groin pain

Groin Pain

2

Anatomic Variability of the Ilioinguinal and Genitofemoral Nerve: Implications for the Treatment of Groin PainMatthias Rab, M.D., Johannes Ebmer, and A. Lee Dellon, M.D.

Vienna, Austria, and Baltimore, Md.PLASTIC AND RECONSTRUCTIVE SURGERY, 108: 1618, 2001.

• In the present study the pattern of cutaneous nerve branches in the inguinal region was investigated through dissection in 64 halves of 32 human embalmed anatomic specimens.

• In contrast to usual textual descriptions, four different types of cutaneous branching patterns are identified:

• type A, with a dominance of genitofemoral nerve in the scrotal/labial and the ventromedial thigh region. In type A, the ilioinguinal nerve gives no sensory contribution to these regions (43.7 percent).

• In type B, with a dominance of ilioinguinal nerve, the genitofemoral nerve shares a branch with the ilioinguinal and gives motor fibers to cremaster muscle in the inguinal canal, but has no sensory branch to the groin (28.1 percent).

• In type C, with a dominance of genitofemoral nerve, the ilioinguinal nerve has sensory branches to the mons pubis and inguinal crease together with an anteroproximal part of the root of the penis or labia majora. The nerve was found to share a branch with the iliohypogastric nerve (20.3 percent).

• In type D, cutaneous branches emerge from both the ilioinguinal and the genitofemoral nerves. Additionally, the ilioinguinal nerve innervates the mons pubis and inguinal crease together with a very anteroproximal part of the root of the penis or labia majora (7.8 percent).

• The described patterns of innervation were bilaterally symmetric in 40.6 percent of the cadavers. • The anatomic variability of both nerves has implications for all surgeons operating in the groin

region and for those caring for the patient with groin pain.



• In 1893, Ruge19 introduced the term “Grenznerven” for these nerves, which was translated as “border nerves” by Bardeen and Elting.20

• ( these three nerves contribute to the skin in the border between the abdomen and thigh.)

• Morikawa pointed out that only 37 percent of the cases investigated were found to have the typical pattern as described in most texbooks.21



• Type A (43.7 percent of the dissections).

• In type A, the skin of the pubis, the skin of the ventral scrotum or the ventral labia, and the skin of the ventromedial thigh were found to be innervated only by the cutaneous component of the genital branch of the genitofemoral nerve .



• Type B (28.1 percent).

• In type B, the skin regions mentioned above were found to be innervated only by the cutaneous component of the ilioinguinal nerve



• Type C (20.3 percent). • The ilioinguinal nerve was found to

have sensory branches to the mons pubis and inguinal crease together with a very anteroproximal part of the root of the penis or labia majora.

• The nerve was found to share a branch with the iliohypogastric nerve after exiting the superficial inguinal ring.

• The cutaneous component of the genital branch of the genitofemoral nerve innervated the remaining, lower located parts of the inguinal and ventromedial thigh regions



• Type D (7.8 percent). • In type D, the two

cutaneous components of the ilioinguinal and genitofemoral nerves shared together the whole skin innervation of the mentioned regions



• Inguinal and Ventromedial Thigh Region

• The described patterns of innervation were bilaterally symmetric in 40.6 percent of the cadavers.



• The “classic” or “normal” pattern of distribution and terminal course, consistent with modern text descriptions, was defined in only 20.3 percent of inguinal and ventromedial thigh regions dissected.17–20 This normal pattern of distribution would correspond with type C according to our classification.

• Regarding the site within the inguinal canal and the relationship between nerve branches and spermatic cord/round ligament, a normal type was found in 56.3 percent of the cases, nevertheless. According to our classification, types B, C, and D would meet these criteria.

• In type A, with 43.7 percent of the dissections, the most frequent type observed, an aberrant course of the cutaneous component of the ilioinguinal nerve was recorded in the inguinal canal.

Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisionsJames L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD

(Am J Obstet Gynecol 2003;189:1574-8.)

• OBJECTIVE: The purpose of this study was to map the course of the ilioinguinal and iliohypogastric nerves.

• STUDY DESIGN: The courses of iliohypogastric and ilioinguinal nerves from 11 fresh frozen cadavers were mapped from their lateral emergence on the anterior abdominal wall to their midline termination in reference to fixed bony landmarks. Bivariate fit ellipses were generated for each nerve and compared with sites of standard abdominal surgical incisions.

• RESULTS: Thirteen iliohypogastric and 16 ilioinguinal nerves were identified and mapped.

• On average, the proximal end of the ilioinguinal nerve entered the abdominal wall 3.1 cm medial and 3.7 cm inferior to the anterior superior iliac spine, then followed a linear course to terminate 2.7 cm lateral to the midline and 1.7 cm superior to pubic symphysis.

• The iliohypogastric nerve entered the abdominal wall on average 2.1 cm medial and 0.9 cm inferior to the anterior superior iliac spine, which followed a linear course to terminate 3.7 cm lateral to the midline and 5.2 cm superior to pubic symphysis.

• CONCLUSION: Abdominal wall surgical sites below the level of the anterior superior iliac spine have the potential for ilioinguinal or iliohypogastric injury.

Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisionsJames 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

Introduction: Chronic pain after hernia repair is common, and it is unclear to what extent the different operation

techniques influence its incidence. The aim of the present study was to compare the three major standardized techniques of hernia repair with regard to postoperative pain.

• Patients and methods: Two hundred and eighty male patients with primary hernias were prospectively, randomly selected to undergo Shouldice, tension-free Lichtenstein or laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty repairs. Patients were examined after 52 months with emphasis on chronic pain and its limitations to their quality of life.

Results: • Chronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein

repair and in 15% after TAPP repair. • Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein

and in 11% after TAPP repair. • Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice,

13% after Lichtenstein and 2.4% after TAPP repair.Conclusion: • Chronic pain after hernia surgery is significantly more common with the open approach to the

groin by Shouldice and Lichtenstein methods. • The presence of the prosthetic mesh was not associated with significant postoperative

complaints. • The TAPP repair represents the most effective approach of the three techniques in the hands of

an experienced surgeon.

Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP

Jrg Kninger Jens Redecke Michael ButtersLangenbecks Arch Surg (2004) 389:361–365

• The incidence of chronic pain following hernia repair is not accurately known. Different studies report frequencies of up to 40%

• Several risk factors have been identified, such as recurrence, patient’s age and resection of the cremasteric muscle, experience of the surgeon and the presence of pre-operative pain.

• Nerve injury during laparoscopic hernia repair, especially to the nervus cutaneus femoris lateralis has also been reported, especially at the beginning of the laparoscopic repair era, but seems to be avoidable with the correct operating technique

• Mesh fixation in the laparoscopic group was performed with between four and six titanium clips (EMS Herniostate; Ethicon) with strict avoidance of clips in the area distal of the ileopubic tract.

• In the case of the Lichtenstein technique the mesh was fixed with a running suture (4/ 0 Prolene) to the inguinal ligament.



• The laparoscopic approach to the groin is surely less traumatic than the open techniques. In the case of the TAPP technique, it involves only the incision of the peritoneum and the preparation of the hernial sac, without major trauma to the abdominal wall, thus minimizing the risk of possible nerve injury and concomitant scarring

• there is a difference in postoperative discomfort and pain after the two tension free-techniques in favour for the laparoscopic technique, although not as evident as that between Shouldice and TAPP

• 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 [18].

• The most common chronic pain syndrome correlates with physical stress and can be reproduced readily with manoeuvres that typically provoke abdominal-wall pain. There is some evidence that the reason for those complaints lies partly in the region of the medial inguinal ligament, where sutures involve pubic periostal structures, and the physiological tensing of this ligament then leads to pain [14].

Chronic pain after laparoscopic and open mesh repair of groin herniaS. Kumar, R. G. Wilson, S. J. Nixon and I. M. C. Macintyre

British Journal of Surgery 2002, 89, 1476±1479

• Background: The aim of this study was to compare the incidence of chronic pain or discomfort after laparoscopic totally extraperitoneal (TEP) repair and open mesh repair of groin hernia, and to assess the impact of such pain on patients' physical activity.

• Methods: A postal questionnaire was sent to patients who had TEP or open mesh repair of groin hernia between January 1998 and December 1999. The patients were asked about any persistent pain or discomfort in relation to the groin hernia repair and whether this pain or discomfort restricted their ability to undertake physical or sporting activity.

Results: • Of the 560 available patients 454 (81´1 per cent) replied. Laparoscopic TEP repair was

performed in 240 patients (52´9 per cent) and open mesh repair in 214 (47´1 per cent). • Of the 454 patients, 136 (30´0 per cent) reported chronic groin pain or discomfort, which was

signifcantly more common after open repair than after laparoscopic repair (38´3 versus 22´5 per cent; P < 0´01).

• Chronic groin pain or discomfort restricted daily physical or sporting activity in 18´1 per cent of the patients. The patients who had open repair complained of signifcantly more restriction of daily physical activity than patients who underwent laparoscopic repair (walking, P < 0´05; lifting a bag of groceries, P < 0´01).

Conclusion: • Chronic pain or discomfort was reported by 30´0 per cent of patients after groin hernia repair and

was significantly more common after open mesh repair than after laparoscopic TEP repair. It restricted physical or sporting activities in 18´1 per cent of the patients and signifcantly more so after open mesh repair.



• The reported incidence of such pain after hernia repair is thought to be about 10 per cent but varies in different studies from 0 to 60 per cent1±3.

• Several risk factors associated with CGP have been identifed, including recurrent hernia repair4, insurance status of the patient5, day surgery6, patient's age less than 60 years2,6, and severe early postoperative pain4



• Laparoscopic TEP repair was performed under general anaesthesia and without fxing the Prolene (Ethicon, Edinburgh, UK) mesh in the preperitoneal space.

• Open mesh repair was performed by the Lichtenstein technique under general anaesthesia, except in patients with signifcant cardiorespiratory disease or those who preferred to have local anaesthesia.

• CGP was defined as groin pain or discomfort lasting more than 3 months after groin hernia repair11.



• CGP restricted daily physical or sporting activities in 18´1 per cent of the present patients after groin hernia repair. The impact of CGP on patients' daily physical or sporting activity is a matter of concern as these patients felt uncomfortable carrying a bag of groceries or playing sports such as golf. The patients with open repair were more likely to be affected than patients with laparoscopic TEP repair.

• Two recently published studies reported that up 60 per cent of patients with pain were unable to enjoy social or leisure activity 1 year after groin hernia repair2,6



• One possible explanation for neuropathic pain is injury to the ilioinguinal, iliohypogastric or genitofemoral nerves, either during exposure of the inguinal canal or handling of the cord and dissection of the hernia sac in open surgery.

• Lichtenstein et al.16 recommended preserving the nerves in the inguinal canal to minimize the incidence of CGP.

• Sometimes this is difficult as the nerves may hinder the dissection or may lie across the prosthetic mesh on the posterior inguinal wall; in such circumstances some surgeons prefer to divide these nerves.

• The genitofemoral nerve may also be at risk when the prosthetic mesh is secured in a continuous suture along the inguinal ligament or when the external spermatic vessels are divided to skeletonize the cord18

• The laparoscopic repair has the advantage of minimal access and less traumatic dissection to free the sac from the inguinal canal.

• the EU Hernia Trialists' systematic review found that mesh repairs are less likely to cause CGP than non-mesh repairs22.

• The implication of this study is that patients should be informed about the risk of developing CGP after groin hernia repair as this may influence their choice of laparoscopic or open repair.

Chronic pain and quality of life following open inguinal hernia repairA. S. Poobalan, J. Bruce, P. M. King*, W. A. Chambers², Z. H. Krukowski* and W. C. S. Smith


• Background: The aim was to determine the frequency and characteristics of chronic pain following open inguinal hernia repair and to identify risk factors for its development.

• Methods: This was a questionnaire survey of a historical cohort of patients who underwent inguinal hernia surgery in Aberdeen. The sample comprised all patients (n = 351) who underwent surgery between January 1995 and December 1997, and who were alive and resident in Grampian in October 1999. Outcome measures included self-report of pain persisting for more than 3 months after operation. Pain was characterized by means of the McGill Pain Questionnaire, and quality of life was assessed with the Short Form 36 (SF-36).

Results: • A total of 226 patients (64 per cent) completed the questionnaire, 67 (30 per cent) of whom

reported chronic pain. Reported pain was predominantly neuropathic in character. • Patients at increased risk of chronic pain were under 40 years old (P < 0´001), • had day-case surgery (P = 0´004), • had subsequent surgery on the same side (P < 0´005) and recalled pain before operation (P = 0

´005). • The SF-36 scores were significantly different in the social functioning, mental health and pain

dimensions in patients with chronic pain.

• Conclusion: Chronic pain occurred in 30 per cent of patients after open hernia repair, a higher frequency than has been reported previously. Several risk factors were identified and further prospective research is recommended.



• Age was the strongest risk factor for developing chronic pain, decreasing from 58 per cent in patients aged under 40 years to 14 per cent in those over 60 years old (P = 0´001).

• There was a non-significant trend in increasing frequency of chronic pain with increasing body mass index (kg/m2).

• Patients in full-time employment were more likely to suffer chronic pain than those who had retired (P = 0´001) (Table 1).

• Patients who underwent mesh repair reported more chronic pain than those who had suture repair, but this was not significant (P = 0´08).

