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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sion of the triple neurectomy to the preperitoneal space and additional
resection of the main trunk of the GFN, which can always be identified
on the ventral surface of the psoas muscle. According to Amid, the triple
neurectomy should be performed without mobilization of the spermatic
cord [ 3 , 4 ]. Only plugs and wrinkled or wadded pieces of mesh
(meshoma) should be removed. Recently, Campanelli et al. [ 24 ] reported
on 40 cases of triple neurectomy with mesh removal and new mesh
placement. The open triple neurectomy and extended open triple neurectomy
are described in detail in Chap. 24 .
Recently, Chen et al. [ 25 ] published a series of 20 retroperitoneoscopic
triple neurectomies. After a medium follow- up of 22 weeks
(16–40 weeks), all patients were pain-free or their pain had improved.
According to our recent anatomic study of the retroperitoneal inguinal
nerves on 30 fixed cadavers, the retroperitoneoscopic approach allows
for reproducible identification of the proximal portion of the IHN and
IIN on the surface of the quadratus lumborum muscle and the GFN on
the ventral surface of the psoas muscle [ 30 ]. The minimally invasive
approach allows for reliable proximal nerve identification and triple
neurectomy in a territory of virtually untouched tissue.
The results of the open and laparoscopic triple neurectomy are excellent.
Ninety-eight percent of the patients are either pain-free, or their pain
improved after surgery. There are no reports on pain relapse. However,
there are no long- term follow-up data available. Except for one minor
wound healing problem after open triple neurectomy and one small
lesion of the diaphragm during laparoscopic triple neurectomy (which
was intraoperatively fixed), there were neither surgical nor general complications
reported, especially no testicular or visceral complications [ 3 ].
Summary
Today neurectomy is the last treatment option for patients with disabling
persistent postherniorrhaphy pain . Selective or triple neurectomy
can be performed open or laparoscopically and give good results with
low morbidity. Wrinkled or wadded mesh and plugs should be removed
concomitantly. Patients do not seem to benefit from the removal of wellincorporated
mesh. According to the available data, triple neurectomy
seems to have an edge over selective neurectomy. However, more than
90 % of the published triple neurectomy data derive from a single institution
with one dedicated surgeon [ 3 – 6 , 24 , 25 ]. There are no reports on
long- term follow-up after triple neurectomy and scarce long-term fol-