Sianesi M

Wide Resection of Inguinal Nerves versus Simple Section to Prevent Postoperative Pain after Prosthetic Inguinal Hernioplasty: Our Experience

BackgroundIn the literature, chronic groin pain (i.e. lasting >3xa0months) occurs in about 10xa0% of patients who undergo inguinal hernioplasty with prosthesis; it is characterized by a broad range of symptoms, and is relative to individual perceptions of pain. In 2–5xa0% of cases, the painful symptomatology is so intense that it interferes with daily activities, and can be debilitating in 0.5–6xa0% of cases. The best known cause of inguinodynia is neuropathy, due to implication of one or more inguinal nerves (iliohypogastric, ilioinguinal, and genitofemoral nerves) into fibroblastic processes; or from nervous stimulation caused by prosthetic material on adjacent nervous trunks. Many therapeutic strategies have been proposed to treat chronic groin pain, including intra-operative prophylactic neurectomy.ObjectiveThe purpose of our study was to perform a comparative analysis between outcomes from wide resections of inguinal nerves versus those from simple nervous section (or minimal resection).Patients and methodsWe considered 350 patients who had undergone inguinal prosthetic hernioplasty with Trabucco’s technique between 2004 and 2010. Wide nervous resection (removal of nerve segments 3–8xa0cm in length) was performed in 180. The other 170 patients underwent simple section or minimal resection. All patients were checked 1xa0week, 1xa0month, and 1xa0year after surgery.ResultsGroup 1: At 1-week follow-up, 63 patients (35xa0%) reported no pain, 113 (63xa0%) reported moderate pain, and 4 (2xa0%) intense pain; 1xa0month after the procedure, 152 patients (84.4xa0%) reported no pain, 25 (14xa0%) complained of moderate pain, and 3 (1.6xa0%) of severe pain; 1xa0year after surgery, only 1 patient (0.5xa0%) complained of constant pain. Group 2: At 1xa0week follow-up, 48 patients (28xa0%) reported no pain, 101 (59xa0%) reported moderate pain, and 21 (13xa0%) intense pain; 1xa0month after the procedure, 81 patients (47.6xa0%) had no pain, 72 (42.4xa0%) complained of moderate pain, and 17 (10xa0%) of severe pain; 1xa0year after surgery, 11 patients (6.5xa0%) had constant pain, and two of them were re-admitted for surgery. The lower incidence of chronic pain after long nervous resection is statistically significant (0.5 vs. 6.5xa0%; pxa0=xa00.006); the incidence of moderate pain 1xa0month after operation is also lower (14 vs. 42.4xa0%; pxa0<xa00.0001); patients who underwent a long resection experienced faster resolution of pain symptomatology, during a month. Also noteworthy is the lower incidence of intense pain in the short and medium term (after 1xa0week, 13 vs. 2xa0%, pxa0=xa00.0005; after 1xa0month, 10 vs. 1.6xa0%, pxa0=xa00.0018).ConclusionsThe prophylactic wide resection of selected segments of inguinal nerves, despite the apparent paradox of greater tissue damage, appears more effective than simple section at preventing postoperative inguinodynia, given both the lower incidence and the faster resolution of painful symptomatology.

Wide nervous section to prevent post-operative inguinodynia after prosthetic hernia repair: a single center experience

BackgroundChronic post-operative inguinodynia occurs in about 10xa0% of patients undergoing inguinal hernioplasty with prosthesis; it is characterized by a broad pleomorphism of symptoms, including relative to individual variability of algic perception. Its intensity can also potentially jeopardize patient’s work and social activities. The most notorious cause of inguinodynia is neuropathy, resulting from the involvement of one or more inguinal nerves (iliohypogastric, ilioinguinal and genitofemoral nerves) in fibroblastic processes, or from nervous stimulation, caused by prosthetic material on adjacent nervous trunks. The aim of our study was to provide a comparative analysis between outcomes of wide nerve resection vs. nerve sparing.Patients and methodsIn our hospital, between 2000 and 2010, 600 patients underwent monolateral prosthetic inguinal hernia repair, using the original Trabucco technique. In 345 cases, to avoid chronic post-operative pain, we carried out intentional neurectomy, between 3 and 8xa0cm in length of either the main and/or peripheral branches of the iliohypogastric nerve, ilioinguinal nerve and the genital branch of the genitofemoral nerve, deemed at risk of entrapment because of the prosthetic material. In the control group, which included the other 255 patients, nerves were identified and spared. Follow-up was scheduled at 1xa0week, 1xa0month and 1xa0year after surgery.ResultsCase: 1 week after the operation, 135 patients (39.1xa0%) did not show pain, 201 (58.3xa0%) reported moderate pain and 9 (2.6xa0%) showed intense pain; 1xa0month after the procedure, 300 patients (87xa0%) did not have pain, 39 (11.3xa0%) complained of moderate pain and 6 (1.7xa0%) demonstrated severe pain; 1xa0year after surgery, only two patients (0.6xa0%) complained of persistent pain.Control: At the 1-week follow-up, 114 patients (44.7xa0%) did not show pain, 111 (43.5xa0%) reported moderate pain and 30 (11.8xa0%) intense pain; 1xa0month after the procedure, 183 patients (71.8xa0%) did not have pain, 45 (17.6xa0%) complained of moderate pain and 27 (10.6%) showed severe pain; 1xa0year after surgery, 11 patients (4.3xa0%) had persistent pain, and two of them were re-submitted to surgery. The lower incidence of chronic pain after nerve resection is statistically significant (0.6 vs. 4.3xa0% pxa0=xa00.0048); the incidence of moderate pain 1xa0month after the operation is also lower (11.3 vs. 17.6xa0% pxa0=xa00.0097). In addition, among patients subjected to nerve resection there is a faster resolution of algetic symptomatology, over the course of a month; also noteworthy is the lower incidence of intense pain in the short-and medium-term (after 1xa0week, 11.8 vs. 2.6xa0% pxa0=xa00.0006 ; after 1xa0month, 10.6 vs. 1.7xa0% pxa0<xa00.0001).ConclusionsDespite the apparent paradox of an higher tissue damage, elective neurectomy of selected segments of inguinal nerves, appears an effective technique in preventing chronic postherniorraphy pain, considering both the lower incidence and the faster resolution of painful symptomatology.