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

30. Prophylactic Neurectomy Versus
Pragmatic Neurectomy
Ryan Berg and Matthew I. Goldblatt
Editor’s Comment (DCC)
The data presented in this chapter represent the best available highquality
studies to date on this topic. The counterargument to the proposition
of prophylactic neurectomy is that the incidence of significant chronic
pain may be reduced to less than 1 % with three-nerve identification and
meticulous operative technique (Alfieri S et al. International guidelines for
prevention and management of post-operative chronic pain following
inguinal hernia surgery. Hernia. 2011;15(3):239–49). This is lower than
the rates of pain reported in both the control and prophylactic neurectomy
groups in each of these cited studies. If pain rates can be reduced with
good technique, intentionally causing the sensory disturbances or risk of
deafferentation pain with neurectomy in all patients may be considered
unnecessary. “Pragmatic neurectomy” was coined in response to the
concept of prophylactic neurectomy and simply refers to the logical practice
of performing a neurectomy at the time of hernia repair whenever a
nerve is recognizably injured or is at risk for injury due to its neuroanatomic
location, course, or operative factors. Neurectomy in these cases is
absolutely recommended. The author’s conclusion that no patient in each
of these studies developed severe pain is significant, and “prophylactic
neurectomy” in at-risk individuals is likely prudent. Mild sensory disturbances
and numbness are vastly preferable to chronic pain in high-risk
patients. Using preoperative risk calculators such as the Carolinas
Equation for Quality of Life (CeQOL; www.carolinashealthcare.org/ceqol )
and understanding high-risk populations for the development of chronic
pain will help surgeons to decide who will benefit from prophylactic neurectomy.
Tailoring the right operation for each patient in conjunction with
a good informed consent makes for good practice.
© Springer International Publishing Switzerland 2016
B.P. Jacob et al. (eds.), The SAGES Manual of Groin Pain,
DOI 10.1007/978-3-319-21587-7_30
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