Groin Pain

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Groin Pain

  1. 1. Groin Pain 2
  2. 2. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>In the present study the pattern of cutaneous nerve branches in the inguinal region was investigated through dissection in 64 halves of 32 human embalmed anatomic specimens. </li></ul><ul><li>In contrast to usual textual descriptions, four different types of cutaneous branching patterns are identified: </li></ul><ul><li>type A, with a dominance of genitofemoral nerve in the scrotal/labial and the ventromedial thigh region. In type A, the ilioinguinal nerve gives no sensory contribution to these regions (43.7 percent). </li></ul><ul><li>In type B, with a dominance of ilioinguinal nerve, the genitofemoral nerve shares a branch with the ilioinguinal and gives motor fibers to cremaster muscle in the inguinal canal, but has no sensory branch to the groin (28.1 percent). </li></ul><ul><li>In type C, with a dominance of genitofemoral nerve, the ilioinguinal nerve has sensory branches to the mons pubis and inguinal crease together with an anteroproximal part of the root of the penis or labia majora. The nerve was found to share a branch with the iliohypogastric nerve (20.3 percent). </li></ul><ul><li>In type D, cutaneous branches emerge from both the ilioinguinal and the genitofemoral nerves. Additionally, the ilioinguinal nerve innervates the mons pubis and inguinal crease together with a very anteroproximal part of the root of the penis or labia majora (7.8 percent). </li></ul><ul><li>The described patterns of innervation were bilaterally symmetric in 40.6 percent of the cadavers. </li></ul><ul><li>The anatomic variability of both nerves has implications for all surgeons operating in the groin region and for those caring for the patient with groin pain. </li></ul>
  3. 3. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>In 1893, Ruge19 introduced the term “Grenznerven” for these nerves, which was translated as “border nerves” by Bardeen and Elting.20 </li></ul><ul><li>( these three nerves contribute to the skin in the border between the abdomen and thigh.) </li></ul><ul><li>Morikawa pointed out that only 37 percent of the cases investigated were found to have the typical pattern as described in most texbooks.21 </li></ul>
  4. 4. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001.
  5. 5. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>Type A (43.7 percent of the dissections). </li></ul><ul><li>In type A, the skin of the pubis, the skin of the ventral scrotum or the ventral labia, and the skin of the ventromedial thigh were found to be innervated only by the cutaneous component of the genital branch of the genitofemoral nerve . </li></ul>
  6. 6. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>Type B (28.1 percent). </li></ul><ul><li>In type B, the skin regions mentioned above were found to be innervated only by the cutaneous component of the ilioinguinal nerve </li></ul>
  7. 7. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>Type C (20.3 percent). </li></ul><ul><li>The ilioinguinal nerve was found to have sensory branches to the mons pubis and inguinal crease together with a very anteroproximal part of the root of the penis or labia majora. </li></ul><ul><li>The nerve was found to share a branch with the iliohypogastric nerve after exiting the superficial inguinal ring. </li></ul><ul><li>The cutaneous component of the genital branch of the genitofemoral nerve innervated the remaining, lower located parts of the inguinal and ventromedial thigh regions </li></ul>
  8. 8. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>Type D (7.8 percent). </li></ul><ul><li>In type D, the two cutaneous components of the ilioinguinal and genitofemoral nerves shared together the whole skin innervation of the mentioned regions </li></ul>
  9. 9. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>Inguinal and Ventromedial Thigh Region </li></ul><ul><li>The described patterns of innervation were bilaterally symmetric in 40.6 percent of the cadavers. </li></ul>
  10. 10. Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D. Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001. <ul><li>The “classic” or “normal” pattern of distribution and terminal course, consistent with modern text descriptions, was defined in only 20.3 percent of inguinal and ventromedial thigh regions dissected.17–20 This normal pattern of distribution would correspond with type C according to our classification. </li></ul><ul><li>Regarding the site within the inguinal canal and the relationship between nerve branches and spermatic cord/round ligament, a normal type was found in 56.3 percent of the cases, nevertheless. According to our classification, types B, C, and D would meet these criteria. </li></ul><ul><li>In type A, with 43.7 percent of the dissections, the most frequent type observed, an aberrant course of the cutaneous component of the ilioinguinal nerve was recorded in the inguinal canal. </li></ul>
  11. 11. 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.) <ul><li>OBJECTIVE: The purpose of this study was to map the course of the ilioinguinal and iliohypogastric nerves. </li></ul><ul><li>STUDY DESIGN: The courses of iliohypogastric and ilioinguinal nerves from 11 fresh frozen cadavers were mapped from their lateral emergence on the anterior abdominal wall to their midline termination in reference to fixed bony landmarks. Bivariate fit ellipses were generated for each nerve and compared with sites of standard abdominal surgical incisions. </li></ul><ul><li>RESULTS: Thirteen iliohypogastric and 16 ilioinguinal nerves were identified and mapped. </li></ul><ul><li>On average, the proximal end of the ilioinguinal nerve entered the abdominal wall 3.1 cm medial and 3.7 cm inferior to the anterior superior iliac spine, then followed a linear course to terminate 2.7 cm lateral to the midline and 1.7 cm superior to pubic symphysis. </li></ul><ul><li>The iliohypogastric nerve entered the abdominal wall on average 2.1 cm medial and 0.9 cm inferior to the anterior superior iliac spine, which followed a linear course to terminate 3.7 cm lateral to the midline and 5.2 cm superior to pubic symphysis. </li></ul><ul><li>CONCLUSION: Abdominal wall surgical sites below the level of the anterior superior iliac spine have the potential for ilioinguinal or iliohypogastric injury. </li></ul>
  12. 12. 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.)
  13. 13. 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.)
