Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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252 J.F.M. Lange Jr. Neuropathic pain without recurrence Recurrence with signs of neuropathic pain After anterior tension-free or tissue repair After TEP, Pelissier or TAPP After anterior tension-free or tissue repair After TEP, Pelissier or TAPP Open anterior triple neurectomy OR preperitoneal (endoscopic) triple neurectomy Anterior correction + open anterior triple neurectomy OR Endoscopic correction + preperitoneal endoscopic triple neurectomy Preperitoneal (endoscopic) triple neurectomy Anterior correction + preperitoneal (endoscopic) triple neurectomy Fig. 18.2. Consensus recommendations for operative approach of CPIP (from Lange et al. [ 14 ], with kind permission Springer Science + Business Media). of recurrence and neuropathic pain after preperitoneal mesh repair [i.e., totally extraperitoneal repair (TEP), transinguinal preperitoneal (TIPP), transabdominal preperitoneal repair (TAPP)], the recurrence should be corrected with an anterior technique (preferably, Lichtenstein procedure) to avoid the prior scarred field. However, a triple neurectomy via this approach would not be useful, as the potentially damaged nerves are located behind the fascia transversalis. As a result, the anterior correction should ideally be combined with an endoscopic triple neurectomy in the “untouched” plane proximally to the preperitoneal mesh. A remedial laparoscopic operation is an alternative approach with proximal neurectomy if indicated. Mesh Removal Partial or complete mesh removal is indicated in case of meshoma pain refractory to conservative management. Meshoma as a pathologic entity can present in different gradations from mass-like density to more subtle effects of mesh wrinkling or fibrosis. While meshoma will require surgical intervention if persistent and severe, occasionally patients whose overall pain levels improve can manage without re- exploration and removal. If the pain team is able to decrease the pain with pharmacologic, behavioral, and interventional treatment, this would be preferable. The greatest morbidity in these reoperative surgeries is from removal of the mesh given its apposition to vital structures with the potential for bleeding, testicular loss, visceral injury, and creation of a new hernia. Any potential to spare a patient from surgery is advisable.
18. Algorithmic Approach to the Workup and Management… 253 Instead of removal of meshoma only or removal of the nerves entrapped by meshoma only, systematic triple neurectomy is recommended because of neuronanatomic and technical considerations [ 20 ]. From a neuroanatomic perspective, there is significant cross-innervation of the nerves within the inguinal canal and within the preperitoneal space. Any neuropathic pain cannot be isolated to one specific nerve, and if neurectomy is performed, all potentially damaged nerves within an operative field should be taken. From a technical perspective, reoperative surgery to remove the mesh will likely damage the nerves within the operative field, and the panel advised neurectomy. Orchialgia Chronic testicular pain (orchialgia) has been left out of the scope of this algorithm, focusing primarily on inguinal pain. In most cases of orchialgia, the etiology is neuroanatomically and causatively distinct from CPIP. Accordingly, triple neurectomy is typically ineffective for this indication. The management of orchialgia after inguinal herniorrhaphy remains challenging, and it is important to note that it can arise after all variants of inguinal repair. Resection of the paravasal fibers or spermatic cord denervation might be an option for patients with neuropathic testicular pain but must be performed proximally to the level of pathology. Orchiectomy remains an option, but should be reserved only for refractory cases with evidence of nociceptive pain and parenchymal testicular compromise [ 23 ]. Conclusion Since the nature of this algorithm is expert opinion, it should not be considered as a strict guideline. Rather, it should serve as a practical tool for surgeons and clinicians treating the complex problem of CPIP. The algorithm can help direct appropriate management based upon the standard practice of an international group of surgeons considered expert on inguinal hernia surgery. It will also serve as a standard for further research representing the starting point for a developing dynamic algorithm. In conclusion, with the frequency of inguinal hernia correction as one of the most performed operations worldwide and the high incidence of CPIP, there is need for guidelines with regard to the management of CPIP.
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Brian P. Jacob · David C. Chen Bru
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The SAGES Manual of Groin Pain Bria
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Foreword Inguinal hernia repair is
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Contents Part I Primary Groin Pain
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Contents ix 22 Management of Inguin
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Contents xi 45 Value-Based Clinical
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xiv Editors and Contributors Jeffre
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xvi Editors and Contributors David
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xviii Editors and Contributors Greg
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xx Editors and Contributors David S
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1. Introduction to Primary and Seco
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10 I.A. Gawlas and W.J. Peacock Ili
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12 I.A. Gawlas and W.J. Peacock Tra
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14 I.A. Gawlas and W.J. Peacock Var
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3. Complex Regional Pain Syndrome T
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4. Chief Complaint of Groin Pain: H
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4. Chief Complaint of Groin Pain…
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42 C. Ma and A. Ramaswamy inguinal
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44 C. Ma and A. Ramaswamy Categoriz
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46 C. Ma and A. Ramaswamy with no s
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48 C. Ma and A. Ramaswamy 26. Aasva
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50 I.M. Daoud and K. Dunn Other per
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52 I.M. Daoud and K. Dunn low herni
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54 I.M. Daoud and K. Dunn In the po
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56 I.M. Daoud and K. Dunn with a he
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58 I.M. Daoud and K. Dunn 13. O’C
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60 G.J. Mancini Occult Hernia Backg
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62 G.J. Mancini Magnetic resonance
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64 G.J. Mancini rocking motion can
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66 G.J. Mancini Unique to the adduc
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68 G.J. Mancini two nerve injuries
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70 G.J. Mancini abdominis has a rep
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72 G.J. Mancini 5. Light D, Ratnasi
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74 J.C. Campbell and G.D. Paiement
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9. Groin Pain Etiology: Spine and B
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10. Groin Pain Etiology: Spermatic
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Table 10.2. European Association of
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138 M. Hibner and C. Coyne Piriform
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140 M. Hibner and C. Coyne Fig. 11.
