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

38. Patient with Groin Pain After Open Inguinal Hernia…
469
any nerve injury or spermatic cord injury. Nor was there any evidence
for infection or balling up of the mesh, i.e., meshoma.
Operative Treatment
Once workup was completed, the patient was offered laparoscopic
exploration to address the recurrence of his inguinal hernia. Chronic groin
pain is not an uncommon complication after open inguinal herniorrhaphy,
with an incidence as high as 62.9 % described in some series [ 1 ]. A generally
accepted definition for the term chronic groin pain is the presence of
pain in the groin region for greater than 3 months after surgery. This may
be further divided into neuropathic pain versus non-neuropathic pain.
Neuropathic pain may be related to injury to the ilioinguinal nerve, the
iliohypogastric nerve, the genitofemoral nerve, or (rarely) the lateral femoral
cutaneous nerve. Nerve injury may be mechanical in nature or otherwise
may be related to an adjacent inflammatory process such as granuloma
or excess fibrotic reaction or mesh encasement of the nerve structures [ 2 ].
For the patient discussed in this scenario, an extensive workup by a pain
management physician suggested a non-neuropathic source of pain, hence
the decision to take the patient to surgery. There was no role for nonoperative
intervention, as the pain was felt to be non-neuropathic in etiology.
We began with a transabdominal laparoscopic evaluation. This identified
multiple loops of small intestine densely adhered to the hernia
mesh (Fig. 38.1 ). This finding was despite the fact that all of the
patient’s previous hernia repairs had been in an open fashion and presumably
as an onlay, and per report, all mesh had been removed. These
adhesions were taken down sharply, and to avoid injury to the small
bowel, a portion of mesh was left adherent to the bowel. This dissection
exposed what appeared to be a plug mesh in his internal ring.
Due to the chronic, non-neuropathic nature of his groin pain, it was
felt that all previous mesh would need to be removed at this operation.
To facilitate subsequent hernia repair following mesh removal , we
began by creating a large, extraperitoneal flap. During this portion, we
encountered multiple pieces of prior mesh, all of which were removed
with a combination of sharp dissection and harmonic scalpel. Great care
was taken to avoid injury to the overlying skin, as the patient was very
thin, and there was not a significant amount of subcutaneous tissue.
Cooper’s ligament was identified and served as our inferomedial landmark,
and dissection was continued laterally. The plug mesh was identified
adherent to the vas deferens, as can often be expected. In the