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Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?
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Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?

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  • 1. PAIN AND NEURALGIA AFTER HERNIA SURGERY: CAN IT BE AVOIDED? AND HOW DO WE TREAT? <ul><li>George S Ferzli MD, FACS </li></ul>
  • 2. Henry Kissinger, 17 Jun 2006 “ Soccer is a game that hides great complexity in an appearance of simplicity.”
  • 3. GROIN PAIN INCIDENCE * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986; 3 (suppl): 1-226. Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years 34.3% >1year 210 EK Aasvang 2006 Mild 4.1% > 1yr Severe 0.5% > 1yr 2.1 %> 6 mo 9.7% > 6 mo 973 Sergio Alfieri 2006 31% >24 to 36 mo 2456 Ulf Fränneby 2006 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo 208 Jrg Kninger 2004 1.8% > 5 yrs 9.7%>1 yr 928 AM Grant 2004 6%>1 yr 25% > 1 yr 593 Marcello Picchio 2004 > 2.5 yrs 71% have pain Severe in 22% Mild in 45% 3% > 3 mo 4062 CA Courtney 2002 30% >21 mo 454 S Kumar 2002 3% 28.7% > year 1166 Morten Bay-Nielsen 2001 30% > 3 mo 226 AS Poobalan 2001 Pain Severe Outcome of Pain Pain * # of Pts Author
  • 4. QUALITY OF LIFE 6% 2456 Ulf Fränneby 2006 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) 208 Jrg Kninger 2004 11.3% to 14.2% 973 Sergio Alfieri, 2006 24.8% 6% after 6.5 years 210 Nb EK Aasvang 2006 18.1% 454 S Kumar 2002 16.6% 1166 Morten Bay-Nielsen 2001 Pain affects the Quality of life Pts Author
  • 5. What Causes Groin Pain Like soccer affects our lives, groin pain also effects the quality of life… How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n.
  • 6. The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh. In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum. The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve. Iliohypogastric n. Ilioinguinal n. Cross innervation
  • 7. <ul><li>Red line = genitofemoral n. Green line = ilioinguinal n. </li></ul><ul><li>Gray area = skin innervated by cutaneous components of </li></ul><ul><li>genitofemoral and/or ilioinguinal n. </li></ul>Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, MD, Johannes Ebmer, and A Lee Dellon, MD Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. Cutaneous branching patterns of ilioinguinal / genitofemoral nerves RISK FACTORS: ANATOMICAL VARIATIONS Type A (43 %) Type B (28.1%) Type C (20.3%) Type D (7.7%). Patterns of innervation were bilaterally symmetric in 40.6 % of the cadavers. The “normal” pattern of distribution, consistent with modern text descriptions, was defined in only 20.3% Re: site within the inguinal canal / relationship between nerve branches and spermatic cord/round lig.- normal type was found in 56.3% Matthias Rab 2001 Only 37 % of the cases had typical textbook patterns Morikawa 1971
  • 8. IDENTIFICATION ZONES FOR THE INGUINAL NERVES <ul><li>The iliohypogastric nerve: 3.8 cm (range 2.5–5.5 cm) cranially from the external ring. </li></ul><ul><li>The ilioinguinal nerve: ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. </li></ul><ul><li>The genital branch: laterocaudal at the level of the internal inguinal ring. </li></ul>Nerve-Identifying Inguinal Hernia Repair: A Surgical Anatomical Study. AR Wijsmuller, JFM Lange, GJ Kleinrensink, D van Geldere, MP Simons, FJPM Huygen, J Jeekel, JF Lange World J Surg (2007) 31: 414-420
  • 9. <ul><li>In the case of difficulty identifying the iliohypogastric nerve, the upper leaf of the external oblique aponeurosis should be separated medially and cranially and lifted cautiously until the iliohypogastric nerve is identified perforating the aponeurose at a zone 2.5–5.5 cm (3.8 cm) cranial from the external ring. </li></ul>THE ILIOHYPOGASTRIC NERVE
  • 10. <ul><li>The genital branch of the genitofemoral nerve should be identified proximally and laterocaudally at the level of the internal ring in the frontal plane where its course variability is least. </li></ul>THE GENITAL BRANCH
  • 11. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n.
  • 12. GENITOFEMORAL NERVE INNERVATION (L1,2) The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle. Genital branch, genitofemoral nerve
  • 13. NERVE INNERVATION - FEMORAL BR. GENITOFEMORAL NERVE (L1,2) The femoral branch supplies sensory innervation to the anterolateral thigh.
