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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Chronic Pain After Preperitoneal Hernia Repair
The preperitoneal nerves most commonly implicated in postherniorrhaphy
neuropathy are the main trunk, femoral branch, and the preperitoneal
segment of the genital branch of the GFN. These nerves lack a
fascial covering and are therefore at increased risk of injury if allowed
to contact mesh. Neuropathic injuries of these nerves can be addressed
by laparoscopic triple neurectomy (discussed in Chap. 25 ) or open
extended triple neurectomy, which includes segmental resection of the
main genitofemoral trunk in the retroperitoneum [ 20 ]. For open
extended triple neurectomy, the exposure utilizes the same split made in
the internal oblique muscle during resection of the intramuscular segment
of the IHN. The underlying transversus abdominis muscle is similarly
split, and the parietal peritoneum is swept medially and cephalad
to expose the psoas muscle and the main trunk of the GFN as it courses
along the body of the muscle (Fig. 24.6 ). Resecting the GFN at this level
additionally addresses neuropathic pain due to injury of the main trunk,
the femoral branch, or the preperitoneal segment of the genital branch,
which are inaccessible during standard triple neurectomy .
Fig. 24.6. Identification and neurectomy of retroperitoneal genitofemoral nerve
trunk over psoas muscles (extended triple neurectomy).