  14. 14. 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 <ul><li>Introduction: </li></ul><ul><li>Chronic pain after hernia repair is common, and it is unclear to what extent the different operation techniques influence its incidence. The aim of the present study was to compare the three major standardized techniques of hernia repair with regard to postoperative pain. </li></ul><ul><li>Patients and methods: Two hundred and eighty male patients with primary hernias were prospectively, randomly selected to undergo Shouldice, tension-free Lichtenstein or laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty repairs. Patients were examined after 52 months with emphasis on chronic pain and its limitations to their quality of life. </li></ul><ul><li>Results: </li></ul><ul><li>Chronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein repair and in 15% after TAPP repair. </li></ul><ul><li>Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein and in 11% after TAPP repair. </li></ul><ul><li>Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice, 13% after Lichtenstein and 2.4% after TAPP repair. </li></ul><ul><li>Conclusion: </li></ul><ul><li>Chronic pain after hernia surgery is significantly more common with the open approach to the groin by Shouldice and Lichtenstein methods. </li></ul><ul><li>The presence of the prosthetic mesh was not associated with significant postoperative complaints. </li></ul><ul><li>The TAPP repair represents the most effective approach of the three techniques in the hands of an experienced surgeon. </li></ul>
  15. 15. 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 <ul><li>The incidence of chronic pain following hernia repair is not accurately known. Different studies report frequencies of up to 40% </li></ul><ul><li>Several risk factors have been identified, such as recurrence, patient’s age and resection of the cremasteric muscle, experience of the surgeon and the presence of pre-operative pain. </li></ul><ul><li>Nerve injury during laparoscopic hernia repair, especially to the nervus cutaneus femoris lateralis has also been reported, especially at the beginning of the laparoscopic repair era, but seems to be avoidable with the correct operating technique </li></ul><ul><li>Mesh fixation in the laparoscopic group was performed with between four and six titanium clips (EMS Herniostate; Ethicon) with strict avoidance of clips in the area distal of the ileopubic tract. </li></ul><ul><li>In the case of the Lichtenstein technique the mesh was fixed with a running suture (4/ 0 Prolene) to the inguinal ligament. </li></ul>
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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 <ul><li>The laparoscopic approach to the groin is surely less traumatic than the open techniques. In the case of the TAPP technique, it involves only the incision of the peritoneum and the preparation of the hernial sac, without major trauma to the abdominal wall, thus minimizing the risk of possible nerve injury and concomitant scarring </li></ul><ul><li>there is a difference in postoperative discomfort and pain after the two tension free-techniques in favour for the laparoscopic technique, although not as evident as that between Shouldice and TAPP </li></ul><ul><li>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 [18]. </li></ul><ul><li>The most common chronic pain syndrome correlates with physical stress and can be reproduced readily with manoeuvres that typically provoke abdominal-wall pain. There is some evidence that the reason for those complaints lies partly in the region of the medial inguinal ligament, where sutures involve pubic periostal structures, and the physiological tensing of this ligament then leads to pain [14]. </li></ul>
  22. 22. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479 <ul><li>Background: The aim of this study was to compare the incidence of chronic pain or discomfort after laparoscopic totally extraperitoneal (TEP) repair and open mesh repair of groin hernia, and to assess the impact of such pain on patients' physical activity. </li></ul><ul><li>Methods: A postal questionnaire was sent to patients who had TEP or open mesh repair of groin hernia between January 1998 and December 1999. The patients were asked about any persistent pain or discomfort in relation to the groin hernia repair and whether this pain or discomfort restricted their ability to undertake physical or sporting activity. </li></ul><ul><li>Results: </li></ul><ul><li>Of the 560 available patients 454 (81´1 per cent) replied. Laparoscopic TEP repair was performed in 240 patients (52´9 per cent) and open mesh repair in 214 (47´1 per cent). </li></ul><ul><li>Of the 454 patients, 136 (30´0 per cent) reported chronic groin pain or discomfort, which was signifcantly more common after open repair than after laparoscopic repair (38´3 versus 22´5 per cent; P < 0´01). </li></ul><ul><li>Chronic groin pain or discomfort restricted daily physical or sporting activity in 18´1 per cent of the patients. The patients who had open repair complained of signifcantly more restriction of daily physical activity than patients who underwent laparoscopic repair (walking, P < 0´05; lifting a bag of groceries, P < 0´01). </li></ul><ul><li>Conclusion: </li></ul><ul><li>Chronic pain or discomfort was reported by 30´0 per cent of patients after groin hernia repair and was significantly more common after open mesh repair than after laparoscopic TEP repair. It restricted physical or sporting activities in 18´1 per cent of the patients and signifcantly more so after open mesh repair. </li></ul>
  23. 23. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479 <ul><li>The reported incidence of such pain after hernia repair is thought to be about 10 per cent but varies in different studies from 0 to 60 per cent1±3. </li></ul><ul><li>Several risk factors associated with CGP have been identifed, including recurrent hernia repair4, insurance status of the patient5, day surgery6, patient's age less than 60 years2,6, and severe early postoperative pain4 </li></ul>
  24. 24. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479
  25. 25. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479
  26. 26. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479 <ul><li>Laparoscopic TEP repair was performed under general anaesthesia and without fxing the Prolene (Ethicon, Edinburgh, UK) mesh in the preperitoneal space. </li></ul><ul><li>Open mesh repair was performed by the Lichtenstein technique under general anaesthesia, except in patients with signifcant cardiorespiratory disease or those who preferred to have local anaesthesia. </li></ul><ul><li>CGP was defined as groin pain or discomfort lasting more than 3 months after groin hernia repair11. </li></ul>
  27. 27. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479
  28. 28. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479
  29. 29. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479 <ul><li>CGP restricted daily physical or sporting activities in 18´1 per cent of the present patients after groin hernia repair. The impact of CGP on patients' daily physical or sporting activity is a matter of concern as these patients felt uncomfortable carrying a bag of groceries or playing sports such as golf. The patients with open repair were more likely to be affected than patients with laparoscopic TEP repair. </li></ul><ul><li>Two recently published studies reported that up 60 per cent of patients with pain were unable to enjoy social or leisure activity 1 year after groin hernia repair2,6 </li></ul>
  30. 30. Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre British Journal of Surgery 2002, 89, 1476±1479 <ul><li>One possible explanation for neuropathic pain is injury to the ilioinguinal, iliohypogastric or genitofemoral nerves, either during exposure of the inguinal canal or handling of the cord and dissection of the hernia sac in open surgery. </li></ul><ul><li>Lichtenstein et al.16 recommended preserving the nerves in the inguinal canal to minimize the incidence of CGP. </li></ul><ul><li>Sometimes this is difficult as the nerves may hinder the dissection or may lie across the prosthetic mesh on the posterior inguinal wall; in such circumstances some surgeons prefer to divide these nerves. </li></ul><ul><li>The genitofemoral nerve may also be at risk when the prosthetic mesh is secured in a continuous suture along the inguinal ligament or when the external spermatic vessels are divided to skeletonize the cord18 </li></ul><ul><li>The laparoscopic repair has the advantage of minimal access and less traumatic dissection to free the sac from the inguinal canal. </li></ul><ul><li>the EU Hernia Trialists' systematic review found that mesh repairs are less likely to cause CGP than non-mesh repairs22. </li></ul><ul><li>The implication of this study is that patients should be informed about the risk of developing CGP after groin hernia repair as this may influence their choice of laparoscopic or open repair. </li></ul>
