Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Introduction: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. Methods: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Results: Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29–51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. Conclusions: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.     

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh

Objectives  Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. Methods  In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19–88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients’ records were retrospectively reviewed for the purpose of this study. Results  Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6–44 months postoperatively. Conclusion  From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.     

Preservation Versus Division of Ilioinguinal Nerve on Open Mesh Repair of Inguinal Hernia: A Meta-analysis of Randomized Controlled Trials

Background

Chronic groin pain after inguinal hernia repair, a serious problem, is caused by entrapment of the ilioinguinal nerve either by mesh or development of fibrosis. Division of the ilioinguinal nerve during hernioplasty has been found to reduce the incidence of chronic groin pain. However, the traditional approach favors preservation of the ilioinguinal nerve during open hernia repair.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials that compared the outcomes of preservation versus division of the ilioinguinal nerve during open mesh repair of inguinal hernia. The primary outcome was the incidence of groin pain; secondary outcomes were numbness and sensory loss.

Results

We reviewed six trials with 1,286 patients. We found no difference between the groups for the incidence of groin pain or numbness at 1, 6, and 12 months after open mesh inguinal repair. The incidence of sensory loss or change was significantly higher in the division group than in the preservation group at 6 months [risk ratio (RR) 1.25; 95?% confidence interval (CI) 1.02–1.53] and at 12 months (RR 1.55; 95?% CI 1.01–2.37) postoperatively. No significant differences between the groups were noted at any other points in time.

Conclusions

Preservation of the ilioinguinal nerve during open mesh repair of inguinal hernia is associated with a decreased incidence of sensory loss at 6 and 12 months postoperatively compared with that of the division technique. No significant differences were found between the groups for chronic groin pain or numbness.     

Lichtenstein无张力疝修补术中腹股沟区神经处理的体会

目的探讨Lichtenstein无张力疝修补术中正确处理腹股沟区神经对术后慢性疼痛的预防效果。方法对我院2007年2月至2010年3月期间收治的158例腹股沟疝患者行Lichtenstein无张力疝修补术,并在术中注意辨认及保护腹股沟区神经,保持神经床的完整性,若神经被损伤或干扰了网片的放置则予切除。结果术中髂腹下神经、髂腹股沟神经和生殖股神经生殖支辨认率分别为87.97%(139/158)、82.28%(130/158)和34.18%(54/158)。术后并发症发生率为5.06%(8/158),其中切口皮下积液5例,阴囊血肿2例,切口感染1例,均通过理疗、切口换药后治愈。随访12个月,无复发病例。术后1个月有轻度疼痛者63例(39.87%),中度疼痛者34例(21.52%),无重度疼痛者,平均疼痛评分为0.83分;术后6个月时慢性疼痛发生率为5.06%(8/158),其中轻度疼痛者7例(4.43%),中度疼痛者1例(0.63%);术后12个月时只有4例(2.53%)患者偶感轻微疼痛或不适,平均疼痛评分为0.03分。多分类logistic回归分析显示:神经切除对术后疼痛无明显影响(P>0.05);未辨清髂腹股沟神经会增加术后早期(1个月)中度疼痛的风险(疼痛风险比值=3.373,P=0.030)。结论只要严格遵照Lichtenstein手术操作规范,术中正确处理腹股沟区神经,就能降低患者术后慢性疼痛的发生,改善其生活质量。     

Laparoscopically guided ilioinguinal nerve block for groin hernia repair

BACKGROUND: Percutaneous ilioinguinal nerve block may reduce postoperative pain after open groin hernia repair but may be complicated by transient femoral nerve palsy in some patients. The technique of laparoscopically guided ilioinguinal nerve block is reported, and its benefits assessed in patients undergoing laparoscopic total extraperitoneal groin hernia repair. MATERIALS AND METHODS: In this prospective study, patients who had laparoscopically guided ilioinguinal nerve block during groin hernia repair were assessed in the post-anaesthetic recovery room and the day surgery ward. Need for opiate analgesia in the recovery room and the day surgery ward was recorded. Verbal pain scores (on a scale of 0 to 3) on rest and leg movement were noted. RESULTS: Thirty-two consecutive men and one woman, mean age 49 years (range, 29-76 years), had laparoscopic total extraperitoneal repair of groin hernia with ilioinguinal nerve block. Postoperatively, 18% of the patients required opiate analgesia in the recovery room and none in the day surgery ward. Median verbal pain scores at rest and movement were 0 (range, 0-2) and 1 (range, 0-3), respectively. No patient developed transient femoral nerve block. CONCLUSION: Laparoscopically guided ilioinguinal nerve block may be applied safely and with improved postoperative comfort after groin hernia repair.     

Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial

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. 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. RESULTS: 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). 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. CONCLUSIONS: 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.     

Does nerve identification during open inguinal herniorrhaphy reduce the risk of nerve damage and persistent pain?

Purpose

Nerve identification during open inguinal hernia herniorrhaphy has been suggested as one of the factors that may reduce the risk of development of persistent postherniorrhaphy pain. In this prospective study, we evaluated whether intraoperative inguinal nerve identification influenced the risk of development of persistent postherniorrhaphy pain, sensory dysfunction in the groin and functional ability score after open hernia repair.

Methods

A total of 244 men with a primary inguinal hernia underwent open Lichtenstein repair in a high-volume hernia surgery centre, where information on inguinal nerve identification was registered during operation. Before the operation and 6?months postoperatively, functional pain-related impairment was assessed with Activities Assessment Scale and pain intensity scores with Numeric Rating Scale (NRS 0–10). Quantitative sensory testing in the groin was performed before operation and 6?months postoperatively, in order to investigate intraoperative inguinal nerve damage.

Results

The intraoperative nerve identification rates for the iliohypogastric, ilioinguinal and genitofemoral nerves were 94.7, 97.5 and 21.3?%, respectively. Thirty-nine patients (16.0?%) had substantial pain-related functional impairment at 6?months follow-up. There was no difference in risk of development of substantial pain-related functional impairment in patients with identification compared with non-identification of the iliohypogastric nerve (P?=?1.0), the ilioinguinal nerve (P?=?0.59), the genitofemoral nerve (P?=?0.40) or all nerves (P?=?0.52). There were no differences in regard to sensory loss in the groin area or in regard to improvement in functional outcome following surgery, between patients with and without nerve identification.

Conclusions

Although intraoperative inguinal nerve identification should be aimed at, other factors may contribute to the risk of nerve damage and persistent pain after open groin hernia repair.     

髂腹下及髂腹股沟神经阻滞用于小儿腹

目的：探讨小儿腹股沟区手术麻醉安全便利的麻醉方法。方法：小儿腹股沟部手术40例．随机分成二组．1组20例以氯胺酮肌注后行髂腹下及髂腹股沟神经阻滞：Ⅱ组20例以氯胺酮胍注后行骶管阻滞麻醉。监测Bp、P．R．SpO2变化,及术毕清醒时间、术中不良反应。结果：平均年龄、手术时间两组无统计学意义（P〉0．05）．所有病例均较好地完成手术。两组生命体征．清醒时间无明显差异;切皮时Ⅱ组有4例出现肢体躁动;处理疝囊及牵拉精索时Ⅰ组中有4例出现肢体躁动;Ⅱ组有4例经多次穿刺成功．1例局部血舯。结论：作者认为髂腹下及髂腹股沟神经阻滞操作简单,穿刺引起的并发症及危险性少,麻醉效果与骶麻相似,可作为小儿腹股淘部手术的麻醉方法之一,特别是骶管阻滞困难时。     

Incidence of chronic groin pain following open mesh inguinal hernia repair,and effect of elective division of the ilioinguinal nerve: meta-analysis of randomized controlled trials

Purpose

Chronic post-operative groin pain is a substantial complication following open mesh inguinal hernia repair. The exact cause of this pain is still unclear, but entrapment or trauma of the ilioinguinal nerve may have a role to play. Elective division of this nerve during hernia repair has been proposed in an attempt to reduce the incidence of chronic groin pain.

Methods

We performed a meta-analysis of nine randomized controlled trials comparing preservation versus elective division of the ilioinguinal nerve during this operation.

