Page 76 - International guidelines for groin hernia management

Hernia

MA-11. 181 References MA-12 and MA-11 reported a One RCT 184 and one cohort study 192 were critically
moderate-to-high degree of heterogeneity with respect to appraised. Both reported no significant differences in the
chronic pain as an outcome measure and questioned the incidence of chronic pain or sensory loss 1-year
suitability of pooling results. This heterogeneity is present postoperatively.
in several RCTs on the subject as well.
Discussion
Discussion
The data from the meta-analyses were graded as moderate, Although the included RCT was well conducted, only one
since the included RCTs are moderately to highly hetero- study of its type exists. Therefore, we considered the evi-
geneous. Evidence from several of the RCTs was also dence quality to be moderate. The GRADE system assesses
graded as moderate due to high loss-to-follow-up rates, 182 the benefit-to-harm ratio as well as the treatment effect
small sample size, 188 and possible selection bias. 183 magnitude and no benefit of prophylactic IHN resection
The GRADE system also assesses the benefit-to-harm has been reported. Furthermore, the development of a
ratio and treatment effect magnitude. Clear benefits of painful neuroma may have been missed as adverse out-
prophylactic IIN division/resection have not been reported. come in the presently available series. In short, no positive
Possible harm might result from a higher rate of sensory treatment effect has been shown, making a strong recom-
loss but the clinical consequence of this loss is unclear. mendation for IHN resection unsupportable.
Therefore, the treatment effect magnitude is low, leaving Genital branch of the genitofemoral nerve
us unable to make a strong recommendation. Finally, since
study follow-up durations are 12-month maximum and Evidence in literature
delayed long-term painful conditions may occur following
neurectomy (i.e., neuroma and deafferentation hypersen- No studies were found comparing prophylactic resection of
sitivity), some of these adverse outcomes may have been the genital branch of the GFN with preservation of this
missed in presently available series. nerve
Iliohypogastric nerve Pragmatic neurectomy

Evidence in literature Introduction
184, 191 174, 192, 193
Two RCTs and three cohort studies —but
no reviews—were found comparing IHN neurectomy with Pragmatic neurectomy refers to nerve resection or removal
IHN preservation. of a segment of a nerve that is ‘‘at risk.’’ An ‘‘at-risk’’
One RCT 191 and one cohort study 193 were eliminated from nerve, in turn, is the one that has been damaged during
this critical appraisal, the RCT, because of systematic bias due surgery, is in danger of being traumatized due to interfer-
to comparison of two adjustments of the surgical technique. ence with mesh position, or is likely to be included in the
The cohort study was eliminated because of imprecision due fibrotic process around mesh. Our search on this topic
to small sample size and possible selection bias. encompassed studies reporting on pain incidence following
Another RCT compared chronic pain incidence after pragmatic resection of inguinal nerves.
tension-free self-gripping mesh repair with sutured Licht-
enstein repair and recorded the type of nerve manage- Key question
174
ment. It too was omitted from our critical appraisal,
since it did not report on the incidence of chronic pain after KQ19P.i Does pragmatic (when nerve injury occurs or
pure prophylactic IHN. Therefore, we deemed the evidence interferes with placement of the mesh) resection of inguinal
to justify prophylactic IHN neurectomy too indirect. nerves reduce pain incidence?

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