• There was no association between chronic pain and grade of surgeon (senior versus middle grade; P = 0´42);

• day-case patients reported chronic pain more often than inpatients (54 versus 24 per cent; P = 0´004) (Table 3). The mean age of day-case patients was 53 years, compared with 62 years for inpatients, which may explain this difference.

• logistic regression revealed that the probability of developing chronic pain decreased by 5 per cent with each 1-year increase in age; the probability of developing chronic pain was 2´5 times higher in day-case patients, controlling for age.

• Patients who had subsequent repair of an ipsilateral recurrent hernia were more than four times as likely to develop chronic pain (odds ratio 4´54, P = 0´005).

• patients who recalled having preoperative pain developed chronic pain more frequently (odds ratio 3´53, P = 0´005).



• Younger patients could be more anxious to report pain or be more sensitive to nerve damage. Studies of chronic pain after other types of operation have also reported a higher frequency of chronic pain in younger patients6.

• The higher frequency of pain reported by patients who had surgery for recurrent herniation is similar to that described by Callesen et al.4 in 1999. This higher prevalence of chronic pain may be due to nerve entrapment in previous scar tissue12.

• The trend of more pain with increasing body mass could be associated with difficulty in identifying the ilioinguinal nerve.

• Although not significant, a higher proportion of patients with chronic pain had undergone mesh repair. The increased surface area of the mesh might allow adherence of nerves or abrasion to account for an increased risk of neuropathic pain. Mesh repairs are generally considered to cause less early postoperative pain13 and this observation, if confirmed, could have important implications.

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

• 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 groupA 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%), • severe in 5 (2%) and 9 (3%), respectively (P=.55; Pearson 2 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.



Arch Surg. 2004;139:755-758



Arch Surg. 2004;139:755-758

• A polypropylene mesh was positioned without sutures in the floor of the inguinal canal and in the lateral space under the aponeurosis of the external oblique muscle, according to the technique described by Trabucco.2

• Division of the ilioinguinal nerve was performed lateral to the deep ring to avoid any contact with the mesh. Histologic analysis of a section of the removed nerve was performed to confirm the division of the ilioinguinal nerve.



Arch Surg. 2004;139:755-758



Arch Surg. 2004;139:755-758

• In our group of study, globally considered, chronic pain 1 year after operation was present in 149 (25%) of 593 patients, and it was described as moderate or severe in 34 (6%) of these patients.

• The telephone interview showed that the proportion of patients who still experienced chronic pain was considerable at long-term follow-up.

• No correlation was found between the presence of preoperative pain and the occurrence of postoperative pain. According to other studies, 4,10 chronic pain was significantly related to the presence and intensity of postoperative pain.

• Damage to 1 or more of the 3 nerves passing through the surgical field is suspected to be one of the main causes of chronic postherniorrhaphy pain. This theory is supported by the association between chronic pain and sensory disturbances.11

• A nerve may be damaged during operation as a result of perineural fibrosis, entrapment by staples, sutures, or prosthetic materials, and direct lesions due to stretching, contusion, electrical injury, and partial or complete division of the nerve.12



Arch Surg. 2004;139:755-758

• Wantz13 showed that chronic pain was not present in 546 patients who underwent hernia repair with elective division of the ilioinguinal nerve, whereas it was seen in patients with the nerve preserved.

• No relation between ilioinguinal nerve preservation or elective division and chronic pain was reported in a large study by Cunningham et al.10

• The study by Ravichandran et al14 was the first to assess the effect of division of the ilioinguinal nerve in a randomized setting. The authors found no evidence to support the benefit of ilioinguinal nerve division with respect to postoperative pain within the limitation of a small sample size.

• Our data confirm that ilioinguinal nerve division does not affect postoperative pain after mesh repair of the inguinal hernia with the support of a large number of patients and an appropriate longterm follow-up. In particular, considering the primary end point of our trial, after 1 year there was no difference in the rates of patients free from pain in both groups, and the 95% CI for the difference was so low that is was without clinical importance.

• After inguinal hernia repair, sensory changes are common.12 In the study by Ravichandran et al,14 loss of sensation in the territory supplied by the ilioinguinal nerve occurred in 40% to 45% of patients when the nerve was divided and in 5% to 25% of cases when it was preserved after 6 months.

• Our data confirm that elective transection of the ilioinguinal nerve leads to a significant increase in the proportion of patients who complain of a decrease in pain and touch sensation in the postoperative period with respect to those with preserved nerve. In particular, touch sensation was still impaired at the 1-year follow-up visit.

Prophylactic Ilioinguinal Neurectomy in Open Inguinal Hernia RepairA 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)

• 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.



(Ann Surg 2006;244: 27–33)

• Chronic groin pain is a significant problem following open inguinal hernia repair, with a reported incidence ranging from 19% to 62.9%.1–3

• Although the pain is often mild in nature, quality of life studies have shown that chronic pain, irrespective of severity, can significantly interfere with normal daily activities.4,5 Moreover, the condition can sometimes be debilitating and treatment is often difficult and challenging.

• ilioinguinal neurectomy is a well-documented effective treatment of relieving chronic groin pain following open hernia repair, achieving more favorable outcomes than nerve block or mesh removal alone.8–10

• More recently, retrospective studies have shown that excision of ilioinguinal nerve during herniorrhaphy were associated with a lower incidence of chronic groin pain after the operation.11–13



(Ann Surg 2006;244: 27–33)

• All patients received the standard flat mesh repair according to the technique described by Lichtenstein et al.15

• In group A, the whole ilioinguinal nerve was excised as far lateral to the deep ring as possible and medially to where it entered the rectus muscles. The cut ends were left alone without implantation into muscle or ligation. Histologic examination of the nerve was performed to confirm complete excision. Any small cutaneous nerves that interfere with mesh placement were excised as well.

• In group B, the ilioinguinal nerve was carefully protected throughout the operation. The rest of the procedure was performed in a standardized manner. A monofilament polypropylene mesh (SURGIPRO MESH, Auto Suture, USSC) was anchored with polypropylene sutures (PROLENE, Ethicon, Johnson & Johnson Unit) to the reflected part of inguinal ligament and the floor of the inguinal canal.

• Extreme care was used during surgery to avoid inclusion of nerve tissue during suturing and mesh placement.



(Ann Surg 2006;244: 27–33)



(Ann Surg 2006;244: 27–33)

• The incidence of chronic groin pain at 6 months was significantly lower in group A compared with group B (4 8% vs. 14 28.6%; P 0.008, Fisher exact test).

• The incidence of pain experienced after walking 3 flights of stairs and cycling for 10 minutes were significantly lower in groupA than group B (1 2% vs. 7 14%; P 0.03; 2 4% vs. 10 20.4%; P 0.015, Fisher exact test, respectively).

• There were no significant differences in the incidence of pain experienced during normal daily activities at home and after coughing for 10 times at 6 months.

• The incidences of groin numbness and sensation changes or loss at groin region were also similar between the 2 groups at 6 months.



(Ann Surg 2006;244: 27–33)

• A proposed mechanism for the development of postoperative chronic groin pain is the inflammation and fibrosis induced by the mesh, which is in close proximity to the ilioinguinal nerve.17

• In addition, unintentional injury or strangulation of the ilioinguinal nerve during suturing may also contribute to the phenomenon.

• There is increasing evidence to suggest that prophylactic excision of ilioinguinal nerve during open hernia repair is not only associated with minimal morbidities but also can potentially decrease the incidence of chronic groin pain following operation.11–13

• The first randomized trial to address this problem by Ravichandran et al was underpowered and no definite conclusion could be made.18

• Results from subsequent trials regarding chronic groin pain following elective neurectomy have been inconsistent. Interestingly, in a retrospective review of 191 patients who underwent elective excision of the ilioinguinal nerve during open hernia repair showed that none of the patients developed chronic groin pain at 12 months of follow-up.12

• In another retrospective study, Dittrick et al reported a significantly lower incidence of chronic groin pain in patients who had elective neurectomy during open inguinal hernia repair when compared with the control group.11



(Ann Surg 2006;244: 27–33)

• However, these results were not confirmed in a recent randomized controlled trial by Picchio et al,19 who found similar incidence of chronic groin pain between ilioinguinal nerve excision group and control.

• Our randomized study revealed that the incidence of chronic groin pain during normal daily activities was similar between the 2 groups which compliment the findings by Picchio et al.19

• However, in addition, we found significantly fewer patients in the neurectomy group developed chronic groin pain upon exertion (cycling for 10 minutes and walking up 3 flights of stairs), which has not been previously studied.

• The other potential disadvantage of ilioinguinal nerve excision is the morbidity associated with sensory loss over the groin region as well as its impact on quality of life.

• The previous study by Picchio et al reported increased incidence of sensory loss to pain and touch around the groin region in patients who had nerve excision during open hernia repair.19

• However, the current study clearly demonstrated that elective excision of the ilioinguinal nerve was not associated with additional morbidities in neurosensory disturbances, groin numbness or quality of life at the 6-month follow-up.

• We postulated that the sensory loss caused by neurectomy might be compensated by cross-innervations from contralateral cutaneous nerves.

• Furthermore, direct meaningful comparison between Picchio et al19 and that of our study is not possible because their methodology used for testing skin sensation was not described. Semmes-Weinstein monofilament testing was adopted in the present study to provide a more standard and objective method to measure skin sensitivity.

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)

• 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.




(Ann Surg April 2006;243: 553–558)

• This report would appear to be the first in the literature presenting the results of a multicentric prospective clinical trial designed to assess the role of identification versus nonidentification and preservation versus division of the inguinal nerves on chronic postoperative pain following open inguinal polypropylene mesh hernia repair.

• All surgeons were asked to complete a form immediately after the operation, providing the following data: hernia type (direct, indirect, combined, sliding),identification/nonidentification and treatment (preserved, injured, or divided) of each inguinal nerve (ilioinguinal, iliohypogastric, genital branch of genitofemoral nerves). A nerve was considered injured if stretched or burned.

• Early postoperative pain (at 1 month) was mild in 185 (19%) cases and moderate to severe in 65 (6.7%). As far as concerns the main outcome of the study, the overall 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% (n 74) and moderate to severe in 2.1% (n 21) at 6 months and mild in 3.6% (n 35) and moderate to severe in 0.5% (n 5) at 1 year (Fig. 1).




(Ann Surg 2006;243: 553–558)




(Ann Surg 2006;243: 553–558)

• Chronic pain following inguinal hernia repair is becoming a significant clinical problem, involving an increasing number of patients and surgeons, as shown by the rising number of publications over the last 10 years dealing with postoperative pain syndrome.

• Several explanations may be offered, namely, the low recurrence rates associated with the use of mesh repair that have shifted the hernia surgeons’ attention from recurrence to other outcome parameters and the fact that patients today are more aware of pain syndromes.

• However, more and more often, patients come to our attention complaining of groin pain, after a hernia operation performed elsewhere, both for a second opinion regarding treatment and for possible legal procedures.

• chronic pain can be defined as “pain persisting beyond the normal tissue healing time, assumed to be 3 months.”6

• Several factors have been proposed as predictors of chronic pain, such as experience of the surgeons and surgery due to recurrence,18 damage to inguinal nerves,19 and mesh implantation.20 However, the pathogenic aspects of chronic pain are still unknown and only hypothesized.

• Some authors think that the widespread use of implanted prosthetic mesh, as well as open, instead of laparoscopic, inguinal hernia repair may play a role in the increased incidence of chronic pain.21,22

• However, tension-free mesh repairs are reported to be less likely to cause chronic groin pain than non-mesh repairs;23,24 albeit, no statistically significant difference appears to exist between open mesh, versus laparoscopic mesh repair,25 even if evidence would appear to be contradictory.21,26–31

• Partial division, neuroma formation, injury or entrapment of the ilioinguinal, iliohypogastric, or genitofemoral nerves are other possible causes reported to be responsible for chronic pain after herniorrhaphy.




(Ann Surg 2006;243: 553–558)

• Some studies recommend that nerve ends be ligated34 or intentionally divided35 to reduce the risk of chronic pain, but no documentation has been forthcoming regarding the outcome of these recommendations.

• Others have suggested that the nerves be divided or ligated only when their course, on the operating field, would lead to the risk of injury or if they interfere with positioning of the mesh.32

• Other studies have failed to show any relationship between the division or preservation of the ilioinguinal nerve and the risk of developing chronic pain,16,36,37 if division of the nerve is performed as close as possible to the site where it leaves the retroperitoneum.

• However, current literature is inconsistent concerning this point and opinions differ considerably.

• Results from studies in which operative management of an injured nerve is reported to be responsible for severe chronic pain suggest that, if the nerve identified is inadvertently divided, it is important to resect it, as proximally as possible, so that it would not interfere or come into contact with the mesh, thus allowing retraction of the proximal segment into the ventral muscle or retroperitoneum.8,33,38

• nerves are most often injured when the surgeon is unaware of the location and course or fails to recognize these during surgery.




(Ann Surg 2006;243: 553–558)

• The present large-scale prospective multicentric study, with a 98% of follow-up rate, clearly shows that the risk of developing chronic postoperative groin pain is directly related to the number of nerves identified.

• Indeed, 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.

• These data would appear to suggest that, if 1 or more nerves are not detected during surgery, it is possible that they could be inadvertently sectioned, entrapped, or secured, for example, if a continuous suture is introduced along the inguinal ligament or injured if the external spermatic vessels are divided to skeletonize the cord and thus generate severe pain even some considerable time after the operation.

