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

25. Laparoscopic Triple Neurectomy
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in females that may alter sexual sensation, testicular atrophy, and loss of
the cremasteric reflex in males. The surgery may cause hypersensitivity
from deafferentation that is typically temporary, though its course is
unpredictable and may be permanent. This technique does not alter nociceptive
pain caused by tissue injury, meshoma, or testicular pain [ 16 ].
Surgical Approach
Laparoscopic retroperitoneal triple neurectomy is a 1-stage procedure
to access the main trunks of the ilioinguinal, iliohypogastric, and genitofemoral
nerves in the lumbar plexus [ 17 ]. This access allows the
nerves to be resected proximal to any potential site of peripheral neuropathy
from the previous surgical field.
The patient is positioned in lateral decubitus position, and the table is
flexed to open the space between the iliac crest and costal margin. A
12-mm transverse incision is made in the midaxillary line 3–4 cm above
the iliac crest (Fig. 25.1 ). The external oblique fascia is incised, and the
oblique muscles are separated until the retroperitoneum is accessed. An
oval dissecting balloon can be placed into this potential space and
inflated under direct visualization. This mobilizes the peritoneum in the
avascular plane, rotating the viscera medially, and exposes the retroperitoneal
space. The dissecting balloon is then exchanged with a 12-mm
balloon trocar, and carbon dioxide is used to insufflate to a pressure of
15 mmHg. Another 5-mm port is inserted 2 cm medially under direct
visualization. The retroperitoneal fat pad is then dissected medially
using laparoscopic cautery or a vessel-sealing device to expose the psoas
and quadratus lumborum muscles.
The lumbar plexus should be defined before any neurectomy is performed
(Fig. 25.2 ) [ 18 ]. The subcostal nerve can first be identified at the
T12 costal margin (Fig. 25.3 ). The iliohypogastric and ilioinguinal
nerves, frequently sharing a common trunk, can then be seen overlying
the quadratus muscle at L1 (Fig. 25.4 ) [19 , 20 ]. The lateral femoral cutaneous
nerve originating at L3 is identified lateral to the psoas, crossing
the iliacus muscle below the iliac crest (Fig. 25.5 ). The femoral nerve can
also be found lateral and deep to the psoas muscle, but does not require
specific dissection. The dissection is then continued toward the groin
where the genitofemoral nerve trunk can be noted running over the psoas
muscle (Fig. 25.6 ). Similar to the iliohypogastric and ilioinguinal nerve
trunks, the genital and femoral nerve trunks have considerable variability
and often have separate trunks. If the dermatomal distribution of the