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Home > Books > Abdominal Hernia Surgery - Practice, Evidence and Advances
Open access peer-reviewed chapter
Written By
Hany Mohammed El-Hadi Shoukat Mohammed
Submitted: 23 July 2024 Reviewed: 12 August 2024 Published: 19 February 2025
DOI: 10.5772/intechopen.1006681
From the Edited Volume
Abdominal Hernia Surgery - Practice, Evidence and Advances
Raimundas Lunevicius
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Abstract
Although hernia repair is one of the oldest surgical procedures with accumulated experience over generations. However, post-herniorrhaphy pain remains a daily patient complaint at the surgical outpatient clinics. Post-herniorrhaphy pain is a type of chronic pain with a neuropathic element that can be disabling to many patients and interfering with their daily lives. Proper diagnosis of this condition is essential before choosing an appropriate management plan. Many treatment options are available including pharmacological, non-pharmacological, and interventional procedures. Pharmacological choices include simple analgesics, opioids, antidepressants, antiepileptics, and steroids. Non-pharmacological approaches comprise psychotherapy, physiotherapy, acupuncture, and lifestyle modification. Interventional nerve blocks or surgical exploration with neurectomy can be employed for many cases.
Keywords
- chronic inguinal pain
- ilioinguinal nerve and iliohypogastric nerve
- neuropathic pain
- peripheral nerve blocks
- neurectomy
- inguinodynia
- hernia
Author Information
Hany Mohammed El-Hadi Shoukat Mohammed*
- Department of Anesthesia, Surgical ICU and Pain Management, Cairo University, Cairo, Egypt
*Address all correspondence to: oblfollower_2001@yahoo.com
1. Introduction
Inguinal hernias represent the most common type of abdominal wall hernias, and consequently, inguinal hernia repair is the most performed surgical procedure worldwide. Today, lichtenstein tension-free open repair and endoscopic/laparoscopic repair are the surgical techniques that are mostly performed. Although post-operative complications after hernia surgery may be low, chronic post-operative pain carries a real challenge to patients, families, and physicians. Many factors can predispose inguinal hernia patients to post-operative pain chronicity. Young age, female gender, diabetic patients, smoking habits, improbably managed acute post-operative pain, poor surgical techniques, and mesh application are among the most common predisposing factors. Investigations should be carried out once post-herniorrhaphy syndrome is suspected to exclude recurrence as a cause of pain and to identify patients who need surgical management from non-surgical approaches. Inguinodynia is a type of chronic pain that should be managed by a multidisciplinary approach. Surgeons, pain physicians, physiotherapists, dietitians, interventional radiologists, and psychologists should be recruited to incorporate an ideal management plan. Unfortunately, there is no single management strategy or an agreed guideline. In many patients, selective or triple neurectomy may be the definitive cure.
2. Definition of post-herniorrhaphy pain
PHPS is a medical condition where pain persists after hernia surgery and may threaten the patient’s quality of life. Post-herniorrhaphy pain is diagnosed when post-operative pain persists for more than 3months and is not related to other causes [1, 2].
3. Incidence
Globally, more than 20 million patients are operated upon for hernia repair annually. Post-herniorrhaphy pain is one of the chronic post-surgical pains (CPSP). Up to 50% of patients report some degree of residual groin pain and discomfort at one year of post-operative follow-up. The incidence of moderate-to-severe post-herniorrhaphy pain is around 3–6% of the patients. However, some authors reported that the incidence of moderate-to-severe inguinodynia ranges from 10 to 12%. This variability in the reported frequencies may be attributed to the varying surgical techniques available to approach inguinal hernia repair and the inconsistent tools used to diagnose post-herniorrhaphy pain. Due to the relatively high incidence of chronic post-surgical pain, the risk of developing post-herniorrhaphy pain should be discussed preoperatively with the patients to obtain informed consent [1, 3, 4].
3.1 Inguinodynia in children and neonates
The rate of chronic post-operative pain after groin hernia repair is lower in children and adolescents compared with that in adults.
