An Overview of Abdominal Pain After Surgery

Unfortunately, abdominal surgery can sometimes lead to chronic abdominal nerve pain or chronic pelvic nerve pain. For people whose abdominal or pelvic nerves have been cut, stretched, or otherwise damaged during abdominal surgery, such as an appendectomy, gynecological surgery or some types of hernia repair, the condition can be very disabling.

It's not certain how often this occurs, but we are learning that nerve pain following surgery is much more common than once thought.

This can be frightening to read if you are planning on having surgery, but there are some things you may be able to do as a patient that could reduce your risk, and research is in progress looking at ways to reduce the risk of, and treat the occurrence of, nerve pain after surgery.

Abdominal surgery has been known, in some cases, to cause damage to the ilioinguinal nerve, the iliohypogastric nerve, and the genitofemoral nerve, all of which can lead to pelvic nerve pain or pelvic neuropathic pain. That said, there is not always a simple relationship between nerve damage and the later experience of nerve-related pain. Here are a few reasons why this might happen:

• Pelvic nerves are close to incisional sites: During routine abdominal and pelvic surgeries, the iliohypogastric and ilioinguinal nerves are often directly in the line of fire. Due to anatomical differences between people, even the most skilled surgeons have the potential to sever these nerves.
• Anatomically, pelvic nerves are different in each person: Pelvic nerve structure can vary greatly from person to person. In some people, the nerves sit under the abdominal muscles. In other people, they may pass right through them. Some people have more pelvic nerve branches than others. Avoiding pelvic nerve damage during surgery is not easy when there are so many potential variations.
• Stretching pelvic nerves can also cause damage: You don’t have to have your pelvic nerves cut or nicked in order to suffer from chronic pelvic nerve pain. Sometimes, the nerves are stretched enough during surgery that damage is done.
• Pelvic nerves may become compressed after surgery: Nerve entrapment—in sutures, staples or mesh—can also lead to pelvic nerve pain and can occur after some types of abdominal and pelvic surgery.

Just as it is not often known exactly what causes chronic pain after surgery, it isn't certain what the precise risk factors are for developing chronic pain. Risk factors can include preoperative pain, psychological factors, demographics, and intensity of acute postoperative pain.

A significant but under-recognized cause of chronic abdominal pain after surgery is cutaneous nerve entrapment. This occurs when nerves near the surface of the abdomen become entrapped as they pass through the rectus muscle. This is thought to be the cause of around 30 percent of cases of chronic pain after abdominal surgery.

Diagnosis can be made by injecting a local anesthetic near the nerve (which can be visualized and done via ultrasound.) Since relative to many other causes of chronic abdominal pain after surgery nerve entrapment is "easy" to resolve, it's important that you mention this to your doctor if you are not getting answers.

Talk to your surgeon if you think your post-operative (post-surgery) pain may be unusual. Most of the time stretched nerves will heal on their own with the proper care. And many times, nerves that are entrapped will resolve on their own when the suture is absorbed by the body. If you're still experiencing pain more than three months after your surgery, it's considered chronic pain.

There are several possible treatments for chronic pelvic nerve pain that doesn't resolve on its own.

• Medications: Your doctor may also recommend certain medications for the pain. The most commonly prescribed drugs for chronic pelvic nerve pain are tricyclic antidepressants and anticonvulsants such as Neurontin (gabapentin). Newer medications such as Lyrica (pregabalin) have also been effective for some people. Although these medications weren't originally developed for treating pain, they have been found to relieve pain in some conditions. It's important to note that antidepressants that are prescribed for chronic pain are thought to work with pain receptors in the brain. In other words, your doctor is not prescribing these medications because she believes "your pain is in your head."
• Nerve blocks: Nerve blocks are very effective for some people coping with chronic pelvic nerve pain.
• TENS: TENS units (transcutaneous electrical nerve stimulation) have helped some people cope with their pain.

Most studies suggest that the best treatment of nerve pain is a combination of medications, other medical therapies, and lifestyle measures. What can you do yourself if you are suffering from pain?

• Keep a pain journal: Writing in a pain journal can be very helpful when you suffer from chronic pain. Not only may it help you further understand your pain so that you can share your symptoms with your doctor, but it can be an effective way to determine what works and what doesn't work to manage your pain.
• Mind/body therapies: From meditation to yoga, "natural" mind and body therapies and remedies may not only decrease your pain but can decrease the stress in your life that worsens your pain.

If you are concerned about pain as you approach surgery, keep in mind that the majority of people who undergo abdominal surgery do not experience chronic nerve pain later on. And as more and more research becomes available, surgeons are using more advanced techniques to avoid damage to pelvic nerves during abdominal and pelvic surgeries.

Though we have a long way to go in determining the best ways to prevent and treat chronic pain following surgery, we do know of a strong predictor for pain that can be altered. Since the severity of acute postoperative pain is strongly linked with the risk for chronic pain, it would seem that aggressive treatment of post-operative pain would be imperative.

With treating post-surgical pain, studies continually show us that aggressive up-front management results in the best control of pain. In other words, you want to stay on top of your pain and not try to play "catch up" with pain medications. Talk to your surgeon about how much pain is acceptable after surgery.

Though we don't yet know if better management of post-op pain will reduce the risk of chronic pain later on, it very well may. And there are other reasons as well to make sure your pain control is adequate directly following surgery.