness, yoga, Pilates, Reiki, acupuncture, traditional Chinese medicine and, when that is not working, behavioral psychotherapy, and possibly even psychedelic-assisted psychotherapy.
My two cents on traditional psychotherapy is that the current medications used today in these patients, including the addictive narcotics and some common anxiolytic and common antidepressants, can mask the existence of the pain, whereas the alternative therapies that I am recommending help the person find the true source of their pain and work through it. In the simplest form, it’s helping people achieve self-forgiveness and self-love, as weird as that might sound sometimes. Understanding that the source of pain has finally been treated—accepting that you were indeed unheard for a period of time, and therefore failed to find definitive treatments for many years, and now it’s time for forgiveness—is important. Working through the sources of pain with a therapist can be very helpful. A lot of people are angry and they hold onto the pain for that reason. Patients in pain just want their normal lives back and that sometimes takes time.
GSN: Can you explain more about psychedelic-assisted psychotherapy?
Dr. Jacob: Within the world of psychedelic-assisted psychotherapy (PAP), the main modality we have today is ketamine-assisted psychotherapy, and the results are pretty promising, but not perfect in terms of treating PTSD, depression and anxiety (Am J Psychiatry 2021;178[2]:193-202; JAMA Psychiatry 2014;71[6]:681-688). Ketamine for PTSD is becoming more mainstream. Ketamine clinics [for treating PTSD, anxiety and depression] are set up now in New York, Toronto, Texas, California, Nevada, Oregon, Baltimore and a few other places.
But there are other very exciting and promising modalities coming down the pike, like psilocybin- and MDMA (3,4-methylenedioxymethamphetamine)-assisted psychotherapy. These novel modalities are dependent on a dedicated and compassionate therapist experienced in working with these types of medicine, as well as the importance of the integration periods that follow the treatments. The medicines themselves alone will not work. As an empathogen-entactogen, MDMA has been heavily researched already, with many new studies currently underway looking at the risks and benefits for treating PTSD, eating disorders, depression, anxiety and suicidal ideation (Curr Opin Psychiatry 2022;35[1]:22-29).
MDMA was even the focus of a recently published phase 3, double-blind, randomized trial in Nature Medicine in May 2021, that showed MDMA was useful for PTSD (Nat Med 2021;27[6]:1025-1033). The Multidisciplinary Association for Psychedelic Studies (MAPS), led by Rick Doblin, is paving the way for most of this research. Interested readers should check them out. I strongly believe that one day, once legal, more rigorously studied and more widely accepted, these medicines, along with experienced therapists to work with them and the patients who need them, will have a role in helping patients suffering from PTSD after chronic groin pain from hernia repairs and hernia mesh, as well as from any traumatic surgery they may have experienced.
GSN: What is the main message you want to get out about your talk?
Dr. Jacob: The messages I want to get out are threefold:
- Please take a thorough history for all your hernia and groin pain patients, even if it seems likely that the pain is from the hernia. The days of missing other causes of groin pain need to wind down sooner than later. Fixing a hernia but missing the other source only adds a variable for the cause of groin pain, making the patient even harder to evaluate.
- Our patients who are complaining of new pain after a hernia repair are really in pain; that pain may not fully resolve and may become chronic (more than 12 weeks of it); and those patients need reassurances that we will stick with them until the pain source is found and managed, no matter how long it takes. If we cannot figure out the source, which does happen from time to time, then we should try to help the patient connect to a surgeon who can continue to help further.
- For those pain patients who seem to be spiraling no matter what you do to help them, we need to ask them if they want to consider alternative therapies to help them work through their experience. There is a true benefit if the patient is open to it, and it can help them in the short and long term.
Dr. Jacob reported equity in Human Xtensions, International Hernia Collaboration and ViaSurgical, and a consultantship with Medtronic.
This article is from the March 2022 print issue.
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