However, patients with repaired inguinal hernias in childhood may have chronic groin pain during their adulthood life [5, 6].
4. Nomenclature
Inguinodynia is a generic term used to describe chronic groin pain after hernia repair. Post-herniorrhaphy pain syndrome (PHPS) is a distinct expression employed by clinicians to label sustained pain suffering after hernia repair. It is also termed chronic post-operative inguinal pain (CPIP) and post-herniorrhaphy groin pain. Chronic inguinal neuralgia is another term used to describe this distressing condition [1, 2].
5. Nature of pain
This chronic pain lasts for more than 3months after hernia repair. It is mainly a neuropathic type of pain. The proportion of PHPS patients who are diagnosed with a neuropathic origin of pain after hernia repair ranges from 28.7 to 64%. This wide discrepancy in the type of pain incidence may be related to the differences in the tools used to diagnose neuropathic pain in different studies.
Somatic (nociceptive) pain may originate from damage to the pubic tubercle or incorporation of the periosteum of the pubic tubercle during suturing or stapling of the mesh predisposing to chronic inflammation and pain [7, 8].
6. Etiology and pathogenesis
Post-herniorrhaphy inguinodynia is caused by a combination of neuropathic (direct nerve injury) and nociceptive (tissue injury and inflammation) etiological factors. Pathogenesis of pain can be linked to pain centralization, neuroplasticity, deafferentation hyperalgesia, and excitatory coupling between sympathetic and afferent nociceptive nerve fibers.
Many factors are postulated to explain the predisposition to the persistence of post-operative inguinal pain.
Injury to inguinal nerves with neuroma formation occurs after surgical manipulation, traction, incision, or thermal damage from cautery use. Mesh inflammatory reaction can lead to fibrotic changes and granuloma formation causing pain.
The most common causes of non-neuropathic etiologies of inguinodynia are mesh mass, exaggerated scar tissue, or recurrence of hernia.
Meshoma is the wadding or wrinkling of the mesh due to inadequate mesh fixation or the use of a large mesh that fails to stay flat. Meshoma may cause nerve entrapment or damage [1, 8, 9, 10]
7. Epidemiology and risk factors
Post-herniorrhaphy pain incidence is increased in young age, obesity, those who had preoperative pain, insufficiently treated post-operative pain, recurrent surgery, radiotherapy, chemotherapy, and patients with psychological disorders [1]. Common risk factors include the following:
Type of patients:
The female gender appeared to have a greater chance of developing PHPS than the male patients. Older patients tend to commence chronic pain less frequently. Severe types of pain are more often experienced in younger patients below 50years.
Smoking and poor glycemic control are considered independent predictors of inguinodynia [3, 9].
Type of anesthesia:
Local infiltration is advantageous over spinal and general anesthesia in having a lower incidence of post-herniorrhaphy pain. Ilioinguinal/iliohypogastric blockade is also advantageous to both general and spinal anesthesia for the prevention of inguinodynia [3, 9].
Existence of preoperative pain:
Studies found that patients with a higher incidence of post-operative chronic pain are more likely to have preoperative pain, hence the importance of adequate perioperative pain management [3].
Acute post-operative pain and pre-emptive analgesia:
Uncontrolled acute post-operative pain may predict the predisposition to chronic pain development. Post-operative complications such as hernia recurrence, infection, and hematoma may also play a role. Aggressive early pain management can reduce chronic pain prevalence [3, 9, 10, 11].
Surgical techniques:
Ilioinguinal nerve injury during surgery is an important factor influencing chronic pain. Debate continues to occur in the literature concerning the utility of elective transection of the nerve. Some authors believe that nerve preservation would minimize chronic pain incidence. At the same time, others suggested that elective intraoperative ligation of the ilioinguinal nerve will be associated with a little risk. It is recommended that all three inguinal nerves should be identified intraoperatively and preserved to prevent chronic pain. Failure to do so could lead to accidental nerve injury, entrapment, or suturing initiating severe pain post-operatively.
