A clinical study of the incidence and disability caused by mesh neuralgia after inguinal mesh hernioplasty and the effects of prophylactic ilioinguinal neurectomy and its role in preventing chronic groin pain after inguinal hernioplasty

Abstract

Background: Residual neuralgia, called as Inguinodynia, is an important complication unique to groin hernia repair. The reported incidence ranges between 9-63%. The symptoms are potentially disabling. Symptoms are often more pronounced on axial twisting of body. Methods for prevention include identification and preservation of all nerves, Ilioinguinal Neurectomy and triple Neurectomy during surgery.Methods: One hundred patients underwent elective unilateral Lichtenstein’s tension free hernioplasty. 50 patients were subjected to elective ilioinguinal neurectomy. The remaining underwent standard Liechtenstein’s mesh hernioplasty, without ilioinguinal neurectomy. Randomization was achieved by allocating alternate patients to each group - prophylactic neurectomy, or nerve preservation. All patients, during each review were asked to fill out a Pain Disability Questionnaire to assess sensory loss and pain disability objectively.Results: At completion of 6 monthly follow up pain at rest (none in group ‘A’ compared with 3 in group ‘B’), after coughing 5 times (none in group ‘A’ compared with 7 in group ‘B’), after climbing 4 flights of stairs(3 in group ‘A’ compared with 16 in group ‘B’) and after cycling for 20 minutes (11 in group ‘A’ compared with 22 in group ‘B’) were all significantly lesser in the neurectomy group as compared with the non neurectomy group. More importantly, exertional chronic pain incidence at 6 months was significantly less in group ‘A’.Conclusions: It was concluded that pain after inguinal mesh hernioplasty is a cause of morbidity, pain was complained of by a significantly larger number of non-neurectomised patients at 6 months of follow-up, prophylactic ilioinguinal neurectomy is associated with reduced exertional chronic groin pain, disability caused by pain after inguinal hernioplasty, is significantly reduced by ilioinguinal neurectomy and an extremely significant reduction in the requirement of medication is brought about by neurectomy compared with controls.

A prospective study comparing prophylactic division versus preservation of the ilioinguinal nerve in open Lichtenstein inguinal hernioplasty

“…20 Also, Sunkar et al reported that significantly fewer patients had pain after coughing 5 times at 6 months, in the neurectomy group as compared with the nonneurectomy group (p value<0.0001). 18 In the present study, after 1 month follows up, pain during vigorous activity was noted in 48.9% of patients in the neurectomy group (A), while it was noted in 55.6% of patients in the nerve preservation group (B). But after 6 months follow up, 16 patients (35.6%) were still experiencing pain in the nerve preservation group whereas, only 6 patients (13.3%) in the neurectomy group were still complaining of pain (p value=0.005) (significant).…”

“…17 Sunkar et al reported that 8% of his patients aged between 15-30 years and 34% aged between 61and 75 years old. 18 Saravanan et al reported that most of his patients aged between 31 to 40 years in both groups followed by 41 to 50 years. 19 In the present study, the right oblique hernia was the commonest and represented 40% in the neurectomy group and 42.2% in the nerve preservation group.…”

“…17 Also, Sunkar et al reported that a significantly lesser number of patients had pain after cycling for 20 minutes at 6 months in the neurectomy group as compared with the non-neurectomy group. 18 Whereas, Picchio and colleagues suggested that nerve preservation and nerve division have similar incidences of pain and that intraoperative nerve division just leads to an increased rate of wound anesthesia. 21 In the present study, we found that in the neurectomy group 12, 8 and 6 patients had groin numbness at 1, 3, and 6 months, respectively.…”

“…17 Also Sunkar et al reported that statistically no significant difference in sensory loss could be demonstrated between the two groups at the end of 6 months follow-up. 18…”

Effect of Prophylactic Ilioinguinal Neurectomy on Postoperative Groin Pain Following Lichenstein Hernioplasty

“…4 There is a symptom complex of neuropathic and nonneuropathic pain. The neuropathic causes include inadvertent entrapment of nerve in suture or mesh, perineural fibrosis, partial division, crushing of nerve, or diathermy burns, 2,3 triggered by hyperextension of the hip and walking. The non-neuropathic pain is actually somatic pain due to periosteal reaction, scar tissue, mechanical pressure caused by folded mesh called 'meshoma' and visceral pain, which is experienced during ejaculation.…”