Surgical management of chronic inguinal pain syndromes - Liespijn

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INTRODUCTIONImplantation of mesh is considered the ‘gold standard’ for the treatment of inguinalhernia repair as the risk of recurrence is half compared to traditional non-mesh techniques1 . Ever since recurrence rates declined, attention has gradually shifted towardsstudying the onset of chronic pain following inguinal mesh repair as an early studyreported a staggering 63% incidence rate of chronic postoperative pain 2 . From the midninetieson somewhat lower (0-53%) incidence rates of chronic pain were published 3-5 .However, the need for additional research on etiology and treatment of these chronicpain syndromes following inguinal mesh repair became increasingly evident.Non-mesh inguinal procedures including Pfannenstiel incisions that are frequently usedas an aid in laparoscopic or gynaecological surgery are also noted to coincide with painsymptoms that appeared similar as observed following mesh inguinal hernia repair 6,7 .Interestingly, efforts that systematically studied incidence rate and risk factors for chronicpain syndromes after a Pfannenstiel incision have not been performed.Chronic pain after mesh implantation for inguinal hernia repair or after a Pfannenstielapproach is likely related to the interference with nerve structures located in the lowerabdominal and inguinal area. A thorough knowledge on the complex anatomy of theseregions aids in understanding the characteristics of these chronic inguinal pain syndromes.AnatomyDifferent myofascial layers compose the lower abdominal and the inguinal canal. Thesensory innervation of these areas is provided by four inguinal nerves, the iliohypogastric,ilioinguinal, genitofemoral and lateral femoral cutaneous nerve. The latter israrely affected due to its lateral position and is not discussed. In contrast, the other threenerves may be injured following surgical manipulation associated with inguinal herniarepair or Pfannenstiel incisions.The iliohypogastric nerve is the most cranial of the three. It arises from T12 / L1 vertebrae,runs ventrally from the lumbar quadrate muscle and gradually pierces various layers ofthe abdominal wall. Its function is to supply the suprapubic region with sensation. Theilioinguinal nerve originates from the same vertebral level and travels a similar coursea few centimetres caudal to the iliohypogastric nerve. Sensation to the base of the pubicarea and inner thigh is provided by this nerve. Endings of both these nerves can befound subcutaneously or subfascially at the lateral margin of the rectus border.The genitofemoral nerve originates from L1/ L2 and pierces the iliopsoas muscle whereit runs caudally on its ventral surface. It usually demonstrates a division into a genitaland femoral branch some centimetres proximal to the inguinal ligament. The genitalbranch subsequently runs underneath the spermatic cord or round ligament innervatingthe scrotum or labia majora. In men, the genital branch also forms the afferent8 Chapter 1Introduction, aims and outline 9
pathway for the cremasteric reflex. The femoral branch innervates the skin of theanterior upper leg region. It should be stressed that anatomical variations in the inguinalcourse of all three inguinal nerves are exceedingly common 8 .Pain characteristics after inguinal hernia repair or Pfannenstiel incisionsThe pathogenesis of chronic pain after inguinal hernia repair in general has been scarcelyinvestigated. An early 1942 study reported on ‘genitofemoral causalgia’ following a herniaoperation 9 . In 1988 Lichtenstein published a review on causes and prevention of postherniorrhaphyneuralgia following mesh repair emphasizing the necessity of nerveidentification and preservation 10 . However, it took nearly twenty years before a classificationfor postherniorrhaphy groin pain syndromes was proposed 11 . It was suggestedthat pain syndromes should be classified as ‘neuropathic’ and ‘non-neuropathic’.Neuropathic pain is thought to be caused by neuroma formation due to damaged nervetissue or entrapment following compressive sutures or mesh material. Developmentof fibrosis over time may also lead to compression of neural structures. Neuropathicpain is characterized as sharp or stabbing and is situated in or around the inguinal scar.Neuropathic pain frequently radiates into its associated skin area. Physical examinationoften reveals neurophysiological abnormalities including hypoesthesia, hyperesthesiaor allodynia. On the other hand, non-neuropathic (‘nociceptive’) pain is due to damagedsurrounding structures such as periostal layers or musculotendinous tissues. Mechanicalpressure due to gradual mesh displacement or contraction is also implicated as a sourceof nociceptive pain 11 . Nociceptive pain is often described as aching or pulling in theFigure 1 Neuro-anatomy of the male inguinal region. Figure 2 The Pfannenstiel incision in relation to the iliohypogastric (A) and ilioinguinal (B) nerve 7 .10 Chapter 1Introduction, aims and outline 11
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INTRODUCTIONWorldwide millions of l
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‘diagnostic’ nerve block. A one
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DISCUSSIONIn the present study a ne
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CHAPTER 9Occupational disability du
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INTRODUCTIONIn the Netherlands, app
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period, a 25% reduction on their in
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17 Madura JA, Madura JA 2nd, Copper
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SUMMARIZING DISCUSSION1. Prevalence
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Results of our study are in concert
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and possible treatment effect. Idea
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CHAPTER 11Nederlandse samenvatting1
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patiënten beschreef hij drie versc
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CHAPTER 12List of publications158 C
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CHAPTER 13Dankwoord162 Chapter 13Da
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CHAPTER 14Curriculum Vitae166 Chapt
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Surgical management of chronic inguinal pain syndromes - Liespijn

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