The site at which the nerve divided could influence the generation of pain. Distal resection of the nerve leaves most of the nerve exposed with the possibility of neuroma formation. Division of the nerve if to be performed should be proximal to the site where it exits from the retroperitoneum.
However, some advocate identifying the five nerves involved in groin innervation and preserving them during herniorrhaphy operation. These five nerves include the ilioinguinal nerve, the iliohypogastric nerve, the genitofemoral nerve, the lateral cutaneous nerve of the thigh, and the femoral nerve. The common nerve trapped in the scar tissue formed between the mesh and underlying muscles is the iliohypogastric nerve.
During the minimally invasive techniques, the lateral cutaneous nerve of the thigh, the femoral branch of the genitofemoral nerve, and the femoral nerve are at greater risk of accidental injury. “Triangle of pain” is a theoretical region identified during laparoscopy and bounded by the gonadal vessels, iliopubic tract, and the peritoneum. Identifying this triangle during laparoscopic inguinal hernia repair is essential to avoid injuries to nerves that pass through that triangle.
Suters and staples carry a greater risk of developing post-operative pain than other mesh-fixing materials. Fibrin glue is used for atraumatic mesh fixation. The incidence of chronic groin pain, foreign body sensation, and groin numbness is reduced when fibrin glue is used instead of sutures [3, 8, 10, 11, 12].
Laparoscopic surgery versus open surgery:
Laparoscopic hernia repair is generally associated with less post-operative pain than open repairs. This advantage may be related to less dissection and tissue trauma to the ilioinguinal and iliohypogastric nerves. Inconsistent reports show a higher incidence of inguinodynia following open hernia repair, particularly with an anterior approach, compared with laparoscopic or robotic hernia repair through the posterior approach.
There are two main approaches for laparoscopic herniorrhaphy: the total extraperitoneal (TEP) and preperitoneal transabdominal (TAPP) approaches. TEP and TAPP are techniques used also in bilateral inguinal hernias repair. Applying mesh without fixation in these cases appeared to lower the incidence of chronic post-operative pain.
Laparoscopic herniorrhaphy with the use of a tacker can cause nerve entrapment due to misplaced tacks.
Minimally invasive techniques using robotic-assisted surgery carry the same incidence of chronic pain [3, 8, 10, 13].
Mesh type, size, and weight:
Polypropylene meshes are commonly used for tension-free repair. Polypropylene as a synthetic material induces granulomatous reactions that encapsulate the mesh. Experimental research demonstrated that when a polypropylene mesh contacts peripheral nerve tissue; myelin degeneration, edema, fibrosis, and neuroma formation can precipitate neuralgia. However, these findings lack strong evidence.
Light macroporous (pores>75 micrometers) polypropylene meshes are preferred over heavy microporous (pores <10 micrometers) materials as the former creates a sufficient inflammatory response, tissue incorporation, and lesser incidence of foreign body sensation. Although the light biocompatible meshes were designed to reduce the foreign body reaction, they carried the same potential forpost-operative chronic groin pain as traditional meshes.
The method by which the mesh is fixed has been found to impact the incidence of CPSP. The use of cyanoacrylate glue (Histoacryl) or a self-gripping mesh (Progrip) did not appear to reduce the risk of post-operative pain and chronic pain [3, 8, 10].
Recurrent cases:
Surgery for recurrent hernias may carry a greater surgical difficulty. Thus, the potential for persistence or even deterioration of pain is increased with the second surgery [10].
Psychologic predisposition:
Patients with a preoperative psychologic vulnerability are at increased risk of post-operative inguinodynia. The resultant lower pain threshold in these emotionally unstable patients could explain this [8].
Genetic predisposition:
People differ in their susceptibility to the experience of pain, as well as their response to analgesics due to inherited factors. This difference in genetic predisposition makes patients different in their sensitivity to nociceptive pain [10].
8. Clinical picture and presentation
8.1 Criteria of pain
Pain is not necessary to begin during the early post-operative days, but some patients may present with late-onset pain after a relatively long period of being symptom-free.