Results

A substantial proportion of patients having open mesh inguinal hernia repair experience chronic groin pain when the ilioinguinal nerve is preserved (estimated rate of 9.4% at 6 months and 4.8% at 1 year). Elective division of the nerve resulted in a significant reduction of groin pain at 6-months post-surgery (RR 0.47, p = 0.02), including moderate/severe pain (RR 0.57, p = 0.01). However, division of the nerve also resulted in an increase of subjective groin numbness at this time point (RR 1.55, p = 0.06). At 12-month post-surgery, the beneficial effect of nerve division on chronic pain was reduced, with no significant difference in the rates of overall groin pain (RR 0.69, p = 0.38), or of moderate-to-severe groin pain (RR 0.99, p = 0.98) between the two groups. The prevalence of groin numbness was also similar between the two groups at 12-month post-surgery (RR 0.79, p = 0.48).

Conclusions

Routine elective division of the ilioinguinal nerve during open mesh inguinal hernia repair does not significantly reduce chronic groin pain beyond 6 months, and may result in increased rates of groin numbness, especially in the first 6-months post-surgery.

     

A pragmatic approach to cutaneous nerve division during open inguinal hernia repair

Aims Chronic pain following inguinal hernia repair may be related to the handling of cutaneous nerves. This study aims to investigate the frequency of cutaneous nerve division in routine practice and the effect that nerve division has on long-term pain outcomes. Methods The outcomes of 172 patients who underwent open inguinal hernia repair over a two-year period during the course of a clinical trial were recorded prospectively for 1 year. Pain scores for patients in whom one of the nerves was divided were compared with those of patients in whom all three were preserved. Result All nerves were preserved in 95 cases (55.2%). The ilioinguinal, genital and iliohypogastric nerves were divided in 33 (19.2%), 12 (7.0%) and 14 (8.1%) cases, respectively. There was no significant difference in pain scores between any of the nerve division groups compared to the group in which all three were preserved. There were three (1.7%) cases of significant chronic pain, two in which no nerves were divided. Conclusion The division of cutaneous nerves during inguinal hernia repair has no significant effect on postoperative pain. However, there are very few adverse outcomes, and so, a pragmatic approach of dividing nerves when they would otherwise be damaged may be appropriate.     

Unilateral groin surgery in children: will the addition of an ultrasound‐guided ilioinguinal nerve block enhance the duration of analgesia of a single‐shot caudal block?

Background: Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single‐shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double‐blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. Methods: Fifty children ages 1–6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US‐guided ilioinguinal nerve block with 0.1 ml·kg^?1 of preservative‐free normal saline and Group B that received an US‐guided nerve block with 0.1 ml·kg^?1 of 0.25% bupivacaine with 1 : 200 000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml·kg^?1 of 0.125% bupivacaine with 1 : 200 000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. Results: Forty‐eight patients, consisting of 46 males and two females, with a mean age of 3.98 (sd ± 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (sd ± 1.59) and 1.18 (sd ± 1.31), respectively. The average pain score difference was 0.72 (sd ± 0.58) and was statistically significant (P < 0.05). In addition, when examined by procedure type, it was found that the difference in the average pain scores between the caudal and caudal/ilioinguinal block groups was statistically significant for the inguinal hernia repair patients (P < 0.05) but not for the other groin surgery patients (P = 0.13). For all groin surgery patients, six of the 23 patients in the caudal group and eight of the 25 patients in the caudal/ilioinguinal block group required pain rescue medications throughout their entire hospital stay or at home (P = 0.76). Overall, the caudal group received an average of 0.54 (sd ± 1.14) pain rescue medication doses, while the caudal/ilioinguinal block group received an average of 0.77 (sd ± 1.70) pain rescue medication doses; this was, however, not statistically significant (P = 0.58). Conclusions: The addition of an US‐guided ilioinguinal nerve block to a single‐shot caudal block decreases the severity of pain experienced by pediatric groin surgery patients. The decrease in pain scores were particularly pronounced in inguinal hernia repair patients.     

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

Background Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). Methods From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. Results The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. Conclusions The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia. The abstract was presented at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2005, 13–16 April 2005 at Fort Lauderdale, Florida     

Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain

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. 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. 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. RESULTS: Overall, the 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% 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. 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. Likewise, division of nerves was clearly correlated with presence of chronic pain. CONCLUSIONS: 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.     

