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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 152-157

Effect of neurectomy versus ilioinguinal nerve preservation in the Lichtenstein tension-free hernioplasty of inguinal hernia


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission06-Nov-2016
Date of Acceptance10-Feb-2017
Date of Web Publication14-Jun-2018

Correspondence Address:
Yasser Z M. Khater
El Raml, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_606_16

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  Abstract 


Objectives
The aim of this study was to evaluate the effectiveness of ilioinguinal neurectomy on postoperative pain in the Lichtenstein tension-free hernioplasty of inguinal hernia.
Background
Chronic pain following tension-free inguinal hernioplasty is a significant clinical problem that can interfere with normal daily activities. Moreover, the condition can sometimes be debilitating, and treatment is often difficult and challenging. Contrary to the previous belief, division of the ilioinguinal nerve prophylactically during mesh repair has been practiced to reduce the incidence and intensity of persistent postoperative pain after hernia repair.
Patients and methods
Between April 2015 and October 2016, this prospective, randomized, controlled study included 40male patients above 18years of age with unilateral inguinal hernia who were undergoing the Lichtenstein hernia repair. Patients were randomized into two groups–the ilioinguinal neurectomy group and the ilioinguinal nerve preservation group. Twenty patients were included in each group. Patients were followed-up for inguinal postoperative pain at 1 and 6months using a four-point categorical scale. Groin numbness was also assessed at 1 and 6months using a self-administered questionnaire.
Results
There were no statistically significant differences between the two groups with regard to postoperative pain after 1 and 6months at rest; however, after coughing 10times, walking up three flights of stairs, and cycling for 10min, there were statistically significant differences–postoperative pain in groupA was 5% and in groupB 30%(P<0.05). There were statistically significant differences with regard to postoperative groin numbness after 1month–postoperative numbness in groupA was 15%(P=0.046). However, after 6months, there were no significant differences between the two groups with regard to groin numbness(P=0.156).
Conclusion
Ilioinguinal neurectomy should be considered a routine surgical step during the Lichtenstein tension-free hernioplasty.

Keywords: chronic groin pain, hernioplasty, ilioinguinal neurectomy, inguinal hernia


How to cite this article:
Omar AA, Rageh TM, M. Khater YZ. Effect of neurectomy versus ilioinguinal nerve preservation in the Lichtenstein tension-free hernioplasty of inguinal hernia. Menoufia Med J 2018;31:152-7

How to cite this URL:
Omar AA, Rageh TM, M. Khater YZ. Effect of neurectomy versus ilioinguinal nerve preservation in the Lichtenstein tension-free hernioplasty of inguinal hernia. Menoufia Med J [serial online] 2018 [cited 2018 Nov 17];31:152-7. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/152/234235




  Introduction Top


Inguinal hernias are the most common abdominal wall hernias. They account for 80% of all hernias diagnosed [1]. Approximately 96% of all groin hernias are inguinal hernias. Inguinal hernias occur in about 15% of adult men [2]. Various techniques have been used for repairing inguinal hernias such as the Lotheissen, McVay, and Shouldice techniques, but a dramatic change appeared when Lichtenstein first introduced a mesh for tension-free reconstruction of hernial defects, which later became the gold standard [3].

Chronic pain following inguinal hernia remains an important measure of clinical outcome that has been reported in 63% of inguinal hernia repair cases [4]. Chronic groin pain can be classified into neuropathic and nociceptive(somatic) pain. Neuropathic pain occurs as a result of entrapment or direct nerve injury. Entrapment of one or more inguinal nerves can be caused by perineural fibrosis, suture material, staples, and mesh prosthetic material [5]. Direct nerve damage can be caused by partial or complete transection of nerves due to accidental cutting, excessive traction of the nerves, or electrical coagulation [6]. Nociceptive(somatic) pain is caused by mesh-related fibrosis, mechanical pressure caused by a folded mesh, gradual mesh displacement or contraction, damaged surrounding structures such as periosteal layers or musculotendinous tissues, or postoperative causes [7].

