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

24. Open Triple Neurectomy
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Fig. 24.3. Identification and neurectomy of ilioinguinal nerve.
[ 20 ]. This chapter focuses on open triple neurectomy with laparoscopic
triple neurectomy described separately. Exposure for open triple neurectomy
typically utilizes the same incision as the original anterior repair.
If the original repair was done laparoscopically, a standard inguinal incision
is used. Extending the incision more cephalad and lateral than typical
for a hernia repair facilitates the exposure of the proximal portions
of the IIN and IHN. Additionally, this allows for access to the inguinal
canal proximal to scarred mesh within the canal.
The IIN is typically identified lateral to the deep inguinal ring and
divided as proximally as possible (Fig. 24.3 ). The IHN is identified in
the plane between the internal and external oblique aponeurosis. It is
traced proximally to its intramuscular segment and divided proximal to
the field of the original repair. Including the intramuscular segment in
the resection avoids missing an occult injury in this segment. If the IHN
is noted to be one of the subaponeurotic variants described previously,
the internal oblique aponeurosis is split proximal to the point where the
nerve traverses both internal and external oblique aponeurosis, and this
hidden portion of the nerve is divided (Fig. 24.4 ). The genital branch of
the GFN is identified adjacent to the external spermatic vein under the
cord or through the lateral crus of the internal ring. In a standard triple
neurectomy for pain after anterior repairs, it is ligated and divided at the
internal ring (Fig. 24.5 ).