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
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in pain, diminished sensation, sensory loss, and paresthesia were lost by
3-month follow-up [ 4 ]. While the authors suggest that nerve preservation
may be favored given the early symptomatic differences, the longerterm
follow-up results suggest nerve division does not portend significant
functional or sensory deficits. In addition, nerve pain during inguinal
hernia repair is typically due to nerve entrapment within suture or mesh,
which are not used during axillary dissection.
Ravichandran et al. were among the first to perform a randomized
trial on the topic of ilioinguinal neurectomy [ 5 ]. This study was, and still
is, unique in this body of literature in that it is self-controlled. The
authors enlisted patients who were planned for bilateral inguinal hernia
repair and randomized the patients’ right or left side to undergo routine
neurectomy, while the other side had nerve preservation. In comparing
the neurectomy side to that of nerve preservation, there was no difference
in pain rated on a 10-point scale noted on postoperative day 1 (2.9
vs. 2.5, p = 0.98). At 6 months, just two patients complained of minor
wound discomfort, one on the divided side and one on the preserved
side. Physical examination on patients 6 months postoperatively
revealed an increased incidence of diminished touch sensation on the
divided side (9 patients vs. 1 patient; no p -value given) as well as
increased incidence of diminished pain sensation (8 vs. 5; no p -value
given). However, it is important to note that just two of the 20 patients
reported any symptoms of numbness at their 6-month follow-up, including
one complaining of lateral thigh numbness, an area not supplied by
the ilioinguinal nerve [ 5 ]. As such, it is reasonable to conclude from this
study that patients undergoing routine neurectomy do not have increased
incidence of immediate postoperative nor chronic pain, nor do they have
increased incidence of symptomatic sensory loss. The study is underpowered
to provide statistically significant differences in these groups
and does not provide statistical analysis of all its data; however, it is a
landmark and otherwise well- designed study of the debate.
As routine neurectomy in inguinal hernia repair increased in popularity,
so did the size of the studies. Tsakayannis et al. prospectively
observed a cohort of 191 patients, all of whom underwent routine, elective
resection of both the ilioinguinal and iliohypogastric nerves [ 6 ].
These patients were followed up at 1 month, 6 months, and 1 year to
determine their pain rating and degree of sensory loss. At no point postoperatively
did any patient report moderate or severe pain. 9.4 % of
patients reported subjective numbness at 1 month, while at both 6 and 12
months postoperatively, 6.3 % of patients noted numbness. Patients who
complained subjectively of sensory loss were subjected to a detailed