  • 14. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n.
  • 15. <ul><li>Sensory innervation </li></ul><ul><li>to anterolateral thigh </li></ul><ul><li>Injury may result in </li></ul><ul><li>a severe burning </li></ul><ul><li>sensation along the </li></ul><ul><li>anterolateral aspect </li></ul><ul><li>of the thigh </li></ul>LATERAL FEMORAL CUTANEOUS NERVE INNERVATION (L2,3)
  • 16. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Femoral n.
  • 17. <ul><li>Sensory innervation </li></ul><ul><li>to anterolateral thigh </li></ul><ul><li>Injury may result in </li></ul><ul><li>atrophy of the quadriceps muscle </li></ul>FEMORAL NERVE INNERVATION (L2,3)
  • 18. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n.
  • 19. RISK FACTORS: MESH REPAIR The presence of the prosthetic mesh was not associated with significant postoperative complaints Jrg Kninger 2004 There was no association between severe or very severe pain following operation and operation type (mesh or non-mesh) CA Courtney 2002 Patients who underwent mesh repair reported more chronic pain than those who had suture repair, but this was not significant (P = 0.08) AS Poobalan 2001 Mesh repairs are less likely to cause CGP than non-mesh repairs Scott N 2000 The behaviour of the prosthetic mesh as a foreign body, with all its implications such as shrinkage and scarring, might be a risk factor for the development of chronic pain itself Heise CP, Starling JR (1998)
  • 20. RISK FACTORS: MESH REPAIR <ul><li>Mechanical compression </li></ul><ul><li>of peripheral nerves is </li></ul><ul><li>associated with myelin </li></ul><ul><li>degeneration, </li></ul><ul><li>endoneurinal and </li></ul><ul><li>perineurinal edema, </li></ul><ul><li>fibrosis, axonal loss, and </li></ul><ul><li>edema that may cause </li></ul><ul><li>peripheral neuropathy. </li></ul>The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin Hernia Seher Demirer, MD Journal of Surgical Research 131 , 175–181 (2006)
  • 21. <ul><li>Spermatic cord problems </li></ul><ul><li>Orchitis </li></ul><ul><li>Vas deferens issues </li></ul><ul><li>Perineural fibrosis </li></ul><ul><li>Neuroma </li></ul><ul><li>Nerve entrapment </li></ul><ul><li>Direct lesions due to stretching, contusion, electrical injury, and partial or complete division. </li></ul>Neuropathic Non-neuropathic Visceral <ul><li>Osteitis pubis </li></ul><ul><li>Stapalgia </li></ul><ul><li>Meshalgia </li></ul>Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK Hernia 2004; 8 : 343–349.
  • 22. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age
  • 23. RISK FACTORS: AGE P < 0.001 345 (33.6%) 205 (21.0%) < 59 > 59 1026 976 Ulf Fränneby, 2006 NS 30.2% 36.5% 31.7% 18-40 41-65 >65 43 126 41 EK Aasvang 2006 P 0.000 47 134 66 72 < 50 > 50 309 Simon Willem Nienhuijs 2005 P < 0.001 8 (42%) 49 (60%) 102 (86%) 11 (58%) 33 (40%) 16 (14%) < 40 40-60 >60 226 19 82 118 7 ? AS Poobalan 2001 Statistical Significance No Pain Pain Age # of Pts Author
  • 24. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Pre-op pain
  • 25. RISK FACTORS: PREOPERATIVE PAIN * Lower than “Affects concentration on daily activities” ** “Affects concentration on daily activities” or higher Statistical significance No Chronic Pain Chronic Pain # of Pts Preop Pain Author No pain* 966 Pain** 1036 No pain Pain 176 (18.2%) 374 (36.1%) 7 (13%) 50 (35%) 47(87%) 95(65%) P <0.001 Ulf Fränneby2006 0.005 AS Poobalan 2001 No correlation was found between the presence of preoperative pain and the occurrence of postoperative pain Marcello Picchio, 2004 Patients who go on to suffer chronic pain are more likely to have complained of pain from the hernia before operation than those who have no postoperative pain and they are more likely to suffer from other chronic pain conditions compared with the normal population. CA Courtney 2002
