Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies

Cirocchi, Roberto; Henry, Brandon Michael; Mercurio, Isabella; Tomaszewski, Krzysztof A.; Palumbo, Piergaspare; Stabile, Anna Maria; Lancia, Massimo; Randolph, Justus

doi:10.1007/s10029-018-1857-2

Cited by 14 publications

(16 citation statements)

References 39 publications

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“…Moreover, the chronic inguinal pain might be caused by the incorporation of the nerve into the mesh due to missed identification of the nerve during surgery. In a systematic review of literature and meta-analysis based on 5265 halfbody examinations, the identification rate of the IIN was 94.4% (95% CI 89.5-97.9) [59]. The subgroup analysis of the studies in which was identified the IIN reported a lower incidence of postoperative pain at 6 months and the same trend in favor of neurectomy.…”

Section: Discussionmentioning

confidence: 98%

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

et al. 2021

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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...

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Section: Discussionmentioning

confidence: 98%

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

et al. 2021

View full text Add to dashboard Cite

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“…Moreover, the chronic inguinal pain might be caused by the incorporation of the nerve into the mesh due to missed identification of the nerve during surgery. In a systematic review of literature and meta-analysis based on 5265 half-body examinations, the identification rate of the IIN was 94.4% (95% CI 89.5–97.9) [ 59 ]. The subgroup analysis of the studies in which was identified the IIN reported a lower incidence of postoperative pain at 6 months and the same trend in favor of neurectomy.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

View full text Add to dashboard Cite

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.

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“…Recently, a systematic review and meta-analysis of worldwide literature reported the identification rates of the inguinal nerves both during open inguinal hernia repair and during cadaveric dissections [ 10 ]. Overall prevalence of IH, II, GF nerves resulted 74.2%, 84.3% e 48.2%, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Guidelines recommend intraoperative inguinal nerve identification in order to limit or prevent postoperative pain [6] and to reduce the risk of iatrogenic injury, such as entrapment between prosthetic material and tissue [9]. Recently, a systematic review and meta-analysis of worldwide literature, which analyzed identification rates of the three inguinal nerves, found great heterogeneity among studies in particular in Europe [10]. Inguinal nerve identification is performed routinely by few surgeons, despite several studies concluding that this procedure is safe and does not affect operative time [11][12][13][14].…”

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confidence: 99%

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair

et al. 2020

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Background Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months. Material A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation. Results Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542). Conclusion The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

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Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies

Cited by 14 publications

References 39 publications

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

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

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

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair

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