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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S.A. Kingman et al.
Discussion
With the advances in technique of tension-free inguinal hernia repair,
chronic groin pain now surpasses recurrence as the most common longterm
postoperative complication. This debilitating condition is a result
of nociceptive and neuropathic factors. Given the lack of clear discrimination
between the two types of pain, confounded with variables such as
excitatory coupling between sympathetic and afferent nociceptive
fibers, deafferentation hyperalgesia, pain centralization, and neuroplasticity,
as well as patient-related factors, prevention of this complication
is of key importance [ 9 , 21 ].
Nociceptive pain can be minimized with gentle handling of tissues
and with the use of local anesthetic to decrease the formation of nociceptive
molecules. Neuropathic pain can be decreased by meticulous identification
and protection of nerves to avoid injury and their direct contact
with mesh, which ultimately changes the structure of their fibers. Doing
so has been shown to reduce the rate of postherniorrhaphy chronic pain
from 5 to 8 % to a fraction of 1 % [ 20 ]. Understanding inguinal and
preperitoneal groin neuroanatomy as well as the pathophysiology of
inguinal pain helps to guide good operative technique in all methods of
inguinal hernia repair. Prevention and avoidance of injury at the time of
the original operation are of paramount importance.
Numerous operative techniques have been used to address chronic
inguinodynia such as revision of the original herniorrhaphy, removal of
mesh or fixation device, and selective neurolysis or neurectomy of the
ilioinguinal, iliohypogastric, and genitofemoral nerves. These techniques,
however, often leave behind injured nerves and do not affect the
ultrastructural changes of nerve fibers. Moreover, the considerable
variation in anatomy and cross-innervation of the inguinal nerves within
the retroperitoneum and inguinal canal can make such procedures unreliable
[ 19 , 20 , 22 – 25 ].
The current most effective therapy for the neuropathic component of
inguinal pain is triple neurectomy [ 12 – 16 , 22 – 24 ]. In our ongoing series
of laparoscopic retroperitoneal triple neurectom y, we have had a 93 %
success rate in reducing numeric pain scores and narcotic dependence
and improving the quality of life and function in daily activities for
patients. Numerically, this demonstrates superior results of the laparoscopic
retroperitoneal approach to standard open triple neurectomy (80
%) and extended open triple neurectomy, which includes the resection