Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?

PAIN AND NEURALGIAPAIN AND NEURALGIA AFTER HERNIA SURGERY:

CAN IT BE AVOIDED?AND HOW DO WE TREAT?

George S Ferzli MD, FACS

Henry Kissinger, 17 Jun 2006

“Soccer is a game that hides great complexity in an appearance of simplicity.”

Author # of Pts Pain* Pain Severe Outcome of Pain

AS Poobalan 2001 226 30% > 3 mo

Morten Bay-Nielsen 2001

1166 28.7% > year 3%

S Kumar 2002 454 30% >21 mo

CA Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have painSevere in 22% Mild in 45%

Marcello Picchio 2004

593 25% > 1 yr 6%>1 yr

AM Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs

Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein)15% (TAPP)> 52 mo

Ulf Fränneby 2006 2456 31% >24 to 36 mo

Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr

EK Aasvang 2006 210 34.3% >1year Less pain 75.8%Same pain 16.7%More severe 7.5%> 6.5 years

* Groin pain or discomfort lasting more than 3 months after groin hernia repair.Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain. 1986; 3 (suppl): 1-226.

GROIN PAIN INCIDENCEGROIN PAIN INCIDENCE

QUALITY OF LIFEQUALITY OF LIFE

Author Pts Pain affects the Quality of life

Morten Bay-Nielsen 2001 1166 16.6%

S Kumar 2002 454 18.1%

Jrg Kninger 2004 208 14% (Shouldice)

13% (Lichtenstein)

2.4% (TAPP)

Ulf Fränneby 2006 2456 6%

EK Aasvang 2006 210 Nb 24.8%

6% after 6.5 years

Sergio Alfieri, 2006 973 11.3% to 14.2%

What Causes Groin Pain

Like soccer affects our lives, Like soccer affects our lives, groin pain also effects the quality of life…groin pain also effects the quality of life…

How to Treat Groin Pain

Ilioinguinal n.

Iliohypogastric n.

The ilioinguinal nerve (T12 and L1) supplies sensory innervation to the proximal and medial thigh.

In the female innervation is supplied to abdominal skin of the mons pubis and labium majus. In the male, the ilioinguinal nerve innervates the root of the penis and upper scrotum.

The iliohypogastric nerve supplies similar sensory innervation to that of the ilioinguinal nerve.

Iliohypogastric n.

Ilioinguinal n.

Cross Cross innervationinnervation

Red line = genitofemoral n. Green line = ilioinguinal n. Gray area = skin innervated by cutaneous components of genitofemoral and/or ilioinguinal n.

Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, MD, Johannes Ebmer, and A Lee Dellon, MD Vienna, Austria, and Baltimore, Md. PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001.

Cutaneous branching patterns of ilioinguinal / genitofemoral nerves

RISK FACTORS: ANATOMICAL VARIATIONSRISK FACTORS: ANATOMICAL VARIATIONS

Morikawa 1971

Only 37 % of the cases had typical textbook patterns

Matthias Rab 2001

Patterns of innervation were bilaterally symmetric in 40.6 % of the cadavers.

The “normal” pattern of distribution, consistent with modern text descriptions, was defined in only 20.3%

Re: site within the inguinal canal / relationship between nerve branches and spermatic cord/round lig.- normal type was found in 56.3%

Type A (43 %) Type B (28.1%)

Type C (20.3%) Type D (7.7%).

• The iliohypogastric nerve: 3.8 cm (range 2.5–5.5 cm) cranially from the external ring.

• The ilioinguinal nerve: ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle.

• The genital branch: laterocaudal at the level of the internal inguinal ring.

Nerve-Identifying Inguinal Hernia Repair: A Surgical Anatomical Study. AR Wijsmuller, JFM Lange, GJ Kleinrensink, D van Geldere, MP Simons, FJPM Huygen, J Jeekel, JF Lange World J Surg (2007) 31: 414-420

IDENTIFICATION ZONES IDENTIFICATION ZONES FOR THE INGUINAL NERVESFOR THE INGUINAL NERVES

• In the case of difficulty identifying the iliohypogastric nerve, the upper leaf of the external oblique aponeurosis should be separated medially and cranially and lifted cautiously until the iliohypogastric nerve is identified perforating the aponeurose at a zone 2.5–5.5 cm (3.8 cm) cranial from the external ring.