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142 M. Hibner and C. Coyne Table 11
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144 M. Hibner and C. Coyne present
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146 M. Hibner and C. Coyne Table 11
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148 M. Hibner and C. Coyne Once the
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150 M. Hibner and C. Coyne 3. Hibne
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12. Chronic Pelvic Pain in Women M.
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12. Chronic Pelvic Pain in Women 15
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174 J.M. Miller et al. Knowing the
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176 J.M. Miller et al. Fig. 13.2. A
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182 J.M. Miller et al. Fig. 13.9. C
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184 J.M. Miller et al. Fig. 13.14.
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192 J.M. Miller et al. Cardiac Cath
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194 B.J. Dunkin Noxious peripheral
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196 B.J. Dunkin Table 14.1. Summary
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23. Mesh Removal for Chronic Pain
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320 I.T. MacQueen et al. inguinodyn
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322 I.T. MacQueen et al. Fig. 24.2.
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324 I.T. MacQueen et al. Timing and
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326 I.T. MacQueen et al. Fig. 24.4.
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328 I.T. MacQueen et al. Posthernio
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330 I.T. MacQueen et al. never be e
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25. Laparoscopic Triple Neurectomy
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26. Chronic Orchialgia: Workup and
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27. The Role of Bioactive Prostheti
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376 G. Campanelli et al. affecting
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378 G. Campanelli et al. into the w
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380 G. Campanelli et al. chronic gr
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382 G. Campanelli et al. A prospect
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384 G. Campanelli et al. open mesh
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386 G. Campanelli et al. 38. Alfier
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29. Prevention of Pain: Optimizing
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30. Prophylactic Neurectomy Versus
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Table 31.1. Selective neurectomy wi
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408 W.M.J. Reinpold and A.D. Schroe
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32. Chronic Groin Pain: Mesh or No
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Part IV Case Reports and Patients
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430 S. Towfigh were irregular and s
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432 S. Towfigh in addressing her sy
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434 S. Towfigh Conclusion We have y
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436 K.W. Kercher Physical Examinati
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438 K.W. Kercher Fig. 34.4. Left ad
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440 K.W. Kercher Fig. 34.5. After d
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442 K.W. Kercher the posterior wall
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444 K.W. Kercher Table 34.2. Surgic
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35. Chronic Post-inguinal Herniorrh
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35 Chronic Post-inguinal Herniorrha
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35 Chronic Post-inguinal Herniorrha
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36. Sports Hernia with Adductor Ten
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464 C.G. DuCoin and G.R. Jacobsen P
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466 C.G. DuCoin and G.R. Jacobsen O
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468 J.A. Blatnik and A.S. Prabhu a
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470 J.A. Blatnik and A.S. Prabhu Fi
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472 J.A. Blatnik and A.S. Prabhu ma
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474 S. Towfigh Physical Exam The pa
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476 S. Towfigh The patient’s loca
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478 S. Towfigh Fig. 39.2. Diagram o
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480 S. Towfigh periphery. He is 2+
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482 S. Towfigh References 1. Matthi
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484 N.A. Al-Enazi and B.P. Jacob
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486 N.A. Al-Enazi and B.P. Jacob Fi
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488 N.A. Al-Enazi and B.P. Jacob pu
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42. Patient with Chronic Pelvic Pai
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42. Patient with Chronic Pelvic Pai
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43. Thoracolumbar Syndrome James A.
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43. Thoracolumbar Syndrome 497 The
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43. Thoracolumbar Syndrome 499 Groi
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44. Patient with Referred Hip Pain
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44. Patient with Referred Hip Pain
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45. Value-Based Clinical Quality Im
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46. Patient Care Manager Perspectiv
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47. Workers’ Compensation: An Occ
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532 Index Athletic pubalgia (cont.)
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534 Index Chronic post-herniorrhaph
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536 Index Groin pain (cont.) magnet
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538 Index Ilioinguinal nerve (IIN)
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540 Index Local anesthetics (cont.)
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542 Index Peripheral nerve entrapme
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544 Index S Sacroiliac (SI) joint d
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546 Index Transperineal pudendal ne
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Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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