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

31. Triple Neurectomy Versus Selective Neurectomy
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the cumulative data of three multiphase studies [ 2 –5 , 7 , 16 , 26 ], there
remained 21 studies with 1035 patients. Ninety-three percent of neurectomies
were performed after open inguinal hernia repair and 7 % after
laparoscopic procedures [transabdominal preperitoneal repair (TAPP);
totally extraperitoneal repair (TEP)]. Four studies with 497 patients
reported on triple neurectomy [ 5 , 6 , 24 , 25 ] and 17 studies with 538
patients on selective neurectomy [ 2 , 8 –23 ]. The overall success rate
(patients pain-free or pain improved) of neurectomy is 87 %, 77 % after
selective neurectomy, and 98 % after triple neurectomy. The interpretation
and comparison of the studies are limited due to different pre- and
postoperative pain assessments; different type, duration, and percentage
of follow-up; and limited reports on surgical complications. Eight studies
did not report on early complications at all [ 4 –6 , 9 , 13 , 19 , 23 , 24 ]. Four
trials assessed pain-related physical disabilities and restrictions of daily
activities [ 2 , 7 , 12 , 17 ]. Three trials reported on pain during sexual activity
[ 2 , 7 , 8 ].
Only seven studies included a workup of a multidisciplinary pain
team [ 3 –6 , 10 , 17 , 25 ], and 12 publications integrated preoperative
peripheral or paravertebral blocks in their study [ 8 , 10 , 11 , 13 , 16 –18 , 20 ,
21 , 24 –26 ]. Fifty-nine (5.6 %) of the neurectomies were performed retroperitoneoscopically
with a success rate of 80 % [ 17 , 25 ]. Patients do
not seem to benefit from a general meshectomy. Table 31.4 [2 , 5 , 6 , 8 –25 ]
shows the success rates of neurectomies with or without mesh removal.
The Rationale of Selective Neurectomy
Starling et al. [ 9 , 10 ] were the first to publish on neurectomy for the
treatment of disabling chronic pain after open inguinal hernia repair.
After a multidisciplinary approach with conservative pain treatment, as
well as local blocks of the inguinal nerves and paravertebral blocks of
L1 and L2, ilioinguinal and genitofemoral neuralgia were diagnosed in
19 and 17 patients, respectively. After a selective neurectomy of the
entrapped portion of the ilioinguinal nerve (IIN), 17 patients were
reported to be completely pain-free. Twelve patients improved after
neurectomy of the entrapped genitofemoral nerve (GFN). The authors
did not report on mesh removal, and there are no follow-up data in their
publications.
The selective neurectomy approach today is commonly used as an
alternative to the triple neurectomy concept coined by Amid and colleagues
in 2004 [ 4 ]. The aim of a selective neurectomy is to resect only