Patients may complain of any feature of neuropathic pain. Hyperalgesia, hypoesthesia, dysesthesia, or allodynia may be elicited at the surgical incision site or territory.
When the genitofemoral nerve is affected, testicular pain or labial pain arises.
Neuropathic pain presentation varies from a dull aching to sharp shooting pain traveling along the distribution of inguinal nerves. Pain can be elicited by wound site touching, tapping the area of tenderness, or tapping the medial aspect of the anterosuperior iliac spine. Also, pain can be triggered by walking, exercise, deep breathing, coughing, bowel activity, hip hyperextension, or twisting. Conversely, pain is usually relieved by bed rest or flexion of the thigh.
Groin pain can radiate to the upper leg, scrotum, or back. Some male patients may complain of testicular or ejaculatory pain, while female may complain of labial pain. Trigger points can be found in the vicinity of the scar tissue. Also, some may report numbness over the thigh or groin.
Inflammatory pain usually presents with throbbing quality and heat hyperalgesia and tends to subside over an expected period. Inflammatory pain is not accompanied by sensory or motor deficits.
Nociceptive (somatic) pain is usually dull aching continuous type of pain, of little intensity, and may be diffuse, localized, or projected to surrounding regions. Nociceptive pain develops acutely and tends to diminish over time, while neuropathic pain continues to persist for longer times.
Distinguishing neuropathic from the nociceptive origin of pain may be impractical as symptoms of both usually overlap making clinical differentiation difficult [1, 3, 8, 10, 12].
8.2 Location of pain
Commonly patients reported pain in the groin, scar, or both. However, others may report pain at unexpected locations, such as the lower abdomen, genitalia, and thigh. These unexpected sites have no apparent relation to the innervation of the surgical field. The development of pain in unforeseen locations, while pain is absent in expected ones, can be explained by the inflammatory processes following surgery and not merely the nerve damage [7, 10].
8.3 Pain intensity
Chronic groin pain following inguinal herniorrhaphy ranges from mild to severe form of pain that can be debilitating [8, 10].
8.4 Impairment of everyday activities
This chronic pain can cause functional limitations in daily tasks such as sitting, standing up, performing sports, going up and down stairs, and driving a car. PHPS impairs the patient’s work capabilities, and social life, and causes sleep disturbances.
Moreover, chronic groin pain contributes to erectile dysfunction and ejaculatory pain. Around one-third of men with inguinodynia had sexual dysfunction [1,3, 10, 12].
9. Evaluation of and diagnosis of post-herniorrhaphy pain
9.1 History
Patients should be interviewed and asked about the onset and quality of pain, radiation of pain, what makes symptoms improve, and what causes symptoms to worsen. Surgical history includes the type of hernia (i.e., direct versus indirect), type of surgery (i.e., open versus laparoscopic), and history of post-operative complications [10].
9.2 Physical examinations
The first step in managing chronic pain following inguinal hernia repair starts with a formal and proper patient examination. General and surgical examination should include evaluation of the inguinal region. Clinical tests aim to diagnose the type of nerve (Table 1) entrapped, for example, in case of ilioinguinal nerve entrapment; hyperextension and twisting the trunk away from the affected side will elicit symptoms. Moreover, urological and gynecologic evaluation must follow to exclude underlying testicular and gynecological pathologies [10].
| Nerve | Innervation | Location |
|---|---|---|
| Ilioinguinal nerve (T12, T1) | Sensory to:
| Go along the spermatic cord |
| Ibiohypogastric nerve (T12, L1): | ||
| Sensory to hypogastric region | Passes between the sponeurosis & internal oblique; to accompany the spermatic cord |
| Sensory to gluteal region | Pierces the internal & external oblique above the iliac crest |
| Genitofemoral nerve (L1, L2): | ||
| Sensory to mons & scrotum/labia | Joins the spermatic cord through the internal ring |
| Sensory to the anterolateral thigh | Passes with the external iliac artery |
| Lateral femoral cutaneous nerve (L2, L3) | Sensory to the anterolateral thigh | Passes under the inguinal ligament |
| Femoral nerve (L2, L3) | Motor innervation to quadriceps femoris | Passes under the inguinal ligament |
| Sensory to the anterior thigh |
Table 1.