  • 26. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age BMI Pre-op pain
  • 27. RISK FACTORS: BMI *The authors of this study considered the association of the BMI with chronic pain a coincidence. The elderly, for the most part, had a higher body mass index. Statistical Significance No Chronic Pain Chronic Pain # Pts BMI Author < 25 282 >25 Normal 66 Overweight 109 Obese 40 76 (27%) 45 (16% 16 (24%) 31 (28%) 15 (38%) 85 (30%) 76 (27%) 50 (76%) 78 (72%) 25 (62%) P 0.059 Simon Willem Nienhuijs * 2005 P 0.341 A S Poobalan 2001
  • 28. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk Pre-op pain BMI
  • 29. RISK FACTORS: POST OP COMPLICATIONS Postoperative complications were found to be linked to an increased risk for longterm pain. (OR, 1.8; 95% CI, 1.2–2.5; P 0.003) Risk Factors for Long-term Pain After Hernia Surgery Ulf Fr ä nneby, MD, ( Ann Surg 2006; 244: 212-219) P < 0.003 Post Op Complications 52/137 (38.0%) Registered 498/1865 (26.7%) Not registered
  • 30. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Recurrent hernia
  • 31. RISK FACTORS: RECURRENT HERNIA *In this study no variables were identified that significantly correlated to pain or functional impairment 6.5 years after surgery. Statistical Significance No Chronic Pain Chronic Pain # Pts Recurrent Hernia Author Recurrent Initial Recurrent Initial 27.8% 35.6% 10 (59%) 39 (24%) 7 (41%) 124 (76%) NS EK Aasvang 2006* 0.005 AS Poobalan 2001
  • 32. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Day case surgery Technique Insurance status Recurrent hernia
  • 33. RISK FACTORS: DAY CASE SURGERY <ul><li>The probability of developing chronic pain was 2´5 times higher in day-case patients, controlling for age. </li></ul>Chronic pain and quality of life following open inguinal hernia repair . AS Poobalan, J Bruce, PM King*, WA Chambers, ZH Krukowski* and WCS Smith British Journal of Surgery 2001, 88: 1122-1126 148 (76%) 47 (24%) Inpatient 0.004 3.72 (1.45± 9.64) 11 (46%) 13 (54 %) Day case P Odds ratio No Chronic pain Chronic pain Risk factor
  • 34. RISK FACTORS: LAPAROSCOPY vs. OPEN P< 0.01 54 (22.5%) 82 (38.3%) TEP Open mesh repair 240 214 S Kumar 2002 532 (27.9%) 18 (18.9%) Anterior approach Posterior approach 1907 95 Ulf Fränneby, 2006 P 0.019 108 (27.7%) 129 (35.6%) TEP Open 390 362 AM Grant 2004 P< 0.01 Slight Moderate Severe 12 (14.8%) 1 (1.2%) - 18 (23.7%) 4 (5.3%) 3 (3.9%) 16 (21.6%) 10 (13.3%) 2 (2.7%) TAPP Lichetenstein Shouldice 81 76 74 Jrg Kninger 2004 Statistical Significance Pain Procedure # Pts Author
  • 35. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Lat. femoral cutaneous n. Mesh Femoral n. Age Post-op complication risk BMI Pre-op pain Day case surgery Technique Insurance status Recurrent hernia Non-surgical management Neurolysis
  • 36. NON-SURGICAL MANAGEMENT <ul><li>Non-operative attempts at pain resolution include: </li></ul><ul><li>Biofeedback </li></ul><ul><li>Medications </li></ul><ul><li>Physical therapy </li></ul><ul><li>Percutaneous treatment with local anesthetics, steroids, phenol, alcohol, cryoprobes, radiofrequency destruction </li></ul><ul><li>Transcutaneous nerve stimulators </li></ul>
  • 37. NEUROLYSIS <ul><li>Dellon AL 1995* : </li></ul><ul><li>23 patients who had lateral femoral cutaneous nerve entrapments : </li></ul><ul><li>Excellent results 78.3% </li></ul><ul><li>Good results in 17.4% </li></ul><ul><li>Poor results in 4.3%. </li></ul><ul><li>Amid 2004 : </li></ul><ul><li>Neurolysis is not recommended because it does not address neuromas or inevitable secondary scarification </li></ul>* Nahabedian MY, Dellon AL. Meralgia paresthetica: Etiology, diagnosis, and outcome of surgical decompression. Ann Plast Surg 1995; 35: 590-594.
  • 38. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Lat. femoral cutaneous n. Femoral n.
