Surgical management of chronic inguinal pain syndromes - Liespijn

QuestionPossible answers1 Could you estimate the average pain intensity No pain, Mild pain, Moderate pain,before your operative inguinal pain treatment? Severe pain, Very severe pain2 Could you estimate the average pain intensity No pain, Mild pain, Moderate pain,directly after your operative inguinal pain Severe pain, Very severe paintreatment?3 Could you estimate the average pain intensity No pain, Mild pain, Moderate pain,in the treated groin during the past two weeks? Severe pain, Very severe pain4 Imagine that your preoperative pain intensity …………%is set at 100%. What is the percentage of painyou experienced during the past two weeks?aan de IJssel, the Netherlands) subcutaneously two hours prior to the procedure.By extending the inguinal incision several centimetres laterally, access was gained to anon-operated area. The iliohypogastric and/or ilioinguinal nerves penetrating theinternal oblique muscles were identified. Any prosthetic material was dissected free ofthese nerves for additional exposure. The genital branch of the genitofemoral nervewas usually found just posterior to the spermatic cord. Nerves were excised if fibroticencasement or neuroma formation was observed. After peripheral division, proximalnerve ends were cauterized, occasionally ligated under traction, and allowed to retractinto the internal oblique muscle to prevent fibrotic encasement. If nerves were thought‘entrapped’ by preperitoneal mesh, the preperitoneal space was opened by dividing theinternal oblique and transversus abdominis layers. When a displaced bulk of meshmaterial was found, parts of the bunched up mesh were removed. The sequence oftechnical steps was not standardized, because perioperative findings guided decisionsconcerning nerve resection and mesh removal (‘tailored approach’).5 Did you experience any of the following Wound infection, Postoperative‘complications’?haemorrhage, Skin numbnessSkin hypersensitivity, Bulge,Onset of other pain symptoms6 How is the sensitivity of your skin? Normal, No sensitivity, Numb,Hypersensitive, Painful at light touch7 How do you judge your treatment result? Excellent - I am pain freeGood - I am almost pain freeModerate - Although there is somepain reduction, I am still frequentlybothered by pain complaintsPoor - The operation had no effectand the pain is virtually the sameWorse - The operation has worsened my pain8 If you had the choice, would you then opt to Yes, Noreceive the operative treatment again?9 Did you experience any inguinal pain During sex, During orgasm, Following anpreoperatively during one or moreorgasm, Not appropriate,of the following situations?No I did not experience sex-induced pain10 If you experienced sex-induced pain, did the Yes, I am now totally pain freeoperation relieve these pain complaints?Yes, there was some improvementNo, these pain symptoms are unchangedTable 1 QuestionnaireQuestionnaire and statistical analysisA slightly modified questionnaire based on a recently published review was sent to allpatients in October 2008 (table 1) 13 . Non-responders received two reminders, one bymail and one by phone. Preoperative and current pain intensity as measured by a5-point Verbal Rating Scale (and percentages), perceived treatment results, and effect onsexual intercourse-related complaints were scored. To identify possible factors predictingpoor treatment results, a multivariate logistic regression analysis was performed.Treatment results served as the dependent factor (excellent/good/moderate vs. poor/worse), whereas presence of recurrent inguinal hernia surgery, type of initial herniarepair (open non-mesh repair, open or laparoscopic mesh repair), previous pain treatmentand presence of nerve tissue at histopathologic examination acted as covariatecategorical factors. In order to detect a possible learning curve for the procedure,treatment results were analyzed per treatment year. Results were considered significantfor p-values ≤ 0.05.RESULTSBetween January 2003 and June 2008, 68 patients underwent operative treatment forpostherniorrhaphy inguinal pain. Fourteen patients were excluded for reasons listed infig 1, leaving 54 patients for analysis (56 groins, bilateral neurectomy in 2 patients).Combined pain syndromes were present in 6 patients (e.g. nerve entrapment and pubicperiostitis or pain from a meshoma). There were 43 males and 11 females with a medianage of 50 years (range: 18-88 years). As most patients (n= 41, 75%) were referred from84 Chapter 6Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia 85