THE ILIOHYPOGASTRIC NERVETHE ILIOHYPOGASTRIC NERVE

• The genital branch of the genitofemoral nerve should be identified proximally and laterocaudally at the level of the internal ring in the frontal plane where its course variability is least.

THE GENITAL BRANCHTHE GENITAL BRANCH

What Causes Groin Pain How to Treat Groin Pain

Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

GENITOFEMORAL NERVE INNERVATION (L1,2)GENITOFEMORAL NERVE INNERVATION (L1,2)

The genital branch of the genitofemoral nerve supplies sensation to the mons pubis and labium majus. In the male, sensation is supplied to the scrotum and motor fibers to the cremasteric muscle.

Genital branch, genitofemoral

nerve

NERVE INNERVATION - FEMORAL BR. NERVE INNERVATION - FEMORAL BR. GENITOFEMORAL NERVE (L1,2)GENITOFEMORAL NERVE (L1,2)

The femoral branch supplies sensory innervation to the anterolateral thigh.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Lat. femoral cutaneous n.

• Sensory innervationto anterolateral thigh

• Injury may result in a severe burning sensation along the anterolateral aspect of the thigh

LATERAL FEMORAL CUTANEOUS NERVE LATERAL FEMORAL CUTANEOUS NERVE INNERVATION (L2,3)INNERVATION (L2,3)


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Femoral n.

• Sensory innervationto anterolateral thigh

• Injury may result in atrophy of the quadriceps muscle

FEMORAL NERVE INNERVATION (L2,3)FEMORAL NERVE INNERVATION (L2,3)


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

RISK FACTORS: MESH REPAIRRISK FACTORS: MESH REPAIR

Heise CP, Starling JR (1998)

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

Scott N 2000 Mesh repairs are less likely to cause CGP than non-mesh repairs

AS Poobalan 2001 Patients who underwent mesh repair reported more chronic pain than those who had suture repair, but this was not significant (P = 0.08)

CA Courtney 2002 There was no association between severe or very severe pain following operation and operation type (mesh or non-mesh)

Jrg Kninger 2004 The presence of the prosthetic mesh was not associated with significant postoperative complaints

RISK FACTORS: MESH REPAIRRISK FACTORS: MESH REPAIR

Mechanical compressionof peripheral nerves isassociated with myelin degeneration, endoneurinal andperineurinal edema,fibrosis, axonal loss, and edema that may cause peripheral neuropathy.

The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin Hernia Seher Demirer, MD Journal of Surgical Research 131, 175–181 (2006)

• Spermatic cord problems

• Orchitis

• Vas deferens issues

• Perineural fibrosis• Neuroma • Nerve entrapment• Direct lesions due to stretching, contusion, electrical injury, and partial or complete division.

NeuropathicNeuropathic Non-neuropathicNon-neuropathic VisceralVisceral

• Osteitis pubis

• Stapalgia

• Meshalgia

Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK Hernia 2004; 8: 343–349.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age

RISK FACTORS: AGERISK FACTORS: AGEAuthor # of Pts Age Pain No Pain Statistical

SignificanceAS Poobalan2001

226 19 82

1187 ?

< 40

40-60

>60

11 (58%)

33 (40%)

16 (14%)

8 (42%)

49 (60%)

102 (86%)

P < 0.001

Simon Willem Nienhuijs 2005

309 < 50

> 50

66

72

47

134

P 0.000

Ulf Fränneby, 2006

1026976

< 59> 59

345 (33.6%)205 (21.0%)

P < 0.001

EK Aasvang 2006

43126 41

18-4041-65>65

30.2%36.5%31.7%

NS


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age

Pre-op pain

RISK FACTORS: PREOPERATIVE PAINRISK FACTORS: PREOPERATIVE PAIN

Author # of Pts

Preop Pain

Chronic Pain

No Chronic

Pain

Statistical significanc

e

AS Poobalan 2001

No pain

Pain

7 (13%)

50 (35%)

47(87%)

95(65%)

0.005

Ulf Fränneby2006

No pain* 966

Pain** 1036

176 (18.2%)

374 (36.1%)

P <0.001

* Lower than “Affects concentration on daily activities”** “Affects concentration on daily activities” or higher

CA Courtney 2002

Patients who go on to suffer chronic pain are more likely to have complained of pain from the hernia before operation than those who have no postoperative pain and they are more likely to suffer from other chronic pain conditions compared with the normal population.