Sensory and motor impairment in inguinal neuropathies [10].
9.2.1 Pain assessment tools
Neuropathic pain can be evaluated by using questionnaires, quantitative sensory testing (QST), and dermatosensory mapping [7, 14].
EuraHS Quality of Life (QoL): The EuraHS-QoL score (Figure 1) is a hernia-specific quality-of-life assessment tool developed and validated by the European Hernia Society. The EuraHS-QoL Scale has nine questions, with a total score ranging from 0 to 90. The patient is scored on an 11-point scale from 0 to 10. A score of 0 means the patient is in the best condition while 10 for the worst condition. The EuraHS-QoL score questions have three domains: pain (0–30), restriction of activities (0–40), and esthetical discomfort (0–20) [15].
DN-4, for neuropathic pain diagnosis :DN4 (Douleur Neuropathique en 4 Questions) is a screening tool designed to assess neuropathic pain. DN-4 consists of an interview questionnaire (DN4-interview) and bedside physical tests. The DN-4 questionnaire (DN4-interview) consists of four groups of questions: First group assesses the characteristics of pain (burning, painful cold, electric shocks), and second group evaluates other symptoms associated with pain (tingling, pins and needles, numbness, itching). Three bedside neurological examinations are done in the painful area (touch hypoesthesia using a soft brush or cotton swab, pinprick hypoesthesia using disposable examination pins such as Von Frey filaments, and tactile dynamic allodynia using a soft brush). For scoring, the 10 items DN-4 tool, 0 is given to each negative item, while 1 is given to each positive item (total score range 0–10).
For neuropathic pain to be diagnosed, the patient should earn a total score of 4 with at least a score of 3 on the DN4-interview questionnaire [1].
The Brief Pain Inventory (BPI) for severity, analgesic use, and interference with activities: The Brief Pain Inventory (BPI) is a quick and easy means of measuring pain intensity and its effects on patients’ lives (Figure 2). It is primarily developed for the assessment of cancer-related pain; however, it can be applied to many types of chronic pain.
BPI covers five fields of functioning. The patient is asked to rate the intensity of pain using a numeric scale of 0 to 10 and report it as being worst, least, and average. A score of 0 means “no pain,” while a score of 10 means “pain as bad as you can imagine.” Then, the patient is requested to document the interference of pain on seven quality-of-life domains including general activity, walking, mood, sleep, work, relations with other persons, and enjoyment of life.
Each point of the seven domains will be answered as “does not interfere” or “interferes completely.” The BPI is available in short and long forms [12, 16].
The SF-12 questionnaire for QoL: Short Form 12-item survey (SF-12) is an instrument used for evaluation of health-related quality of life (HRQL). It consists of a 12-item questionnaire grouped into two main domains: the physical component summary (PCS-12) scores and the mental component summary (MCS-12) scores. The PCS-12 domain involves physical functioning (PF), role-physical (RP), bodily pain (BP), and general health (GH) subdomains, while the MCS-12 domain involves vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH) subdomains. Each item’s raw scores range from 1 to 6 with a total score transformed into a 0–100 scale. A higher score indicates a good health status [17].
Visual analogue scale (VAS): This simple pain assessment tool uses a scale of 10cm in length, where 0 means no pain and 10 means severe pain [16].
9.2.2 Pain maps
Surgeons use dermatome inguinal mapping tests to map the pain distribution on patients’ skin. Pain mapping can identify areas with hypothesia, numbness, and pain sensation (Figures 3 and 4). Exposure and examination of the groin, abdomen, thigh, and genitals are made, and then, a mark is applied by a surgical marker over the examined skin. A “zero” sign can be used to indicate areas with no pain, and a “minus” sign is used to indicate a numb area, while a “plus or х” sign is used to mark the area with pain. By generating pain maps identification of the involved nerves can be easily outlined. Photos can be taken of these maps and comparisons can be made between pain location and intensity before and after initiation of treatment [14].