Chronic pain after Kugel inguinal hernia repair

Background The incidence of chronic pain after Kugel herniorrhaphy is not well documented, since it was not used as a primary outcome measure in studies reporting on the Kugel technique. The aim of the present study was to report on the incidence and severity of chronic pain 1 year after Kugel herniorrhaphy and to identify the risk factors associated with the development of chronic pain. Methods The study population comprised all patients in our teaching hospital who underwent a Kugel inguinal hernia repair between January 2002 and June 2005. Postoperative complications, analgesia consumption and postoperative functional impairment were recorded during an outpatient clinic after 4–6 weeks. Chronic pain and cutaneous sensory changes were followed-up by means of a telephone questionnaire 1 year after surgery. Results After 1 year, 57 (15.1%) of 377 patients complained of mild to moderate pain. The incidence of mild and moderate chronic pain was 14.3 and 0.8%, respectively. None of the patients had severe chronic pain. Only one patient reported numbness in the groin area. Age and immediate postoperative pain were significant risk factors associated with chronic pain after Kugel inguinal herniorrhaphy. Although the difference was not significant, female patients seemed to be more prone to develop chronic pain. Conclusions The Kugel inguinal hernia repair is associated with a low rate of postoperative chronic pain. The minimally invasive preperitoneal approach of the Kugel technique probably causes less nerve damage and subsequent neuropathic pain. Chronic pain seems to be more common in young female patients with immediate postoperative pain.     

Randomized controlled trial of preservation or elective division of ilioinguinal nerve on open inguinal hernia repair with polypropylene mesh

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. DESIGN: Double-blind, randomized trial. SETTING: Four public, government-financed hospitals in Italy. 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). INTERVENTION: Hernia repair with sutureless apposition of a polypropylene mesh. 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. Telephone interview was performed 35.5 months (range, 12-59 months) after operation to assess the presence of chronic pain. RESULTS: Of the 302 group A and 291 group B patients who made an office visit 1 year postoperatively, pain was absent in 231 (76.5%) and 213 (73%) (difference, 3.30%; 95% confidence interval, -3.68% to 10.28%), mild in 55 (18%) and 60 (21%), moderate in 11 (4%) and 9 (3%), and severe in 5 (2%) and 9 (3%), respectively (P =.55; Pearson chi2(3) test). 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. 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. At telephone interview, the presence of chronic pain was similar in both groups. CONCLUSIONS: 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.     

Combined open and laparoscopic approach to chronic pain after inguinal hernia repair

Chronic groin pain is the most frequent long-term complication after inguinal hernia repair affecting up to 34 per cent of patients. Traditional surgical management includes groin exploration, mesh removal, and neurectomy. We evaluate outcomes of a combined laparoscopic and open approach to chronic pain after inguinal herniorrhaphy. All patients undergoing surgical exploration for chronic pain after inguinal herniorrhaphy were analyzed. In most, the operation consisted of mesh removal (open or laparoscopic), neurectomy, and placement of mesh in the opposite location of the first mesh (laparoscopic if the first was open and vice-versa). Main outcome measures included pain status, numbness, and hernia recurrence. Twenty-one patients (16 male and 5 female) with a mean age of 41 years (22-51 years) underwent surgical treatment for unilateral (n = 18) or bilateral (n = 3) groin pain. Percutaneous nerve block was unsuccessful in all patients. Four had previous surgery for pain. There were no complications. With a minimum of 6 weeks follow-up, 20 of 21 patients reported significant improvement or resolution of symptoms. A combined laparoscopic and open approach for postherniorrhaphy groin pain results in excellent patient satisfaction with minimal morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after hernia repair.     

Ilioinguinal nerve excision in open mesh repair of inguinal hernia--results of a randomized clinical trial: simple solution for a difficult problem?

