Page 75 - International guidelines for groin hernia management

Hernia

patients and 1.6% of 614 patients in whom all nerves were prophylactic inguinal neurectomy on chronic pain. A sep-
identified (p \ 0.001). arate search was conducted for studies involving the IIN,
The conclusion from both studies was that N-R (all three the IHN, and the GB of the GFN.
nerves) results in a significantly lower incidence of chronic
pain. Key questions

Discussion KQ19P.f Does prophylactic ilioinguinal nerve resection
Both cited studies were observational and, therefore, ‘‘low’’ reduce pain incidence?
grade. In addition, in the McVay-repair study, only one KQ19P.g Does prophylactic iliohypogastric nerve resec-
surgeon performed all operations possibly resulting in a tion reduce pain incidence?
systematic bias and, therefore, a ‘‘very low’’ grade. The KQ19P.h Does prophylactic resection of the GB of the
multicenter center study quality was ‘‘high.’’ Overall, the GFN reduce pain incidence?
evidence quality on the subject is ‘‘low.’’

The GRADE system also assesses benefit-to-harm ratio. Ilioinguinal nerve
An N-R approach presumably improves operative out-
comes by avoiding iatrogenic nerve injury, suture entrap- Evidence in literature
ment of nerves, and mesh-stimulated scarring with Three meta-analyses 177, 180, 181 and seven RCTs 182–188
resultant nerve damage. Chronic pain leads to disability, have investigated the influence of IIN resection during
repeated clinical encounters, consultations with anesthesi- open IH mesh repair. Studies investigating a pragmatic
ologists and other specialists, additional imaging studies, approach to perioperative inguinal nerve handling were
and extra costs in various ways. Although there is only a excluded, since they did not compare a group in which the
‘‘low’’ level of medical evidence to support it, a strong IIN was prophylactically neurectomized with a group in
recommendation for an N-R/nerve-preservation approach which it was preserved. 175, 178, 189, 190
seems justified, since this is associated with less chronic A 2012 meta-analysis 180 (MA-12) covers all prior
pain. To be clear, N-R/preservation in this context does RCTs 182–184, 186, 188 except two. 185, 187 One of these two
NOT involve formal surgical dissection and identification, was published after the 2012 meta-analysis. 187 We have
but rather simple recognition of nerves and their course as excluded it from our discussion due to a systematic bias
they are encountered. resulting from inadequate study design. The other was also
excluded from the meta-analysis and from our discussion
because of selection bias. 185 This meta-analysis reported no
Prophylactic nerve resection inter-group differences in chronic pain scores and numb-
ness at 6- and 12-month postoperatively. 180 However,
Introduction increased sensory loss was reported at 6- and 12-month
Medical literature describes different nerve handling postoperatively following IIN resection.
techniques: nerve preservation, prophylactic neurectomy These chronic pain outcomes were confirmed by another
(resection, removal of a segment of the nerve along the 2007 meta-analysis 177 (MA-07). A 2011 meta-analysis
inguinal canal), and pragmatic neurectomy (in cases of (MA-11) of fewer studies than reference MA-12 reported a
nerve injury or if mesh/nerve interference occurs). A search lower chronic pain incidence after IIN resection on the
was conducted for studies investigating the influence of basis of fewer studies than were analyzed by reference

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