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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S. Towfigh
The patient’s localized areas of pain were marked in the preoperative
area. This often helps intraoperatively with correlation of the pain with
the operative findings and also to help guide the procedure. The operation
was performed under local anesthesia with sedation. The prior incision
was reincised along its lateral portion. Once the external oblique
aponeurosis was identified, the lateral edge of the mesh was noted, as
was the greenish hue of Ethibond sutures. The fascia was incised and
lifted off of the mesh using a combination of blunt, sharp, and cautery
dissection. There were two sutures of Ethibond with multiple knots each
at the superolateral edge of the mesh. These were both removed. The
ilioinguinal nerve was identified entering this area on top of the internal
oblique muscle and under the mesh. This was dissected out proximally
and distally. The nerve seems to have tracked in the same region as one
of these sutures. Thus, most likely the patient had nerve entrapment of
the right ilioinguinal nerve with a laterally placed suture within the
muscle. The right ilioinguinal nerve was skeletonized proximally and
distally. It was tied off and transected distally at the level of the mesh
edge. It was then dissected proximally and injected with local anesthetic
proximally. A 3-0 Chromic tie was used to tie its end to reduce bleeding
from the neurovascular bundle. It was transected and sent to pathology
for identification. The stump of the nerve was further dissected and
implanted into a pocket of internal oblique muscle just deep to it. The
purpose of this is to help reduce the risk of postoperative neuroma. The
wound was then closed in layers.
Postoperative Course
The patient had complete resolution of his pain postoperatively. He
was followed up for 2 years and has not had any recurrence of his
symptoms.
Outcomes and Discussion
Nerve injury at the time of Lichtenstein hernia repair is either due to
a technical error (e.g., direct injury, suture entrapment, manipulation,
and dissection of the nerve) or due to mesh folding or scar tissue with