  • 39. SURGICAL MANAGEMENT: NEURECTOMY 3% 25% 72% 100 James A Madura 2005 5% 15% 80% 225 Amid PK 2004 10% 11% 17% 25% 68% II 78% IH 83% GF 50% 54 Cathy H Lee 2000 83% 30 Starling 1987 100% 5 Magee 1945 83% 6 Lyon 1942 Poor result Partial relief Excellent relief # of Pts Author
  • 40. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Lat. femoral cutaneous n. Femoral n.
  • 41. SURGICAL MANAGEMENT: MESH REMOVAL <ul><li>Heise 1998: Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia). </li></ul><ul><li>Amid 2004 :Treatment of chronic inguinodynia caused by ‘‘meshoma’’ is their surgical explanation. </li></ul>Mesh Inguinodynia: A New Clinical Syndrome after Inguinal Herniorrhaphy? Charles P Heise, MD, and James R Starling, MD, FACS J Am Coll Surg 1998; 187: 514-518.
  • 42. <ul><li>Surgical treatment for periosteal reaction or osteitis pubis consists of removing suture materials, staples, bulky suture knots, and/or bulk forming or rolled mesh material from the pubic tubercle area. </li></ul>SURGICAL MANAGEMENT Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8: 343-349.
  • 43. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Lat. femoral cutaneous n. Femoral n.
  • 44. Combined Laparoscopic and Open Treatment <ul><li>The laparoscopic approach: </li></ul><ul><li>Diagnostic </li></ul><ul><li>Definitive hernia repair in unaltered tissues. </li></ul><ul><li>Anterior approach: </li></ul><ul><li>Removal of the offending foreign body </li></ul><ul><li>Appropriate nerve resection </li></ul><ul><li>12 pts {Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1)}. 6 weeks F/U, all pts were significantly improved. </li></ul><ul><li>(2 pts had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. ) </li></ul>Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair MJ Rosen Æ YW Novitsky Æ WS Cobb K W Kercher Æ B Todd Heniford, Hernia (2006) 10: 20–24
  • 45. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Lat. femoral cutaneous n. Femoral n.
  • 46. WATCHFUL WAITING The rate of acute incarceration and strangulation is very low. The risk of this complication should not be the sole indication for repair of the hernia. Patients who have pain benefit from repair; however, many patients experience pain after hernia repair; and in some patients, this is new or worse pain than before their operation. Preoperative discussions with patients should include disclosure of this risk. Delaying repair appears safe, although major life-threatening complications can occur in any patient undergoing even a simple operation. Leigh Neumayer, 2006 Repair of an asymptomatic inguinal hernia does not affect the rate of long-term chronic pain and may be beneficial to patients in improving overall health and reducing potentially serious morbidity. Patrick J O’Dwyer, 2006 A strategy of watchful waiting is a safe and acceptable option for men with asymptomatic or minimally symptomatic inguinal hernias. Acute hernia incarcerations occur rarely (1.8 per 1000 patient years), and patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic hernia repair Fitzgibbons RJ Jr 2006
  • 47. PREVENTION: WATCHFUL WAITING 20% by 1 year 23% by 2years Conversion P 0.11 P 0.34 P 0.036 P 0.39 P 0.99 P 0.93 P 0.20 Statistical significance 1% 0.3% Acute incarceration Pain in Observation Gp Pain in Repair Gp # of Pts Mean (SD) At rest 6 mo: 8.0 (14.0) At rest 12 mo: 3.7 (8.2) At movement 6 mo: 10.9 (16.0) At movement 12 mo: 7.6 (15.0) Mean (SD) At rest 6 mo: 4.8 (10.7) At rest 12 mo: 5.2 (12.3) At movement 6 mo: 6.1 (11.9) At movement 12 mo: 5.7 (11.5) 160 Repair 75 Observe 78 Patrick J O’Dwyer, 2006 At rest: 8.2 (15.6) Nl activities: 10.4 (14.9) Work/Exercice:14.6 (20.7) At rest: 8.2 (13.1) Nl activities: 10.3 (14.9) Work/Exercice: 17.1 (24.6) 720 Repair 356 Observe 364 Fitzgibbons RJ Jr 2006
  • 48. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Prophylactic neurectomy Lat. femoral cutaneous n. Femoral n.
