Current trends in the diagnosis and management of post-herniorraphy chronic groin pain

Table 1 Studies showing neurectomy performed by open, laparoscopic or a combination of both open and laparoscopic approach

Author	Country	No. of pts	Surgical approach	Which nerve excised?	Was mesh excised?	Follow-up duration	Recurrence/Persistent pain	Complications	Remarks
Hameroff et al[49], 1981	USA	2	Open	IIN	N/A	NM	2/2	Nil	Only temporary pain relief following neurectomy
Stulz et al[48], 1982	Switzerland	5	Open	IIN	N/A	NM	No separate data for inguinal hernia patients	Nil	Out of 22 patients who underwent neurectomy, 5 had previous inguinal hernia repair. In all inguinal hernia cases, IIN was entrapped within the scarred tissue and was excised
Harms et al[30], 1984	USA	2	Open	GFN, IIN + GFN	N/A	18 mo (patient 1), NM in other patient	2/2	Wound infection (2)	First patient had 2 unsuccessful exploration, followed by successful GFN block and 3rd exploration with GFN neurectomy. Second patient had IIN neurectomy on 1st exploration and due to recurrence of pain further exploration and GFN neurectomy
Starling et al[33], 1987	USA	26	Open	IIN or GFN	N/A	NM	2/13 in IIN group and 3/13 in all GFN group patients	Nil	No differentiation possible in GFN group to establish only patients with previous hernia repair. Overall 10 out of 13 with GFN neurectomy were pain free
Starling et al[29], 1989	USA	31	Open	IIN or GFN	NM	NM	2/19 in IIN	Nil	Selective nerve blocks used to identify involved nerve(s). In GFN group, no data was given to differentiate those patients who had hernia repair and those who had other abdominal operations
							4/12 in GFN
Bower et al[34], 1996	USA	15	Open	IIN, IHN, GFN or LFC	No	66 mo	3/12	Nil	Three patients had persistent pain following redo exploration. Redo explorations could not identify involved nerve in two patients and identified a recurrent hernia in the other patient
Nahabedian et al[51], 1997	USA	2	Open	IIN, IHN or GFN	NM	21 mo	0/2	Nil	In one of the patients, no nerve was identified intra-operatively and on the tissue excised, but pain relief was noted post-operatively
Heise et al[11], 1998	USA	20	Open	IIN or IHN or GFN	Yes	16 ± 3 mo	8/20	Haematoma (1), Testicular atrophy (1)	4 patients had only mesh excised and 6 patients underwent selective neurectomy based on operative findings plus mesh excision
Lee et al[53], 2000	USA	11	Open	IIN, IHN, GFN or LFC	Yes	10 mo	NM	Haematoma (1) and recurrent hernia (1)	History and clinical examination alone was done for pre-operative assessment. Mesh removal alone did not relieve pain in any patients. IIN was commonly excised. Majority of patients had excellent pain relief, no differentiation could be done to identify those with hernia repair
Deysine et al[32], 2002	USA	22	Open	IIN	No	NM	0/22	Nil	Diagnostic nerve blocks were attempted in all patients. 8 out of 30 patients responded to conservative treatment and the rest were subjected to IIN neurectomy alone. No follow-up data was available and complications were not mentioned
Ducic et al[56], 2004	USA	4	Open	GFN + IIN	No	9 mo	0/4	Nil	All patients had failed medical treatment. No clear information on diagnosis of nerve entrapment, One patient had previous unsuccessful GFN resection and another patient had previous failed IIN resection
Kim et al[38], 2005	USA	16 (33 total)	Open	IIN, IIN + IHN	NM	12-46 mo	3/33, 10% had recurrent pain, but no clear mention about hernia patients	NM for hernia patients	33 patients were operated for CGP, but only 16 had previous hernia repair. Diagnostic nerve blocks done on all patients. Of all 33 patients operated, 91% of IIN neurectomies and 90% of combined IIN + IHN neurectomies were successful