  31. 31. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126 <ul><li>Background: The aim was to determine the frequency and characteristics of chronic pain following open inguinal hernia repair and to identify risk factors for its development. </li></ul><ul><li>Methods: This was a questionnaire survey of a historical cohort of patients who underwent inguinal hernia surgery in Aberdeen. The sample comprised all patients (n = 351) who underwent surgery between January 1995 and December 1997, and who were alive and resident in Grampian in October 1999. Outcome measures included self-report of pain persisting for more than 3 months after operation. Pain was characterized by means of the McGill Pain Questionnaire, and quality of life was assessed with the Short Form 36 (SF-36). </li></ul><ul><li>Results: </li></ul><ul><li>A total of 226 patients (64 per cent) completed the questionnaire, 67 (30 per cent) of whom reported chronic pain. Reported pain was predominantly neuropathic in character. </li></ul><ul><li>Patients at increased risk of chronic pain were under 40 years old (P < 0´001), </li></ul><ul><li>had day-case surgery (P = 0´004), </li></ul><ul><li>had subsequent surgery on the same side (P < 0´005) and recalled pain before operation (P = 0´005). </li></ul><ul><li>The SF-36 scores were significantly different in the social functioning, mental health and pain dimensions in patients with chronic pain. </li></ul><ul><li>Conclusion: Chronic pain occurred in 30 per cent of patients after open hernia repair, a higher frequency than has been reported previously. Several risk factors were identified and further prospective research is recommended. </li></ul>
  32. 32. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126
  33. 33. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126
  34. 34. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126
  35. 35. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126 <ul><li>Age was the strongest risk factor for developing chronic pain, decreasing from 58 per cent in patients aged under 40 years to 14 per cent in those over 60 years old (P = 0´001). </li></ul><ul><li>There was a non-significant trend in increasing frequency of chronic pain with increasing body mass index (kg/m2). </li></ul><ul><li>Patients in full-time employment were more likely to suffer chronic pain than those who had retired (P = 0´001) (Table 1). </li></ul><ul><li>Patients who underwent mesh repair reported more chronic pain than those who had suture repair, but this was not significant (P = 0´08). </li></ul><ul><li>There was no association between chronic pain and grade of surgeon (senior versus middle grade; P = 0´42); </li></ul><ul><li>day-case patients reported chronic pain more often than inpatients (54 versus 24 per cent; P = 0´004) (Table 3). The mean age of day-case patients was 53 years, compared with 62 years for inpatients, which may explain this difference. </li></ul><ul><li>logistic regression revealed that the probability of developing chronic pain decreased by 5 per cent with each 1-year increase in age; the probability of developing chronic pain was 2´5 times higher in day-case patients, controlling for age. </li></ul><ul><li>Patients who had subsequent repair of an ipsilateral recurrent hernia were more than four times as likely to develop chronic pain (odds ratio 4´54, P = 0´005). </li></ul><ul><li>patients who recalled having preoperative pain developed chronic pain more frequently (odds ratio 3´53, P = 0´005). </li></ul>
  36. 36. Chronic pain and quality of life following open inguinal hernia repair A. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith British Journal of Surgery 2001, 88, 1122±1126 <ul><li>Younger patients could be more anxious to report pain or be more sensitive to nerve damage. Studies of chronic pain after other types of operation have also reported a higher frequency of chronic pain in younger patients6. </li></ul><ul><li>The higher frequency of pain reported by patients who had surgery for recurrent herniation is similar to that described by Callesen et al.4 in 1999. This higher prevalence of chronic pain may be due to nerve entrapment in previous scar tissue12. </li></ul><ul><li>The trend of more pain with increasing body mass could be associated with difficulty in identifying the ilioinguinal nerve. </li></ul><ul><li>Although not significant, a higher proportion of patients with chronic pain had undergone mesh repair. The increased surface area of the mesh might allow adherence of nerves or abrasion to account for an increased risk of neuropathic pain. Mesh repairs are generally considered to cause less early postoperative pain13 and this observation, if confirmed, could have important implications. </li></ul>
  37. 37. 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 <ul><li>Hypothesis: Our study aimed to evaluate the effect of preservation or elective division of the ilioinguinal nerve on pain and postoperative symptoms after open inguinal hernia repair with mesh. </li></ul><ul><li>Design: Double-blind, randomized trial. Setting: Four public, government-financed hospitals in Italy. </li></ul><ul><li>Patients: From January 1, 1997, to June 30, 2002, 813 patients with primary inguinal hernia were randomly allocated to undergo inguinal hernia repair either with ilioinguinal nerve preservation (408 patients, group A) or elective transection (405 patients, group B). </li></ul><ul><li>Intervention: Hernia repair with sutureless apposition of a polypropylene mesh. </li></ul><ul><li>Main Outcome Measures: The primary outcome was the evaluation of chronic pain 1 year after operation. Secondary outcomes were postoperative symptoms assessment at 1 week and 1, 6, and 12 months after operation. </li></ul><ul><li>Telephone interview was performed 35.5 months (range, 12-59 months) after operation to assess the presence of chronic pain. </li></ul><ul><li>Results: </li></ul><ul><li>Of the 302 groupA and 291 group B patients who made an office visit 1 year postoperatively, </li></ul><ul><li>pain was absent in 231 (76.5%) and 213 (73%) (difference, 3.30%; 95 confidence interval, −3.68% to 10.28%), </li></ul><ul><li>mild in 55 (18%) and 60 (21%), </li></ul><ul><li>moderate in 11 (4%) and 9 (3%), </li></ul><ul><li>severe in 5 (2%) and 9 (3%), respectively ( P =.55; Pearson 2 3 test). </li></ul><ul><li>At 1-month and 6-month follow-up visits, no difference was found between the 2 groups with respect to pain, but loss of pain or touch sensation were significantly greater when the ilioinguinal nerve was divided. </li></ul><ul><li>One year after operation, the 2 groups were also comparable with respect to loss of pain sensation, but touch sensation remained decreased in group B. </li></ul><ul><li>At telephone interview, the presence of chronic pain was similar in both groups. </li></ul><ul><li>Conclusions: </li></ul><ul><li>Pain after open hernia repair with polypropylene mesh is not affected by elective division of the ilioinguinal nerve; sensory disturbances in the area of distribution of the transected nerve are significantly increased. </li></ul>
  38. 38. 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
  39. 39. 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
  40. 40. 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 <ul><li>A polypropylene mesh was positioned without sutures in the floor of the inguinal canal and in the lateral space under the aponeurosis of the external oblique muscle, according to the technique described by Trabucco.2 </li></ul><ul><li>Division of the ilioinguinal nerve was performed lateral to the deep ring to avoid any contact with the mesh. Histologic analysis of a section of the removed nerve was performed to confirm the division of the ilioinguinal nerve. </li></ul>
  41. 41. 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
  42. 42. 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
  43. 43. 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 <ul><li>In our group of study, globally considered, chronic pain 1 year after operation was present in 149 (25%) of 593 patients, and it was described as moderate or severe in 34 (6%) of these patients. </li></ul><ul><li>The telephone interview showed that the proportion of patients who still experienced chronic pain was considerable at long-term follow-up. </li></ul><ul><li>No correlation was found between the presence of preoperative pain and the occurrence of postoperative pain . According to other studies, 4,10 chronic pain was significantly related to the presence and intensity of postoperative pain. </li></ul><ul><li>Damage to 1 or more of the 3 nerves passing through the surgical field is suspected to be one of the main causes of chronic postherniorrhaphy pain. This theory is supported by the association between chronic pain and sensory disturbances.11 </li></ul><ul><li>A nerve may be damaged during operation as a result of perineural fibrosis, entrapment by staples, sutures, or prosthetic materials, and direct lesions due to stretching, contusion, electrical injury, and partial or complete division of the nerve.12 </li></ul>
  44. 44. 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 <ul><li>Wantz13 showed that chronic pain was not present in 546 patients who underwent hernia repair with elective division of the ilioinguinal nerve, whereas it was seen in patients with the nerve preserved. </li></ul><ul><li>No relation between ilioinguinal nerve preservation or elective division and chronic pain was reported in a large study by Cunningham et al.10 </li></ul><ul><li>The study by Ravichandran et al14 was the first to assess the effect of division of the ilioinguinal nerve in a randomized setting. The authors found no evidence to support the benefit of ilioinguinal nerve division with respect to postoperative pain within the limitation of a small sample size. </li></ul><ul><li>Our data confirm that ilioinguinal nerve division does not affect postoperative pain after mesh repair of the inguinal hernia with the support of a large number of patients and an appropriate longterm follow-up. In particular, considering the primary end point of our trial, after 1 year there was no difference in the rates of patients free from pain in both groups, and the 95% CI for the difference was so low that is was without clinical importance. </li></ul><ul><li>After inguinal hernia repair, sensory changes are common.12 In the study by Ravichandran et al,14 loss of sensation in the territory supplied by the ilioinguinal nerve occurred in 40% to 45% of patients when the nerve was divided and in 5% to 25% of cases when it was preserved after 6 months. </li></ul><ul><li>Our data confirm that elective transection of the ilioinguinal nerve leads to a significant increase in the proportion of patients who complain of a decrease in pain and touch sensation in the postoperative period with respect to those with preserved nerve. In particular, touch sensation was still impaired at the 1-year follow-up visit. </li></ul>
