By Monica J. Smith

AUSTIN, Texas—Chronic pain can cause disabling suffering, puts a significant economic strain on the healthcare system and, in the world of complex abdominal wall repair, is unfortunately and maddeningly common. Although there is no straightforward solution, there are ways to address and sometimes resolve it.

Bruce Ramshaw, MD, the chief medical informatics officer for Caresyntax in Knoxville, Tenn., discussed the burden of chronic pain in hernia repair, why it’s such a mystery, and how surgeons might be able to identify patients at risk for chronic pain.

It’s Not Just the Mesh

As Dr. Ramshaw became increasingly involved in complex hernia repair and patients with chronic pain, he wondered about otherwise healthy patients who undergo a simple outpatient procedure and soon after surgery develop chronic, disabling pain. “We see a lot of lawyer ads blaming the doctor and blaming the mesh; mesh isn’t itself a cause and effect, otherwise everyone would get chronic pain after a mesh repair, but it can be a contributing factor of many that results in bad outcomes.”

It seems logical that the mesh will do its job when handled properly and placed with careful technique, but that doesn’t account for biological variability. In some patients, when the mesh is explanted years after placement, it is just as pliable as it was out of the package; in others, the mesh is about as bendable as a brick, Dr. Ramshaw said.

A book that helped him understand this complex biological variability, “The End of Average,” by Todd Rose (HarperOne, 2016), described the early days of Air Force aviation, which was rife with crashes. At the time, the cockpits were designed to fit an average body based on arm length, leg length and head circumference measurements taken from every pilot.

“The problem was, there is no average-sized pilot,” Dr. Ramshaw said. The solution was to build adjustable cockpits and limit the size of pilots. “That’s our situation in the world of hernia repair and for healthcare in general. If we do a one-size-fits-all approach, we’re going to have variable outcomes because of that complex biological variability.”

Reading the textbook “Introduction to Standards and Standardization” (Beuth Verlag GmbH, 1998), Dr. Ramshaw saw that the true definition of standardization is not uniformity, but optimal variety. “What we want to understand is the subset of patients at risk for chronic pain and what we can do about that.”

Cognitive Rewiring

Lacking identifiable markers of those at risk, guidelines suggest informing patients that pain is a possible outcome of any invasive surgical procedure. “The best we can do today is a shared decision process to help patients come to a decision they feel is right for them,” Dr. Ramshaw said.

However, there are some patterns that Dr. Ramshaw and others identified in patients who developed chronic pain. “They were angry; they had unrealistic expectations or other signs of prior traumatic experiences. We began to look at this in a nonlinear way, working with social scientists to better understand this anger toward the mesh company or the former surgeon, and address that; otherwise, the patient would likely not have a good outcome. It’s important to note that these patterns are actual neurophysiologic changes in the brain due to past traumatic experiences resulting in a chronic stress state, not just a psychological flaw or a personal weakness.”

They started doing prehabilitation and presurgery cognitive behavioral therapy (CBT) and started seeing better results. Some patients’ chronic pain resolved to such a degree that they did not return to the OR. “We’re still just scratching the surface, but this is one of many ways to rewire the brain in a positive way and address chronic pain,” said Dr. Ramshaw, who presented his insights at the 2023 annual meeting of the American Hernia Society.

Meeting the Patient Where They Are

Eric Pauli, MD, acknowledges that patients with chronic pain can be very challenging to manage. “There are a lot of ways to think about the burden of pain postoperative patients can have, how it affects the patient and their life. But these patients also represent a stressor on a hernia practice,” he said.

Research has shown that patients with chronic pain after hernia repair are more likely to call the office, show up for unscheduled clinic visits, and turn to emergency departments for care and management (Am J Surg 2018;2154:610-617).

“Part of the reason many of these patients deal with these problems for so long is because when they call the office repeatedly, they are considered a bother to the office and subsequently referred to another center. That patient gets looked over because they’re being vocal about their pain,” Dr. Pauli said.

Surgeons and practices who are willing to manage these patients need to do so in a very comprehensive fashion because of the wide array of preexisting conditions—physical and behavioral—they may have.

“The steps you need to go through have to be well thought out and not always intuitive. There could be a variety of things causing that pain. It could be the mesh and how it was secured. It could be injury to a nerve. It could be a recurrent hernia, back pain, hip pain, orthopedic injuries. Many of these patients have underlying psychiatric conditions that are either not being addressed or are being poorly addressed,” Dr. Pauli said.

So, it’s essential to be able to think about possible causes logically but also creatively, and from a variety of angles. “The other part is to meet the patient where they are,” Dr. Paul said. “It may be hard to get buy-in from a patient who has been overlooked by previous providers because of the nature of their complaint. But you need the ability to say to the patient, ‘I hear and understand your complaint, and we’re going to go over this in a logical fashion.’”

Dr. Ramshaw noted that chronic pain is not restricted to hernia disease, and that given the burden it places on sufferers, physicians and systems alike, it’s a problem that warrants ongoing investigation. As for any complex problem, there is no one cause; there are many factors that come together in just the wrong way to result in such a devastating outcome. Until we have the appropriate data and analytics infrastructure in healthcare to generate predictive algorithms that can identify this subpopulation of patients at risk for chronic pain, we will continue to rely on shared decision-making with the patient.

“It’s a real issue; it’s very complex, but there are ways to address it when we have the appropriate data and analytics infrastructure implemented. As we learn more and more, we’ll get better and better at addressing this devastating problem,” Dr. Ramshaw said.