Marcello Picchio, 2004

No correlation was found between the presence of preoperative pain and the occurrence of postoperative pain


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age

BMI

Pre-op pain

RISK FACTORS: BMIRISK FACTORS: BMI

Author # Pts BMI Chronic Pain

No Chronic Pain

Statistical Significance

A S Poobalan 2001

Normal 66

Overweight 109

Obese 40

16 (24%)

31 (28%)

15 (38%)

50 (76%)

78 (72%)

25 (62%)

P 0.341

Simon Willem Nienhuijs * 2005

< 25

282

>25

76 (27%)

45 (16%

85 (30%)

76 (27%)

P 0.059

*The authors of this study considered the association of the BMI with chronic pain a coincidence. The elderly, for the most part, had a higher body mass index.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age

Post-op complication

risk

Pre-op pain

BMI

RISK FACTORS: POST OP COMPLICATIONSRISK FACTORS: POST OP COMPLICATIONS

Postoperative complications were found to be linked to an increased risk for longterm pain. (OR, 1.8; 95% CI, 1.2–2.5; P 0.003)

Risk Factors for Long-term Pain After Hernia Surgery Ulf Fränneby, MD, (Ann Surg 2006; 244: 212-219)

Post Op Complications P < 0.003

Not registered 498/1865 (26.7%)

Registered 52/137 (38.0%)


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age


risk

BMI

Pre-op pain

Recurrent hernia

RISK FACTORS: RECURRENT HERNIARISK FACTORS: RECURRENT HERNIA

Author # Pts

Recurrent Hernia

Chronic Pain No Chronic Pain

Statistical Significance

AS Poobalan 2001 Recurrent

Initial

10 (59%)

39 (24%)

7 (41%)

124 (76%)

0.005

EK Aasvang 2006* Recurrent

Initial

27.8%

35.6%

NS

*In this study no variables were identified that significantly correlated to pain or functional impairment 6.5 years after surgery.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age


risk

BMI

Pre-op pain

Day case surgery

Technique Insurance status

Recurrent hernia

RISK FACTORS: DAY CASE SURGERYRISK FACTORS: DAY CASE SURGERY

• The probability of developing chronic pain was 2´5 times higher in day-case patients, controlling for age.

Chronic pain and quality of life following open inguinal hernia repair. AS Poobalan, J Bruce, PM King*, WA Chambers, ZH Krukowski* and WCS Smith British Journal of Surgery 2001, 88: 1122-1126

Risk factor Chronic pain No Chronic pain Odds ratio P

Day case 13 (54 %) 11 (46%) 3.72 (1.45± 9.64) 0.004

Inpatient 47 (24%) 148 (76%)

RISK FACTORS: LAPAROSCOPY vs. OPENRISK FACTORS: LAPAROSCOPY vs. OPEN

Author # Pts Procedure Pain Statistical Significance

S Kumar 2002

240

214

TEP

Open mesh repair

54 (22.5%)

82 (38.3%)

P< 0.01

Jrg Kninger 2004

817674

TAPPLichetensteinShouldice

Slight Moderate Severe12 (14.8%) 1 (1.2%) -18 (23.7%) 4 (5.3%) 3 (3.9%)16 (21.6%) 10 (13.3%) 2 (2.7%)

P< 0.01

AM Grant 2004

390

362

TEP

Open

108 (27.7%)

129 (35.6%)

P 0.019

Ulf Fränneby, 2006

1907

95

Anterior approach

Posterior approach

532 (27.9%)

18 (18.9%)


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.