Amid et al[54], 2004	USA	225	Open	Triple neurectomy	Yes	6 mo	15% had transitional incisional pain with no functional impairment	Nil	Proposed 1-stage procedure of simultaneous neurectomy of all three nerves without mobilisation of spermatic cord. The nerve ends were implanted proximally into the fibres of internal oblique muscle
Murovic et al[50], 2005	USA	1	Open	GFN	No	NM	0/1	Nil	Ten patients with Genitofemoral neuralgia were analysed, but only one patient had previous hernia repair. Diagnostic nerve blocks were used prior to GFN neurectomy by lateral extraperitoneal approach
Ducic et al[27], 2008	USA	18	Open	IIN, IHN, GFN or LFC	NM	12-24 mo	3/18	Nil	Nerve blocks not routinely done. Patients selected for surgical intervention based on history and physical findings
Delikoukos et al[12], 2008	Greece	6	Open	IIN	Yes	28 mo	0/6	Nil	No nerve blocks were utilised. Persistent pain in spite of analgesics were indication for surgery in this study. IIN were either excised or freed from the mesh, if entrapped
Vuilleumier et al[24], 2009	Switzerland	43	Open	IIN + IHN	Yes	12 mo	2/43	Recurrent hernia (1)	Diagnosis of neuropathy was done using clinical findings and positive Tinel’s sign. All patients had failed conservative treatment with systemic analgesics, injection of local anaesthetics and steroids, and physiotherapy. Radical neurectomy done in all cases. GFN not excised in any case
Zacest et al[58], 2010	USA	27	Open	IIN, GFN	Yes	35 mo	6/19 (followed-up patients)	Nil	Diagnosis was made using selective nerve blocks. Only 19 of the 27 patients responded to telephone follow-up and 67% mentioned either complete pain relief or pain lesser than before
Loos et al[52], 2010	Netherlands	54	Open	IIN, IHN, GFN	Yes	18 mo	24%	Haematoma (1), wound infection (1), haemorrhage (1), ischaemic orchitis (1)	Diagnostic nerve blocks were used in majority of them (78%) and some patients underwent CT or MRI (22%). Tailored neurectomy performed depending on intra-operative findings
Krähenbühl et al[55], 1997	Switzerland	2	Laparoscopic (Retro-peritoneal)	GFN and IIN	No	3 mo	0/2	Nil	No information given about the diagnosis of CGP and indication for laparoscopic neurectomy. Retroperitoneal neurectomy done, but no clear mention about how the nerves were identified intra-operatively
Wong et al[59], 2001	Canada	1	Laparoscopic (pre-peritoneal approach, under fluoroscopic guidance)	Nerve not excised	Yes (mesh and staples)	NM	0/1	Nil	Single patient report with 5 month history of groin pain following laparoscopic hernia repair. Mesh and tackers were found to entrap the IIN and were removed laparoscopically aided by fluoroscopy
Rosen et al[57], 2006	USA	12	Combined open and laparoscopic	IIN + IHN	Yes	6 wk	0/12	Nil	All patients had previous open hernia repair and 2 failed percutaneous nerve blocks to treat CGP. TAPP repair done initially, followed by groin exploration, mesh removal and nerve transection. Too short follow-up
Keller et al[41], 2008	USA	21	Combined open and laparoscopic	Triple neurectomy	Yes	6 wk	1/19 (followed up patients)	Nil	Percutaneous nerve block was unsuccessful in all patients. Initially transabdominal diagnostic laparoscopy was performed irrespective of the route of initial surgery. Mesh was placed in the opposite location to the first mesh (laparoscopic if the first was open and vice-versa). Too short follow-up

NM: Not mentioned; IIN: Ilioinguinal neurectomy; IHN: Iliohypogastric neurectomy; GFN: Genitofemoral neurectomy; LFC: Lateral femoral cutaneous neurectomy; CGP: Chronic groin pain; N/A: Not applicable; Triple Neurectomy: IIN + IHN + GFN neurectomy; TAPP: Trans-abdominal pre-peritoneal repair; CT: Computed tomographic; MRI: Magnetic resonance imaging.