Neuralgia Following Hernia Repair
Chronic inguinal pain following hernia repair can be a severe handicap, often leading to problems in both home and working life. Permanent disability is not rare. Nevertheless, Devlin asserted in 1995 that chronic neuralgia after hernia repair by a specia
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Chronic inguinal pain following hernia repair can be a severe handicap, often leading to problems in both home and working life. Permanent disability is not rare. 1 Nevertheless, Devlin 2 asserted in 1995 that chronic neuralgia after hernia repair by a specialist is nonexistent. Other studies by reputable hernia surgeons show that the incidence of chronic inguinal pain after hernia repair ranges from 2 to 7%, regardless of the surgical technique used.3--8 The risk of chronic neuralgia is signjficantly higher after repair of a recurrent hernia than after primary hernia repair.9-11 Most data about chronic inguinal pain have referred to the conventional anterior approach repairs without prostheses; now studies dealing with chronic neuralgia following endoscopic and anterior mesh hernia repairs are beginning to reveal a comparable clinical picture.1,3,12-17
lateral scrotum. 22 These results demonstrate that irritation of the genital branch of the genitofemoral nerve has been underestimated as a direct cause of chronic neuralgia after hernia repair. The irritation of this nerve may be caused by the surgical manipulation of the internal inguinal ring and resection of the cremaster muscle. 22- 24 The causal mechanisms for chronic inguinal pain after mesh hernia repair with either the open anterior or endoscopic approach are still under debate. The application of clips or sutures in the proximity of the nerves was once thought responsible for chronic inguinal pain.14 Two further causes are discussed here: mesh migration and mesh shrinkage near the nerves and the persistent inflammatory reaction caused by the implanted biomaterials. 17
Causes
Diagnosis
As a rule, chronic inguinal pain is the consequence of a disorder
Chronic inguinal pain as a consequence of surgical hernia repair can be assessed only after a clinical follow-up of at least 6 months. This follow-up should include a neurological examination (tactile hypo- and hyperesthesia, two-point discrimination, cremaster reflex), a standardized interview about the character of the pain, and, eventually, infiltration with local anesthetic. To achieve optimal diagnosis and therapy, the interpretation of the character of the pain seems to be of central importance. Chevrel et al. 25 have listed pain characteristics and their clinical significance:
of the sensory and motor nerves of the inguinal region: the ilioinguinal and iliohypogastric nerves and the genitofemoral nerve, particularly its genital branch (Fig. 111.1).18 Neuroma formation on these herves may be caused by complete or partial nerve section, contact with foreign material, compression by scar tissue, or nerve ligation. Sinus formation around a suture, with concomitant irritation of the adjacent nerves, was often reported in the past. Since the elimination of multifilament nonabsorbable suture material in hernia surgery, this complication has become rare. 19 The painful persisting periostitis of the pubic bone is rarely seen nowadays, primarily because the Bassini procedure is practiced to a much lesser ext
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