9.3 Investigations
Ultrasound and CT examination can diagnose occult recurrences and non-neuropathic sources of pain. MRI can recognize abnormal mesh position and the presence of recurrence. MR neurography can identify the accurate site of injured nerves. Both US and MRI can confirm the presence of neuroma. Imaging studies can diagnose osteitis pubis as a preventable cause of pain induced by a suture or staples placed into the pubic tubercle [10].
9.4 Diagnostic algorithm
Any patient having persistent groin pain for more than 6–8weeks following inguinal hernia repair despite standard pain management should be suspected to have post-herniorrhaphy neuralgia.
9.4.1 Confirm the diagnosis
Clinical examination will confirm the diagnosis if the following three criteria are positive:
History of burning or stabbing pain near the groin incision radiating along a specific inguinal nerve distribution.
Sensory impairment along the distribution of a specific groin nerve.
Peripheral nerve block alleviates the pain.
Groin nerve blocks are used for diagnostic and curative purposes. Injection of long-acting local anesthetic with steroids is commonly performed. However, a negative diagnostic peripheral nerve block does not exclude the diagnosis, as the spread of local anesthetic may be impaired in the presence of mesh fibrosis.
9.4.2 Recognition of the possible etiology and identification of the involved nerve
Imaging studies may help confirm the diagnosis, exclude recurrence and other pain causes, identify nerve abnormalities, and differentiate between patients requiring surgical and non-surgical management.
Algorithms have been developed for diagnosis and treatment (Figures 5 and 6) [10].
9.5 Differential diagnosis
The pain of post-herniorrhaphy neuralgia should be differentiated from the following:
Other causes of groin pain such as hernia recurrence, mesh infection or displacement, hematoma, fluid collection, and osteitis pubis.
Other causes of lower abdominal pain such as diseases of the spine, lumbosacral plexus, and peripheral nerves of the lower abdomen [10].
10. Prevention
10.1 Preoperative management
Acute pain therapy is a cornerstone in the prevention of post-operative chronic pain. Adequate control of post-operative pain may prevent central sensitization, neuroplasticity, and progression to post-operative pain.
Perioperative multimodal analgesia approaches include N-methyl-d-aspartate receptor antagonists such as ketamine, COX inhibitors, gabapentin or pregabalin, corticosteroids, and regional blocks. Diclofenac prescription as a type of NSAID in the 1st week after surgery was shown to prevent the development of inguinodynia [3, 11].
10.2 Intraoperative preventive strategy
Several studies showed that regional anesthesia could prevent surgical pain from becoming chronic.
Comprehensive knowledge of the inguinal region anatomy with cautious surgical techniques preserving the inguinal nerves is the basis for the prevention of inguinodynia. Some recommend performing inguinal ultrasound to identify the relevant nerves.
During open herniorrhaphy, the following maneuvers and surgical techniques are recommended intraoperatively to minimize nerve injury: avoid unnecessary subcutaneous tissue dissection, avoid cremasteric muscle destruction, identify and preserve all the inguinal nerves, particularly the ilioinguinal nerve, avoid sutures in the lower edge of the internal oblique muscle, and avoid tightening of the inguinal ring. Avoiding nerve damage by laparoscopic approach may help to decrease post-operative chronic pain development.
Intraoperatively, the surgeon can identify the ilioinguinal nerve lateral to the internal ring, the genital branch of the genitofemoral in the lateral crus of the internal ring. In contrast, the iliohypogastric nerve can be identified in the plane between the external and internal oblique muscles.
Selection of a light (≤50g/m2) mesh, the use of fibrin glue rather than suture or tack, and the use of absorbable sutures to secure a mesh when glue is not available all can reduce the incidence of post-operative pain [3, 8, 9, 10].
