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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postherniorrhaphy inguinodynia in 95 % of patients. These results represent
patients whose triple neurectomy included resection of the intramuscular
segment of the IHN, a technique we have employed since
2004. Prior to this modification, only the extramuscular portion of the
IHN was resected, with an associated success rate of 85 % [ 7 ].
We have performed open extended triple neurectomy including the
main trunk of the GFN in 40 patients with chronic inguinodynia following
preperitoneal mesh inguinal hernia repair, with over 90 % of these
patients experiencing significant improvement of their pain. We have
additionally combined paravasal neurectomy with triple neurectomy for
24 patients with postherniorrhaphy groin pain and orchialgia. The orchialgia
was eliminated in 83 % of patients. These limited series suggest
that both procedures are safe and effective, though additional study is
indicated before they become standard practice.
Conclusion
There is no level 1 or 2 evidence regarding the operative management
of inguinodynia, and best available recommendations are derived from
case reports, case series, expert opinion, and expert consensus [ 5 , 18 ].
Our experience with over 750 triple neurectomy operations (700+ open,
50+ laparoscopic) performed by two surgeons (PKA and DCC) is the
largest single-institution experience. Since the inception of the
Lichtenstein Hernia Institute in 1984, we have additionally evaluated
and treated thousands of patients without surgery, with mesh removal,
selective neurectomy, quadruple neurectomy, and all other variants of
therapy. Triple neurectomy, pioneered in our institute, remains the most
definitive and common remedial operation performed. The operative
principles of open triple neurectomy involve segmental resection of the
IIN, the genital branch of the GFN, and the IHN proximal to the site of
injury and resection of the intramuscular portion of the IHN. For
patients with a prior preperitoneal hernia repair, open triple neurectomy
must be extended to the retroperitoneum to include the main trunk of the
GFN, or this nerve can be addressed during laparoscopic triple neurectomy.
Patients with concurrent postherniorrhaphy orchialgia may benefit
from combining paravasal neurectomy with open triple neurectomy.
With success rates of over 90 %, triple neurectomy provides the greatest
chance of improving pain and symptoms and is the most definitive
option to remediate these problems in an operative field that will ideally