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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et al. conducted a small retrospective chart review in 90 patients who
underwent open inguinal hernia repair. These patients had either routine
nerve preservation or nerve excision, primarily owing to differing practice
patterns of two surgeons whose patients were included. Data were
obtained through patient interview, which in most cases included asking
the patient to recall the severity and duration of pain at different time
points. The endpoints assessed included 1 month, 6 months, 1 year, and
3 years postoperatively. The study found that patients who underwent
routine ilioinguinal neurectomy reported decreased incidence of neuralgia
at 1 month (5 vs. 21 %, p = 0.016), at 6 months (3 vs. 26 %,
p < 0.001), and at 1 year (3 vs. 25 %, p = 0.003). No difference was
observed at 3 years (6 vs. 8 %, p = 0.75). Additionally, patients were
asked to report postoperative paresthesia, and comparison between the
groups revealed no differences at any endpoint in the reported incidence
of sensory loss [ 1 ]. This study was clearly limited in a number of ways,
not the least of which includes a likely significant recall bias. The study
was also not randomized, had small enrollment, and may have been
influenced by the other surgical technical differences between surgeons,
and patients may not all have been blinded to the details of their procedure.
That said, this was one of the first studies to suggest an improvement
in outcomes in patients undergoing routine neurectomy during this
procedure and laid the foundation for more convincing evidence to
follow.
Among the more recent studies to examine this topic, Malekpour and
associates recently conducted a double-blind randomized controlled trial
comparing routine ilioinguinal nerve preservation to excision. One hundred
twenty one patients were studied, and their pain rated on a 10-point
visual analog scale (VAS) . Their analysis revealed that the incidence of
chronic inguinodynia , defined as the presence of pain at 3 months postoperatively,
was lower in the nerve excision group (6 vs. 21 %,
p = 0.033). Further, the mean severity score on the VAS was noted to be
lower in the neurectomy group 1 day after surgery (2.2 vs. 2.8, p < 0.001)
as well as at 1 month (0.7 vs. 1.5, p < 0.001). However, at both 6 months
and 1 year, these differences had been eliminated, with median pain
scores of 0 in both groups. Patient rating of hypoesthesia at all time
points was also equivalent between the groups, with no patients complaining
of loss of sensation at 1 year in either treatment arm [ 2 ]. As with
much of the research on this topic, this study is limited in part by the
subjectivity of the data it analyzes. Given this, it is noted that cultural
differences may factor into these data, as this Middle Eastern study
population provided lower overall VAS scores when compared to their