Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve

BACKGROUND: The neuropathic groin pain after inguinal hernia repair is usually due to a neuroma of the ilioinguinal, iliohypogastric, or genitofemoral nerve. When the postherniorrhaphy pain symptoms include mostly testicular pain, then the genital branch of the genitofemoral nerve comes first in the differential diagnosis. Nerve blocks are helpful in determining which of the three nerves is implicated in the pain syndrome. Although the surgical approach to the ilioinguinal nerve is now well established, it has been difficult to identify the genitofemoral reliably enough to permit resection of this nerve. STUDY DESIGN: Anatomic cadaver dissections of nerves exiting the lumbosacral plexus were performed. Their course was followed to their final terminations. Based on these findings, an operative approach was designed to address the involved nerve at a specific site. The results and outcomes were prospectively followed. RESULTS: The present anatomic study identifies the site within the inguinal canal where the genital branch of the genitofemoral nerve may be identified. The designed operative approach points to the proximal site of the canal to be opened for an exposure. It also dictates that the nerve should be dissected and resected proximal to the surgical repair or mesh reconstruction, which allows its retroperitoneal placement. All four patients were relieved of their preoperative symptoms using this approach. CONCLUSIONS: Severe and chronic testicular pain after inguinal hernia repair can be treated by a designed approach that identifies the genital branch of the genitofemoral nerve in the proximal inguinal canal, its resection point proximal to the previous operative field, and placement behind the peritoneum.