Surgical management of chronic inguinal pain syndromes - Liespijn

of the genitofemoral nerve is identified just underneath the spermatic cord. The genitalbranch can also be affected at the level of the internal ring, making an anterior approachdifficult or less effective. Therefore an additional retroperitoneal approach can be chosenin case of a suspected genital branch neuropathy. Occasionally the genital branch isabsent or is not found due to previous procedures. Nerves are excised if fibroticencasement or possible neuroma formation is observed. After peripheral division includingthe intramuscular segment, proximal nerve ends are cauterized, occasionallyligated under traction and allowed to retract into the internal oblique muscle to preventa relapse of fibrotic encasement. If nerves are thought ‘entrapped’ by preperitonealmesh placement, the preperitoneal space is opened by dividing the internal obliqueand transversus abdominis layers. In case of displaced bulky mesh material, parts ofmesh are removed. In case of mesh removal, it is always accompanied by a neurectomy.The sequence of surgical steps is dictated by the perioperative findings. A decisionconcerning nerve resection and (partial) mesh removal is thus guided by the individualsituation, the ‘tailored approach’, which has been published recently by our group ofinvestigators 11 . All resected specimens are histopathologically examined.Neuropathic pain afteringuinal hernia repairDiagnostic nerve blockInclusion:Temporary pain reliefExclusion:No pain or persistentpain relief afterdiagnostic nerve blockCollection of data and clinical follow-upA total of five assessments are planned for each patient by the principal investigators.Baseline details and a standard questionnaire assessment are collected at inclusion(visit 1). In case of randomization for nerve blocks, patients return two weeks after thefirst nerve block to the outpatient department for clinical examination and a secondquestionnaire assessment (visit 2). If pain reduction after nerve bocks is only temporary,a cross-over to the neurectomy group is offered 6 months post-inclusion (Fig. 1).If randomized to neurectomy, the surgeon tabulates all operative details including allsurgical steps in a standard report. Two weeks after the operation, patients are assessedRandomizationGroup Ainjection therapyGroup BNeurectomy2 weeks 2 weeks3 months 3 monthsCross-over6 monthspossible6 months12 months 12 monthsFigure 1 Study design.Figure 2 Diagnostic nerve block in a left groin.100 Chapter 7Randomized controlled trial of neurectomy versus injection with lidocain, corticosteroids... 101