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Original Investigation | Pacific Coast Surgical Association

Operative Management of Refractory Neuropathic Inguinodynia by a Laparoscopic Retroperitoneal Approach

David C. Chen, MD1; Jonathan R. Hiatt, MD1; Parviz K. Amid, MD1
[+] Author Affiliations
1Department of Surgery, Lichtenstein-Amid Hernia Clinic, David Geffen School of Medicine, University of California, Los Angeles
JAMA Surg. 2013;148(10):962-967. doi:10.1001/jamasurg.2013.3189.
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Importance  With the technical success of tension-free inguinal herniorrhaphy, chronic groin pain has far surpassed recurrence as the most common long-term complication.

Objective  To evaluate laparoscopic triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerve trunks in the retroperitoneal lumbar plexus for treatment of refractory inguinodynia.

Design  Prospective study.

Setting  University hernia center.

Participants  Twenty consecutive patients with chronic inguinodynia (14 male; mean age, 46 years; all failing pain management; prior neurectomy in 4 patients) and follow-up to 180 days (minimum, 90 days).

Main Outcomes and Measures  Groin pain (Numeric Rating Scale score), dermatomal mapping, hernia recurrence, histologic confirmation, and complications.

Results  There were no intraoperative complications. All patients had histologic confirmation of neurectomy and clinical confirmation with dermatomal mapping. Mean numeric pain scores were significantly decreased (baseline score, 7.8) on postoperative days 1 (score, 2.9; P < .001), 7 (score, 2.2; P < .001), 30 (score, 1.7; P < .001), and 90 (score, 1.9; P < .001). Narcotic dependence decreased and activity level increased. Five patients reported transient hypersensitivity consistent with deafferentation. All had numbness in the distribution of neurectomy without complaint. Four had residual meshoma pain, with 2 undergoing subsequent reoperation to remove mesh. Orchialgia was not improved.

Conclusions and Relevance  This represents the largest series of laparoscopic retroperitoneal triple neurectomies for treatment of inguinodynia. The rate of successful intervention was better than reported for standard triple neurectomy and open extended triple neurectomy. The procedure allows access proximal to all potential sites of peripheral neuropathy and overcomes many of the limitations of open triple neurectomy. In the absence of recurrence or meshoma, it is the preferred technique for definitive management of chronic inguinal neuralgia.

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Figure 1.
Intraoperative Identification of Retroperitoneal Nerve Anatomy (Cephalad View)

Iliohypogastric nerve (IHN) and ilioinguinal nerve (IIN) over the quadratus lumborum muscle exiting behind the psoas muscle at L1, with the retroperitoneal fat pad rotated over the psoas muscle medially.

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Figure 2.
Intraoperative Identification of Retroperitoneal Nerve Anatomy (Caudal View)

Genitofemoral nerve (GFN) trunk at the bottom coursing over the psoas muscle, with the ureter crossing over the iliac artery seen medially.

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