  45. 45. 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) <ul><li>Objective: We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia. </li></ul><ul><li>Method: One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner. </li></ul><ul><li>Results: </li></ul><ul><li>The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P 0.008). </li></ul><ul><li>No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation . </li></ul><ul><li>Conclusions: </li></ul><ul><li>Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation. </li></ul>
  46. 46. 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) <ul><li>Chronic groin pain is a significant problem following open inguinal hernia repair, with a reported incidence ranging from 19% to 62.9%.1–3 </li></ul><ul><li>Although the pain is often mild in nature, quality of life studies have shown that chronic pain, irrespective of severity, can significantly interfere with normal daily activities.4,5 Moreover, the condition can sometimes be debilitating and treatment is often difficult and challenging. </li></ul><ul><li>ilioinguinal neurectomy is a well-documented effective treatment of relieving chronic groin pain following open hernia repair, achieving more favorable outcomes than nerve block or mesh removal alone.8–10 </li></ul><ul><li>More recently, retrospective studies have shown that excision of ilioinguinal nerve during herniorrhaphy were associated with a lower incidence of chronic groin pain after the operation.11–13 </li></ul>
  47. 47. 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) <ul><li>All patients received the standard flat mesh repair according to the technique described by Lichtenstein et al.15 </li></ul><ul><li>In group A, the whole ilioinguinal nerve was excised as far lateral to the deep ring as possible and medially to where it entered the rectus muscles. The cut ends were left alone without implantation into muscle or ligation. Histologic examination of the nerve was performed to confirm complete excision. Any small cutaneous nerves that interfere with mesh placement were excised as well. </li></ul><ul><li>In group B, the ilioinguinal nerve was carefully protected throughout the operation. The rest of the procedure was performed in a standardized manner. A monofilament polypropylene mesh (SURGIPRO MESH, Auto Suture, USSC) was anchored with polypropylene sutures (PROLENE, Ethicon, Johnson & Johnson Unit) to the reflected part of inguinal ligament and the floor of the inguinal canal. </li></ul><ul><li>Extreme care was used during surgery to avoid inclusion of nerve tissue during suturing and mesh placement. </li></ul>
  48. 48. 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)
  49. 49. 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)
  50. 50. 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)
  51. 51. 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)
  52. 52. 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) <ul><li>The incidence of chronic groin pain at 6 months was significantly lower in group A compared with group B (4 8% vs. 14 28.6%; P 0.008, Fisher exact test). </li></ul><ul><li>The incidence of pain experienced after walking 3 flights of stairs and cycling for 10 minutes were significantly lower in groupA than group B (1 2% vs. 7 14%; P 0.03; 2 4% vs. 10 20.4%; P 0.015, Fisher exact test, respectively). </li></ul><ul><li>There were no significant differences in the incidence of pain experienced during normal daily activities at home and after coughing for 10 times at 6 months. </li></ul><ul><li>The incidences of groin numbness and sensation changes or loss at groin region were also similar between the 2 groups at 6 months. </li></ul>
  53. 53. 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) <ul><li>A proposed mechanism for the development of postoperative chronic groin pain is the inflammation and fibrosis induced by the mesh, which is in close proximity to the ilioinguinal nerve.17 </li></ul><ul><li>In addition, unintentional injury or strangulation of the ilioinguinal nerve during suturing may also contribute to the phenomenon. </li></ul><ul><li>There is increasing evidence to suggest that prophylactic excision of ilioinguinal nerve during open hernia repair is not only associated with minimal morbidities but also can potentially decrease the incidence of chronic groin pain following operation.11–13 </li></ul><ul><li>The first randomized trial to address this problem by Ravichandran et al was underpowered and no definite conclusion could be made.18 </li></ul><ul><li>Results from subsequent trials regarding chronic groin pain following elective neurectomy have been inconsistent. Interestingly, in a retrospective review of 191 patients who underwent elective excision of the ilioinguinal nerve during open hernia repair showed that none of the patients developed chronic groin pain at 12 months of follow-up.12 </li></ul><ul><li>In another retrospective study, Dittrick et al reported a significantly lower incidence of chronic groin pain in patients who had elective neurectomy during open inguinal hernia repair when compared with the control group.11 </li></ul>
  54. 54. 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) <ul><li>However, these results were not confirmed in a recent randomized controlled trial by Picchio et al,19 who found similar incidence of chronic groin pain between ilioinguinal nerve excision group and control. </li></ul><ul><li>Our randomized study revealed that the incidence of chronic groin pain during normal daily activities was similar between the 2 groups which compliment the findings by Picchio et al.19 </li></ul><ul><li>However, in addition, we found significantly fewer patients in the neurectomy group developed chronic groin pain upon exertion (cycling for 10 minutes and walking up 3 flights of stairs), which has not been previously studied. </li></ul><ul><li>The other potential disadvantage of ilioinguinal nerve excision is the morbidity associated with sensory loss over the groin region as well as its impact on quality of life. </li></ul><ul><li>The previous study by Picchio et al reported increased incidence of sensory loss to pain and touch around the groin region in patients who had nerve excision during open hernia repair.19 </li></ul><ul><li>However, the current study clearly demonstrated that elective excision of the ilioinguinal nerve was not associated with additional morbidities in neurosensory disturbances, groin numbness or quality of life at the 6-month follow-up. </li></ul><ul><li>We postulated that the sensory loss caused by neurectomy might be compensated by cross-innervations from contralateral cutaneous nerves. </li></ul><ul><li>Furthermore, direct meaningful comparison between Picchio et al19 and that of our study is not possible because their methodology used for testing skin sensation was not described. Semmes-Weinstein monofilament testing was adopted in the present study to provide a more standard and objective method to measure skin sensitivity. </li></ul>
  55. 55. 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) <ul><li>Objective: To evaluate whether the various surgical treatment reserved for ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves, during open hernia mesh repair, is effective in reducing chronic postoperative pain. </li></ul><ul><li>Background: Interest in chronic groin pain following herniorrhaphy has escalated, in recent years, due both to treatment and legal implications. However, much debate still exists concerning which treatment to reserve for the 3 inguinal sensory nerves. </li></ul><ul><li>Methods: A multicentric prospective study involving 11 Italian institutions led to the recruitment of 973 cases of hernioplasty. All surgeons were asked to report whether or not each nerve had been identified and preserved or divided. The main endpoint of the study was the evaluation of moderate to severe chronic pain at 6 months and 1 year. </li></ul><ul><li>Results: </li></ul><ul><li>Overall, the presence of groin pain at the 6-month and 1-year follow-up was 9.7% and 4.1%, respectively. </li></ul><ul><li>Pain was mild in 7.9% and moderate to severe in 2.1%, at 6 months, and mild in 3.6% and moderate to severe in 0.5%, at 1 year. </li></ul><ul><li>Univariate and multivariate analysis showed that lack of identification of nerves is significantly correlated with presence of chronic pain, the risk of developing inguinal pain increasing with the number of nerves not detected. </li></ul><ul><li>Likewise, division of nerves was clearly correlated with presence of chronic pain. </li></ul><ul><li>Conclusions: </li></ul><ul><li>The present findings indicate that identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain and that, in the majority of patients with chronic pain at 6 months, the pain at 1 year is resolved only with conservative or medical treatment. </li></ul>