10.2.1 Prophylactic neurectomy
Identification and preservation of all inguinal nerves passing through the operative field during open hernia repair has been advocated as a standard practice. However, some surgeons support prophylactic ilioinguinal neurectomy to reduce the incidence of post-operative chronic inguinal pain. Nevertheless, studies failed to find a statistical significance in the incidence of inguinodynia. Prophylactic neurectomy may result in loss of inguinal sensation and groin numbness.
Thus, the decision for groin nerve preservation versus scarification should be made on individual basis with a clear explanation of potential outcomes [3, 8, 9, 10].
11. Management
Due to the multifactorial etiology of the disease, there are no globally accepted guidelines or consensus for the management of ingunodynia. Careful diagnosis and exclusion of other causes of pain especially hernia recurrence is an essential step before starting the treatment plan [10].
11.1 Conservative management
The first line of treatment comprises a watchful waiting strategy with or without analgesia. Pain usually improves in many cases.
Modalities include oral analgesics, gabapentinoids, pregabalin, tricyclic antidepressants, selective serotonin reuptake inhibitor, serotonin/norepinephrine reuptake inhibitors, regional nerve blocks, and acupuncture. Local applications of lidocaine or capsaicin patches have been tried in some cases but failed to find a significant benefit.
Selective nerve blocks can be done for both diagnostic and therapeutic purposes. Some patients may benefit from combined injections of lidocaine, corticosteroids, and hyaluronic acid.
Cognitive behavioral therapy can be used alone or in combination with nerve block techniques. Spinal cord stimulation by using an implanted device has been tried in some cases.
Lifestyle modifications including healthy diet, exercise, and smoking cessation are proven to improve the condition [3, 8, 9, 10].
11.2 Neurectomy
If the response to a specific groin nerve block was transient and the pain recurred, this will indicate the need for a nerve sacrifice procedure. Nerve sacrifice can be achieved by either percutaneous nerve ablation or surgical neurectomy [10].
11.2.1 Nerve ablation procedure
Nerve ablation is considered a minimally invasive procedure with minimal side effects less than neurectomy. Nerve ablation should be tried as a first line for managing patients with refractory responses to repeated nerve blocks. The technique of nerve ablation is like that of nerve block but with an injection of either phenol or alcohol to destroy the offending nerve ending permanently. Percutaneous nerve ablation may fail to relieve permanent pain as nerve regeneration may occur in many cases.
Cryoablation and radiofrequency ablation are alternative techniques of percutaneous nerve ablation. Pulsed radiofrequency gained popularity as a technique for nerve destruction. It can be applied at either the level of peripheral nerves or at the dorsal root ganglia [7, 10].
11.2.2 Surgical management
Surgical management appeared to be the most effective treatment option for persistent groin pain in patients with post-herniorrhaphy neuralgia. There is no evidence-based nor optimal strategy for surgical treatment of chronic pain following inguinal hernia repair.
Surgical options include laparoscopic mesh removal with or without retroperitoneal neurectomies.
11.2.2.1 Indication
Surgical intervention is indicated when non-surgical measures including nerve block/ablation fail to control the pain. A surgical treatment plan will be based on the character of the pain, the original repair technique, confirmation of recurrence, the presence of meshoma, and the method and type of fixation material.
Surgical management includes exploration with mesh excision, neuroma identification and excision, and surgical neurectomy.
11.2.2.2 Neurolysis
Freeing the nerve by surgical neurolysis only has been associated with a high failure rate.
11.2.2.3 Surgical neurectomy
Neurectomy can be either selective or triple neurectomy. It can also be performed laparoscopically or by an open technique. Some authors recommend an open approach when the original triggering surgery was open surgery, while a laparoscopic approach is recommended when the original surgery was laparoscopic.