Evidence concerning treatment options for chronic groin pain syndromes is limited. Nonsurgical treatment options including analgesics(e.g.,NSAIDS, antidepressants, or anticonvulsants), peripheral nerve blocks with local anesthetics, transcutaneous electric nerve stimulation, laser therapy, pulsed radio frequency for chronic posthernioplasty pain have been used for a limited number of patients [8]. Surgical treatment is based on the repair technique, subsequent reoperations, pain character, the presence of recurrence, meshoma, and the fixation material. Selective ilioinguinal, iliohypogastric, and genitofemoral neurolysis or neurectomy, removal of mesh, and revision of repair are common options of surgical treatment [9].

Much controversy exists regarding the best management for the ilioinguinal nerve during hernia repair. Traditional surgical techniques dictate that the ilioinguinal nerve should be preserved at all times during repair because of the morbidity associated with cutaneous sensory loss and chronic groin pain following nerve injury. Elective division of the ilioinguinal nerve to reduce development of chronic posthernioplasty pain has been recommended by some workers. Recently reported randomized controlled trials have confirmed the benefits of neurectomy in chronic posthernioplasty pain [10].

The aim of this study was to evaluate the effect of prophylactic ilioinguinal neurectomy on the incidence and severity of chronic groin pain following the Lichtenstein tension-free hernioplasty for inguinal hernia.


  Patients and Methods Top


After receiving approval from the appropriate ethics committee, this prospective, randomized study was conducted at Menoufia University Hospitals and Ras Elteen General Hospital between April 2015 and October 2016.

Randomization was carried out as listed by randomization technique inMicrosoftExcel Program (Excel Township, Marshall county, Minnesota, USA).

Forty male patients with primary unilateral inguinal hernias were included in this study. All of them were above 18years of age and were undergoing the Lichtenstein tension-free hernioplasty.

Patients with recurrent hernias, irreducible or strangulated hernias, peripheral neuropathy, and previous abdominal surgery within the past 1year were excluded.

Informed consent was obtained from patients before the procedures.

Each patient was subjected to full history taking, thorough clinical examination, laboratory investigations, and radiological investigation in the form of chest radiography.

Patients were stratified according to the Nyhus etal. [11] classification, which differentiates four types of hernia:

  • TypeI is an indirect hernia with a normal internal ring
  • TypeII is an indirect hernia with an enlarged internal ring
  • TypeIIIa is a direct inguinal hernia
  • TypeIIIb is an indirect hernia causing posterior wall weakness
  • TypeIIIc is a femoral hernia
  • TypeIV represents all recurrent hernia.


All patients undergoing the Lichtenstein tension-free hernioplasty were randomly divided into two groups, and each group included 20patients. In groupB, the repair was performed and a polypropylene mesh measuring 7×15cm was secured to the floor of the inguinal canal by 2/0 nylon stitches. The ilioinguinal nerve mentioned above was identified and preserved. Next, the external oblique fascia was closed above the spermatic cord. In groupA, the whole ilioinguinal nerve was excised as far lateral to the deep ring as possible and medially to where it enters the rectus muscles. The cut ends were left free without implantation into muscle or ligation. Apolypropylene mesh was placed as described.

Assessment of pain immediately postoperatively was carried out using a numeric pain-rating scale, and the amount of analgesia required was recorded.

Early postoperative complications such as wound infection, hematoma, retention of urine, chest infection, or deep vein thrombosis were recorded.

Follow-up for the presence or absence of pain at 1 and 6months postoperatively at rest and upon completion of various activities(coughing 10times, walking up three flights of stairs, and cycling for 10min) was carried out using a four-point scale(none, mild, moderate, and severe).

Numbness at the groin region was assessed postoperatively, documented by a self-administered questionnaire with a four-point scale(none, mild, moderate, and severe).

Statistical analysis

Data were collected and entered into a personal computer. Allstatisticalanalyses were carried out using statistical package for the social sciences (SPSS, version20) software. The arithmetic mean and SD for categorized parameters were calculated. The χ2-test was used for numerical data, and the t-test was used to compare between two groups. The level of significance was set at 0.05.


  Results Top


The present study included 40male patients who were randomly allocated into two groups with 20patients each. GroupA patients underwent ilioinguinal neurectomy, whereas groupB patients had ilioinguinal nerve preservation. The patients were followed-up for 6months after the operation.