  • 49. PROPHYLACTIC NEURECTOMY 42 vs 42.9 (P 0.931) 8% vs 28.6% (p 0.008) NS - rt. vs lt. (p 0.345) After 2 years (p 0.974) 50 vs 50 100 male pts bilateral (iliohypogast. neurect. rt. side only) Wilfred Lik-Man Mui 2006 Pappalardo etal 2007 18% vs. 4% (p 0.10) 13% vs. 5% (p 0.32) 6 mos.3% vs 26% (p 0.001) 1 yr 3% vs 25% (p 0.003) 66 vs 24 George W Dittrick 2004 Numbness 6.28% Sensory Loss 1.04% 0 191 DE Tsakayannis 2004 Numbness 4% vs 6% p 0.39 Loss of touch sensation 11% vs 4% p 0.002 Loss of pain sensation 9% vs 8% p 0.89 Mild: 21% vs 18% Moderate: 3% vs 4% Severe: 3% vs 2% p 0.55 408 vs 405 Marcello Picchio 2004 10% vs 0% 0% vs 5% 20 bilat. Ravichandran 2000 Paresthesia Pain (Neurectomy vs Non-neurectomy) # of Pts Author
  • 50. What Causes Groin Pain How to Treat Groin Pain Ilioinguinal n. Iliohypogastric n. Genitofemoral n. Mesh Age Post-op complication risk BMI Pre-op pain Recurrent hernia Mesh removal Neurectomy Day case surgery Technique Insurance status Non-surgical management Neurolysis Repair recurrent hernia Watchful waiting Nerve identification Prophylactic neurectomy Lat. femoral cutaneous n. Femoral n.
  • 51. NERVE IDENTIFICATION <ul><li>Identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain . </li></ul><ul><li>Chronic pain at 6 months after surgery was zero in those patients in whom all 3 nerves were identified and preserved, compared with the 40% incidence when these nerves were all divided, or 4.7% when not all nerves were identified. </li></ul>Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy Prospective Multicentric Study of Chronic Pain Sergio Alfieri, MD, Ann Surg, April 2006; 243: 553-558 * Univariate Analysis: Risk of Complaining of Pain at 6 Months According to Nerve Treatment **Multivariate Analysis:Risk of Complaining of Pain at 6 Months According to Nerve Treatment 19.2 2.3–157.7 0.006 3.8 1.2–11.4 0.019 3 12.4 1.3–115.3 0.027 2.1 0.6–8.1 NS 2 2.2 0.2–26.4 0.539 0.9 0.2–3.4 NS 1 MV** RR 95%CI P UA* RR 95%CI P Nerves not identified
  • 52. CONCLUSIONS <ul><li>Should wait more than one year before treating pain </li></ul><ul><li>Nerve identification/preservation and careful surgical technique are probably the key to winning this game </li></ul><ul><li>Headbutt with nerves? </li></ul><ul><li>Keep your own “nerves” cool. </li></ul>
  • 53. References <ul><li>Mesh Inguinodynia: A New Clinical Syndrome after Inguinal Herniorrhaphy? Charles P Heise, MD, and James R Starling, MD, FACS J Am Coll Surg 1998; b187: 514-518. </li></ul><ul><li>Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, MD, Johannes Ebmer, and A. Lee Dellon, MD Plastic and Reconstr. Surg, 108: 1618, 2001. </li></ul><ul><li>Chronic pain and quality of life following open inguinal hernia repair AS Poobalan, J Bruce, PM King*, WA Chambers², ZH Krukowski and WCS Smith British J Surg. 2001, 88, 1122-1126 </li></ul><ul><li>Pain and Functional Impairment 1 Year After Inguinal Herniorrhaphy: A Nationwide Questionnaire Study Morten Bay-Nielsen, MD, Frederick M. Perkins, MD, and Henrik Kehlet, PhD, for the Danish Hernia Database Ann. Surg. vol. 233, No. 1, 1– © 2001 </li></ul><ul><li>Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, RG Wilson, SJ Nixon and IMC Macintyre British J Surg. 2002, 89, 1476-1479 </li></ul><ul><li>Outcome of patients with severe chronic pain following repair of groin hernia CA Courtney, K Duffy, MG Serpell and PJ O'Dwyer British J Surg. 2002, 89, 1310-1314 </li></ul><ul><li>Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD Am J Obstet Gynecol 2003; 189: 1574-8 </li></ul><ul><li>Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP Jrg Kninger Jens Redecke Michael Butters Langenbecks Arch Surg (2004) 389: 361-365 </li></ul><ul><li>Randomized Controlled Trial of Preservation or Elective Division of Ilioinguinal Nerve on Open Inguinal Hernia Repair With Polypropylene Mesh Marcello Picchio, MD; Domenico Palimento, MD; Ugo Attanasio, MD; Pietro Filippo Matarazzo, MD; Chiara Bambini PhD; Angelo Caliendo, MD Arch Surg. 2004; 139: 755-758 </li></ul>
