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

23. Mesh Removal for Chronic Pain…
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Operative Management
For surgeons who are experienced with pelvic and groin laparoscopy,
a diagnostic laparoscopy is an appropriate first step. A laparoscopic
view will identify intra-abdominal adhesions and possibly
interstitial and/or recurrent hernias. An interstitial hernia can occur as a
defect through the deeper layers of the groin, but not completely through
all layers of the groin or through the mesh when placed in an open
Lichtenstein- type hernia repair. Sometimes, offending tacks or staples
can be viewed and removed without entering the preperitoneal space.
After intraperitoneal exploration, the preperitoneal space may be
explored laparoscopically to view the cord structures and nerves (genital
and femoral branches of the genitofemoral nerve and lateral femoral
cutaneous nerves) that course along the psoas muscle with and lateral to
the spermatic cord and internal ring and usually posterior to the iliopubic
tract. The location and course of the nerves in the preperitoneal space
can be variable, especially in patients with a previous groin operation(s).
Fixation devices such as sutures, tacks, and/or staples and mesh (placed
laparoscopically or through some open techniques) can be identified in
the preperitoneal space. The laparoscopic exploration of the preperitoneal
space may include repairing an interstitial or recurrent hernia and/
or removal of mesh (including plugs that may be visualized laparoscopically)
and/or fixation devices. If a hernia is found and thought to be the
cause of the pain, the goal of the operation is to provide a durable hernia
repair. If there is no hernia, the goal is to eliminate any adhesions from
the groin and to clear the groin of all foreign materials (mesh and fixation
devices), freeing up the cord structures and nerves. Neurolysis
(freeing up the nerves) is frequently possible with a laparoscopic
approach; however, a neurectomy may be indicated if a nerve is embedded
in scar and/or mesh and cannot be freed and/or if the patient chooses
a planned neurectomy during the preoperative shared decision process.
The laparoscopic removal of mesh from the preperitoneal space of
the groin can be a difficult and potentially dangerous procedure, especially
if the previous mesh had been cut and passed behind the cord
structures. Injuries to the cord structures, the iliac vein and artery, the
obturator vessels, the inferior epigastric vessels, and the bladder are all
possible. Even inadvertent bowel injury is possible, especially if there
are bowel adhesions to the groin or mesh. Sometimes it is appropriate to
leave a portion of mesh on one or more of these structures to minimize
the risk of injury.