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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R. Berg and M.I. Goldblatt
physical exam. Just two patients (1 %) had sensory loss confirmed in the
distribution of the excised nerves on exam, of which neither deficit was
found to be disabling [ 6 ]. This study was certainly limited by its observational
nature with lack of a control group; however, it serves to demonstrate
in a large cohort that neurectomy may be safely performed in the
inguinal region without disabling consequences.
Perhaps the largest study on the topic of neurectomy during inguinal
hernia repair came from Picchio and colleagues. In 2004, they enlisted
813 patients in a double-blind study and randomized them into routine
ilioinguinal nerve transection versus preservation [ 7 ]. They followed
these patients at 1 month, 6 months, and 1 year postoperatively. Utilizing
a survey with a 4-point pain scale (none, mild, moderate, severe), the
study did not find any significant differences in patient pain rating
between the two groups at any endpoint. The study did, however, find
differences in touch and pain sensation between the groups. These sensory
deficits were tested with focused, detailed physical examination on
follow-up visits. There was an increased incidence in loss of touch sensation
for those undergoing routine neurectomy at 1 month (49 vs. 21 %,
p < 0.001), 6 months (29 vs. 6 %, p < 0.001), and 1 year (11 vs. 4 %,
p = 0.002). There was also an increased incidence in loss of pain sensation
for neurectomy at 1 month (56 vs. 45 %, p = 0.004) and 6 months
(33 vs. 25 %, p = 0.04). There was no difference in loss of pain sensation
at 1 year (9 vs. 8 %, p = 0.89) [ 7 ]. Given the size of enrollment and study
design, these were the strongest data to date suggesting that there is
increased incidence of sensory deficits for patients undergoing routine
ilioinguinal nerve excision. At the same time, the study did not address
the question of whether these deficits were disabling or disturbing to the
patient. As demonstrated previously by Ravichandran et al., it is possible
for patients to have little to no subjective complaints of sensory loss
despite objective physical exam findings to suggest that a deficit is present.
Again, given that the endpoints of chronic groin pain and troubling
or disabling neurologic deficits are primarily subjective in nature, to
disregard the patients’ subjective neurologic complaints is a shortcoming
of this otherwise strong evidence.
Prophylactic Neurectomy
As studies on this controversial topic have continued, evidence has
become increasingly suggestive of a potential benefit of routine neurectomy
in combating chronic inguinal pain after hernia repair. Dittrick