  56. 56. 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) <ul><li>This report would appear to be the first in the literature presenting the results of a multicentric prospective clinical trial designed to assess the role of identification versus nonidentification and preservation versus division of the inguinal nerves on chronic postoperative pain following open inguinal polypropylene mesh hernia repair. </li></ul><ul><li>All surgeons were asked to complete a form immediately after the operation, providing the following data: hernia type (direct, indirect, combined, sliding),identification/nonidentification and treatment (preserved, injured, or divided) of each inguinal nerve (ilioinguinal, iliohypogastric, genital branch of genitofemoral nerves). A nerve was considered injured if stretched or burned. </li></ul><ul><li>Early postoperative pain (at 1 month) was mild in 185 (19%) cases and moderate to severe in 65 (6.7%). As far as concerns the main outcome of the study, the overall presence of groin pain at the 6-month and 1-year follow-up was 9.7% and 4.1%, respectively. Pain was mild in 7.9% (n 74) and moderate to severe in 2.1% (n 21) at 6 months and mild in 3.6% (n 35) and moderate to severe in 0.5% (n 5) at 1 year (Fig. 1). </li></ul>
  57. 57. 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 2006;243: 553–558)
  58. 58. 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 2006;243: 553–558)
  59. 59. 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 2006;243: 553–558)
  60. 60. 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 2006;243: 553–558)
  61. 61. 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 2006;243: 553–558)
  62. 62. 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 2006;243: 553–558)
  63. 63. 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 2006;243: 553–558)
  64. 64. 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 2006;243: 553–558) <ul><li>Chronic pain following inguinal hernia repair is becoming a significant clinical problem, involving an increasing number of patients and surgeons, as shown by the rising number of publications over the last 10 years dealing with postoperative pain syndrome. </li></ul><ul><li>Several explanations may be offered, namely, the low recurrence rates associated with the use of mesh repair that have shifted the hernia surgeons’ attention from recurrence to other outcome parameters and the fact that patients today are more aware of pain syndromes. </li></ul><ul><li>However, more and more often, patients come to our attention complaining of groin pain, after a hernia operation performed elsewhere, both for a second opinion regarding treatment and for possible legal procedures. </li></ul><ul><li>chronic pain can be defined as “pain persisting beyond the normal tissue healing time, assumed to be 3 months.”6 </li></ul><ul><li>Several factors have been proposed as predictors of chronic pain, such as experience of the surgeons and surgery due to recurrence,18 damage to inguinal nerves,19 and mesh implantation.20 However, the pathogenic aspects of chronic pain are still unknown and only hypothesized. </li></ul><ul><li>Some authors think that the widespread use of implanted prosthetic mesh, as well as open, instead of laparoscopic, inguinal hernia repair may play a role in the increased incidence of chronic pain.21,22 </li></ul><ul><li>However, tension-free mesh repairs are reported to be less likely to cause chronic groin pain than non-mesh repairs;23,24 albeit, no statistically significant difference appears to exist between open mesh, versus laparoscopic mesh repair,25 even if evidence would appear to be contradictory.21,26–31 </li></ul><ul><li>Partial division, neuroma formation, injury or entrapment of the ilioinguinal, iliohypogastric, or genitofemoral nerves are other possible causes reported to be responsible for chronic pain after herniorrhaphy. </li></ul>
  65. 65. 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 2006;243: 553–558) <ul><li>Some studies recommend that nerve ends be ligated34 or intentionally divided35 to reduce the risk of chronic pain, but no documentation has been forthcoming regarding the outcome of these recommendations. </li></ul><ul><li>Others have suggested that the nerves be divided or ligated only when their course, on the operating field, would lead to the risk of injury or if they interfere with positioning of the mesh.32 </li></ul><ul><li>Other studies have failed to show any relationship between the division or preservation of the ilioinguinal nerve and the risk of developing chronic pain,16,36,37 if division of the nerve is performed as close as possible to the site where it leaves the retroperitoneum. </li></ul><ul><li>However, current literature is inconsistent concerning this point and opinions differ considerably. </li></ul><ul><li>Results from studies in which operative management of an injured nerve is reported to be responsible for severe chronic pain suggest that, if the nerve identified is inadvertently divided, it is important to resect it, as proximally as possible, so that it would not interfere or come into contact with the mesh, thus allowing retraction of the proximal segment into the ventral muscle or retroperitoneum.8,33,38 </li></ul><ul><li>nerves are most often injured when the surgeon is unaware of the location and course or fails to recognize these during surgery. </li></ul>
  66. 66. 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 2006;243: 553–558) <ul><li>The present large-scale prospective multicentric study, with a 98% of follow-up rate, clearly shows that the risk of developing chronic postoperative groin pain is directly related to the number of nerves identified. </li></ul><ul><li>Indeed, 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><ul><li>These data would appear to suggest that, if 1 or more nerves are not detected during surgery, it is possible that they could be inadvertently sectioned, entrapped, or secured, for example, if a continuous suture is introduced along the inguinal ligament or injured if the external spermatic vessels are divided to skeletonize the cord and thus generate severe pain even some considerable time after the operation. </li></ul><ul><li>The increased risk of developing chronic pain with the number of nerves divided can be explained by the fact that resection of the nerve has generally been performed distal to its origin, leaving the site of the injured nerve intact to continue to generate the pain signal and exposed to neuroma formation. </li></ul>
  67. 67. 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 2006;243: 553–558) <ul><li>However, it is important to underline that most of our patients with chronic pain slowly recovered at 1 year only with conservative or medical treatment. </li></ul><ul><li>This suggests that no surgical treatment should be considered for at least 1 year for these patients. </li></ul><ul><li>Bearing in mind the results emerging from the present prospective multicentric study, and in agreement with other authors,14 we wish to stress the importance of always identifying and preserving all 3 nerves of the inguinal canal, during hernioplastic surgery, to minimize the incidence of chronic postoperative groin pain. </li></ul>
  68. 68. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740 <ul><li>Background: Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed as a means to avoid this complication. The purpose of this report is to evaluate the long-term outcomes of neuralgia and paresthesia following routine ilioinguinal nerve excision compared to nerve preservation. </li></ul><ul><li>Methods: Retrospective chart review identified 90 patients who underwent Lichtenstein inguinal hernia repairs with either routine nerve excision (n 66) or nerve preservation (n 24). All patients were contacted and data was collected on incidence and duration of postoperative neuralgia and paresthesia. Comparison was made by 2 analysis. </li></ul><ul><li>Results: </li></ul><ul><li>The patients with routine neurectomy were similar to the group without neurectomy based on gender (male/female 51/15 vs. 19/5) and mean age (68 14 vs. 58 18 years). </li></ul><ul><li>In the early postoperative period (6 months), the incidence of neuralgia was significantly lower in the neurectomy group versus the nerve preservation group (3% vs. 26%, P 0.001). </li></ul><ul><li>The incidence of paresthesia in the distribution of the ilioinguinal nerve was not significantly higher in the neurectomy group (18% vs. 4%, P 0.10). </li></ul><ul><li>At 1 year postoperatively, the neurectomy patients continued to have a significantly lower incidence of neuralgia (3% vs. 25%, P 0.003). </li></ul><ul><li>The incidence of paresthesia was again not significantly higher in the neurectomy group (13% vs. 5%, P 0.32). </li></ul><ul><li>In patients with postoperative neuralgia, mean severity scores on a visual analog scale (0 –10) were similar in neurectomy and nerve preservation patients at all end points in time (2.0 0.0 to 2.5 0.7 vs. 1.0 0.0 to 2.2 1.5). </li></ul><ul><li>In patients with postoperative paresthesia, mean severity scores on a visual analog scale (0 –10) were similar in the neurectomy and nerve preservation patients at 1 year (2.5 2.2 vs. 4.0 0.0) and 3 years (3.5 2.9 vs. 4.0 0.0). </li></ul><ul><li>Conclusions: </li></ul><ul><li>Routine ilioinguinal neurectomy is associated with a significantly lower incidence of postoperative neuralgia compared to routine nerve preservation with similar severity scores in each group. </li></ul><ul><li>There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy at 1 month, but there is no significant increase at any other end point in time. </li></ul><ul><li>When performing Lichtenstein inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option. </li></ul>
