Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta‐analysis

Abstract

Objective This study aimed to evaluate the incidence of chronic groin pain (primary outcome) and alterations of sensitivity (secondary outcome) after Lichtenstein inguinal hernia repair, comparing neurectomy with ilioinguinal nerve preservation surgery. Summary background data The exact cause of chronic groin postoperative pain after mesh inguinal hernia repair is usually unclear. Section of the ilioinguinal nerve (neurectomy) may reduce postoperative chronic pain. Methods We followed PRISMA guidelines to identify randomized studies reporting comparative outcomes of neurectomy versus ilioinguinal nerve preservation surgery during Lichtenstein hernia repairs. Studies were identified by searching in PubMed, Scopus, and Web of Science from April 2020. The protocol for this systematic review and meta-analysis was submitted and accepted from PROSPERO: CRD420201610. Results In this systematic review and meta-analysis, 16 RCTs were included and 1550 patients were evaluated: 756 patients underwent neurectomy (neurectomy group) vs 794 patients underwent ilioinguinal nerve preservation surgery (nerve preservation group). All included studies analyzed Lichtenstein hernia repair. The majority of the new studies and data comes from a relatively narrow geographic region; other bias of this meta-analysis is the suitability of pooling data for many of these studies. A statistically significant percentage of patients with prosthetic inguinal hernia repair had reduced groin pain at 6 months after surgery at 8.94% (38/425) in the neurectomy group versus 25.11% (113/450) in the nerve preservation group [relative risk (RR) 0.39, 95% confidence interval (CI) 0.28–0.54; Z = 5.60 (P < 0.00001)]. Neurectomy did not significantly increase the groin paresthesia 6 months after surgery at 8.5% (30/353) in the neurectomy group versus 4.5% (17/373) in the nerve preservation group [RR 1.62, 95% CI 0.94–2.80; Z = 1.74 (P = 0.08)]. At 12 months after surgery, there is no advantage of neurectomy over chronic groin pain; no significant differences were found in the 12-month postoperative groin pain rate at 9% (9/100) in the neurectomy group versus 17.85% (20/112) in the inguinal nerve preservation group [RR 0.50, 95% CI 0.24–1.05; Z = 1.83 (P = 0.07)]. One study (115 patients) reported data about paresthesia at 12 months after surgery (7.27%, 4/55 in neurectomy group vs. 5%, 3/60 in nerve preservation group) and results were not significantly different between the two groups [RR 1.45, 95% CI 0.34, 6.21;Z = 0.51 (P = 0.61)]. The subgroup analysis of the studies that identified the IIN showed a significant reduction of the 6th month evaluation of pain in both groups and confirmed the same trend in favor of neurectomy reported in the previous overall analysis: statistically significant reduction of pain 6 months after surgery at 3.79% (6/158) in the neurectomy group versus 14.6% (26/178) in the nerve preservation group [RR 0.28, 95% CI 0.13–0.63; Z = 3.10 (P = 0.002)]. Conclusion Ilioinguinal nerve identification in Lichtenstein inguinal hernia repair is the fundamental step to reduce or avoid postoperative pain. Prophylactic ilioinguinal nerve neurectomy seems to offer some advantages concerning pain in the first 6th month postoperative period, although it might be possible that the small number of cases contributed to the insignificancy regarding paresthesia and hypoesthesia. Nowadays, prudent surgeons should discuss with patients and their families the uncertain benefits and the potential risks of neurectomy before performing the hernioplasty.

Significant factors influencing chronic postoperative inguinal pain: A conditional time-dependent observational cohort study

“…Results from this study might indicate that the use of nonresorbable staples should be avoided in IH repair, as other types of fixations are available. Cirocchi et al [6] wrote an extensive review with respect to prophylactic nerve transection to prevent CPIP. As results varied between studies, the authors made it clear that no conclusions could be drawn from their meta-analysis.…”

“…Intra-operative nerve transection for the prevention of CPIP has been thoroughly investigated by many studies, and also in a meta-analysis by Cirocchi and colleagues [6][7][8]. Although decrease in pain in the early postoperative period is observed, this difference is not observed anymore one year postoperatively.…”

The Issues of Post‐Lichtenstein Chronic Groin Pain

“…The varied incidence of chronic postoperative inguinal pain (CPIP) is reflected in the published literature, as reported by the authors, from 0 to 53 percent [2].…”

Somatosensory Outcomes Following Re-Surgery in Persistent Severe Pain After Groin Hernia Repair: A Prospective Observational Study

“…Neurectomy in GHR procedures has been discussed as a prophylactical measure preventing the development of PSPG or as a selective procedure in the management of PSPG. 26 While prophylactic neurectomy has been debated, it is presently not recommended. 5 Other pain-relieving procedure includes triple neurectomy by a laparoscopic extraperitoneal approach 27–29 or, as in the current study, selective neurectomy of damaged nerves in the surgical field (cf.…”

“…Neurectomy in GHR procedures has been discussed as a prophylactical measure preventing the development of PSPG or as a selective procedure in the management of PSPG. 26 While prophylactic neurectomy has been debated, it is presently not Notes: Summed scores of the Activities Assessment Scale (AAS) for the specific activities and the overall activities (cf. text for explanation), and the pain at rest, average, and maximal pain intensity scores (numeric rating scale [NRS: 0-10]) before and after the re-surgery.…”