Mesh

Femoral n.

Age


risk

BMI

Pre-op pain

Day case surgery


Recurrent hernia

Non-surgical management Neurolysis

NON-SURGICAL MANAGEMENTNON-SURGICAL MANAGEMENT

• Non-operative attempts at pain resolution include:

• Biofeedback

• Medications

• Physical therapy

• Percutaneous treatment with local anesthetics, steroids, phenol, alcohol, cryoprobes, radiofrequency destruction

• Transcutaneous nerve stimulators

NEUROLYSISNEUROLYSIS

Dellon AL 1995* : • 23 patients who had lateral femoral cutaneous nerve entrapments : Excellent results 78.3% Good results in 17.4% Poor results in 4.3%.

Amid 2004 : • Neurolysis is not recommended because it does not address neuromas or

inevitable secondary scarification

* Nahabedian MY, Dellon AL. Meralgia paresthetica: Etiology, diagnosis, and outcome of surgical decompression. Ann Plast Surg 1995; 35: 590-594.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Neurectomy

Day case surgery




Femoral n.

SURGICAL MANAGEMENT: NEURECTOMYSURGICAL MANAGEMENT: NEURECTOMY

Author # of Pts Excellent relief

Partial relief Poor result

Lyon 1942 6 83%

Magee 1945 5 100%

Starling 1987 30 83%

Cathy H Lee 2000

54 68%

II 78%

IH 83%

GF 50%

10%

11%

17%

25%

Amid PK 2004 225 80% 15% 5%

James A Madura 2005

100 72% 25% 3%


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Mesh removal

Neurectomy

Day case surgery




Femoral n.

SURGICAL MANAGEMENT: SURGICAL MANAGEMENT: MESH REMOVALMESH REMOVAL

• Heise 1998: Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia).

• Amid 2004 :Treatment of chronic inguinodynia caused by ‘‘meshoma’’ is their surgical explanation.

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.

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

• Surgical treatment for periosteal reaction or osteitis pubis consists of removing suture materials, staples, bulky suture removing suture materials, staples, bulky suture knots, and/or bulk forming or rolled mesh material from the knots, and/or bulk forming or rolled mesh material from the pubic tubercle area. pubic tubercle area.

Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8: 343-349.


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Mesh removal

Neurectomy

Day case surgery



Repair recurrent hernia


Femoral n.

Combined Laparoscopic and Open TreatmentCombined Laparoscopic and Open Treatment

• The laparoscopic approach:

Diagnostic

Definitive hernia repair in unaltered tissues.

• Anterior approach:

Removal of the offending foreign body

Appropriate nerve resection

• 12 pts {Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1)}. 6 weeks F/U, all pts were significantly improved.

• (2 pts had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure.)

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repairMJ Rosen Æ YW Novitsky Æ WS Cobb K W Kercher Æ B Todd Heniford, Hernia (2006) 10: 20–24


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Mesh removal

Neurectomy

Day case surgery




Watchful waitingLat. femoral

cutaneous n.

Femoral n.

WATCHFUL WAITINGWATCHFUL WAITING

Fitzgibbons RJ Jr 2006

A strategy of watchful waiting is a safe and acceptable option for men with asymptomatic or minimally symptomatic inguinal hernias.

Acute hernia incarcerations occur rarely (1.8 per 1000 patient years), and patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic hernia repair

Patrick J O’Dwyer, 2006

Repair of an asymptomatic inguinal hernia does not affect the rate of long-term chronic pain and may be beneficial to patients in improving overall health and reducing potentially serious morbidity.

Leigh Neumayer, 2006

The rate of acute incarceration and strangulation is very low.

The risk of this complication should not be the sole indication for repair of the hernia.

Patients who have pain benefit from repair; however, many patients experience pain after hernia repair; and in some patients, this is new or worse pain than before their operation.

Preoperative discussions with patients should include disclosure of this risk.

Delaying repair appears safe, although major life-threatening complications can occur in any patient undergoing even a simple operation.

