Is the nerve in the inguinal canal really protected by an investing fascia? Is it a real entity?
- PDF / 650,236 Bytes
- 2 Pages / 595.276 x 790.866 pts Page_size
- 107 Downloads / 195 Views
LETTER TO THE EDITOR
Is the nerve in the inguinal canal really protected by an investing fascia? Is it a real entity? M. Narita1 · K. Moriyoshi2 Received: 31 August 2020 / Accepted: 14 September 2020 © Springer-Verlag France SAS, part of Springer Nature 2020
Lichtenstein repair is a standard procedure for inguinal her‑ nia repair with low recurrence rates [1, 2]. However, a new concern has been raised regarding chronic postoperative inguinal pain (CPIP) in the era of synthetic mesh repair. According to the Swedish Hernia Registry, the proportion of patients reporting unignorable pain that affects their daily activities at 1 year after Lichtenstein repair is 15.1% out of a total of 18,034 patients [3], which significantly exceeds that of recurrence. Neurogenic problems are one of the most common causes of CPIP, and they can be caused by nerve compression and actual intraoperative nerve injury [4]. The nerve frequently comes in contact with the mesh during Lichtenstein repair, which presents the risk of nerve entrap‑ ment and may result in nerve injury. Several authors describe the presence of “investing fascia,” which covers the nerves passing through the inguinal canal. The genital branch of the genitofemoral nerve is ensheathed by the cremasteric fascia, and both the ilioinguinal and anterior branches of the iliohypogastric nerve are ensheathed by the investing fascia of the internal oblique muscle [5, 6]. Therefore, it is believed that preserving the nerves in their natural bed helps prevent iatrogenic injury and mesh contact [7]. However, whether or not it is a real entity remains controversial because it has not been pathologically proven so far [8].
Here, we show the pathological specimen of pragmati‑ cally resected ilioinguinal nerve during Lichtenstein repair (Fig. 1a, b). Hematoxylin and eosin staining demonstrates that all nerve bundles are covered by the fascia, composed of collagenous fibrous tissue, which continues directly from the muscle. Moreover, not only are there nerve bundles within the fascia, there are also rich adipose tissue and vascular structures (Fig. 1a). The magnified image clearly shows the fascia connected to the muscle and covering a neural bundle (Fig. 1b). Now it is evident that the nerves are protected by the investing fascia. As an authority on CPIP treatment has stated, it is impor‑ tant not only to identify the nerves during surgery but also to maintain them in their natural beds as much as possible [7]. By doing so, the investing fascia would help prevent direct contact between the mesh and the nerve epineurium, thus minimizing the risk of neuropathic pain. A pragmatic resection of the nerves must be implemented if the nerves are dissected and the investing fascia is possibly destroyed.
* M. Narita [email protected]‑u.ac.jp 1
Department of Surgery, National Hospital Organization, Kyoto Medical Center, 1‑1 Fukakusamukaihata‑cho, Fushimi‑ku, Kyoto 612‑8555, Japan
Department of Diagnostic Pathology, National Hospital Organization, Kyoto Medical Center, 1‑1 Fukakusa
Data Loading...