The age range of patients in groupA was from 22 to 47years with a mean of 34.7±8.92years, whereas it ranged from 19 to 50years with a mean of 32.55±9.52 in groupB. There was no significant statistical difference between the two groups, as the P value was 0.233[Table1].
Table 1: Comparison between the two studied groups regarding age

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According to the Nyhus classification, it was found that in groupA eight(40.0%) patients were typeI, seven(35.0%) patients were typeII, three(15.0%) patients were typeIIIa, and two(10.0%) cases typeIIIb, whereas in groupB it was found that seven(35.0%) patients were typeI, eight(40.0%) patients were typeII, two(10.0%) patients were typeIIIa, and three(15.0%) cases typeIIIb. On comparing the two groups, it was found that there was no significant difference between the two groups, as the P value was 0.265[Table2].
Table 2: Distribution of the studied patients regarding the type of hernia according to the Nyhus classification

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The ilioinguinal nerve was identified and excised in groupA, whereas it was identified and preserved in groupB.

In both groups, all patients had immediate postoperative pain(at 12 and 24h). At 12h, postoperative pain ranged from 2 to 7 on the numeric pain-rating scale in groupA, whereas it ranged from 1 to 7 in groupB. At 24h, pain in both groups ranged from 0 to 6. At 7days, pain ranged from 0 to 4 in groupA, whereas it ranged from 0 to 3 in groupB. Pain at 7days was significantly lower than at 12 and 24h[Table3].
Table 3: Comparison between the two studied groups according to immediate postoperative pain

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At 12h, in groupA, 18(90%) patients were relieved by regular analgesia consisting of NSAIDs only, and two(10%) patients needed opioid analgesia. In groupB, 17(85%) patients were relieved by regular analgesia, and three(15%) patients needed opioid analgesia. At 24h, 16(80%) patients needed regular analgesia in both groups, and only one patient needed opioid analgesia in groupB. At 7days, three(15%) patients in groupA and two(10%) patients in groupB needed regular analgesia. Analgesic needs at 7days were significantly lower than that at 12 and 24h[Table4].
Table 4: Comparison between the two studied groups according to need of analgesia at immediate postoperative periods

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Two(10%) patients in both groups had superficial wound infection and received appropriate antibiotics. One(5%) patient each from both groups had hematoma. One(5%) patient in groupB had retention of urine. There was no statistically significant difference regarding incidence of early postoperative complications in the two studied groups, with a P value was 0.246[Table5].
Table 5: Incidence of early postoperative complications in the two studied groups

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All patients in both groups were assessed with regard to postoperative pain and groin numbness after 1month. There were no statistically significant differences between the two groups at rest(P=0.369); however, after coughing 10times, walking up three flights of stairs, and cycling for 10min, there were statistically significant differences as postoperative pain in groupA was 5% and in groupB 30%(P<0.05). Regarding sensory disturbance after 1month postoperatively, there were statistically significant differences, as postoperative numbness was 15% in groupA, with a P value of 0.046[Table6].
Table 6: Comparison between the two studied groups according to postoperative pain after 1 month

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Follow-up of patients in both groups after 6months showed that there were no statistically significant differences between the two groups with regard to postoperative pain after 6months at rest(P=0.152), but after coughing 10times, walking up three flights of stairs, and cycling for 10min, there were statistically significant differences, as postoperative pain in groupA was 5% and in groupB 30%(P<0.05). Regarding sensory disturbance after 6months postoperatively, there were no statistically significant differences, as the P value was 0.156[Table7].
Table 7: Comparison between the two studied groups according to postoperative pain after 6 months

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  Discussion Top


In the present study, patients of both groups were comparable with respect to age. The mean age of patients in groupA was 34.7±8.92, and in groupB it was 32.55±9.52. In a study by Mui etal. [12], the age ranges were 65.1±10.1 and 63.0±16.3, respectively. The mean age of patients in a study by Alfieri etal. [6] was 55years, and in a study by Zanghi etal. [13] it was 58years. The mean age reported by Nienhuijs etal. [14] was 57.5years. Thus, inguinal hernia is a disease affecting all age groups. Prolonged straining and heavy lifting are mostly the causes in younger patients, whereas urinary problems comprise the chief etiology in older patients as a result of benign prostatic hyperplasia [15],[16].