  • 54. References <ul><li>Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, MD*, Kimberly Ridl, MD, Joseph A. Kuhn, MD, Todd M. McCarty, MD The Am J Surg 188 (2004) 736-740 </li></ul><ul><li>Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia AM Grant 1 , NW Scott 2 and PJ O’Dwyer 3 , on behalf of the MRC Laparoscopic Groin Hernia Trial Group British J Surg 2004; 91: 1570-1574 </li></ul><ul><li>Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8 : 343-349. </li></ul><ul><li>Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair DE Tsakayannis Æ AC Kiriakopoulos Æ DA Linos Hernia (2004) 8: 67-69 </li></ul><ul><li>Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, MDa,*, James A Madura, II, MDa, Chad M. Copper, MDa, Robert M. Worth, MDb The Am J Surg 189 (2005) 283-287 </li></ul><ul><li>Surgical management of chronic pain after inguinal hernia repair E Aasvang and H Kehlet British J Surgery 2005; 92: 795-801 </li></ul><ul><li>Pain after Anterior Mesh Hernia Repair Simon Willem Nienhuijs, MD, Oliver BA Boelens, MD, Luc JA Strobbe, MD J Am Coll Surg 2005; 200: 885-889. </li></ul><ul><li>Prophylactic Ilioinguinal Neurectomy in Open Inguinal Hernia Repair A Double-Blind Randomized Controlled Trial Wilfred Lik-Man Mui, MB, ChB, FRCS Ed, FRACS,* Calvin S. H. Ng, MBBS (Hons), MRCS Ed,* Terence Ming-Kit Fung, MB, ChB, FRCS Ed,* Frances Ka Yin Cheung, MBBS, MRCS Ed,* Chi-Ming Wong, BSc (OT),† Tze-Hin Ma, BSc (OT),† Man-Yee Yung, BN,* and Enders Kwok-Wai Ng, MD, FRCS Ed* Ann Surg 2006; 244: 27-33 </li></ul><ul><li>Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy Prospective Multicentric Study of Chronic Pain Sergio Alfieri, MD,* Fabio Rotondi, MD,* Andrea Di Giorgio, MD,* Uberto Fumagalli, MD,† Antonio Salzano, MD,‡ Dario Di Miceli, MD,* Marco Pericoli Ridolfini, MD,* Antonio Sgagari, MD,*Giovannibattista Doglietto, MD,* and the Groin Pain Trial Group§ Ann Surg April 2006; 243: 553-558 </li></ul>
  • 55. References <ul><li>The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin Hernia Seher Demirer, MD, Ilknur Kepenekci, MD, 1 O Evirgen, MD, O Birsen, MD, A Tuzuner, MD, S Karahuseyinoglu, MD, M Ozban, MD, and E Kuterdem, MD, 1 J Surg. Res. 131 , 175-181 (2006) </li></ul><ul><li>Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair M. J. Rosen Æ YW Novitsky Æ WS Cobb K. W. Kercher Æ B Todd Heniford Hernia (2006) 10: 20-24 </li></ul><ul><li>Observation or Operation for Patients With an Asymptomatic Inguinal Hernia A Randomized Clinical Trial Patrick J O’Dwyer, FRCS, John Norrie, MSc, Ahmed Alani, FRCS, Andrew Walker, PhD, Felix Duffy, RN, and Paul Horgan, FRCS Ann Surg 2006; 244: 167-173 </li></ul><ul><li>Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA . 2006; 295: 285-292 </li></ul><ul><li>Is the Presence of an Inguinal Hernia Enough to Justify Repair? Leigh Neumayer, MD, MS Annals of Surgery • Volume 244, Number 2, August 2006 </li></ul>
  • 56. <ul><li>The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5–5.5 cm) cranially from the external ring. </li></ul><ul><li>The ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. </li></ul><ul><li>The course of the genital branch is laterocaudal at the level of the internal inguinal ring. </li></ul>IDENTIFICATION ZONES FOR THE INGUINAL NERVES

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