The scale of the problem is easy to underestimate. Inguinal hernia repair is among the most common operations performed worldwide, which means that even a double-digit percentage of chronic pain translates into an enormous burden of long-term morbidity. The pain is not a single entity. It can be neuropathic, driven by injured or entrapped nerves such as the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve; it can be nociceptive and inflammatory, linked to the mesh or the healing tissues; it can be mechanical, caused by a folded mesh or a meshoma; or it can be nociplastic, a sensitisation phenomenon with no clear structural correlate. Many patients present with a mixture of these mechanisms, which is precisely why no single treatment works for everyone.

Management has remained stubbornly inconsistent. The updated international HerniaSurge guidelines acknowledge that the evidence base for most chronic postoperative inguinal pain, or CPIP, interventions is sparse and heterogeneous, with few advances over the past decade and correspondingly weak recommendations. Several treatment algorithms have been proposed over the last twenty years, but none has achieved universal acceptance. Many were built predominantly around a surgical perspective, lacked standardised patient evaluation and follow-up, and were developed without multidisciplinary input, even though CPIP patients present to both surgeons and pain specialists. The EurA-CPIP group set out to translate the broad HerniaSurge recommendations into a practical clinical framework that could actually be implemented, measured and improved.

The design process was pragmatic. A working group of surgeons, anaesthesiologists and pain specialists from centres in Denmark, the Netherlands, Belgium and the United Kingdom critically appraised all previously published CPIP algorithms through a scoping review, examining their underlying evidence, patient selection criteria, outcomes and follow-up durations. Through iterative consensus meetings, they agreed on a step-up structure that progresses from the least to the most invasive interventions, ultimately reaching reoperation with neurectomy or mesh removal. Patients may enter the algorithm at different stages depending on what treatments they have already received before referral, which reduces selection bias. Critically, the algorithm is not a static document: it is paired with a prospective data-collection platform and will be revised regularly as real-world outcomes accumulate, in the spirit of a learning healthcare system.

The pathway begins with a thorough work-up designed to identify or exclude treatable structural causes such as recurrent hernia or mesh complications, supplemented when necessary by imaging and review of previous operative reports. A standardised assessment form, including the Douleur Neuropathique 4 questionnaire, supports phenotyping of the pain as predominantly neuropathic, inflammatory, visceral, mechanical, nociplastic or mixed. From there, conservative pharmacological treatment comes first: paracetamol and non-steroidal anti-inflammatory drugs, plus first-line neuropathic agents such as tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors or gabapentinoids when neuropathic features dominate. Long-term strong opioids are explicitly discouraged. Topical lidocaine or capsaicin may be tried despite limited evidence, given their low risk profile. Response is assessed after three to six weeks.

If medication fails, the algorithm escalates to interventional options. Trigger point injections with local anaesthetics serve a dual diagnostic and therapeutic role, since temporary relief suggests a peripheral pain generator. Ultrasound-guided peripheral nerve blocks of the ilioinguinal, iliohypogastric and genitofemoral nerves follow, used primarily to confirm a peripheral neuropathic source and to map the sensory territory. For patients who show a meaningful, reproducible response to these diagnostic blocks, three investigational add-ons are embedded in the pathway: pulsed radiofrequency, which modulates nociceptive transmission without creating a thermal lesion; cryoneurolysis, which uses a probe freezing to between minus 20 and minus 100 degrees Celsius to induce temporary axonal degeneration while preserving the nerve’s connective tissue scaffold; and botulinum toxin A, which may inhibit the release of pain-related neurotransmitters such as substance P, CGRP and glutamate from peripheral sensory terminals. All three remain investigational in CPIP and are permitted only with systematic outcome registration and clear stopping rules.

Before any escalation to surgery, a formal multidisciplinary team review is mandatory. The team must include an experienced hernia surgeon and a pain specialist, ideally supported by physiotherapy, psychology and other specialties as the clinical picture demands. Psychological screening is built into the framework using validated instruments: a score of 8 or more on the Hospital Anxiety and Depression Scale flags possible anxiety or depression, while a Pain Catastrophizing Scale score of 30 or more indicates clinically relevant catastrophising. Patients exceeding these thresholds are at increased risk of poor outcomes and may benefit from early referral into the multidisciplinary pathway, reflecting the biopsychosocial understanding that successful CPIP care extends well beyond anatomical correction.

Surgery itself is reserved for carefully selected patients and should not be considered until at least six months after the index hernia repair, allowing time for non-surgical treatment and for mesh-related inflammation to settle. The sobering benchmark is that roughly 30 percent of patients do not achieve meaningful pain relief after remedial CPIP surgery, and a small proportion may even experience worsening pain. Options include exploration, selective or triple neurectomy, mesh removal, or combinations thereof, with spermatic cord denervation possible in trial settings. The best comparative evidence comes from the GroinPain trial, in which selective neurectomy achieved more than 50 percent pain reduction in 71 percent of patients at six months. Mesh removal reports success rates of 60 to 100 percent, though these are confounded by concomitant nerve resection, and laparoscopic mesh removal carries a risk of serious complications including major vascular injury. For refractory neuropathic or nociplastic cases where surgery is not appropriate, advanced pharmacological escalation and, exceptionally, dorsal root ganglion stimulation remain options within specialist centres.