Bittner etal. [17] reported an overall risk of complications after inguinal hernia operations from 15 to 28%. The authors found that hematomas and seromas were the most frequent early complications. Schmedt etal. [18] found a similar incidence of complications. However, Nordin etal. [19] found a higher incidence of complications ranging from 17 to 50%.

McCormack etal. [20] reported that early complications included hematomas, seromas, urinary retention, and early pain, whereas late complications included chronic pain and recurrences. Life-threatening complications were rarely reported. Simons etal. [21] stated that the risk for hematomas varies between 5.6 and 16%, whereas the risk of wound infection should be below 5%.

In our study, the overall incidence of postoperative complications in the two groups was 20%. Superficial wound infection was the most frequent, found in 10% of cases in both groupA and groupB. Inguinal hematoma was the second most common complication; it was present in 5% of cases in both groups.

In the study by Ravichandran etal. [22], the first to assess the effect of division of the ilioinguinal nerve in a randomized manner, they performed randomization in a patient with bilateral inguinal hernia(neurectomy on one side and preservation of the ilioinguinal nerve on the other side). No evidence was found to support the benefit of ilioinguinal nerve division with respect to postoperative pain. However, this study was limited by its small sample size as well as the short follow-up of 6months.

Ravichandran etal. [22] did not compare between two groups, and also did not study chronic pain after various exercises as well as numbness along the ilioinguinal nerve distribution.

In another retrospective study, Dittrick etal. [23] included 156patients who were randomly divided into two groups either with ilioinguinal nerve preservation or transection. They found that there were no statistically significant differences between the two groups with regard to groin pain after 1month postoperatively. Dittrick etal. [23] did not test groin numbness as well as groin pain after various activities.

Our study was performed on 40patients aged 18years and older who had primary inguinal hernia, and were randomized into [2] groups–groupA underwent ilioinguinal neurectomy and groupB underwent ilioinguinal nerve preservation.

There were no statistically significant differences between the two groups with regard to postoperative pain after 1month at rest(P=0.369); however, after coughing 10times, walking up three flights of stairs, and cycling for 10min, there were statistically significant differences. Postoperative pain in groupA was 5%, and in groupB it was 30%(P<0.05). Regarding sensory disturbance after 1month postoperatively, numbness was 15% in groupA(P=0.046).

Dittrick etal. [23] reported a significantly lower incidence of chronic groin pain in patients who had elective neurectomy during open inguinal hernia repair when compared with the control group(3vs. 2.5%) after 6months. They did not test groin pain after various activities and groin numbness as in our study.

Crea and Pata [24] randomized 97 consecutive patients into nerve division and preservation groups. They found reduced intensity of mild-to-moderate chronic groin pain after 6months in the prophylactic nerve division group as compared with the preservation group.

In a randomized study by Picchio etal. [25], who performed their study on 813patients randomly allocated into two groups either with ilioinguinal nerve preservation or transection, only 593patients made an office visit 1year postoperatively They concluded that pain after open hernia repair with a polypropylene mesh was a relevant problem and was unaffected by elective division of the ilioinguinal nerve. In addition, the division of the ilioinguinal nerve was significantly related to sensory disturbances in the area of nerve distribution.

In our study, there were no statistically significant differences between the two groups with regard to postoperative pain after 6months at rest(P=0.152); however, after coughing for 10times, walking up three flights of stairs, and cycling for 10min, there were statistically significant differences. Postoperative pain in groupA was 5% and in groupB 30%(P<0.05). Regarding sensory disturbance after 6months postoperatively, there were no statistically significant differences(P=0.156).

Despite controversies in management of the ilioinguinal nerve during hernioplasty, our results revealed that elective resection was better in terms of chronic postoperative pain. In addition, postoperative numbness was not such a frequent complaint that affected daily activities of patients when compared with chronic postoperative pain, especially because it was no longer present after 6months. Our results support that elective resection of the ilioinguinal nerve is superior to its preservation.


  Conclusion Top


Chronic postoperative pain following the Lichtenstein tension-free hernioplasty was significantly less after resection of the ilioinguinal nerve. Furthermore, the procedure is not associated with additional morbidities in terms of local cutaneous neurosensory disturbances or deterioration in quality of life. Ilioinguinal neurectomy should be considered a routine surgical step during open-mesh hernioplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5], [Table6], [Table7]



 

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