• The increased risk of developing chronic pain with the number of nerves divided can be explained by the fact that resection of the nerve has generally been performed distal to its origin, leaving the site of the injured nerve intact to continue to generate the pain signal and exposed to neuroma formation.




(Ann Surg 2006;243: 553–558)

• However, it is important to underline that most of our patients with chronic pain slowly recovered at 1 year only with conservative or medical treatment.

• This suggests that no surgical treatment should be considered for at least 1 year for these patients.

• Bearing in mind the results emerging from the present prospective multicentric study, and in agreement with other authors,14 we wish to stress the importance of always identifying and preserving all 3 nerves of the inguinal canal, during hernioplastic surgery, to minimize the incidence of chronic postoperative groin pain.

Routine ilioinguinal nerve excision in inguinal hernia repairsGeorge W. Dittrick, M.D.*, Kimberly Ridl, M.D., Joseph A. Kuhn, M.D., Todd M. McCarty, M.D.

Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave., 1st Floor Roberts, Dallas, TX 75246, USA

The American Journal of Surgery 188 (2004) 736–740

• Background: Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed as a means to avoid this complication. The purpose of this report is to evaluate the long-term outcomes of neuralgia and paresthesia following routine ilioinguinal nerve excision compared to nerve preservation.

• Methods: Retrospective chart review identified 90 patients who underwent Lichtenstein inguinal hernia repairs with either routine nerve excision (n 66) or nerve preservation (n 24). All patients were contacted and data was collected on incidence and duration of postoperative neuralgia and paresthesia. Comparison was made by 2 analysis.

Results: • The patients with routine neurectomy were similar to the group without neurectomy based on gender

(male/female 51/15 vs. 19/5) and mean age (68 14 vs. 58 18 years). • In the early postoperative period (6 months), the incidence of neuralgia was significantly lower in the neurectomy

group versus the nerve preservation group (3% vs. 26%, P 0.001). • The incidence of paresthesia in the distribution of the ilioinguinal nerve was not significantly higher in the

neurectomy group (18% vs. 4%, P 0.10). • At 1 year postoperatively, the neurectomy patients continued to have a significantly lower incidence of neuralgia

(3% vs. 25%, P 0.003). • The incidence of paresthesia was again not significantly higher in the neurectomy group (13% vs. 5%, P 0.32). • In patients with postoperative neuralgia, mean severity scores on a visual analog scale (0 –10) were similar in

neurectomy and nerve preservation patients at all end points in time (2.0 0.0 to 2.5 0.7 vs. 1.0 0.0 to 2.2 1.5). • In patients with postoperative paresthesia, mean severity scores on a visual analog scale (0 –10) were similar in

the neurectomy and nerve preservation patients at 1 year (2.5 2.2 vs. 4.0 0.0) and 3 years (3.5 2.9 vs. 4.0 0.0).Conclusions: • Routine ilioinguinal neurectomy is associated with a significantly lower incidence of postoperative neuralgia

compared to routine nerve preservation with similar severity scores in each group. • There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy

at 1 month, but there is no significant increase at any other end point in time. • When performing Lichtenstein inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option.




• In fact, 5% to 7% of patients who experience postherniorraphy neuralgia will sue their surgeons, with virtually all such cases resulting in an out-of-court settlement [6].

• The concept of routine neurectomy in surgery is not unique to inguinal hernia repairs. Routine neurectomy often is performed during axillary and neck dissections in which the intercostobrachial and greater auricular nerves, respectively, are sacrificed. A prospective, randomized study has supported the practice of routine intercostobrachial nerve excision during axillary dissections [7].

• Theoretically, excision of the ilioinguinal nerve would eliminate the possibility of postoperative neuralgia arising from entrapment, inflammation, neuroma, or fibrotic reactions.




• Ravichandran et al conducted a pilot study comparing preservation or division of the ilioinguinal nerve in inguinal hernia open mesh repairs [9].

• Twenty patients with bilateral hernias were randomized to nerve preservation on one side and division on the other. At 6 months postoperatively, pain was present in 1 of 20 patients (5%) on the nerve-preserved side versus 0 of 20 patients (0%) on the nerve division side.

• Numbness was present in 0 of 20 (%) on the nerve-preserved side versus 2 of 20 patients (10%) on the nerve divided side. These differences were all non significant and led the authors to conclude that elective division of the ilioinguinal nerve was not associated with a significant increase in postoperative symptoms in inguinal hernia repairs [9].

• Our study showed a statistically significant decrease in the incidence of postoperative neuralgia at 1 month, 6 months, and 1 year for patients in the nerve excision group versus the nerve preservation group. The significance disappeared at 3 years, but only roughly 50% of the patients had progressed to that end point in time.

• These differences were dramatic, with the incidence of pain up to 1 year postoperatively much lower in the nerve excision group versus the nerve preservation group: 3%–5% versus 21%– 26% (Table 2). Mean severity scores in patients who reported neuralgia were similar in both groups.

• The decrease in the incidence of postoperative neuralgia in the nerve excision group was not accompanied by a significant increase in postoperative paresthesia.

• Furthermore, there was a consistent decrease in incidence of postoperative paresthesia at each successive end point in time in the nerve excision group (Table 4). This may suggest progressive compensation from adjacent sensory nerves that could continue to improve over time.

• Concerns regarding postoperative paresthesia thus become of secondary importance as there seems to be continued resolution of this postoperative symptomatology.

Elective neurectomy during open, ‘‘tension free’’ inguinal hernia repair D. E. Tsakayannis Æ A. C. Kiriakopoulos Æ D. A. Linos

Hernia (2004) 8: 67–69

• In this prospective trial, we evaluated the impact of elective iliohypogastric and ilioinguinal nerve resection on the incidence of pain, numbness, and sensory loss following anterior, ‘‘tension free’’ herniorrhaphy.

• One hundred ninety-one patients were enrolled and were reviewed 1 month, 6 months, and 1 year postoperatively.

• Pain, numbness, or any loss of sensation were recorded and categorized on a ‘‘mild,’’ ‘‘moderate,’’ or ‘‘severe’’ scale.

• No persistent pain syndrome was encountered. • Numbness was found in 9.42% of the patients at the first month and

in 6.28% of the patients after 1 year. • Sensation loss (1.04%) was never bothersome or incapacitating at

the end of the follow-up period. • Elective neurectomy is safe to perform, well tolerated by patients,

and is not associated with chronic postoperative inguinal pain.


Hernia (2004) 8: 67–69


Hernia (2004) 8: 67–69

• The ilioinguinal nerve is usually found as a single trunk on top of the spermatic cord. However, it may give branches before entering the inguinal canal, or it may even be absent with branches of the genital and iliohypogastric nerves taking its place.

• Anomalous position of the ilioinguinal nerve was found in 40% of inguinal dissections, whereas the aberrant origin and course of the ilioinguinal nerve was most often behind and within the cremaster muscle [4].

• the incidence of disabling inguinal neuralgia approximates 10% after 2 years [2],

Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patientsJames A. Madura, M.D.a,*, James A. Madura, II, M.D.a, Chad M. Copper, M.D.a, Robert M. Worth, M.D.b

aDivision of General Surgery, The Indiana University Medical Center, 545 Barnhill Drive, EM Hall, Indianapolis, IN 46202, USAbDivision of Neurosurgery, The Indiana University Medical Center, Indianapolis, IN, USA


• Background: Inguinal nerve entrapment is a debilitating postoperative problem.• Patients and Methods: One hundred patients were treated for inguinal nerve

entrapment, including 52 men and 48 women with an average age of 45 14 years. Most patients had inguinal hernia repairs or Pfannenstiel incisions. Mesh was found in 27% of patients. Symptoms included pain (100%), radiation of pain to the thigh and/or genital area (59%), and postural pain (59%). Diagnosis was made by physical examination, postural maneuvering, and inguinal nerve block. Proximal nerve resection was followed by Mersiline (Ethicon, Inc., Somerville, NJ) ligature and absolute alcohol or phenol application to prevent neuromas.

Results: • Five percent of patients had minor complications. • There was abnormal nerve histopathology in 18%. • Total pain relief was attained in 72% of patients, partial relief in 25%, and no relief in

3%.• Two patients complained of numbness postoperatively. • Multifactorial analysis showed recurrent hernia repair as a significant predictive factor.




• The incidence of postherniorrhaphy neuropathic pain is not well known, but reports present incidence rates from 0% to more than 30% (Table 1).

• Nonoperative attempts at pain resolution include biofeedback, medications, physical therapy, and percutaneous treatment with local anesthetics, steroids, phenol, alcohol, cryoprobes, and radiofrequency destruction.

• The most successful method available is surgical resection of the involved nerves with reasonably good pain relief.

• Although many noted pain immediately after their inguinal operations, a delay in onset of symptoms from a few weeks to several years was observed. Fifty-nine percent had pain that radiated to the leg, thigh, genital areas, or flank, and an equal number complained of activity-related symptoms.

• The truncal motions inciting the pain were usually bending, lifting, walking, and twisting of the trunk.

• Only a few of the men reported pain with an erection or intercourse. • Nine patients were diagnosed with depression or other neuropsychiatric

disorders, but this did not seem to affect their final outcome.




• Confirmation of inguinal nerve entrapment was made by asking the patient to stand and hyperextend their trunk and rotate both toward and away from the symptomatic inguinal site (Fig. 2).

• This “arch and twist” maneuver acutely stretches the tethered affected nerves and usually reproduces the typical pain.

• Subcutaneous injection of the inguinal region with 0.5% bupivacaine transiently relieved the pain, even when the arch and twist maneuver was repeated.

• The operations were done under general (93%) or regional/ local (7%) anesthesia and consisted of identification of the nerves followed by proximal resection where they exited the internal oblique muscle near the anterior iliac spine or the internal ring in the case of the genital branch of the genitofemoral nerve. The proximal end of the nerves were crushed and ligated with fine braided polyester suture, followed by application of either absolute alcohol or 12% phenol solution to the nerve end to prevent neuroma formation.

• All nerves were sent for routine histopathologic examination. In those patients with mesh, the prostheses and affixing screws, tacks, and sutures were removed. The patients were seen in follow-up at 1 month and as often as needed thereafter for complaints of postoperative discomfort or referred pains.




• Histopathologic examination showed normal nerve in 82% of patients, whereas 10% had perineural fibrosis and/or inflammation. Six patients had traumatic neuromas, and two patients were found to have a suture through the nerve.

• Complete pain relief was seen in 72% of patients, whereas 10% reported a marked decrease in symptoms.

• In 15 patients, the inguinal pain was gone, but other symptoms such as abdominal, pelvic, or thigh pain persisted.

• Only three patients failed to attain any relief of their symptoms. • Two patients complained of significant postoperative numbness. • The majority of patients were able to resume all daily activities

including their regular occupation. • Comparison between those patients whose pain was totally relieved

with the remaining patients showed that the only factor achieving statistical significance was previous repair of a recurrent hernia (Table 2).




• The ilioinguinal and iliohypogastric nerves are the most frequently entrapped, and the mechanism seems to be injury by suture, adherence to overlying implanted mesh, or involvement in scar tissue.

• The genitofemoral nerve might be compromised by too tight a closure of the internal ring, inadvertent inclusion in sutures used to close the internal ring, or by adherence to mesh inserted into the internal ring orifice.

• The three nerves may share interconnecting fibers, and, therefore, the exact preoperative identification of the entrapped nerve(s) may be difficult.

• Local anesthetic injection cephalad and medial to the anterior iliac spine may differentiate the entrapped ilioinguinal and iliohypogastric nerves, whereas a more medial injection along the distal inguinal canal might suggest a genitofemoral nerve etiology for the symptoms.

• Harms et al. proposed [1] a paravertebral block at L1-L2 to help distinguish the specific nerves involved, but this was not used in the current series of patients.

• The ilioinguinal nerve is at the most risk for entrapment because it lies immediately beneath the divided external oblique fascia and can be included in sutures used for the hernia repair or to reapproximate the external oblique fascia.

• Mesh placed atop the internal oblique fascia/muscle can adhere to the ilioinguinal and/or iliohypogastric nerves during healing.




• In the reoperative field, it may be prudent to approach the nerves more laterally, where the ilioinguinal and iliohypogastric nerves exit the internal oblique muscle.

• There is no good reason to excise the entire nerve segment but to divide it proximally where it exits the internal oblique.

• The genital branch of the genitofemoral nerve, on the other hand, may be more difficult to locate, especially if mesh has been used.

• The removal of mesh from the spermatic cord may endanger the vascular supply of the testicle.• In that situation, as well when properitoneal mesh has been applied, a pelvic fossa approach can be helpful, using

an incision similar to that used for a renal transplant. • A few reports of laparoscopic approach to the inguinal and genitofemoral nerves have appeared recently with

good results, although the experience is relatively small [11].• The initial reports of neurectomy for postoperative inguinal pain were by Lyon in 1945 [12] and Magee in 1942

[13]. Both were small series of patients treated by neurectomy with excellent results and long-term follow-up.• It was not until the 1980s that others began to report series of patients with complete pain relief in the 70% to

80% range (Table 3). • Amid [14] suggests that all three inguinal nerves should be treated by neurectomy because intercommunicating

nerve fibers may result in persistent symptoms if only a single nerve is divided. Division of the nerves may relieve the pain, but there is the potential for neuromas to occur when regenerating nerve fascicles spill outside the neurilemma and may cause severe pain.