  69. 69. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740 <ul><li>In fact, 5% to 7% of patients who experience postherniorraphy neuralgia will sue their surgeons, with virtually all such cases resulting in an out-of-court settlement [6]. </li></ul><ul><li>The concept of routine neurectomy in surgery is not unique to inguinal hernia repairs. Routine neurectomy often is performed during axillary and neck dissections in which the intercostobrachial and greater auricular nerves, respectively, are sacrificed. A prospective, randomized study has supported the practice of routine intercostobrachial nerve excision during axillary dissections [ 7]. </li></ul><ul><li>Theoretically, excision of the ilioinguinal nerve would eliminate the possibility of postoperative neuralgia arising from entrapment, inflammation, neuroma, or fibrotic reactions. </li></ul>
  70. 70. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740
  71. 71. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740
  72. 72. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740
  73. 73. Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D. Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA The American Journal of Surgery 188 (2004) 736–740 <ul><li>Ravichandran et al conducted a pilot study comparing preservation or division of the ilioinguinal nerve in inguinal hernia open mesh repairs [9]. </li></ul><ul><li>Twenty patients with bilateral hernias were randomized to nerve preservation on one side and division on the other. At 6 months postoperatively, pain was present in 1 of 20 patients (5%) on the nerve-preserved side versus 0 of 20 patients (0%) on the nerve division side. </li></ul><ul><li>Numbness was present in 0 of 20 (%) on the nerve-preserved side versus 2 of 20 patients (10%) on the nerve divided side. These differences were all non significant and led the authors to conclude that elective division of the ilioinguinal nerve was not associated with a significant increase in postoperative symptoms in inguinal hernia repairs [9]. </li></ul><ul><li>Our study showed a statistically significant decrease in the incidence of postoperative neuralgia at 1 month, 6 months, and 1 year for patients in the nerve excision group versus the nerve preservation group. The significance disappeared at 3 years, but only roughly 50% of the patients had progressed to that end point in time. </li></ul><ul><li>These differences were dramatic, with the incidence of pain up to 1 year postoperatively much lower in the nerve excision group versus the nerve preservation group: 3%–5% versus 21%– 26% (Table 2). Mean severity scores in patients who reported neuralgia were similar in both groups. </li></ul><ul><li>The decrease in the incidence of postoperative neuralgia in the nerve excision group was not accompanied by a significant increase in postoperative paresthesia. </li></ul><ul><li>Furthermore, there was a consistent decrease in incidence of postoperative paresthesia at each successive end point in time in the nerve excision group (Table 4). This may suggest progressive compensation from adjacent sensory nerves that could continue to improve over time. </li></ul><ul><li>Concerns regarding postoperative paresthesia thus become of secondary importance as there seems to be continued resolution of this postoperative symptomatology. </li></ul>
  74. 74. Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair D. E. Tsakayannis Æ A. C. Kiriakopoulos Æ D. A. Linos Hernia (2004) 8: 67–69 <ul><li>In this prospective trial, we evaluated the impact of elective iliohypogastric and ilioinguinal nerve resection on the incidence of pain, numbness, and sensory loss following anterior, ‘‘tension free’’ herniorrhaphy. </li></ul><ul><li>One hundred ninety-one patients were enrolled and were reviewed 1 month, 6 months, and 1 year postoperatively. </li></ul><ul><li>Pain, numbness, or any loss of sensation were recorded and categorized on a ‘‘mild,’’ ‘‘moderate,’’ or ‘‘severe’’ scale. </li></ul><ul><li>No persistent pain syndrome was encountered. </li></ul><ul><li>Numbness was found in 9.42% of the patients at the first month and in 6.28% of the patients after 1 year. </li></ul><ul><li>Sensation loss (1.04%) was never bothersome or incapacitating at the end of the follow-up period. </li></ul><ul><li>Elective neurectomy is safe to perform, well tolerated by patients, and is not associated with chronic postoperative inguinal pain. </li></ul>
  75. 75. Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair D. E. Tsakayannis Æ A. C. Kiriakopoulos Æ D. A. Linos Hernia (2004) 8: 67–69
  76. 76. Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair D. E. Tsakayannis Æ A. C. Kiriakopoulos Æ D. A. Linos Hernia (2004) 8: 67–69 <ul><li>The ilioinguinal nerve is usually found as a single trunk on top of the spermatic cord. However, it may give branches before entering the inguinal canal, or it may even be absent with branches of the genital and iliohypogastric nerves taking its place. </li></ul><ul><li>Anomalous position of the ilioinguinal nerve was found in 40% of inguinal dissections, whereas the aberrant origin and course of the ilioinguinal nerve was most often behind and within the cremaster muscle [4]. </li></ul><ul><li>the incidence of disabling inguinal neuralgia approximates 10% after 2 years [2], </li></ul>
  77. 77. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>Background: Inguinal nerve entrapment is a debilitating postoperative problem. </li></ul><ul><li>Patients and Methods: One hundred patients were treated for inguinal nerve entrapment, including 52 men and 48 women with an average age of 45 14 years. Most patients had inguinal hernia repairs or Pfannenstiel incisions. Mesh was found in 27% of patients. Symptoms included pain (100%), radiation of pain to the thigh and/or genital area (59%), and postural pain (59%). Diagnosis was made by physical examination, postural maneuvering, and inguinal nerve block. Proximal nerve resection was followed by Mersiline (Ethicon, Inc., Somerville, NJ) ligature and absolute alcohol or phenol application to prevent neuromas. </li></ul><ul><li>Results: </li></ul><ul><li>Five percent of patients had minor complications. </li></ul><ul><li>There was abnormal nerve histopathology in 18%. </li></ul><ul><li>Total pain relief was attained in 72% of patients, partial relief in 25%, and no relief in 3%. </li></ul><ul><li>Two patients complained of numbness postoperatively. </li></ul><ul><li>Multifactorial analysis showed recurrent hernia repair as a significant predictive factor. </li></ul>
  78. 78. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>The incidence of postherniorrhaphy neuropathic pain is not well known, but reports present incidence rates from 0% to more than 30% (Table 1). </li></ul><ul><li>Nonoperative attempts at pain resolution include biofeedback, medications, physical therapy, and percutaneous treatment with local anesthetics, steroids, phenol, alcohol, cryoprobes, and radiofrequency destruction. </li></ul><ul><li>The most successful method available is surgical resection of the involved nerves with reasonably good pain relief. </li></ul><ul><li>Although many noted pain immediately after their inguinal operations, a delay in onset of symptoms from a few weeks to several years was observed. Fifty-nine percent had pain that radiated to the leg, thigh, genital areas, or flank, and an equal number complained of activity-related symptoms. </li></ul><ul><li>The truncal motions inciting the pain were usually bending, lifting, walking, and twisting of the trunk. </li></ul><ul><li>Only a few of the men reported pain with an erection or intercourse. </li></ul><ul><li>Nine patients were diagnosed with depression or other neuropsychiatric disorders, but this did not seem to affect their final outcome. </li></ul>
  79. 79. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287
  80. 80. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>Confirmation of inguinal nerve entrapment was made by asking the patient to stand and hyperextend their trunk and rotate both toward and away from the symptomatic inguinal site (Fig. 2). </li></ul><ul><li>This “arch and twist” maneuver acutely stretches the tethered affected nerves and usually reproduces the typical pain. </li></ul><ul><li>Subcutaneous injection of the inguinal region with 0.5% bupivacaine transiently relieved the pain, even when the arch and twist maneuver was repeated. </li></ul><ul><li>The operations were done under general (93%) or regional/ local (7%) anesthesia and consisted of identification of the nerves followed by proximal resection where they exited the internal oblique muscle near the anterior iliac spine or the internal ring in the case of the genital branch of the genitofemoral nerve. The proximal end of the nerves were crushed and ligated with fine braided polyester suture, followed by application of either absolute alcohol or 12% phenol solution to the nerve end to prevent neuroma formation. </li></ul><ul><li>All nerves were sent for routine histopathologic examination. In those patients with mesh, the prostheses and affixing screws, tacks, and sutures were removed. The patients were seen in follow-up at 1 month and as often as needed thereafter for complaints of postoperative discomfort or referred pains. </li></ul>
  81. 81. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287
  82. 82. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287
  83. 83. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287
