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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C.G. DuCoin and G.R. Jacobsen
Physical Exam and Workup
On physical exam, he was found to have a firm palpable mass in the
right groin that was quite solid and not consistent with that of herniated
tissue. He had hyperesthesia in the region of the mass and full deep
examination was not feasible due to his pain. His abdomen was benign.
He was able to walk without a limp, but this caused an extreme amount
of pain. We could not delineate any specific neuropathic distribution of
the pain. Targeted injections by our anesthesia pain colleagues provided
little relief and therefore did not provide guidance as to which nerve
might be definitively involved.
Diagnosis and Management Options
(Nonoperative vs. Operative)
We had a discussion regarding his diagnosis and possible treatment
options. Nonoperative management was discussed; however, both the
patient and surgeon felt that this would be of little merit, as the pain was
chronic and conservative therapies had failed over prior years. Indeed, he
had resorted to chronic narcotic use as the only modality that helps his pain.
The reducible painful nature of the mass represented either a recurrence
of his hernia, poor integration of the plug, or both. Also, nerve
entrapment or other involvement could not be definitively ruled out. His
surgical treatment options were discussed. The final plan consisted of
diagnostic laparoscopy for evaluation of the groin area for recurrence,
possible recurrent inguinal hernia repair with mesh, possible laparoscopic
versus open explant of mesh plug, and possible triple neurectomy, depending
on operative findings. The risk of injury to the testicular vessels and
subsequent ischemic orchitis was discussed with the patient, as was the
possible need for vasectomy or orchiectomy. It is important in the reoperative
patient to discuss these potential complications and their implications,
as this may sway some patients to continue with observation.
Operative Management
The operation began with a diagnostic laparoscopy via the umbilicus.
There was no inguinal hernia on the left. On the right, the mesh plug
could be seen to be freely floating through the deep inguinal ring and
was almost completely enveloping the spermatic cord structures. It was