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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I.T. MacQueen et al.
Timing and Patient Selection
A systematic approach is imperative for proper identification of
patients suited for operative intervention. Recommended timing of surgical
intervention for postherniorrhaphy pain unresponsive to standard
nonsurgical modalities is 6 months to 1 year after the original hernia
repair [ 1 , 5 ]. Failure of conservative measures, in of itself, is not an
indication for further surgery. Successful outcomes are entirely dependent
upon choosing patients with discrete neuroanatomic problems amenable
to surgical correction. A thorough preoperative evaluation should
include symptomatology, review of the prior operative report for technique
(specifically, the type of repair, type of mesh used, position of the
mesh, method of fixation, and nerve handling), imaging to assess for
meshoma or other anatomic abnormalities, and response to prior interventions
[ 5 , 19 ]. The patients most likely to benefit from operative neurectomy
are those with neuropathic pain isolated to the inguinal distribution that
was not present prior to the original operation and that showed improvement
with diagnostic and therapeutic nerve blocks.
Risks of Surgery
Operative remediation of inguinodynia carries risk of complications,
including refractory pain, exacerbation of underlying pain, deafferentation
hypersensitivity, and anticipated permanent numbness involving
unilateral labial numbness and potential associated sexual dysfunction
in women. Risks related to reoperation in the scarred field include bleeding,
disruption of the prior hernia repair, recurrence, vascular injury, and
testicular loss. These risks should be discussed with the patient and
documented prior to proceeding to operation.
Technique
Triple neurectomy involves resecting segments of the IIN, the genital
branch of the GFN, and the IHN from a point proximal to the original
surgical field to the most distal accessible point. The main trunk of the
GFN over the psoas muscle may also be resected in the case of pain after
open or laparoscopic preperitoneal hernia repair, as described below