Page 77 - International guidelines for groin hernia management

Hernia

Evidence in literature divided. Furthermore, the third study prospectively recor-
Our search found one cohort study comparing pragmatic ded type of nerve management in 781 Lichtenstein and
neurectomy of ‘‘at-risk’’ nerves with a routine nerve- Shouldice repairs. 189 They reported 12 patients with rele-
preservation approach. 173 Three other cohort studies vant chronic pain (VAS [ 3) at 5 years. In 11 of these 12,
involving only pragmatic neurectomy (without a nerve- IIN neurolysis had been performed during a Lichtenstein
preservation control group) were identified, but excluded repair. The conclusion of this study was that mesh contact
from analysis. 178, 189, 194 with a nerve removed from its natural bed should be
The analyzed cohort study involved 364 Lichtenstein her- avoided, supporting the notion that nerve resection is a
nia repair patients who underwent neurectomies for ‘‘at-risk’’ better alternative to leaving an intact mobilized nerve
nerves (traumatized, stretched, or interfered with by mesh). 173 in situ allowing mesh/nerve contact to occur.
In a different group of 161 Lichtenstein patients, no recom-
mendations were given for nerve handling and a nerve- Discussion
preservation routine was employed. There were no significant Overall, the strength of evidence on this topic is low. Only
inter-group differences in the number of identified nerves. In one cohort study exclusively compared a pragmatic
the larger group, significantly more IHN resections were done resection of nerves ‘at-risk’ approach with a general rou-
(40 versus 12%, respectively). No inter-group differences tine of preservation, supporting pragmatic ‘at-risk’
existed for IIN and GB resections. At 3-month postopera- neurectomy. 173 One other cohort study indirectly supports
tively, there was significantly less pain in the nerves-at-risk the view that nerves should be pragmatically resected in
resection group. It was concluded that, in Lichtenstein hernia case of iatrogenic damage or interference with the position
repair patients, a pragmatic approach of at-risk neurectomy of the mesh. 178 Two other cohort studies report no down-
produced less chronic postoperative pain. 173 side to pragmatic neurectomy. The level of evidence is low,
Three other cohort studies were excluded from analy- since only cohort studies were conducted.
178, 189, 194
sis. These studies investigated the influence of a When considering the benefit-to-harm ratio, IIN or IHN
pragmatic approach of ‘‘at-risk’’nerves but did not compare division does not influence the incidence of chronic
this group to a group in which all nerves were preserved. pain. 180 Sensory loss has been reported to increase fol-
For example, one study prospectively investigated a cohort lowing IIN neurectomy. 180
of patients in which the influence of a pragmatic approach Pragmatic resection of at-risk nerves seems justified and
was investigated in all 172 patients: preservation of ingu- provides a better alternative to nerve preservation of an
inal nerves unless it was felt that they would hinder the injured nerve or a nerve that interferes with mesh position.
placement of the mesh or would become entrapped by the Hernia sac resection in indirect hernia
mesh or suture material, in which case, they were divided
cleanly at the edge of the wound. 194 They reported no Introduction
differences in mean VAS score between the groups in
which the IIN or IHN or GB was divided compared to the Hernia sac excision and ligation in indirect hernia man-
group in which all three nerves were preserved. Another agement has been standard treatment for as long as radical
study prospectively recorded type of nerve management in hernia operations have been performed. The hernia sac—
973 primary IH patients undergoing elective Lichtenstein part of the parietal peritoneum—is well innervated. Early
or Trabucco repair. 178 No recommendations were made postoperative pain reduction might be achieved if the sac
regarding identification or preservation of inguinal nerves. was resected or invaginated, but not ligated.
They reported no significant difference in moderate-to-
severe pain at 6 months and 1 year between a group of 310 Key question
patients in which all nerves were identified and preserved
and a group of 60 patients in which one or two nerves were KQ19P.j Does hernia sac resection and ligation increase
divided and a group of 10 patients in which all nerves were the incidence of acute and/or chronic pain?

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