  84. 84. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287
  85. 85. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>Histopathologic examination showed normal nerve in 82% of patients, whereas 10% had perineural fibrosis and/or inflammation. Six patients had traumatic neuromas, and two patients were found to have a suture through the nerve. </li></ul><ul><li>Complete pain relief was seen in 72% of patients, whereas 10% reported a marked decrease in symptoms. </li></ul><ul><li>In 15 patients, the inguinal pain was gone, but other symptoms such as abdominal, pelvic, or thigh pain persisted. </li></ul><ul><li>Only three patients failed to attain any relief of their symptoms. </li></ul><ul><li>Two patients complained of significant postoperative numbness. </li></ul><ul><li>The majority of patients were able to resume all daily activities including their regular occupation. </li></ul><ul><li>Comparison between those patients whose pain was totally relieved with the remaining patients showed that the only factor achieving statistical significance was previous repair of a recurrent hernia (Table 2). </li></ul>
  86. 86. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>The ilioinguinal and iliohypogastric nerves are the most frequently entrapped, and the mechanism seems to be injury by suture, adherence to overlying implanted mesh, or involvement in scar tissue. </li></ul><ul><li>The genitofemoral nerve might be compromised by too tight a closure of the internal ring, inadvertent inclusion in sutures used to close the internal ring, or by adherence to mesh inserted into the internal ring orifice. </li></ul><ul><li>The three nerves may share interconnecting fibers, and, therefore, the exact preoperative identification of the entrapped nerve(s) may be difficult . </li></ul><ul><li>Local anesthetic injection cephalad and medial to the anterior iliac spine may differentiate the entrapped ilioinguinal and iliohypogastric nerves, whereas a more medial injection along the distal inguinal canal might suggest a genitofemoral nerve etiology for the symptoms. </li></ul><ul><li>Harms et al. proposed [1] a paravertebral block at L1-L2 to help distinguish the specific nerves involved, but this was not used in the current series of patients. </li></ul><ul><li>The ilioinguinal nerve is at the most risk for entrapment because it lies immediately beneath the divided external oblique fascia and can be included in sutures used for the hernia repair or to reapproximate the external oblique fascia. </li></ul><ul><li>Mesh placed atop the internal oblique fascia/muscle can adhere to the ilioinguinal and/or iliohypogastric nerves during healing. </li></ul>
  87. 87. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b a Division of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USA b Division of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA The American Journal of Surgery 189 (2005) 283–287 <ul><li>In the reoperative field, it may be prudent to approach the nerves more laterally, where the ilioinguinal and iliohypogastric nerves exit the internal oblique muscle. </li></ul><ul><li>There is no good reason to excise the entire nerve segment but to divide it proximally where it exits the internal oblique. </li></ul><ul><li>The genital branch of the genitofemoral nerve, on the other hand, may be more difficult to locate, especially if mesh has been used. </li></ul><ul><li>The removal of mesh from the spermatic cord may endanger the vascular supply of the testicle. </li></ul><ul><li>In that situation, as well when properitoneal mesh has been applied, a pelvic fossa approach can be helpful , using an incision similar to that used for a renal transplant. </li></ul><ul><li>A few reports of laparoscopic approach to the inguinal and genitofemoral nerves have appeared recently with good results, although the experience is relatively small [11]. </li></ul><ul><li>The initial reports of neurectomy for postoperative inguinal pain were by Lyon in 1945 [12] and Magee in 1942 [13]. Both were small series of patients treated by neurectomy with excellent results and long-term follow-up. </li></ul><ul><li>It was not until the 1980s that others began to report series of patients with complete pain relief in the 70% to 80% range (Table 3). </li></ul><ul><li>Amid [14] suggests that all three inguinal nerves should be treated by neurectomy because intercommunicating nerve fibers may result in persistent symptoms if only a single nerve is divided . Division of the nerves may relieve the pain, but there is the potential for neuromas to occur when regenerating nerve fascicles spill outside the neurilemma and may cause severe pain. </li></ul><ul><li>Several methods are described to prevent neuroma formation, including burying the cut end of the nerve into muscle [14,15], end-to-side nerve anastomosis [16], and epineural ligation and flap [17]. </li></ul><ul><li>Experimentally, treatment of the nerve end with electrofulguration, YAG laser destruction, and tissue bioglues [18] also are reported to prevent neuroma formation. </li></ul>
  88. 88. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>Background: Chronic pain after inguinal hernia repair is an adverse outcome that affects about 12 per cent of patients. Principles of treatment have not been defined. This review examines neurectomy and mesh or staple removal as possible treatments. </li></ul><ul><li>Method: A literature search was carried out using the Medline and Ovid databases. Keywords were ‘pain; chronic’, ‘herniorrhaphy; inguinal’, ‘neurectomy’ and similar words. Article references were crosschecked for additional references. Articles were reviewed for data on surgical treatment of chronic pain after hernia repair. </li></ul><ul><li>Results: </li></ul><ul><li>Neurectomy of the ilioinguinal, iliohypogastric, genitofemoral or lateral femoral cutaneous nerve was described in 14 papers. </li></ul><ul><li>Overall, a favourable outcome was reported. However, the methodological quality was poor in all studies in respect of preoperative diagnostic criteria and treatment, intraoperative success in identifying a pathological lesion or nerve and quality of follow-up; this hindered interpretation of the data. Insufficient information is available at present on the effect of removal of mesh or staples. </li></ul><ul><li>Conclusion: Chronic pain after hernia repair is a significant problem and there is a need for a definitive assessment of its surgical treatment </li></ul>
  89. 89. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>Preoperative nerve block </li></ul><ul><li>The use of preoperative nerve block to aid the decision of which nerve to excise varied. </li></ul><ul><li>Deysine et al .42 used an ilioinguinal nerve block if the neurological examination suggested involvement of the ilioinguinal nerve, and recommended ilioinguinal neurectomy if the block relieved pain. Nevertheless, five patients had total pain relief after nerve blockade and non-steroidal anti-inflammatory drugs and were discharged, whereas the remaining 22 patients had neurectomy, without information on the response to nerve blockade. </li></ul><ul><li>Starling et al .37 , 38 used a preoperative ilioinguinal nerve block, and if this relieved pain the patient underwent ilioinguinal neurectomy. </li></ul><ul><li>In situations of continuous pain after an ilioinguinal block, a L1–L2 plexus block was performed and, if successful, led to genitofemoral neurectomy . If pain was partially relieved by both blocks a staged surgical exploration of both nerves was performed. However, data on the effectiveness of the selective blocks were not presented nor was any correlation with the effect of surgery on postoperative pain described. </li></ul><ul><li>Heise and Starling30 diagnosed 11 of 16 patients by selective, unspecified nerve blocks, but only nine had a neurectomy with five patients described as having a good or excellent outcome. </li></ul><ul><li>Nahabedian and Dellon40 found that an unspecified nerve block relieved pain in two patients, with a successful outcome after genitofemoral or ilioinguinal neurectomy. </li></ul><ul><li>Bower et al .28 stated that 13 of 15 patients had relief after an unspecified nerve block and 12 of these had a successful neurectomy of the ilioinguinal, iliohypogastric and/or lateral femoral cutaneous nerve. </li></ul><ul><li>None of the studies had a methodological evaluation and/or protocol for medical treatment of pain before or after neurectomy, except for that by Deysine et al .42, who used failure of non-steroidal anti-inflammatory therapy as an inclusion criterion for neurectomy. </li></ul>
  90. 90. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>Neurectomy </li></ul><ul><li>One article considered laparoscopic neurectomy41 </li></ul><ul><li>In 1989 Starling and Harms38 reported 19 patients with ‘ilioinguinal neuralgia’ who underwent ilioinguinal neurectomy;16 had total and permanent pain relief, although three underwent subsequent genitofemoral neurectomy,which relieved pain in two. Twelve patients with ‘genitofemoral neuralgia’ underwent genitofemoral neurectomy.Eight operations resulted in considerable or complete pain relief, but the remaining four were unsuccessful. </li></ul><ul><li>Bower et al .28 operated on 15 patients, carrying out 11 ilioinguinal, two iliohypogastric and three lateral femoral cutaneous neurectomies; some patients had two neurectomies and in two the nerves could not be identified. Ligation and division of the nerve was the most common procedure. Three patients also had neural alcohol injection, and two had mobilization and decompression of the nerve. </li></ul><ul><li>Amid31 , 32 reported that 80 per cent of 49 and 225 patients respectively had complete pain relief after a month, and that 15 per cent had transient incisional pain for a few months, but without functional impairment. </li></ul>