• Several methods are described to prevent neuroma formation, including burying the cut end of the nerve into muscle [14,15], end-to-side nerve anastomosis [16], and epineural ligation and flap [17].

• Experimentally, treatment of the nerve end with electrofulguration, YAG laser destruction, and tissue bioglues [18] also are reported to prevent neuroma formation.

Surgical management of chronic pain after inguinal hernia repairE. Aasvang and H. Kehlet

Section of Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark

British Journal of Surgery 2005; 92: 795–801

• Background: Chronic pain after inguinal hernia repair is an adverse outcome that affects about 12 per cent of patients. Principles of treatment have not been defined. This review examines neurectomy and mesh or staple removal as possible treatments.

• Method: A literature search was carried out using the Medline and Ovid databases. Keywords were ‘pain; chronic’, ‘herniorrhaphy; inguinal’, ‘neurectomy’ and similar words. Article references were crosschecked for additional references. Articles were reviewed for data on surgical treatment of chronic pain after hernia repair.

• Results: • Neurectomy of the ilioinguinal, iliohypogastric, genitofemoral or lateral femoral cutaneous nerve

was described in 14 papers. • Overall, a favourable outcome was reported. However, the methodological quality was poor in all

studies in respect of preoperative diagnostic criteria and treatment, intraoperative success in identifying a pathological lesion or nerve and quality of follow-up; this hindered interpretation of the data. Insufficient information is available at present on the effect of removal of mesh or staples.

• Conclusion: Chronic pain after hernia repair is a significant problem and there is a need for a definitive assessment of its surgical treatment




Preoperative nerve block• The use of preoperative nerve block to aid the decision of which nerve to excise varied. • Deysine et al.42 used an ilioinguinal nerve block if the neurological examination suggested

involvement of the ilioinguinal nerve, and recommended ilioinguinal neurectomy if the block relieved pain. Nevertheless, five patients had total pain relief after nerve blockade and non-steroidal anti-inflammatory drugs and were discharged, whereas the remaining 22 patients had neurectomy, without information on the response to nerve blockade.

• Starling et al.37,38 used a preoperative ilioinguinal nerve block, and if this relieved pain the patient underwent ilioinguinal neurectomy.

• In situations of continuous pain after an ilioinguinal block, a L1–L2 plexus block was performed and, if successful, led to genitofemoral neurectomy. If pain was partially relieved by both blocks a staged surgical exploration of both nerves was performed. However, data on the effectiveness of the selective blocks were not presented nor was any correlation with the effect of surgery on postoperative pain described.

• Heise and Starling30 diagnosed 11 of 16 patients by selective, unspecified nerve blocks, but only nine had a neurectomy with five patients described as having a good or excellent outcome.

• Nahabedian and Dellon40 found that an unspecified nerve block relieved pain in two patients, with a successful outcome after genitofemoral or ilioinguinal neurectomy.

• Bower et al.28 stated that 13 of 15 patients had relief after an unspecified nerve block and 12 of these had a successful neurectomy of the ilioinguinal, iliohypogastric and/or lateral femoral cutaneous nerve.

• None of the studies had a methodological evaluation and/or protocol for medical treatment of pain before or after neurectomy, except for that by Deysine et al.42, who used failure of non-steroidal anti-inflammatory therapy as an inclusion criterion for neurectomy.




Neurectomy• One article considered laparoscopic neurectomy41• In 1989 Starling and Harms38 reported 19 patients with ‘ilioinguinal

neuralgia’ who underwent ilioinguinal neurectomy;16 had total and permanent pain relief, although three underwent subsequent genitofemoral neurectomy,which relieved pain in two. Twelve patients with ‘genitofemoral neuralgia’ underwent genitofemoral neurectomy.Eight operations resulted in considerable or complete pain relief, but the remaining four were unsuccessful.

• Bower et al.28 operated on 15 patients, carrying out 11 ilioinguinal, two iliohypogastric and three lateral femoral cutaneous neurectomies; some patients had two neurectomies and in two the nerves could not be identified. Ligation and division of the nerve was the most common procedure. Three patients also had neural alcohol injection, and two had mobilization and decompression of the nerve.

• Amid31,32 reported that 80 per cent of 49 and 225 patients respectively had complete pain relief after a month, and that 15 per cent had transient incisional pain for a few months, but without functional impairment.




Mesh or staple removal• Apart from four patients in the article by Heise and Starling30, the search

revealed no other description of the effect of mesh removal alone on chronic pain.

• Three articles described removal of staples after laparoscopic hernia repair. Wong and Anvari29 removed helical tackers (staples) and part of the mesh from a patient who had experienced 5 months of postoperative pain,which resulted in complete pain relief.

• Sampath et al.34 treated two patients by removing staples. In one a staple had pierced the lateral femoral cutaneous nerve and its removal along with part of the mesh led to reduced pain and dyspareunia, but there was persistent numbness at 12 months’ follow-up. The other patient had removal of mesh and a staple piercing the lateral femoral cutaneous nerve and was pain free at 6-month follow-up.

• Seid and Amos35 described one patient in whom removal of a staple penetrating the femoral nerve resulted in pain relief, although numbness of the anterior thigh persisted.




• As far as surgery is concerned, neurectomy results seem impressive at a first glance, with 60–100 per cent of patients apparently being cured or improved.

• However, meaningful interpretation of the data is barely possible for the following reasons: lack of objective assessment of pain before operation, previous treatment, lack of neurophysiological examination to achieve a specific diagnosis, no standardized surgical procedure in a well defined patient population, lack of randomization and control group, and absence of detailed follow-up.

• The correlation between the effectiveness of nerve block and the effect of neurectomy was not assessed systematically, although Heise and Starling30 found no correlation as only five of nine patients who had a positive response to a nerve block were improved after neurectomy.

• Isotonic saline as a placebo nerve block was not used in any study.• Only one paper described the need for analgesics before operation, drugs that would

seem necessary for a pain intense enough for neurectomy to be indicated. This paper contained a protocol that mentioned the lack of effect of non-steroidal anti-inflammatory agents as an indication for neurectomy42, but these drugs are not generally regarded as an effective treatment for neuropathic pain46.




• Future strategies to improve knowledge on the pathogenetic mechanisms and thereby the treatment and prevention of chronic pain after hernia operations have been described previously48. They include:

• Preoperative pain, neurophysiological and psychological assessment, with exclusion of a recurrent hernia or other diseases in the region; intraoperative description of the surgical approach, findings and handling of nerves and muscles; early postoperative pain intensity, character, treatment modality and neurophysiological assessment; and late postoperative pain intensity, character and psychosocial consequences, and neurophysiological assessment.

Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia

A. M. Grant1, N. W. Scott2 and P. J. O’Dwyer3, on behalf of the MRC Laparoscopic Groin Hernia Trial Group1Health Services Research Unit and 2Department of Public Health, University of Aberdeen, Aberdeen and 3Department of Surgery, University of Glasgow, Glasgow, UK


• Background: Claims that laparoscopic groin hernia repair is followed by less persisting pain and numbness than open mesh repair were tested by follow-up within a multicentre randomized clinical trial.

• Methods: Participants in the UK Medical Research Council Laparoscopic Groin Hernia Trial were followed up by means of self-completed postal questionnaires from 2 to 5 years after trial entry. The principal measures were pain (groin and testicular) and numbness (groin and thigh).

Results: • Seven hundred and fifty (80·8 per cent) of the original 928 participants returned at least

one questionnaire between 2 and 5 years; respondents were similar to the baseline randomized groups.

• Fewer respondents in the laparoscopic group had groin pain (absolute differences varied between 7·9 and 2·0 per cent, but were of marginal statistical significance);

• rates of testicular pain were similar in the two groups. • Groin numbness was reported about half as commonly at all time points in the

laparoscopic group (P < 0·001); there were no significant differences in thigh numbness.Conclusion: • Laparoscopic surgery was associated with less long-term numbness and probably less

pain in the groin.




• The trial meta-analyses also suggested that there is less persisting pain and numbness after laparoscopic repair, but this finding was based mainly on unpublished data from trials with variable lengths of follow-up and definitions of outcome1,4.

• Five-year follow-up of one randomized trial, involving 242 people, showed significantly less groin pain and numbness after TAPP compared with open repair5.

• This is a report of the 5-year postal follow-up of a large multicentre trial in which the predominant operations were totally extraperitoneal (TEP) laparoscopic repair and open tension-free mesh repair.

• A total of 928 participants were recruited to the full trial between 1994 and 1997 by 27 consultant surgeons from 26 hospitals in the UK and Ireland.




• Respondents in the laparoscopic repair group were more likely to be very satisfied with the appearance of the operation scars (82·2 versus 70·7 per cent at 36 months; χ2 = 12·62, 1 d.f., P < 0·001), and also to report that their recovery was faster than expected (59·2 versus 45·3 per cent at 36 months; χ2 = 13·77, 1 d.f., P < 0·001).

• However, there was no difference in impact on day-to-day life (62·3 versus 61·4 per cent described life as ‘much better’ at 36 months; χ2 = 0·22, 1 d.f., P = 0·638) or in the proportion who would recommend the operation they received to another person (91·4 versus 91·2 per cent at 36 months; χ2 = 0·005, 1 d.f., P = 0·942).

• Extending follow-up to 5 years for all participants in this large multicentre trial has shown that the risk of numbness in the groin after laparoscopic repair is about half that after open repair. The results are consistent with those of other trials in suggesting less groin pain after laparoscopic surgery.

• However, no differences were detected in the rate of testicular pain or thigh numbness.

• Respondents in the laparoscopic group were more likely to be satisfied with the appearance of their operation scars and to have recovered faster than expected, but there was no difference in impact on day-to-day life or the likelihood of recommending the operation they received to someone else.

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.

• Background: Chronic inguinodynia or neuralgia after conventional inguinal herniorrhaphy is rare, and diagnosing the exact cause is difficult. Treatment has ranged from local injection to remedial surgery with variable results. The increasing popularity of prosthetic mesh repairs (tension free, plug, or laparoscopic) has not eliminated these pain syndromes from occasionally occurring.

• Recommended management in these situations is extremely difficult. • Study Design: Since 1994, 117 inguinal reexplorations have been performed for inguinodynia and 20 of

these patients had primary mesh herniorrhaphy. All 20 patients had mesh removal. Records were reviewed and patients contacted to evaluate outcomes.

• Results: All 20 patients were evaluated (15 by telephone or direct contact, 5 by chart review). Three patients had their initial repair performed laparoscopically. Symptoms persisted for 12.2 6 1.7 months before remedial surgery. Four patients underwent inguinal reexploration and mesh removal; 16 had mesh removal plus ilioinguinal or iliohypogastric neurectomy. Good to excellent results were achieved in 12 out of 20 patients (60%). Average followup time was 15.9 6 3.1 months. Two of 3 patients who had laparoscopic herniorrhaphy had favorable outcomes (67%). Ten of the 16 patients who had mesh removal plus neurectomy reported good to excellent results (62%) compared with 2 of 4 reporting the same with mesh excision only (50%). Eleven patients had pain relief with preoperative nerve block. Of these, 9 had elective neurectomy resulting in good to excellent results in 5 (56%).

• Conclusions: Remedial inguinal exploration and mesh removal with or without neurectomy resulted in favorable outcomes in 60% of patients with mesh herniorrhaphy chronic inguinodynia (neuralgia). It appears that coincident neurectomy affords better results than mesh removal alone. Relief with nerve block did not predict favorable outcomes. Despite the popularity and favorable outcomes of prosthetic mesh repairs, persistent postoperative pain still occurs in a small cohort of patients. This may become more evident with the rising interest in laparoscopy. Correcting this problem once presented can be a formidable task. Remedial inguinal surgery with mesh removal and neurectomy will cure selected patients.


J Am Coll Surg 1998;187:514–518.


J Am Coll Surg 1998;187:514–518.

• Our previous publications have stressed the importance of a multidisciplinary approach to patients with preoperative nerve blocks performed by an anesthesiologist.15-17 This attempts to localize the involved nerve and to determine the best approach for specific neurectomy.

• In the current study, however, the clinical outcomes of those patients reporting relief with selective preoperative nerve blocks were not different from those of patients who did not respond to nerve blocks. This was the case whether neurectomy was included or not.

• Because of these observations, we no longer recommend preoperative nerve blocks in these unique patients who had mesh herniorrhaphy.

• In our experience, the result of nerve blocks neither predicts nor changes outcomes. • Unlike the patient with chronic inguinodynia without mesh herniorrhaphy, there is no need to

determine the surgical approach for a specific entrapped nerve, because all surgery is performed through an anterior inguinal incision.

• Suggestions have been made for laparoscopic-induced neuralgia only. Seid and Amos12 recommend treating with local injection after reporting a 100% success rate of 9 cases induced by prior laparoscopic herniorrhaphy. They have reserved operative reexploration only for those cases that failed to resolve after 4 to 6 weeks.

• Tanner8 suggested a laparoscopic (transabdominal) approach with staple removal for postlaparoscopy meralgia paresthetica.

• Other cases describe operative intervention via an open transabdominal or extraperitoneal approach with mesh removal, neurectomy, or both.9,10 Each of these has described favorable outcomes.

• In this larger series, however, we have a success rate of 60%. This may be attributable to the increased severity of chronic neuralgia because patients in this study had an average symptom duration of 1 year.


J Am Coll Surg 1998;187:514–518.

