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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modifications in recent years, has yielded response rates of 85–97 %
[ 13 – 15 ].
Triple neurectomy , whereby the three nerves are resected proximal to
the area of the initial hernia repair and as distal as possible, is conventionally
done via an open anterior approach [ 13 , 16 ]. The open operation
has limitations, as it may be difficult to identify and access the three
inguinal nerves in the reoperative field, and there is considerable neuroanatomic
variation especially distal to the retroperitoneum within the
inguinal canal. Operating in scarred tissues increases the risk of disrupting
the previous hernia repair as well as injuring the spermatic cord and
testicle. In patients whose initial operation was a preperitoneal (open or
laparoscopic) repair, accessing the nerves proximal to the pathology is
not always possible from an inguinal approach. These challenges, in
addition to causing surgical pain in an already hypersensitive area, make
a minimally invasive retroperitoneal approach very desirable.
Preoperative Workup
The recommended timing of surgery for chronic postherniorrhaphy
pain not controlled with conservative treatments is 6 months to 1 year
after the initial inguinal hernia repair. Prior to surgery, a detailed and
methodical preoperative workup is recommended to define the potential
causes of a patient’s groin pain. This should involve characterization of
symptoms, assessment of prior conservative pain management with
pharmacologic and interventional therapies, as well as imaging to evaluate
for presence of meshoma or other anatomic abnormalities. Previous
operative reports should be analyzed for technique such as type of
repair, presence, type and position of mesh, method of fixation, and
identification and handling of nerves, as these factors would influence
the type of intervention and remedial surgery possible. Patients should
also have multidisciplinary treatment, including evaluation by a pain
specialist. All patients considered for surgery should undergo diagnostic
and therapeutic nerve blocks of the ilioinguinal, iliohypogastric, and
genitofemoral nerves.
Finally, it is imperative to thoroughly discuss and document possible
benefits and risks of remedial surgery with patients, including failure to
identify or resect all three nerves, persistent pain despite successful neurectomy
due to various etiologies of pain, permanent numbness in the
corresponding dermatomal distributions, abdominal wall laxity secondary
to partial denervation of the oblique muscles, numbness in the labia