PREVENTION: WATCHFUL WAITINGPREVENTION: WATCHFUL WAITING

# of Pts Pain in Repair Gp Pain in Observation Gp Statistical significance

Conversion Acute incarceration

Fitzgibbons RJ Jr 2006

720

Repair 356

Observe 364

At rest: 8.2 (13.1)

Nl activities: 10.3 (14.9)

Work/Exercice: 17.1 (24.6)

At rest: 8.2 (15.6)

Nl activities: 10.4 (14.9)

Work/Exercice:14.6 (20.7)

P 0.99

P 0.93

P 0.20

23% by 2years

0.3%

Patrick J O’Dwyer, 2006

160

Repair 75 Observe 78

Mean (SD)

At rest 6 mo: 4.8 (10.7)

At rest 12 mo: 5.2 (12.3)

At movement 6 mo: 6.1 (11.9)

At movement 12 mo: 5.7 (11.5)

Mean (SD)

At rest 6 mo: 8.0 (14.0)

At rest 12 mo: 3.7 (8.2)

At movement 6 mo:

10.9 (16.0)

At movement 12 mo:

7.6 (15.0)

P 0.11

P 0.34

P 0.036

P 0.39

20% by

1 year

1%


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Mesh removal

Neurectomy

Day case surgery




Watchful waiting

Prophylactic neurectomy


Femoral n.

PROPHYLACTIC NEURECTOMYPROPHYLACTIC NEURECTOMY

Author # of Pts Pain (Neurectomy vs Non-neurectomy)

Paresthesia

Ravichandran 2000

20 bilat. 0% vs 5% 10% vs 0%

Marcello Picchio 2004

408 vs 405 Mild: 21% vs 18%Moderate: 3% vs 4% Severe: 3% vs 2% p 0.55p 0.55

Numbness 4% vs 6% p 0.39Loss of touch sensation 11% vs 4% p 0.002Loss of pain sensation 9% vs 8% p 0.89

DE Tsakayannis 2004

191 0 Numbness 6.28%Sensory Loss 1.04%

George W Dittrick 2004

66 vs 24 6 mos.3% vs 26% (p 0.001)1 yr 3% vs 25% (p 0.003)

18% vs. 4% (p 0.10)13% vs. 5% (p 0.32)

Wilfred Lik-Man Mui 2006

Pappalardo etal2007

50 vs 50

100 male pts bilateral(iliohypogast. neurect.

rt. side only)

8% vs 28.6% (p 0.008)

NS - rt. vs lt. (p 0.345)After 2 years (p 0.974)

42 vs 42.9 (P 0.931)


Ilioinguinal n.

Iliohypogastric n.

Genitofemoral n.

Mesh

Age


risk

BMI

Pre-op pain

Recurrent hernia

Mesh removal

Neurectomy

Day case surgery




Watchful waiting

Nerve identification

Prophylactic neurectomy


Femoral n.

NERVE IDENTIFICATIONNERVE IDENTIFICATION

• Identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain .

• 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.

Influence of Preservation Versus Division of Ilioinguinal, Iliohypogastric, and Genital Nerves During Open Mesh Herniorrhaphy Prospective Multicentric Study of Chronic Pain Sergio Alfieri, MD, Ann Surg, April 2006; 243: 553-558

Nerves not identified

UA*

RR 95%CI P

MV**

RR 95%CI P

1 0.9 0.2–3.4 NS 2.2 0.2–26.4 0.539

2 2.1 0.6–8.1 NS 12.4 1.3–115.3 0.027

3 3.8 1.2–11.4 0.019

19.2 2.3–157.7 0.006

* Univariate Analysis: Risk of Complaining of Pain at 6 Months According to Nerve Treatment**Multivariate Analysis:Risk of Complaining of Pain at 6 Months According to Nerve Treatment

CONCLUSIONSCONCLUSIONS

• Should wait more than one year before treating pain

• Nerve identification/preservation and careful surgical technique are probably the key to winning this game

• Headbutt with nerves?Keep your own “nerves” cool.