• Previous reports suggest a link between workman’s compensation-related cases and postoperative recovery time after inguinal herniorrhaphy.18

• They found that compared to patients with commercial insurance, workman’s compensation cases had a longer duration of postoperative pain and recovery time.

• Seven of our cases were workman’s compensation related. None of these patients reported an “excellent” outcome.

• However, the current study could not establish a link, as 57% of these patients described a “good” outcome with no statistically significant difference when compared to non-workman’s compensation-related cases.

• We strongly believe that mesh inguinodynia does occur, will occur more frequently than anticipated now that mesh is used with impunity, and is nonspecific as to which nerve is entrapped.

• Therefore, we no longer require preoperative nerve blocks before recommending mesh removal.

• Remedial surgery via the anterior inguinal approach with sheet mesh excision plus or minus neurectomy offers relief to most patients.

• Although we have had minimal complications, removing the mesh is extremely difficult and tedious.We have not been able to identify factors that could help us better select patients to improve our results.

Outcome of patients with severe chronic pain following repair of groin herniaC. A. Courtney, K. Duffy, M. G. Serpell* and P. J. O'Dwyer

University Departments of Surgery and *Anaesthesia, Western Infirmary, Glasgow G11 6NT, UKBritish Journal of Surgery 2002, 89, 1310±1314

• Background: Chronic pain is the most serious long-term complication that can occur after repair of a groin hernia. The aim of this study was to assess the outcome of patients who report severe or very severe pain 3 months after groin hernia repair.

• Methods: This was a population-based study of all patients who underwent repair of a groin hernia between April 1998 and March 1999 in Scotland. All received a postal questionnaire 3 months after hernia repair and those who reported severe or very severe pain at the operation site were asked to complete a further questionnaire 2´5 years later. The main outcome measure included the number of patients with persistent pain and the effect of pain on daily activities and quality of life.

Results: • Of 5506 patients who underwent repair of a groin hernia, 4062 (74 per cent) returned the first

questionnaire and • 125 (3 per cent) reported severe or very severe pain. • Eight-six (72 per cent) of 120 patients (five had died or could not be contacted at the original

address) replied to the second questionnaire; 61 (71 per cent) still reported pain, which was severe or very severe pain in 22 (26 per cent) and mild or very mild in 39 (45 per cent).

• Twenty-nine (48 per cent) sought further medical help from their general practitioner or surgeon. Nine (15 per cent) attended a pain clinic while five (8 per cent) had further surgery.

• Chronic pain had significant effects (P < 0´001) on all daily activities including walking, work, sleep, relationships with other people, mood and general enjoyment of life.

Conclusion: • Chronic pain persists in most patients who report severe or very severe pain at 3 months after

hernia repair, and has a significant effect on the patients' daily activities and quality of life.


University Departments of Surgery and *Anaesthesia, Western In®rmary, Glasgow G11 6NT, UKBritish Journal of Surgery 2002, 89, 1310±1314



• Patients with severe or very severe pain were significantly younger (54 versus 60 years; P < 0´001) and more likely to be female (odds ratio 1´73 (95 per cent confidence interval 1´07 to 2´81)) compared with the total population that had a hernia.

• There was no association between severe or very severe pain following operation and hernia type (primary or recurrent), operation type (mesh or non-mesh), grade of operator and whether the operation was performed as a day case or not.

• Patients with severe or very severe pain were significantly more likely to have sought further treatment than those with very mild or mild pain (19 of 22 versus ten of 39; P < 0´001).

• The presence of chronic pain interfered significantly (P < 0´001) with all of the activities measured irrespective of whether the pain was very mild, mild, severe or very severe. Not surprisingly this effect was more marked in the severe±very severe group.



• The role of non-absorbable material, either sutures or mesh, should also be considered. While there have been no comparative studies in hernia repair, use of absorbable suture materials has consistently been shown to cause less chronic pain after abdominal wall closure than non-absorbable materials15±17.

• Whatever the mechanism of chronic pain following hernia repair it would seem that the individual's perception of pain may also be important. 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 pain7.

• In addition, this study indicates that they are more likely to suffer from other chronic pain conditions compared with the normal population. In population-based studies18,19 27±39 per cent of patients surveyed indicated that they had had back pain in the previous week or month; the respective figures for patients with very mild±mild or severe±very severe pain were 46 and 77 per cent.

• An alternative explanation for the high incidence of back pain in the severe pain group may be related to placing excessive strain on the back muscles in an effort to protect the groin. Further studies on the interrelationship between these conditions and the psychological profile of the patients are required.



• Over two-thirds of patients who complain of severe or very severe chronic groin pain at 3 months after groin hernia repair still have pain 2±3 years later.

• While the mechanism of this pain is unclear, counselling patients on its probability before operation is required, while early referral to an established pain clinic should be considered for those who develop this debilitating problem.

Pain and Functional Impairment 1 Year Afte Inguinal Herniorrhaphy: A Nationwid Questionnaire StudyMorten Bay-Nielsen, MD,* Frederick M. Perkins, MD,† and Henrik Kehlet, PhD,* for the Danish Hernia Database

From the *Department of Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark, and th †Departmen of Anesthesiology, University of Rochester, Rochester, New York

ANNALS OF SURGERY Vol. 233, No. 1, 1– © 2001

• Objective To determine the incidence of groin pain 1 year after inguinal herniorrhaphy and to assess the influence of chronic groin pain on function.

• Summary Background Data The reported incidence of chronic pain after inguinal herniorrhaphy varies from 0% to 37%. No cross-sectional cohort studies with high follow-up rates have addressed this problem, and there is a lack of assessment of the functional consequences

• of chronic groin pain after herniorrhaphy.• Methods Two sets of self-administered questionnaires were mailed 1 year after surgery. The first established the

incidence of chronic groin pain. The second characterized the pain and the effect of the pain on the function of those reporting pain. The study population comprised patients older than age 18 years registered in the Danish Hernia Database who underwent surgery between February 1, 1998, and March 31, 1998.

• Results• The response rate to the first questionnaire was 80.8%. Pain in the groin area was reported by 28.7%, and 11.0%

reported that pain was interfering with work or leisure activity. • Older patients had a lower incidence of pain. • There were no differences in the incidence of pain with regard to the different types of hernia, the different types

of surgical repairs, or the different types of anesthesia. • The second questionnaire was returned by 83%. Of these, 46 (4%) reported constant pain. The intensity of pain

while at rest was moderate or severe in 40 (3%); with physical activity, pain was moderate or severe in 91 (8%). Impairment of specific daily activities as a result of pain was reported by 194 (16.6%). Pain characteristics were predominantly sensory, with a low use of affective terms.

• Conclusion• One year after inguinal hernia repair, pain is common (28.7%) and is associated with functional impairment in

more than half of those with pain. These factors should be addressed when discussing the need for surgical intervention for an inguinal hernia.

Pain after Anterior Mesh Hernia RepairSimonWillem Nienhuijs, MD, Oliver BA Boelens, MD, Luc JA Strobbe, MD

J Am Coll Surg 2005;200:885–889.

• BACKGROUND: The results of a randomized clinical trial comparing the Lichtenstein procedure, mesh plug repair, and the Prolene Hernia System provided a database for analyzing chronic pain after anterior mesh hernia repair to determine the characteristics and identify risk factors.

• STUDY DESIGN: A total of 334 patients with primary inguinal hernia were randomly allocated to receive one of the three meshes. Data on patient characteristics, hernia, and procedure were collected. Longterm followup was completed for 319 of 333 (95.8 %) patients with a postal questionnaire that included aVisual Analog Scale pain score, pain descriptions, and questions about numbness and prosthesis awareness. Chronic pain was analyzed irrespective of the technique used.

RESULTS: • With increasing age, significantly less intense chronic pain was reported (R 0.267, p 0.001) and pain descriptors

were used less frequently (p 0.001). • This indirectly reflected the significance of employment (p 0.019) and body mass index (R0.166, p 0.005) in a

univariate analysis because the elderly were, for the most part, unemployed and had a higher body mass index. • Longterm Visual Analog Scale pain score correlated significantly with pain directly after an operation (R 0.253, p

0.001). Reported pain increased with the presence of numbness (p 0.001) and the number of descriptions used (R 0.389, p 0.001).

• Patients using only neuropathic descriptions (n 56) suffered significantly more intense pain (Visual Analog Scale 26.5 versus 16.6, p 0.014) than those using only words indicating nociceptive pain (n 47).

CONCLUSIONS: • Chronic pain after anterior mesh hernia repair is determined by younger age and stronger pain directly after the

operation. • Especially in patients with chronic neuropathic pain, its intensity is aggravated when numbness is present and the

number of words to describe pain increases.


J Am Coll Surg 2005;200:885–889


J Am Coll Surg 2005;200:885–889

• A univariate analysis revealed age, employment status, and BMI as contributors. Age was found to be the only notable determinant of longterm pain in a multivariate regression analysis.

• Hernia type, defect size, surgeon degree or experience, operating time, length of incision, and choice of spinal or general anesthesia were of no significance.

• Direct postoperative pain increased the intensity of chronic pain. • Patients with numbness reported considerably more intense and frequent pain. • Patients with severe chronic pain used more words, especially neuropathic ones, to

describe their pain. • Poobalan and associates12 reported a relationship, though not pronounced, between

pain and BMI. Their explanation was the possibility of difficulties in identifying the ilioinguinal nerve in patients with a higher BMI. The authors of this study considered the association of the BMI with chronic pain a coincidence.

• An association between sensory disturbance and chronic pain was found; numbness was reported considerably more often by patients with pain. This has been reported previously.1,15


J Am Coll Surg 2005;200:885–889

• In conclusion, chronic pain after anterior mesh hernia repair is determined by younger age and more intense direct postoperative pain. Especially in cases of neuropathic chronic pain, more words were used to describe the pain, and its intensity was aggravated when numbness was present. With the limitations of the pain measurement tools used, these results apply to the largest group of hernia repair patients. One can hypothesize that aggressive postoperative pain relief could affect chronic pain intensity and frequency. More research should settle the problem of tackling chronic pain.

• Whether pain measurement in the elderly can be optimized using appropriate means is a matter for more debate. Additional studies should focus not on other demographic and operative details, but rather on other influential factors such as surgical approach, preservation of nerves, and different anesthetic techniques, and they may involve more objective pain measurement.

The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin HerniaSeher Demirer, M.D.,* Ilknur Kepenekci, M.D.,*,1 O. Evirgen, M.D.,† O. Birsen, M.D.,* A. Tuzuner, M.D.,* S. Karahuseyinoglu, M.D.,† M. Ozban, M.D.,* and E.

Kuterdem, M.D.*,1*Department of Surgery and †Department of Histology-Embryology, Ankara University School of Medicine, Ankara, Turkey

Journal of Surgical Research 131, 175–181 (2006)

• Objectives. Repair of groin hernia is one of the most common operations performed by general surgeons, and mesh repair methods have gained wide acceptance. Chronic pain is the most serious long-term complication that can occur after repair of groin hernia. The development of chronic pain after herniorraphy has been attributed to several mechanisms, including damage to sensory nerves and mesh inguinodynia.

• Material and methods. Twenty-four rabbits underwent bilateral inguinal dissection and synthetic polypropylene mesh laid on one side. Bilateral inguinal dissection was performed again after 3 months, and samples of nerve tissue were taken from both sides for histological examination.

• Results. Light microscopic examination of the sections of control group peripheral nerves were in normal appearance, but the nerve fascicles in experimental group operated with mesh showed axonal dilation and mild-to-severe loss of myelinated axons. Examination of semi-thin and ultra-thin sections in control group peripheral nerve fascicles showed normal morphology. Ultrastructural nerve morphology in experimental group operated with mesh exhibited endoneurinal edema with thickening of both endoneurium and perineurium, causing separation of nerve fibers. Myelin sheaths of fibers showed an ondulation toward the axoplasm and the endoneurium. Separation of myelin layers from each other as a prominent feature of myelin degeneration in nerve fibers was also observed. Axoplasms exhibited edema and crystallization.

• Conclusions. The light microscopic and ultrastructural changes seen in peripheral nerves in experimental group operated with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, fibrosis, axonal loss, and edema that may cause peripheral neuropathy.

• Chronic groin pain after hernia repair can be possibly caused by the entrapment of peripheral nerves in the scar tissue formed by the mesh.

The Effect of Polypropylene Mesh on Ilioinguinal Nerve in Open Mesh Repair of Groin HerniaSeher Demirer, M.D.,* Ilknur Kepenekci, M.D.,*,1 O. Evirgen, M.D.,† O. Birsen, M.D.,* A. Tuzuner, M.D.,* S. Karahuseyinoglu, M.D.,† M. Ozban, M.D.,* and E. Kuterdem, M.D.*,1

*Department of Surgery and †Department of Histology-Embryology, Ankara University School of Medicine, Ankara, Turkey

Journal of Surgical Research 131, 175–181 (2006)

• Uzzo et al. [27] demonstrated that the entrapment of ilioinguinal nerve or its branches by the mesh reaction cause a traumatic neuroma.

• In our study, the light microscopic and ultrastructural changes observed in peripheral nerves in the experimental group that underwent operation with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, thickening of collagen layers around axons (which is called “onion bulb formation”), and axonal loss that may cause chronic inflammatory demyelinative peripheral neuropathy.

• We think that inflammatory and fibrotic reaction occurring in response to the foreign material, which may cause adhesions and mechanical compression of peripheral nerves.