BACKGROUND: Inguinodynia is the second most common complication occurring after inguinal hernia repair. This study was undertaken to evaluate the effect of ilioinguinal nerve excision, a concept previously proposed to be performed during open hernia mesh repair, on postsurgical pain and hyposthesia. METHODS: A double-blind randomized clinical trial was performed on 121 patients undergoing open anterior mesh repair of inguinal hernia in 1 center from April 2005 through June 2006. The ilioinguinal nerve was excised in half of the patients and preserved in the other half. Pain and hyposthesia at POD 1, 1 and 6 months after surgery, and 1 year after surgery was evaluated in both groups using a visual analog scale. Results were compared using chi-square analysis. RESULTS: Of the total number of 121 patients who entered the study, with an age range of 18 to 86 years (mean +/- SD 45 +/- 18), 115 (95%) were male. Sixty-one were in the nerve-excision group, and 60 were in the nerve-preservation group. One hundred patients were followed-up until the end of the first year. Using the visual analog scale to detect pain severity on postsurgical day 1, mean scores in the nerve-excision and nerve-preservation groups were 2.2 +/- .8 (range 1 to 4) versus 2.8 +/- .7 (range 2 to 4.5), respectively (P < .001). At 1 month after surgery, these scores were .7 +/- .7 (range 0 to 3) versus 1.5 +/- .7 (range 0 to 3.5), respectively (P < .001). Between 6 months and 1 year after surgery, median scores of zero were detected in both groups. After postsurgical day 1, the median score of hyposthesia was near zero in both groups. Thirteen patients developed chronic inguinodynia (13%), 10 of whom were in the nerve-preservation group. Chronic postsurgical inguinodynia was seen in 6% of patients in the ilioinguinal nerve-excision and 21% of the patients in the ilioinguinal nerve-preservation group (P = .033). COMMENTS: Neurectomy decreases postsurgical pain after elective inguinal hernia repair. Although chronic inguinodynia was less frequent in our study than reported by many previous studies, it is still wise to recommend ilioinguinal neurectomy in patients undergoing anterior inguinal hernia mesh repair.     

The Comparison of Inflammatory Responses and Clinical Results After Groin Hernia Repair Using Polypropylene or Polyester Meshes

The aim of this study was to compare the clinical results and the inflammatory responses against polypropylene and polyester meshes after groin hernia repair. Ninety patients with unilateral inguinal hernia randomly underwent Shouldice herniorrhaphy or Lichtenstein hernioplasty using polypropylene or polyester meshes. Venous blood samples were collected to evaluate serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Postoperative acute and chronic pain and time to attain to normal activities were evaluated. IL-6 levels decreased to preoperative levels in all groups at 48th hour. CRP levels of mesh-implanted groups are significantly higher than preoperative level at 48th hour, while it reduced to preoperative level in Shouldice herniorrhaphy group. Patients treated with mesh repair had less postoperative acute pain and recovered more rapidly than those who underwent Shouldice herniorrhaphy. It was concluded that polypropylene and polyester meshes used in hernia repair caused similar inflammatory responses and that clinical results after groin hernia repair with these prostheses were not significantly different.     

Planned inguinal herniorrhaphy but no hernia sac?

Background. Planned inguinal herniorrhaphy may present a clinical dilemma when no hernia is found. No large-scale data are available on the incidence of this problem, and, therefore, no recommendations exist for choice of surgical intervention. Material and methods. Data were extracted from the Danish Hernia Database covering the interval from 1 January 1998–5 April 2002, and included 42,356 groin hernia repairs. Results. No hernia was found in 313 cases (0.74%). These patients were divided into three groups (lipomas, no pathology, and a weak abdominal wall) and analysed according to surgical technique. There were 11 reoperations (3.5%) of which three were femoral and eight inguinal hernias, without differences between type of initial operation (herniorrhaphy or no herniorrhaphy). Conclusion. This study of 42,356 groin hernia repairs showed that in 313 patients (0.74%), no hernia was found. Recurrences did not occur with higher frequency in patients receiving no repair. Based on these data and the risk of chronic postherniorrhaphy pain, we suggest that no repair be performed when no inguinal hernia is found during planned inguinal herniorrhaphy.     

Cryoanalgesia for pain after herniorrhaphy

The effect of freezing the ilioinguinal nerve on postoperative pain relief was examined in a double blind study in 36 patients undergoing herniorrhaphy, randomly allocated into two groups. Patients in the experimental group had their ilioinguinal nerves frozen during surgery and were compared with the patients in the control group who did not have cryoanalgesia. Pain relief was assessed over a 48-hour period in three ways, namely the linear analogue pain scale, peak expiratory flow rates and the amount of analgesic drugs required by patients in the two groups. We conclude that cryoanalgesia of the ilioinguinal nerve alone does not produce significant early post herniorrhaphy pain relief.