ReferencesReferences• Mesh Inguinodynia: A New Clinical Syndrome after Inguinal Herniorrhaphy? Charles P Heise, MD, and

James R Starling, MD, FACS J Am Coll Surg 1998; b187: 514-518.

• Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin Pain Matthias Rab, MD, Johannes Ebmer, and A. Lee Dellon, MD Plastic and Reconstr. Surg, 108: 1618, 2001.

• Chronic pain and quality of life following open inguinal hernia repair AS Poobalan, J Bruce, PM King*, WA Chambers², ZH Krukowski and WCS Smith British J Surg. 2001, 88, 1122-1126

• Pain and Functional Impairment 1 Year After Inguinal Herniorrhaphy: A Nationwide Questionnaire StudyMorten Bay-Nielsen, MD, Frederick M. Perkins, MD, and Henrik Kehlet, PhD, for the Danish Hernia DatabaseAnn. Surg. vol. 233, No. 1, 1– © 2001

• Chronic pain after laparoscopic and open mesh repair of groin hernia S. Kumar, RG Wilson, SJ Nixon and IMC Macintyre British J Surg. 2002, 89, 1476-1479

• Outcome of patients with severe chronic pain following repair of groin hernia CA Courtney, K Duffy, MG Serpell and PJ O'Dwyer British J Surg. 2002, 89, 1310-1314

• 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

• Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPPJrg Kninger Jens Redecke Michael Butters Langenbecks Arch Surg (2004) 389: 361-365

• 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

References References • Routine ilioinguinal nerve excision in inguinal hernia repairs George W. Dittrick, MD*, Kimberly Ridl, MD,

Joseph A. Kuhn, MD, Todd M. McCarty, MD The Am J Surg 188 (2004) 736-740

• Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia AM Grant1, NW Scott2 and PJ O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group British J Surg 2004; 91: 1570-1574

• Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation. Amid PK. Hernia 2004; 8: 343-349.

• Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair DE Tsakayannis Æ AC Kiriakopoulos Æ DA Linos Hernia (2004) 8: 67-69

• Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients James A. Madura, MDa,*, James A Madura, II, MDa, Chad M. Copper, MDa, Robert M. Worth, MDb The Am J Surg 189 (2005) 283-287

• Surgical management of chronic pain after inguinal hernia repair E Aasvang and H Kehlet British J Surgery 2005; 92: 795-801

• Pain after Anterior Mesh Hernia Repair Simon Willem Nienhuijs, MD, Oliver BA Boelens, MD, Luc JA Strobbe, MD J Am Coll Surg 2005; 200: 885-889.

• 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

• 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

References References • The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin Hernia

Seher Demirer, MD, Ilknur Kepenekci, MD,1 O Evirgen, MD, O Birsen, MD, A Tuzuner, MD, S Karahuseyinoglu, MD, M Ozban, MD, and E Kuterdem, MD,1 J Surg. Res. 131, 175-181 (2006)

• Combined open and laparoscopic approach to chronic pain following open inguinal hernia repairM. J. Rosen Æ YW Novitsky Æ WS Cobb K. W. Kercher Æ B Todd Heniford Hernia (2006) 10: 20-24

• Observation or Operation for Patients With an Asymptomatic Inguinal Hernia A Randomized Clinical Trial Patrick J O’Dwyer, FRCS, John Norrie, MSc, Ahmed Alani, FRCS, Andrew Walker, PhD, Felix Duffy, RN, and Paul Horgan, FRCS Ann Surg 2006; 244: 167-173

• Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA. 2006; 295: 285-292

• Is the Presence of an Inguinal Hernia Enough to Justify Repair? Leigh Neumayer, MD, MS Annals of Surgery • Volume 244, Number 2, August 2006

• The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5–5.5 cm) cranially from the external ring.

• The ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle.

• The course of the genital branch is laterocaudal at the level of the internal inguinal ring.

IDENTIFICATION ZONES IDENTIFICATION ZONES FOR THE INGUINAL NERVESFOR THE INGUINAL NERVES

Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?

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Transcript of Pain and Neuralgia After Hernia Surgery: Can It Be Avoided? And How Do We Treat It?