Quantitative validation of sensory mapping in persistent postherniorrhaphy inguinal pain patients undergoing triple neurectomy.

PURPOSE: Neurectomy of the inguinal nerves may be considered for selected refractory cases of chronic postherniorrhaphy inguinal pain (CPIP). There is to date a paucity of easily applicable clinical tools to identify neuropathic pain and examine the neurosensory effects of remedial surgery. The present quantitative sensory testing (QST) pilot study evaluates a sensory mapping technique. METHODS: Longitudinal (preoperative, immediate postoperative, and late postoperative) dermatomal sensory mapping and a comprehensive QST protocol were conducted in CPIP patients with unilateral, predominantly neuropathic inguinodynia presenting for triple neurectomy (n = 13). QST was conducted in four areas on the affected, painful side and in one contralateral comparison site. QST variables were compared according to sensory mapping outcomes: (o)/normal sensation, (+)/pain, and (-)/numbness. Diagnostic ability of the sensory mapping outcomes to detect QST-assessed allodynia or hypoesthesia was estimated through calculation of specificity and sensitivity values. RESULTS: Preoperatively, patients exhibited mechanical hypoesthesia and allodynia and pressure allodynia and hyperalgesia in painful areas mapped (+) (p < .05); sensory mapping outcome (+) demonstrated high ability to detect mechanical allodynia [sensitivity 0.74 (95% CI 0.61-0.86), specificity 0.94 (0.84-1.00)] and pressure allodynia [sensitivity 0.96 (0.89-1.00), specificity 1.00 (1.00-1.00)], but not thermal allodynia. Postoperatively, mapped areas of numbness (-) were associated with mechanical and thermal hypoesthesia (p < .05); (-) showed high sensitivity and specificity to detect mechanical and cold hypoesthesia. CONCLUSIONS: Sensory mapping provides an accurate clinical neuropathic assessment with strong correlation to QST findings of preoperative mechanical and pressure allodynia, and postoperative mechanical and thermal hypoesthesia in CPIP patients undergoing neurectomy.

An international consensus algorithm for management of chronic postoperative inguinal pain.

PURPOSE: Tension-free mesh repair of inguinal hernia has led to uniformly low recurrence rates. Morbidity associated with this operation is mainly related to chronic pain. No consensus guidelines exist for the management of this condition. The goal of this study is to design an expert-based algorithm for diagnostic and therapeutic management of chronic inguinal postoperative pain (CPIP). METHODS: A group of surgeons considered experts on inguinal hernia surgery was solicited to develop the algorithm. Consensus regarding each step of an algorithm proposed by the authors was sought by means of the Delphi method leading to a revised expert-based algorithm. RESULTS: With the input of 28 international experts, an algorithm for a stepwise approach for management of CPIP was created. 26 participants accepted the final algorithm as a consensus model. One participant could not agree with the final concept. One expert did not respond during the final phase. CONCLUSION: There is a need for guidelines with regard to management of CPIP. This algorithm can serve as a guide with regard to the diagnosis, management, and treatment of these patients and improve clinical outcomes. If an expectative phase of a few months has passed without any amelioration of CPIP, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Surgeons less experienced with remedial operations for CPIP should not hesitate to refer their patients to dedicated hernia surgeons.

International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery.

PURPOSE: To provide uniform terminology and definition of post-herniorrhaphy groin chronic pain. To give guidelines to the scientific community concerning the prevention and the treatment of chronic groin and testicular pain. METHODS: A group of nine experts in hernia surgery was created in 2007. The group set up six clinical questions and continued to work on the answers, according to evidence-based literature. In 2008, an International Consensus Conference was held in Rome with the working group, with an audience of 200 participants, with a view to reaching a consensus for each question. RESULTS: A consensus was reached regarding a definition of chronic groin pain. The recommendation was to identify and preserve all three inguinal nerves during open inguinal hernia repair to reduce the risk of chronic groin pain. Likewise, elective resection of a suspected injured nerve was recommended. There was no recommendation for a procedure on the resected nerve ending and no recommendation for using glue during hernia repair. Surgical treatment (including all three nerves) should be suggested for patients who do not respond to no-surgery pain-management treatment; it is advisable to wait at least 1 year from the previous herniorraphy. CONCLUSION: The consensus reached on some open questions in the field of post-herniorrhaphy chronic pain may help to better analyze and compare studies, avoid sending erroneous messages to the scientific community, and provide some guidelines for the prevention and treatment of post-herniorraphy chronic pain.

Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia: triple neurectomy with proximal end implantation.

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.

The Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty.

Lichtenstein tension-free hernioplasty began in 1984. Based on our own mistakes, in the late 1980s, we established a set of key principles and reported the causes of our recurrences. Recently, other authors analyzing the causes of their own recurrences with tension-free repair are drawing the same conclusions. This indicates that others are repeating our previously reported mistakes. To prevent recurrence, the mesh size was increased to 7.5x15 cm to extend well beyond the boundary of the inguinal floor and give the mesh a dome-shaped laxity to compensate for the increased intra-abdominal pressure and mesh shrinkage. Wide extension of the mesh beyond the inguinal floor and the dome-shaped laxity of the mesh served to further reduce recurrence rate. Following the key principles of the Lichtenstein tension-free hernioplasty, which can be facilitated by using a recently developed prosthesis that addresses all the key principles of the procedure, achieves the best result.

Today's controversies in hernia surgery.

For more than a century, since the introduction of modern hernia repair by Basinni, technical aspects of hernia surgery have been surrounded by controversies. The purpose of this article is to examine these controversies with special attention to (a) mechanical versus degenerative nature of hernias, (b) traditional tissue approximation repair (tension repair) versus tension-free mesh repair, (c) patch or plug repair, and (d) open versus laparoscopic approach. It is concluded that the concept of open tension-free hernioplasty, utilizing a patch of appropriate synthetic material through an anterior approach, is a potential resolution of the controversies that have surrounded the subject of hernia surgery for more than a century.