• We concluded that a similar mechanism may in part be responsible for chronic groin pain in humans.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repairM. J. Rosen Æ Y. W. Novitsky Æ W. S. Cobb K. W. Kercher Æ B. Todd Heniford

Hernia (2006) 10: 20–24

• Abstract 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.

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

M. J. Rosen Æ Y. W. Novitsky Æ W. S. Cobb K. W. Kercher Æ B. Todd Heniford

Hernia (2006) 10: 20–24

• Chronic neuralgia includes paresthesia, hypoesthesia, and dysesthesia.

• Non-surgical treatment modalities include local nerve blocks, steroid injections, various neuropathic pharmaceuticals, behavioral therapy, cryotherapy, alcohol or phenol injections, transcutaneous nerve stimulators, and neurectomy / neurolysis

• After failed nonoperative treatment, traditional surgical management of the associated neuralgia consists of groin exploration, mesh removal, and nerve resection



Hernia (2006) 10: 20–24

• When using an isolated anterior approach, with extensive associated dissection and mesh removal, the inguinal anatomy can be quite distorted and the remaining tissues can be exceedingly friable and/or scarred. These limitations can lead to an inadequate hernia repair, risk of further nerve injury, and hernia recurrence.

• After recognizing the drawbacks of an isolated anterior approach, we began performing a combined laparoscopic and open approach for this difficult problem.

• The laparoscopic approach affords the visualization necessary to determine any anatomic explanation for the patients’ symptoms as well as provide for a definitive hernia repair in unaltered tissues. Additionally, the anterior approach allows simultaneous removal of the offending foreign body with appropriate nerve resection in a single session.

• A diagnostic laparoscopy is performed. Special attention is directed to bilateral groins for evidence of recurrent hernias, abnormal adhesions, malpositioned mesh, or other pelvic pathology. If no gross abnormalities are identified, a standard transabdominal preperitoneal hernia repair is performed as has been previously described.

• The anterior approach commences with re-exploration through the prior hernia incision. The prior hernia repair is routinely taken down and all suture material or mesh is removed. In particular, medial sutures to the pubic tubercle are removed.

• After complete resection of the mesh and suture material, the ilioinguinal and iliohypogastric nerves are identified at the level just below the external oblique. It is often easiest to identify these nerves from the lateral aspect of the groin as this area is often free of scar and adhesions from the prior dissection. We resect the appropriate nerve or nerves as far proximally as possible. The nerves are divided and not tied unless they bleed. If they are ligated we use absorbable sutures. The nerve is tucked under the internal oblique muscle. This is an important detail, as the ends of the transected proximal nerve can adhere to the external oblique aponeurosis and result in recurrent chronic pain during movement of the abdominal wall.

• The external oblique fascia is reapproximated. No attempt is made to reinforce the inguinal floor or internal ring from the anterior approach.



Hernia (2006) 10: 20–24

• In general, three chronic groin pain syndromes have been defined: somatic, neuropathic, and visceral pain [11].

• Somatic pain is localized to the pubic tubercle and is a result of periosteal damage during stapling of prosthetic mesh or incorporation of the periosteum into the most medial stitch of an open anterior repair [2, 12, 13].

• Neuropathic pain usually develops in the sensory distribution of the injured nerve and can present days to weeks after the repair [14].

• Chronic neuralgia results from nerve trauma secondary to partial or complete division, stretching, contusion, crushing, electrical damage, suture compression, and adjacent inflammation from mesh or suture material [2, 5, 15].

• The most commonly offended nerves after open inguinal hernia repair include the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve.

• Visceral pain usually presents as chronic orchalgia, or pain during ejaculation, and can be a result of stricture of the spermatic duct or damage to the somatic sacral or sympathetic nerves [2, 13].

• The diagnostic laparoscopy performed in our procedure can aid in elucidating many of these issues by enabling the surgeon to rule out other common causes of chronic groin pain including recurrent herniation, spermatic cord problems, pelvic tumors, and endometriosis.



Hernia (2006) 10: 20–24

• Several surgical approaches to the treatment of chronic inguinal pain have been described.

• Heise and Starling advocate an anterior approach for mesh removal and neurectomy [7]. The resultant hernia is repaired using a tension repair (McVay or Bassinni). As these authors point out, the removal of mesh from the groin can be a difficult and tedious process requiring extensive dissection.

• In our experience, the native tissue is typically very friable and immobile at the conclusion of this dissection. With the inherently higher recurrence rates of these tension-based repairs for primary hernia, this approach seems to have significant limitations with long-term hernia recurrence.

• Some authors have suggested the routine division of the genital branch of the genitofemoral nerve in treating patients with chronic neuralgia after hernia repair [8].

• We have not found routine resection of the genital branch necessary. To date, no patient has complained of dysejaculation in our series.

Surgical Management of Groin Pain of Neural OriginCathy H Lee, A Lee Dellon, MD, FACS(J Am Coll Surg 2000;191:137–142

• Background: An approach to surgical management of the patient with groin pain is described based on our experience with 54 patients, six of whom had bilateral symptoms. History and physical examination are sufficient to relate the pain to one or more of the lateral femoral cutaneous (LFC), ilioinguinal (II), iliohypogastric (IH), or genitofemoral (GF) nerves.

• Study Design: Retrospective analysis of patients with groin pain is reported, with emphasis on cause, involved nerves, and outcomes of operative management. The LFC was decompressed. The II, IH, and GFnerves were resected. Outcomes were graded as excellent, good, and poor in terms of pain relief and functional restoration.

• Results: For the entire series of patients with painful groins, excellent relief of pain was achieved in 68% and restoration of function achieved in 72%. Ten percent had a poor result. The best results were for II and IH, which were 78% and 83% excellent for both pain relief and restoration of function, with 11% and 17% having a poor result, respectively. The worst results were for the small group of patients with a GF problem, 50% of whom had an excellent and 25% a poor result. Patients who were likely to get an LFC entrapment were those with a nerve located above or within the inguinal ligament. Complications included bruising and cautery injury to the LFC.

• Conclusions: Groin pain of neural origin can be relieved with a high degree of patient satisfaction by considering whether one or more of four different nerves are the source of that pain, by realizing that symptoms can be referred to regions other than the groin, such as the pelvic viscera (IH), the knee (LFC), and the testicle (GF), and by treating the appropriate nerve(s) by either neurolysis (LFC) or resection.


• Our initial experiences with treatment of groin pain of neural origin began with the recognition that this pain could be referred to areas outside the groin itself, such as the pelvic viscera, from the iliohypogastric nerve,12 and to the knee, from the lateral femoral cutaneous nerve.13

• In 1995, our experience with 23 patients who had lateral femoral cutaneous nerve entrapments was reported, 14 indicating that excellent results could be achieved in 78.3%, good results in 17.4% and poor results in 4.3% of the patients by neurolysis of this entrapped nerve. In 1997, our experience with 13 patients with neuromas of the cutaneous nerves to the groin was reported,15 indicating that excellent results could be achieved in 77% and good results in 23% of the patients by resection of the involved nerve. Based on our intraoperative observations, we hypothesized that there were significant variations in the lateral femoral cutaneous nerve.


• The surgical approach to these patients has been described previously as a neurolysis of the LFC, including release of all potentially constricting fascial bands from the pelvis to the thigh,14 and a resection of a portion of the II, IH, or GF nerves, as indicated, so that the proximal end of the nerves lies within the pelvis instead of the abdominal wall.

• The II nerve is identified through an oblique incision at the anterior superior iliac crest (ASIC). The fascia of the external oblique is split in the direction of its fibers, and a 1-mm white nerve, often with a small vein, is noted coursing over the reddish internal oblique muscle toward the groin.

• The IH nerve is identified in the same manner, but it often requires a second oblique split to be made into the external oblique fascia, about 2cm more cephalad.

• The LFC nerve is identified by sequentially sectioning the inguinal ligament beginning next to the anterior superior iliac crest. There may be one or two branches that are usually covered by fat and may look like a lipoma. These are released distally into the thigh, and proximally into the retroperitoneum.

• This proximal dissection usually requires division of bands from the internal oblique in the region of the circumflex iliac vessels.

• The GF nerve will have many variations and is usually found in the groin in proximity to either the round ligament or the spermatic cord. Dissection using intravenous sedation and local anesthesia can be very helpful in identifying these small whitish nerve twigs in a fatty environment by allowing the patient to report when a certain structure reproduces the pain sensation.


• The series of 23 patients reported by Stulz and Pfeiffer4 in 1982 achieved complete pain relief in 5 of 5 patients in whom they resected the II nerve (100%), in 2 of 3 patients in whom they resected both the II and the IH nerve (67%), in just 9 of 14 patients in whom they resected just the IH nerve (64%), and in 0% of the one patient in whom a neurolysis of the IH was done.

• Their failure rate was 30.5%. Six of their seven failures were in patients in whom an unresected II or IH nerve may have been the source of the remaining pain.

• Their approach was to identify the distal end of the II or IH nerve in the region of the previous scar, resect the scar, and then make the proximal transaction “as close as possible to the site where it leave the retroperitoneum.

• The neuroma which develops on the central part of the nerve, comes into the retroperitoneum, where usually no neuroma pain is felt.”

• In our study, this same, very proximal transaction site was used, attempting to let the proximal end of the nerve drop into the retroperitoneum so that it did not become fixed into the abdominal wall as a site of recurrent pain with trunk movements.

• But in this study, as with our earlier approach,15 the II and IH are identified just superior and medial to the anterior superior iliac spine. In this location, the external oblique fascia can be split longitudinally, and the II and IH thin white nerve branches identified most easily against the red color of the internal oblique muscle.

• It is not necessary to reexplore the previous hernia or low transverse abdominal incision again.• In 1987, Starling and associates5 reported complete relief of pain in 15 of 17 patients (88%) with

a neuroma of the II after hernia repair.• They also resected the II nerve at the level of the transversalis. In the present study, the overall

90% success rate in treating groin pain from II or IH nerves by identifying the nerves laterally and resecting them at a proximal level, suggests that this approach to groin pain is effective.


• Patients with pain related to the GF nerve had the worst outcomes in this study, with just 50% of the group of four patients achieving an excellent result.

• Starling’s group seems to have had the most experience with GF nerve problems after hernia surgery.5,22 Overall, they had control of persistent pain in 12 of 17 patients (71%).

• Their surgical approach is through a lateral incision in the flank,• similar to the approach for a lumbar sympathectomy. The retroperitoneum is exposed, the ureter

identified, and the GF nerve identified passing through the psoas muscle. A segment of the GF nerve is resected. They suggest differentiating pain from the GF nerve from the II nerve by local anesthetic block at the iliac crest and a paravertebral block at L1 and L2.

• A similar series of anesthetic blocks has been suggested by Lichtenstein and col-leagues.23 The retroperitoneal approach for GF neuroma resection has been accomplished with an endoscope in three men.24 In our series of patients, these nerve blocks were not used.

• Localized pain within the incision of a hernia repair correlated well with a neuroma of the II nerve. Pain with deeper pressure at the external ring, or when the spermatic cord or round ligament was palpated against the pubic bone correlated well with a neuroma of the GF nerve. In these situations, it would be the genital branch of the GF nerve that has been injured, and there is no need for a retroperitoneal exploration to resect the neuroma. In the present study the four patients had their GF nerve resected at the level of the external ring. It is possible that a staple for the mesh repair could injure the GF nerve within the retroperitoneum, requiring the retroperitoneal approach. It is likely that there is the same wide anatomic variation with the GF nerve as there was found to be with the LFC nerve, deserving the attention of a future anatomic investigation.

Risk Factors for Long-term Pain After Hernia SurgeryUlf Fra¨nneby, MD,* Gabriel Sandblom, MD, PhD,† Pa¨r Nordin, MD, PhD,‡ Olof Nyre´n,§ and Ulf Gunnarsson

(Ann Surg 2006;244: 212–219)

• Objective: To estimate the prevalence of residual pain 2 to 3 years after hernia surgery, to identify factors associated with its occurrence, and to assess the consequences for the patient.

• Summary Background Data: Iatrogenic chronic pain is a neglected problem that may totally annul the benefits from hernia repair.

• Methods: From the population-based Swedish Hernia Register 3000 patients aged 15 to 85 years were sampled from the 9280 patients registered as having undergone a primary groin hernia operation in the year 2000. Of these, the 2853 patients still alive in 2003 were requested to fill in a postal questionnaire.

• Results: After 2 reminders, 2456 patients (86%), 2299 men and 157 women responded. • In response to a question about “worst perceived pain last week,” 758 patients (31%) reported

pain to some extent. In 144 cases (6%), the pain interfered with daily activities. • Age below median, a high level of pain before the operation, and occurrence of any postoperative

complication were found to significantly and independently predict long-term pain in multivariate logistic analysis when “worst pain last week” was used as outcome variable. The same variables, along with a repair technique using anterior approach, were found to predict long-term pain with “pain right now” as outcome variable.

• Conclusion: Pain that is at least partly disabling appears to occur more often than recurrences. The prevalence of long-term pain can be reduced by preventing postoperative complications. The impact of repair technique on the risk of long-term pain shown in our study should be further assessed in randomized controlled trials.


(Ann Surg 2006;244: 212–219)


(Ann Surg 2006;244: 212–219)

• After 24 to 36 months, nearly 30% of the patients reported some form of pain or discomfort and close to 6% of all patients reported inguinal pain of such intensity that it disturbed their concentration in activities of daily life during the week preceding follow-up.