What most distinguishes EurA-CPIP, however, is its measurement infrastructure. Every patient is assessed at baseline and at roughly six-month intervals with a standardised battery of patient-reported outcome measures: the numeric rating scale for pain severity, with a reduction of at least two points defined as clinically meaningful improvement; the Patient Global Impression of Improvement; the Activities Assessment Scale for function; sexual function questioning; the Hospital Anxiety and Depression Scale; the Pain Catastrophizing Scale; and the SF-12 quality-of-life survey. Success is therefore defined not solely by pain reduction but by function and global improvement, a patient-centred perspective increasingly demanded in surgical research. Supportive and rehabilitative care, including cognitive behavioural therapy, acceptance and commitment therapy and mindfulness-based approaches, is integrated early as a core component rather than a last resort, with the aim of functional restoration and improved self-management.

The authors are candid about the limitations. Many recommendations rest on expert consensus because randomised controlled trials in CPIP are rare, and the algorithm’s success depends on consistent implementation, adherence to outcome protocols and timely data entry across centres with varying resources. Registry-based observation cannot establish causation, and prospective comparative studies will still be needed. Yet the framework’s ambition is clear: by harmonising phenotyping, treatment sequencing and outcome capture across an expanding network of centres, and by linking eventually to national hernia registries, EurA-CPIP aims to identify which patient characteristics predict response to which treatments, stratify patients toward therapies with the highest probability of success, and generate the well-characterised populations needed for future intervention trials. For a condition that has languished in the gap between surgery and pain medicine for decades, that would be a genuinely transformative step.

Subject of Research: Management of chronic postoperative inguinal pain after inguinal hernia repair using a European multidisciplinary treatment algorithm

Article Title: A European algorithm and strategy for management of chronic postoperative inguinal pain (EurA-CPIP)

Article References: Andersen, K. G., van der Meer, T. W. K., van Veenendaal, N., Foss, N. B., Loos, M. J. A., Miserez, M., Pawlak, M., Roumen, R. M. H., Naddaf, T., Togsverd-Bo, M., Stadeager, M. W., Aasvang, E. K., & Zwaans, W. A. R. (2026). A European algorithm and strategy for management of chronic postoperative inguinal pain (EurA-CPIP). Journal of Abdominal Wall Surgery, 5, Article 16944. https://doi.org/10.3389/jaws.2026.16944

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.16944

Keywords: chronic postoperative inguinal pain, inguinal hernia repair, persistent postsurgical pain, treatment algorithm, multidisciplinary care, neurectomy, mesh removal, nerve blocks, cryoneurolysis, botulinum toxin A, patient-reported outcomes, HerniaSurge guidelines

The research team, led by surgeons at Hospital Universitari Vall d’Hebron and the Universitat Autònoma de Barcelona, examined 748 adult male patients who underwent elective unilateral inguinoscrotal hernia repair between January 2021 and December 2024. EVEREG is an audited, voluntary national registry drawing data from more than 200 hospitals across Spain, prospectively collecting anonymised information on patient characteristics, surgical technique, complications, and follow-up. Because participation is voluntary, the registry cannot be assumed to capture every hernia repair performed in the country, but it provides a rare window into routine practice rather than the carefully controlled conditions of a clinical trial.

The patients in the cohort were typical of a complex surgical population. Mean age was 66.3 years and mean body mass index 27.5. Nearly one in five had diabetes, almost half had hypertension, and roughly one in six suffered from chronic obstructive pulmonary disease. More than a quarter of patients with recorded anaesthetic fitness were classified as ASA grade III to V, indicating severe systemic disease. Almost all hernias were symptomatic at presentation, and according to the Kingsnorth classification, 78.3 percent were H3-type hernias, reducible with manual manipulation, while 21.7 percent were H4-type, meaning the hernia was irreducible. A small but notable proportion, 11.5 percent, were recurrences after previous repair.

Technically, the operations followed a clear pattern. Open repair dominated, accounting for 83.4 percent of cases, with minimally invasive surgery used in 16.6 percent. The preferred mesh position was anterior in 70.8 percent of cases and posterior in the remainder. Permanent synthetic mesh, overwhelmingly polypropylene, was used in 99.4 percent of recorded cases. Just over half of all procedures, 51.3 percent, were performed as ambulatory or day surgery, and in 56.8 percent of cases the operating surgeon had recognised experience in abdominal wall surgery. General anaesthesia was used in 63.6 percent of operations, and antibiotic prophylaxis was administered to 83.2 percent of patients. Preoperative progressive pneumoperitoneum, a technique for gradually expanding the abdominal cavity before repairing giant hernias, was used in only 0.8 percent of cases, and botulinum toxin prehabilitation in 0.4 percent.