  91. 91. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>Mesh or staple removal </li></ul><ul><li>Apart from four patients in the article by Heise and Starling30, the search revealed no other description of the effect of mesh removal alone on chronic pain. </li></ul><ul><li>Three articles described removal of staples after laparoscopic hernia repair. Wong and Anvari29 removed helical tackers (staples) and part of the mesh from a patient who had experienced 5 months of postoperative pain,which resulted in complete pain relief. </li></ul><ul><li>Sampath et al .34 treated two patients by removing staples. In one a staple had pierced the lateral femoral cutaneous nerve and its removal along with part of the mesh led to reduced pain and dyspareunia, but there was persistent numbness at 12 months’ follow-up. The other patient had removal of mesh and a staple piercing the lateral femoral cutaneous nerve and was pain free at 6-month follow-up. </li></ul><ul><li>Seid and Amos35 described one patient in whom removal of a staple penetrating the femoral nerve resulted in pain relief, although numbness of the anterior thigh persisted. </li></ul>
  92. 92. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>As far as surgery is concerned, neurectomy results seem impressive at a first glance, with 60–100 per cent of patients apparently being cured or improved. </li></ul><ul><li>However, meaningful interpretation of the data is barely possible for the following reasons: lack of objective assessment of pain before operation, previous treatment, lack of neurophysiological examination to achieve a specific diagnosis, no standardized surgical procedure in a well defined patient population, lack of randomization and control group, and absence of detailed follow-up . </li></ul><ul><li>The correlation between the effectiveness of nerve block and the effect of neurectomy was not assessed systematically, although Heise and Starling30 found no correlation as only five of nine patients who had a positive response to a nerve block were improved after neurectomy. </li></ul><ul><li>Isotonic saline as a placebo nerve block was not used in any study. </li></ul><ul><li>Only one paper described the need for analgesics before operation, drugs that would seem necessary for a pain intense enough for neurectomy to be indicated. This paper contained a protocol that mentioned the lack of effect of non-steroidal anti-inflammatory agents as an indication for neurectomy42, but these drugs are not generally regarded as an effective treatment for neuropathic pain46. </li></ul>
  93. 93. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801 <ul><li>Future strategies to improve knowledge on the pathogenetic mechanisms and thereby the treatment and prevention of chronic pain after hernia operations have been described previously48. They include: </li></ul><ul><li>Preoperative pain, neurophysiological and psychological assessment, with exclusion of a recurrent hernia or other diseases in the region; intraoperative description of the surgical approach, findings and handling of nerves and muscles; early postoperative pain intensity, character, treatment modality and neurophysiological assessment; and late postoperative pain intensity, character and psychosocial consequences, and neurophysiological assessment. </li></ul>
  94. 94. Surgical management of chronic pain after inguinal hernia repair E. Aasvang and H. Kehlet Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark British Journal of Surgery 2005; 92 : 795–801
  95. 95. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574 <ul><li>Background: Claims that laparoscopic groin hernia repair is followed by less persisting pain and numbness than open mesh repair were tested by follow-up within a multicentre randomized clinical trial. </li></ul><ul><li>Methods: Participants in the UK Medical Research Council Laparoscopic Groin Hernia Trial were followed up by means of self-completed postal questionnaires from 2 to 5 years after trial entry. The principal measures were pain (groin and testicular) and numbness (groin and thigh). </li></ul><ul><li>Results: </li></ul><ul><li>Seven hundred and fifty (80·8 per cent) of the original 928 participants returned at least one questionnaire between 2 and 5 years; respondents were similar to the baseline randomized groups. </li></ul><ul><li>Fewer respondents in the laparoscopic group had groin pain (absolute differences varied between 7·9 and 2·0 per cent, but were of marginal statistical significance); </li></ul><ul><li>rates of testicular pain were similar in the two groups. </li></ul><ul><li>Groin numbness was reported about half as commonly at all time points in the laparoscopic group ( P < 0·001); there were no significant differences in thigh numbness. </li></ul><ul><li>Conclusion: </li></ul><ul><li>Laparoscopic surgery was associated with less long-term numbness and probably less pain in the groin. </li></ul>
  96. 96. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574 <ul><li>The trial meta-analyses also suggested that there is less persisting pain and numbness after laparoscopic repair, but this finding was based mainly on unpublished data from trials with variable lengths of follow-up and definitions of outcome1 , 4. </li></ul><ul><li>Five-year follow-up of one randomized trial, involving 242 people, showed significantly less groin pain and numbness after TAPP compared with open repair5. </li></ul><ul><li>This is a report of the 5-year postal follow-up of a large multicentre trial in which the predominant operations were totally extraperitoneal (TEP) laparoscopic repair and open tension-free mesh repair. </li></ul><ul><li>A total of 928 participants were recruited to the full trial between 1994 and 1997 by 27 consultant surgeons from 26 hospitals in the UK and Ireland. </li></ul>
  97. 97. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574
  98. 98. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574
  99. 99. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574
  100. 100. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group 1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK British Journal of Surgery 2004; 91: 1570–1574 <ul><li>Respondents in the laparoscopic repair group were more likely to be very satisfied with the appearance of the operation scars (82·2 versus 70·7 per cent at 36 months; χ2 = 12·62, 1 d.f., P < 0·001), and also to report that their recovery was faster than expected (59·2 versus 45·3 per cent at 36 months; χ2 = 13·77, 1 d.f., P < 0·001). </li></ul><ul><li>However, there was no difference in impact on day-to-day life (62·3 versus 61·4 per cent described life as ‘much better’ at 36 months; χ2 = 0·22, 1 d.f., P = 0·638) or in the proportion who would recommend the operation they received to another person (91·4 versus 91·2 per cent at 36 months; χ2 = 0·005, 1 d.f., P = 0·942). </li></ul><ul><li>Extending follow-up to 5 years for all participants in this large multicentre trial has shown that the risk of numbness in the groin after laparoscopic repair is about half that after open repair. The results are consistent with those of other trials in suggesting less groin pain after laparoscopic surgery. </li></ul><ul><li>However, no differences were detected in the rate of testicular pain or thigh numbness. </li></ul><ul><li>Respondents in the laparoscopic group were more likely to be satisfied with the appearance of their operation scars and to have recovered faster than expected, but there was no difference in impact on day-to-day life or the likelihood of recommending the operation they received to someone else. </li></ul>
  101. 101. 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. <ul><li>Background: Chronic inguinodynia or neuralgia after conventional inguinal herniorrhaphy is rare, and diagnosing the exact cause is difficult. Treatment has ranged from local injection to remedial surgery with variable results. The increasing popularity of prosthetic mesh repairs (tension free, plug, or laparoscopic) has not eliminated these pain syndromes from occasionally occurring. </li></ul><ul><li>Recommended management in these situations is extremely difficult. </li></ul><ul><li>Study Design: Since 1994, 117 inguinal reexplorations have been performed for inguinodynia and 20 of these patients had primary mesh herniorrhaphy. All 20 patients had mesh removal. Records were reviewed and patients contacted to evaluate outcomes. </li></ul><ul><li>Results: All 20 patients were evaluated (15 by telephone or direct contact, 5 by chart review). Three patients had their initial repair performed laparoscopically. Symptoms persisted for 12.2 6 1.7 months before remedial surgery. Four patients underwent inguinal reexploration and mesh removal; 16 had mesh removal plus ilioinguinal or iliohypogastric neurectomy. Good to excellent results were achieved in 12 out of 20 patients (60%). Average followup time was 15.9 6 3.1 months. Two of 3 patients who had laparoscopic herniorrhaphy had favorable outcomes (67%). Ten of the 16 patients who had mesh removal plus neurectomy reported good to excellent results (62%) compared with 2 of 4 reporting the same with mesh excision only (50%). Eleven patients had pain relief with preoperative nerve block. Of these, 9 had elective neurectomy resulting in good to excellent

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