• By contrast, the 6-year cumulative incidence of reoperation for recurrence was reported to be 4.5%.4

• Furthermore, this pain caused social disability, interfering with such activities as walking, standing, and sitting in 11.3% to 14.2% of the surgically treated patients.

• The prevalence of long-term pain in this Swedish patient population conforms with the data reported by Bay- Nielsen and Poobalan3,8 but differs substantially from the experience of Condon9 who found that chronic pain occurred in less than 1%.

• Of the variables that were independently associated with an increased risk of residual pain, ie, age, pain level before the operation, techniques involving anterior approach, and postoperative complications, only the operative technique and complications can potentially be controlled by the surgeon.

• Postoperative complications were found to be linked to an increased risk for long-term pain in our study. Others have not found this link.10

• In most studies, however,3,8,11–15 complications do not seem to be evaluated at all in respect to residual pain.


(Ann Surg 2006;244: 212–219)

• Operations by posterior approach (ie, laparoscopic and open posterior operations) have, in or study, shown to cause less pain than operations by groin incision. Our study did not have sufficient power to detect clinically important advantages of specific repair methods. Hence, differences might well exist.

• When combined into one category, surgical techniques not involving dissection of the groin were associated with a lower prevalence of residual pain after 24 to 36 months, compared with techniques requiring groin dissection.

• The results from recent randomized clinical trials comparing laparoscopic TEP or TAPP repair with open tension free mesh repair are conflicting. Some trials resulted in a lower prevalence of postoperative pain in the laparoscopic group,12,13,17 whereas others showed no difference between the treatment arms.11,14

• Our finding, if true, should further be weighed against a possibly increased risk of recurrence with such techniques, as indicated in some studies.11,18


(Ann Surg 2006;244: 212–219)

• In our study, a high level of preoperative pain indicated an increased risk of long-term pain, as reported also by Poobalan et al8 and Courtney et al.15

• This might suggest that the hernia disease was already complicated prior to surgery in some patients; stretching, entrapment, and/or inflammation of local nerves are conceivable mechanisms, but psychologic susceptibility or increased pain sensitivity may also play a role.

• Moreover, the pain prior to the operation may also have originated from other conditions than the hernia, and will then persist after the operation

• A third possibility is that interindividual variations in the manner of communicating subjective feelings may have affected the observed relationship.

• A general inclination to report pain and other feelings in an exaggerated way will most likely persist both before and after the operation and so will a propensity for being stoical.

• However, a cautious interpretation of these results is needed since the answer to the question of preoperative pain is the patient’s recollection of the pain level. The complexity of inguinal pain is underlined by the fact that a substantial proportion of patients also reported pain from the nontreated contralateral groin.

• Randomized intervention studies are required to answer the question whether special preoperative investigations and/or tailored management, for instance specially adapted analgesia and anesthesia or particularly atraumatic surgical techniques, may diminish the risk of longterm pain among patients with atypically high preoperative pain levels.


(Ann Surg 2006;244: 212–219)

• An important drawback is that we did not include patients who underwent further inguinal surgery during the 24- to 36-month follow-up period.

• According to the register, the proportion of the year 2000 cohort that underwent reoperation during our follow-up period was 1.5%. Some of these reoperations might have been prompted by inguinal pain with or without noticeable hernia recurrence, which could lead to an underestimation of the prevalence of severe postoperative pain.

• Another limitation is the lack of clinical evaluation of the patients who reported residual pain. Although the questionnaire contained questions that were designed to capture obvious recurrences, some of the patients with residual pain may still have had a recurrent hernia.

Observation or Operation for Patients With an Asymptomatic Inguinal HerniaA 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)

• Objective: Many patients with an inguinal hernia are asymptomatic or have little in the way of symptoms from their hernia. Repair is often associated with long-term chronic pain and has a recurrence rate of 5% to 10%. Our aim was to compare operation with a wait-and-see policy in patients with an asymptomatic hernia.

• Methods: A total of 160 male patients 55 years or older were randomly assigned to observation or operation. Patients were assessed clinically and sent questionnaires at 6 months and 1 year. The primary endpoint was pain and general health status at 12 months; other outcome measures included costs to the health service and the rate of operation for a new symptom or complication.

• Results: At 12 months, there were no significant differences between the randomized groups of observation or operation, in visual analogue pain scores at rest, 3.7 mm versus 5.2 mm (mean difference, 1.6; 95% confidence interval (CI), 4.8 to 1.6, P 0.34), or on moving, 7.6 mm versus 5.7 mm (mean difference, 1.9; 95% CI, 6.1 to 2.4, P 0.39). Also, the number of patients 29 versus 24 (difference in proportion, 8%; 95% CI, 7% to 23%, P 0.31), who recorded pain on moving and the number taking regular analgesia, 9 versus 17 (difference in proportion, 10%; 95% CI, 21% to 2%, P 0.14) was similar. At 6 months, there were significant improvements in most of the dimensions of the SF-36 for the operation group, while at 12 months although the trend remained the same the differences were only significant for change in health (mean difference, 7.3; 95% CI, 0.4 to 14.3, P 0.039). The rate of crossover from observation to operation 23 patients at a median follow-up of 574 days was higher than predicted. The observation group also suffered 3 serious hernia-related adverse events compared with none in the operation group.

• Conclusions: 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.



(Ann Surg 2006;244: 167–173)

• The most common symptom patients have from their hernia is pain that is usually mild to moderate and generally does not affect work or leisure activities. Up to one third of patients are asymptomatic or have very little in the way of symptoms from their hernia.2

• For those that undergo repair, around 10% will have a significant wound infection or hematoma, 3% will have severe chronic pain, and 5% to 10% will develop a recurrent hernia.3

• One of the most common reasons for recommending inguinal hernia repair to patients is the risk of strangulation.

• Strangulation is associated with an increased morbidity and mortality; however, it is uncommon with only around 1 in 400 of all patients presenting with an inguinal hernia requiring bowel resection for this complication.2 Using life-table analyses based on 2 population groups, Fitzgibbons et al estimated that the lifetime risk of strangulation for an 18- year-old with an inguinal hernia is 0.272% (or 1 in 368) while that for a 72-year-old is 0.034% (or 1 in 2941).4

• It is not known what the risk of pain or strangulation from an asymptomatic inguinal hernia is or if these patients are likely to develop warning symptoms before the latter event occurs. If this were the case, then there may be a window of opportunity to operate before a serious complication arises. This study examines patient outcome comparing operation with a wait-and see policy in patients with an asymptomatic inguinal hernia.



(Ann Surg 2006;244: 167–173)



(Ann Surg 2006;244: 167–173)

• on any parameter measured up to 1 year after randomization, pain scores, the number who reported pain, and analgesia consumption, there was no difference between those that were observed and those that had an operation.

• Moreover, patients that underwent operation perceived that their general health had improved, whereas those that were observed felt that their health had declined in keeping with increasing age in an elderly population.

• There were 3 serious adverse events in the observation group in this trial: 1 patient had an acute hernia, 1 had a postoperative stroke, and 1 had a myocardial infarction and died postoperatively.

• The patient with the acute hernia had it reduced at another hospital, whereas all had their operations on an urgent elective basis for pain.

• Serious morbidity and mortality are rare after elective hernia repair, even for elderly patients.

• The 30-day mortality for elective patients over 60 years of age was 0.48% from the Danish Hernia Database, whereas that for patients over 70 years was 0.32% for the corresponding Swedish Hernia Register.11,12 Interestingly the latter was lower than the standardized mortality rate for individuals of the same age in the Swedish population as a whole.



(Ann Surg 2006;244: 167–173)

• Despite improvements in perioperative care, mortality from acute groin hernia surgery remains high. In the prospective nationwide study from Denmark, 7% of patients with an acute presentation died within 30 days of operation.11

• This high mortality occurs mostly because of severe comorbid illness with only a small subset having strangulated bowel.13

• While there are a number of reasons for this, a significant contribution is made by clinicians turning high-risk patients down for elective operation in the first instance.14

• Given the safety and ease of local anesthetic groin hernia repair, this approach needs to change as most patients will be suitable for elective repair by this method irrespective of the nature or severity of any coexisting illness.

• The rate of crossover to operation in this observation group was higher than expected in this study. This occurred at a steady rate over the period of observation and may indicate that such a tactic would merely delay rather than avoid operation.

• In our initial calculation based on expected survival for the age group, our estimate was that, if 15% of patients developed pain or a complication that required operation each year, then a nonoperative policy would not be viable. In the first year of follow-up, almost 20% have required an operation for such an event and a further 6% of the at risk population have been operated on 3 months into the second year of follow-up. Interestingly, the only factor to predict crossover from observation to operation was the degree of protrusion of the hernia.

• Factors such as the duration the hernia was present, whether the hernia was direct or indirect, the side of the hernia and age of the patient had no effect. However, these data need to be interpreted with caution as the study was not designed to look at predictors of crossover.



(Ann Surg 2006;244: 167–173)

• Hernia repair in the patient with an asymptomatic inguinal hernia does not increase long-term pain.

• In addition, it may reduce serious morbidity and improve general health.

• Further clinical trials with longer follow-up are required to determine if such a strategy produces sufficient health gain to justify the additional health care costs.

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.

• Context Many men with inguinal hernia have minimal symptoms. Whether deferring surgical repair is a safe and acceptable option has not been assessed.

• Objective To compare pain and the physical component score (PCS) of the Short Form-36 Version 2 survey at 2 years in men with minimally symptomatic inguinal hernias treated with watchful waiting or surgical repair.

• Design, Setting, and Participants Randomized trial conducted January 1, 1999, through December 31, 2004, at 5 North American centers and enrolling 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years.

• Interventions Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; repair patients received standard open tensionf ree repair and were followed up at 3 and 6 months and annually.

• Main Outcome Measures Pain and discomfort interfering with usual activities at 2 years and change in PCS from baseline to 2 years. Secondary outcomes were complications, patient-reported pain, functional status, activity levels, and satisfaction with care.

• Results Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1% vs 2.2%, respectively; P=.52); PCS (improvement over baseline, 0.29 points vs 0.13 points; P=.79). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17% assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over improved after repair. Occurrence of postoperative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. One watchful-waiting patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, with a frequency of 1.8/1000 patient-years inclusive of patients followed up for as long as 4.5 years.

• Conclusions Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.


JAMA. 2006;295:285–292.

• The natural history of an untreated inguinal hernia is not known. For minimally symptomatic men, the usual basis for recommending surgical repair is to prevent a hernia accident (ie, acute hernia incarceration with bowel obstruction, strangulation of intra- abdominal contents, or both), but this is a rare event.

• Only an 1896 report from Berger’s Paris truss clinic 5 and a 1981 report from Colombia6 are available to assess this risk. Both estimated the annual risk of a hernia accident to be approximately 3 per thousand patients.

• Whether watchful waiting is a good option has not been critically tested.


JAMA. 2006;295:285–292.


JAMA. 2006;295:285–292.

• Two years after randomization, similar proportions of patients in the watchful waiting and surgical repair groups had pain sufficient to limit usual activities, and their levels of physical functioning were similar.

• Patients assigned to watchful waiting who requested surgical repair most commonly reported increased pain as the reason for the crossover, and nearly half reported that pain interfered with normal activities.

• These symptoms improved for most patients after hernia repair.• Hernia accidents were extremely uncommon (rate of 1.8 per 1000 patient years).• Others have suggested that hernia accidents are more common in elderly patients,

many of whom are unaware of their diagnosis and have not sought surgical care.5,18 In a review of the VA database (W. Henderson, PhD, National Surgical Quality Improvement Program, written communication, 2005), the mean age of patients having hernia emergencies was 77 years, and the rate of death after repair was found to be only 2.2%.

• The low accident rate of 1.8 per 1000 patients per year found in this strategy, the low mortality rate associated with surgical repair, and the similar pain and health outcomes identified at 2 years suggest that deferring surgery for men without troublesome symptoms is a reasonable option.


JAMA. 2006;295:285–292.

• By 2 years, 23% of our watchfulwaiting patients crossed over to receive surgical repair. We had anticipated that progression of symptoms in some men assigned to watchful waiting would lead them to request repair.

• Unexpectedly, nearly the same proportion of men assigned to receive repair (17%) did not have the operation, despite being well informed that participation in this study would give them a 50% chance of being directed to an operative intervention.

• Crossovers from watchful waiting to surgical repair continued to the close of the study, reaching 31% at 4 years.

• It appeared that certain baseline characteristics of patients assigned to watchful waiting who requested surgical repair differed from those of the other groups.

• At baseline, these patients reported high levels of sensory and affective pain during their normal activities (as measured by the hernia-specific Surgical Pain Scale11) and had impaired physical function (as measured by the PCS of the Short Form-36 Version 2).

• Prostatism was also common. The men assigned to surgical repair who did not undergo repair may have been less healthy than patients in other groups, as indicated by a somewhat higher American Society of Anesthesiologists classification and greater frequency of diabetes and hypertension.

• This crossover group also had worse physical functioning at baseline, but after repair they experienced considerably greater improvement in physical functioning than did the patients who received surgical repair as assigned.


JAMA. 2006;295:285–292.

• Adverse consequences of surgical repair were identified in some patients, including short-term complications in 32.7%; longer-term problems, including chronic pain sufficient to limit activities in 1.7% at 3 years and 1.3% at 4 years for the subset of the group available for analysis at these points; and recurrence of the hernia in 1.4%.