11.2.2.3.1 Triple neurectomy
Groin exploration with triple neurectomy that involves the ilioinguinal, iliohypogastric, and genitofemoral results in permanent pain relief in about 90% of patients. However, the genital branch of the genitofemoral nerve must be preserved in females to preserve the sensory supply to labia majora. Although triple neurectomy is safe and recommended by many,it is an aggressive procedure with an increased risk of a larger area of anesthesia. A complete loss of sensation over the distributions of the resected nerves is a common morbidity of triple neurectomy. Thus, selective neurectomy is preferred by some surgeons over triple neurectomy.
The surgical neurectomy procedure involves nerve identification, dissection, and resection of the entire length of a nerve. The remaining smooth ends of the nerve should be ligated, cauterized, or implanted within a healthy muscle or retroperitoneal tissue. In the case of orchialgia, paravasal nerve resection may also be needed.
Patients undergoing laparoscopic triple neurectomy procedures should be informed about the possible post-operative complications. These complications may include abdominal wall laxity from the oblique muscle denervation, persistent numbness, female labia numbness, loss of a male cremasteric reflex, interference with normal sexual sensation, testicular atrophy, and failure to identify the inguinal nerves.
Open triple neurectomy technique:
Triple neurectomy by an open approach has many challenges and difficulties such as difficult access through the scarred tissues, intractable identification of the three inguinal nerves at the reoperated inguinal canal tissues, and the potential to disrupt the previous repair or injure the spermatic cord.
Endoscopic/laparoscopic triple neurectomy technique:
Endoscopic triple neurectomy can be approached through a transabdominal or extraperitoneal (retroperitoneal) approach. Laparoscopic retroperitoneal triple neurectomies are the preferred definitive treatment of chronic inguinal neuralgia in the absence of both recurrence and meshoma. Laparoscopic retroperitoneal triple neurectomy is a minimally invasive technique that allows proximal division of main trunks of the IIN, IHN, and GFN at the lumbar plexus origin.
After anesthesia induction, the patient is placed on lateral decubitus with the involved side being the uppermost one. The plane between the iliac crest and lower costal margin is exposed by flexion of the operating table. At 4cm proximal to the iliac crest in the midaxillary line, a transverse incision is done. Then, dissection through external oblique muscle and abdominal wall muscles is made to reach the retroperitoneal space. Thereafter, a 12-mm trochar is inserted at that plane and through the incision CO2 insufflation starts. To identify the nerves, the quadratus lumborum and psoas muscle should be identified first.
Resection of the common trunk of the ilioinguinal and iliohypogastric nerves can be achieved between the quadratus lumborum and psoas muscles. These nerves should be resected as distal as possible. The genitofemoral nerve can be identified as penetrating the middle part of psoas muscle, while the lateral cutaneous femoral nerve can be seen lateral to the psoas muscle. After neurectomies, the mesh can be removed through a transabdominal approach after turning the patient to the supine position [3, 7, 8, 9, 10, 19, 20].
11.2.2.3.2 Selective neurectomy
Although selective neurectomy avoids the permanent sensory deficit caused by triple neurectomy, it may be less effective in relieving chronic pain than a triple neurectomy.
Mesh removal
Removal of the mesh is sufficient to reverse the chronic pain in many cases but accidental nerve damage during the procedure leads to post-operative pain persistence. So, it is recommended to combine neurectomy with mesh removal. Mesh removal alone but without neurectomy does not lead to life-long pain relief. Surgical treatment typically includes mesh removal and replacement with a new one. Mesh removal without replacement can predispose patients to develop a recurrent hernia. Some authors advocate the placement of the new mesh in an opposite location to the old one, for example, in the preperitoneal space. If the original repair was open, the new mesh is recommended to be inserted laparoscopically and if the previous repair was laparoscopic, the following repair is advised to be open.
Laparoscopically repaired hernia causing chronic pain due to improperly placed tacks requires laparoscopic re-exploration and removing the offending tacks [3, 8, 9, 10, 19, 20].
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Written By
Hany Mohammed El-Hadi Shoukat Mohammed
Submitted: 23 July 2024 Reviewed: 12 August 2024 Published: 19 February 2025
© The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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