The headline safety finding was reassuring: postoperative complications occurred in 6.95 percent of patients, and the overwhelming majority were low-grade events, classified as Clavien-Dindo grade I or II in 84.6 percent of affected patients. Among patients with complications and available event-level data, hematoma was the most frequently recorded occurrence, followed by seroma; surgical site infection was uncommon, and no mesh infections were reported. Early recurrence within 30 days of surgery was documented in 1.63 percent of patients with available data. At the latest available follow-up, which averaged only 3.36 months, recurrence was reported in 7.5 percent of the small subgroup with follow-up data, a figure the authors treat with caution given how quickly follow-up completion fell away over time.

The statistical analysis identified a consistent set of risk factors. In bivariate comparisons, advanced age, diabetes, chronic obstructive pulmonary disease, higher ASA grade, H4-type hernias, an open surgical approach, intraoperative complications, and longer operative times were all significantly associated with postoperative complications. Conversely, ambulatory surgery and the involvement of a surgeon experienced in abdominal wall repair were associated with better outcomes. When the team moved to multivariable binary logistic regression, adjusting for age, diabetes, COPD, ASA grade, recurrence status, hernia type, intraoperative complications, and operative time, the protective signals held firm. Ambulatory surgery cut the odds of complications by roughly 64 percent, with an adjusted odds ratio of 0.359, and an experienced abdominal wall surgeon nearly halved them, with an odds ratio of 0.49. The laparoscopic approach also appeared protective, with an odds ratio of 0.127, but the authors stress this finding rests on very few events and a borderline p value of 0.046, so it must be interpreted with great caution. Longer operative time remained independently associated with higher odds of complications, each additional minute carrying a small but measurable increase in risk.

The model performed reasonably well as a risk-prediction tool, achieving an area under the receiver operating characteristic curve of 0.797, and a sensitivity analysis produced consistent estimates. Recurrence analysis was more limited. Within the first postoperative month, seven recurrences were detected, and none of the demographic or surgical variables, including surgeon experience, were significantly associated with early recurrence, although patients with early recurrence did stay longer in hospital. At the latest available follow-up, recurrence was documented in three of 40 patients, and the only factor linked to lower recurrence risk was the participation of an abdominal-wall-experienced surgeon, with zero recurrences in that group compared with 21.4 percent otherwise. Because so few recurrence events were recorded, these analyses were explicitly exploratory and were not subjected to multivariable modelling.

The discussion section places these findings in context. The complication and surgical site occurrence rates exceeded those generally reported for conventional inguinal hernia repairs, which is consistent with the known technical difficulty of scrotal hernias, where the hernia sac descends into the scrotum and distorts the anatomy. The authors note that comorbidity-related factors such as age and ASA grade, although largely non-modifiable, may be useful for preoperative risk assessment. The apparent advantage of ambulatory surgery likely reflects case selection, since day-surgery patients were predominantly those with simpler H3-type hernias. The benefit associated with experienced surgeons, however, aligns with international guideline recommendations and with prior registry-based work showing that abdominal wall specialists improve outcomes in complex hernia care, supporting individualised management and referral of difficult cases to experienced teams.

The study also raises questions about the future direction of scrotal hernia surgery. Conversion from minimally invasive to open surgery occurred in 5.5 percent of laparoscopic cases, higher than in conventional groin hernia series, and the authors suggest that robotic platforms deserve evaluation for complex groin hernias. They also point to open preperitoneal approaches, which accounted for only 16 percent of open procedures in this cohort but have shown strong results in experienced centres and may offer an economical alternative to both the Lichtenstein technique and laparoscopy. The limitations are candidly acknowledged: incomplete registry data, particularly for recurrence and loss of domain; short and fading follow-up; voluntary participation that may skew the sample toward abdominal-wall-interested centres; and the absence of information on sac management, chronic pain, testicular atrophy, and costs. The registry’s Kingsnorth-based classification also predates the classification recommended in current guidelines. The authors conclude that open repair with anterior mesh placement remains the dominant approach in Spain, that complications cluster in patients with greater comorbidity and hernia complexity, and that while the data cannot establish the superiority of any single technique, they make a strong case for entrusting complex inguinoscrotal hernias to surgeons who repair abdominal walls for a living.

Subject of Research: Risk factors for complications and recurrence after elective inguinoscrotal hernia repair in the Spanish EVEREG national registry

Article Title: Inguinoscrotal hernia repair: analysis of the national EVEREG registry

Article References: Verdaguer-Tremolosa, M., Rodrigues-Gonçalves, V., Martínez-López, M. P., López-Cano, M., & in representation of EVEREG group (2026). Inguinoscrotal hernia repair: analysis of the national EVEREG registry. Journal of Abdominal Wall Surgery, 5, Article 17525. https://doi.org/10.3389/jaws.2026.17525

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17525

Keywords: inguinoscrotal hernia, hernia repair, EVEREG registry, abdominal wall surgery, mesh repair, Clavien-Dindo complications, laparoscopic surgery, ambulatory surgery, surgical recurrence, Kingsnorth classification, HerniaSurge guidelines, surgical outcomes