• Progression of hernia-related symptoms is time-dependent and the main outcomes of the study were assessed at 2 years.

• For all patients, the median length of follow-up was only 3.2 years. • Because the risk of a hernia accident increases with the length of

time the hernia is present and because accidents are more common in elderly individuals, a longer follow-up period may be needed to ascertain the longerterm risks of either treatment strategy.

• 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, and patients who develop symptoms have no greater risk of operative complications than those undergoing prophylactic hernia repair.

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 conclusions from the WW trial were: “Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias” and “Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.”

• O’Dwyer and coinvestigators conclude: “Repair of an asymptomatic inguinal hernia does not affect the rate of long-term chronic pain and may be beneficial of patients in improving overall health and reducing potential serious morbidity.”

• The O’Dwyer trial was limited to men over age 55 with “asymptomatic hernias,” whereas the WW trial enrolled men as young as 18 years with asymptomatic or minimally symptomatic hernias.

• Although nearly a third of the patients in the WW trial were over age 65, these differences in inclusion criteria resulted in a higher mean age of subjects in the O’Dwyer study (nearly 13 years older than the patients in the WW trial).

• The higher rate of postoperative cardiovascular complications in the O’Dwyer study could be accounted for by this difference in age.

• In the O’Dwyer trial, 2 patients (1% overall, both were originally assigned to observation but crossed over to repair) had postoperative cardiovascular complications; whereas in the WW trial, 2 patients (0.1% overall) experienced this type of complication.



• Both trials found that there was no difference between groups in pain scores (primary outcome measure) at any time. Both trials also found that the groups experienced similar changes in the SF-36, except “change in health” in the O’Dwyer trial, which showed more improvement in the operation group (this specific measure was not used in the WW trial).

• Importantly, the rate of hernia accident (acute incarceration or strangulation) was very low in both trials (0.3% in WW trial, 1% in O’Dwyer trial).

• In the WW trial, the crossover rate from observation to repair at 2 years was 23% and continued at a rate of 4% per year until the close of the trial at 4.5 years.

• Twenty percent of the observation patients in the O’Dwyer trial crossed over to repair by 1 year; by 15 months, 26% had received repair.



• Between these 2 randomized trials, more than 400 men were followed for their asymptomatic or minimally symptomatic hernias.

• Several conclusions can be drawn when taking the results of these 2 trials together.

• First, 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.

• Second, 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. • Third, delaying repair appears safe, although major life-threatening

complications can occur in any patient undergoing even a simple operation.• An alternative conclusion to that of O’Dwyer and colleagues would be that

the safest course in a patient with significant comorbidities is not to repair an asymptomatic hernia.

A 1-stage Surgical Treatment for Postherniorrhaphy Neuropathic PainTriple neurectomy and proximal end implantation without mobilization of the cord

Parviz.k AmidArch surg 2002;137:100-104

Causes, prevention, and surgical management of postherniorrhaphy neuropathic inguidynia: Triple neurectomy with proximal end implantation.

Amid PK. Hernia 2004; 8: 343–349.

Abstract • The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy

has been a two-stage operation including: (a) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (b) genital nerve neurectomy through a flank approach.

• Two hundred twenty-five patients underwent triple neurectomies with proximal end implantation to treat chronic postherniorrhaphy neuralgia.

• Four patients reported no improvement. • Eighty percent of patients recovered completely, and 15% had transient insignificant

pain with no functional impairment. • These results are comparable to the results of the two-stage operation. • Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves

without mobilization of the spermatic cord is an effective one-stage procedure to treat postherniorrhaphy neuralgia. It can be performed under local anesthesia and avoids testicular complications.

• Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structures of the groin, which can result in recurrence of the pain.

• A one-stage surgical procedure resecting all three nerves from an anterior approach avoids a second operation through the flank and successfully treats chronic neuralgia.


Amid PK. Hernia 2004; 8: 343–349.

• The neuropathic pain complex can also be reproduced by tapping the skin medial to the anterosuperior spine of the iliac bone or over an area of localized tenderness (Tinel’s test).

• It is extremely difficult, if not impossible, to pinpoint the involved nerve because:• 1. Peripheral communication between the ilioinguinal, iliohypogastric, and genital branch

of the genital femoral nerve is very common and results in an overlap of their sensory innervation [1, 2].

• 2. In addition to the intercommunication, the innervation field of the three nerves overlaps [2, 3].

• 3. At the spinal level, both ilioinguinal and iliohypogastric nerves derive from the 12th thoracic and first lumbar nerve, and both the genital and ilioinguinal nerves receive communication from the first lumbar nerve [1, 2].

• 4. Frequently more than one involved nerve can cause postherniorrhaphy neuropathic pain.

• Peripheral nerve block or differential paravertebral root block, although helpful for differentiating neuropathic from nonneuropathic pain, is often inconclusive in making a discriminatory diagnosis of the involved nerve.

• MR neurography, a new technology based on the water content of the nerve fibers, is a good diagnostic tool for diagnosis of neuropathic pain. In my limited experience, although MR neurography has virtually no false positive, a negative study does not rule out nerve involvement.


Amid PK. Hernia 2004; 8: 343–349.


Amid PK. Hernia 2004; 8: 343–349.

Great variations in the nerves are common as follows:• 1. ilioinguinal nerve within the cremasteric muscle [1]• 2. premature surfacing of the ilioinguinal nerve or a

branch of the same from the inguinal canal through the external oblique aponeurosis anywhere between the external and the internal ring

• 3. ilioinguinal nerve joining the iliohypogastric nerve or one of the nerves being completely absent [2]

• 4. an aberrant branch of the ilioinguinal nerve descending within the genital branch of the genitofemoral nerve [2]


Amid PK. Hernia 2004; 8: 343–349.


Amid PK. Hernia 2004; 8: 343–349.

• Nerve injuries resulting in axonotmesis, neurotmesis, and complete transection of the nerve lead to traumatic neuroma formation via inward migration and proliferation of fibroblast and perineural cells and outward growth of axons.

• With complete transection, the neuroma manifests itself as a round tumor at the proximal cut end of the nerve .

• With lesions in-continuity, neuromas manifest as small bulbar deformities along the course of the nerve .


Amid PK. Hernia 2004; 8: 343–349.

• Pain related to neurapraxia, which may last up to 6 months postoperatively, is usually a self-limiting condition and does not necessitate surgical intervention.

• However, perineural fibrosis, nerve entrapment by sutures, staples, or tacks, and neuroma formation, as a result of axonotmesis, neurotmesis, or complete nerve transection, do require surgery.

• Stretch and blunt injuries resulting in lesions in-continuity show maximal improvement after 3–6 months. At such time, it is reasonable to proceed with any indicated surgical interventions.

• Because of central and peripheral communication and frequent multiple nerve involvement (Fig. 4, Fig. 9, Fig. 10), discerning which nerve is specifically involved can be extremely difficult, if not impossible. Therefore, surgical treatment of postherniorrhaphy neuralgia should address all three nerves. The operation should not be limited only to a grossly involved nerve [6].


Amid PK. Hernia 2004; 8: 343–349.

• Surgical treatment for periosteal reaction or osteitis pubis consists of removing suture materials, staples, bulky suture knots, and/or bulk forming or rolled mesh material from the pubic tubercle area. Injection of 80 mg of methylprednisone acetate under direct vision during the operative procedure may also be helpful.

• Treatment of chronic inguinodynia caused by ‘‘meshoma’’ is their surgical explantation..

• Surgical treatment of neuropathic pain consists of resection of the three peri-inguinal nerves (ilioinguinal, iliohypogastric, and genital).

• Neurolysis is not recommended because it does not address neuromas or inevitable secondary scarification [6].

• Similarly, simple division of the nerves without complete resection is not recommended.

• The transacted nerve ends should be ligated to close the neurilemmal sheath in order to prevent neuroma formation. Any staple, suture, or prosthetic material along the course of the nerve should be included with the resected portion of the nerve [6].

• Complete removal of mesh is not necessary because, similar to Starling [6], we did not find any predilection to a previous mesh repair.


Amid PK. Hernia 2004; 8: 343–349.

• The ligated proximal ends of the ilioinguinal and iliohypogastric nerves should be implanted within the fibers of the internal oblique muscle.

• The ilioinguinal nerve can easily be identified lateral to the internal ring

• The iliohypogastric nerve can easily be identified by separation of the external oblique aponeurosis from the underlying internal oblique muscle and aponeurosis as cephalad as possible .

• The dissected nerves should be resected as proximally and distally as possible.

• The genital nerve is the most difficult to identify from the anterior approach. However, in all but three of our cases (two patients had previous multiple hernia repairs), the nerve could be visualized within the lateral crus of the internal ring, within the internal ring, or between the spermatic cord and the inguinal ligament.


Amid PK. Hernia 2004; 8: 343–349.

• The most common nerve affected by perineural fibrosis was the ilioinguinal nerve, and the most frequent location of involvement was at the suture line of the external oblique closure, particularly at the level of the external ring.

• The next most common affected nerve was the iliohypogastric nerve, and the most frequent location of injury was the intramuscular part of the nerve, due to sutures through the lower edge of the external oblique muscle.


Amid PK. Hernia 2004; 8: 343–349.

• To prevent raising a red flag, it is important to avoid such a term as ‘‘nerve entrapment’’ for compression of the nerve(s) due to ‘‘perineural fibrosis,’’ which is a naturally occurring condition after inguinal hernia repair.

• In another series of 315 patients with postherniorrhaphy chronic pain, none of the patients had a previous mesh repair [9].

• Furthermore, the E.U. hernia trialists collaboration study [10], the Danish nationwide study [11], and The Netherlands study [12] all demonstrated that using mesh was not a factor in postherniorrhaphy chronic pain.


Amid PK. Hernia 2004; 8: 343–349.

• The most common cause of nerve injury is failure to identify and protect the nerves, particularly when dissection is minimized in order to complete the operation faster. To reduce the incidence of this incapacitating complication of hernia surgery, it is necessary to have a thorough knowledge of the groin anatomy to avoid injury or entrapment of the nerves. To that end, we suggest the following:

• 1. Avoid removal of the cremasteric layer to prevent injuring the ilioinguinal and genital nerves.

• 2. Avoid making the external ring too small to prevent tight contact between the ilioinguinal nerve and the suture line of the external oblique closure.

• 3. Avoid lifting the ilioinguinal nerve from its bed (particularly retracting the nerve behind the inguinal ligament) to prevent injury to the neurilemmal sheath of the nerve.

• 4. Look at and identify the nerves, and particularly avoid the so-called minimal dissection for completing the operation faster.

• 5. Avoid incising the subcutaneous adipose tissue hastily to prevent injury to the prematurely surfaced branches of the ilioinguinal or iliohypogastric nerves.

• 6. Avoid suturing the lower edge of the internal oblique muscle to the inguinal ligament, plugs, or flat mesh because passing sutures through the internal oblique muscle can lead to injury (by needle) or entrapment (by suture) of the intramuscular portion of the iliohypogastric nerve, which is the most vulnerable part of this nerve.

• 7. Avoid deep insertion of staples or tacks during laparoscopic inguinal hernia repairs.

Pain and functional impairment 6 years after inguinal herniorrhaphyE. K. Aasvang Æ M. Bay-Nielsen Æ H. Kehlet

Hernia (2006) 10: 316–321

Abstract • Pain impairing daily activities following inguinal herniorrhaphy is reported by about 10% of

patients, when asked 1–2 years postoperatively. However, the time course and consequences of postherniorrhaphy pain is not known in detail.

• A nationwide follow-up questionnaire study was undertaken 6.5 years postoperatively in 335 well-described patients reporting pain 1 year after inguinal herniorrhaphy in a previous questionnaire study.

• Three hundred and three patients, who were alive and could be contacted, received a questionnaire 6.5 years after the herniorrhaphy. Response rate was 88%. Of 267 patients responding, 57 were analyzed separately due to subsequent inguinal herniorrhaphy or other major surgery in the observation period, leaving 210 patients (69.3%) for primary analysis.

• Pain from the previous hernia site was reported by 72 patients (34.3%), and 52 patients (24.8%) reported that pain affected daily activities.

• Less pain, compared to the 1-year follow-up, was reported by 75.8%, while 16.7% had the same intensity level and 7.5% reported increased pain severity. In the subgroup of patients operated for a recurrence during the observation period and not included in primary analysis, 22 of 44 (50%) still experienced pain at 6.5 years, and 17 (38.6%) reported that pain affected daily activities (mean observation period 4.5 years).

• Pain after inguinal herniorrhaphy decreased from about 11% 1 year after surgery, but still affects daily activities in about 6% after 6.5 years. Patients operated for a recurrence are at higher risk for persistent pain.


Hernia (2006) 10: 316–321

• Thus, pain (inguinal or testicular) and numbness (inguinal and thigh) following laparoscopic (TAPP) (n=462) or open-mesh (n=453) inguinal herniorrhaphy were followed by annual questionnaires from 1 to 5 years postoperatively [8, 9], and pain was reported by 31.5% of patients at 1 year and 19.1% at the 5-year questionnaire.

• Severe or very severe postherniorrhaphy pain was reported by 9.7% of patients at 1 year and by 1.8% at 5 years [9], with a response rate of 60% after 5 years.


Hernia (2006) 10: 316–321


Hernia (2006) 10: 316–321

• However, the response rate was only about 60% at 5 years, compared with 89% at 6.5 years in our study.

groin pain

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