Page 79 - International guidelines for groin hernia management

Hernia

hernia operations, 111 completed a questionnaire. Fourteen Evidence in literature
of these patients (13%) had undergone pubic tubercle Orchialgia results from damage to the testicle’s visceral
suture removal. 205 Total or partial mesh removals were innervation. These nerves run along the spermatic vessels
done at the same time and the results of suture removal and are derived from paravertebral ganglia mainly at the
alone were not calculated. The results within this subgroup kidney level. It is known that ipsilateral orchialgia occurs
did not significantly differ from the results in the whole in 6–44% of kidney donors. 207, 208 Laparoscopic standard
study group of 111 patients answering the questionnaire, procedure involves an en bloc dissection of the ureter and
improvement being reported by 62% of the patients. In gonadal vein divided at the level of the iliac vessels’
those with chronic postherniorrhaphy pain (10–12% of IH crossing. 207 Orchialgia does not occur if a gonadal-vein-
repair patients), approximately 12–13% will have pain sparing approach is used (so as not to disturb the vessel
probably caused by tubercle mesh fixation, representing below the point of ligation at the renal vein). A study of
about 1% of chronic pain cases. genitofemoral neurectomy in 23 patients found that three of
six patients with persistent neuralgia had significant
Discussion orchialgia. None of the patients who had significant pain
Despite this being an uncommon problem and the subject relief after neurectomy had preoperative testicular pain. 209
of a limited number of publications, pain due to pubic bone Another study found that orchialgia was not affected by
periosteal interference is an important issue with a signif- laparoscopic triple neurectomy in refractory neuropathic
icant impact on patient wellbeing. Our recommendation on inguinodynia, because the testes have a separate
the subject is, therefore, ungraded to strong. innervation. 210
In open anterior mesh repairs, the mesh overlapping the Testicular pain occurs after open and laparoscopic her-
medial pubic tubercle is, in fact, an ‘‘onlay’’ mesh part, nia operations. Etiologies include: spermatic cord trauma,
meaning that local preparation for mesh placement is inflammation and fibrosis due to mesh ingrowth, and cord
important. Overlap should compensate for mesh shrink- strangulation at the passage through a cut slit in the mesh.
age. 206 Deeply positioned sutures for medial mesh fixation Note that publications on testicular problems that do not
should be avoided, and if local treatment with anesthetics cite patient numbers are excluded from our discussion.
and corticosteroids fail, surgical suture removal must be A meta-analysis on endoscopic versus open mesh and
considered. 203 non-mesh techniques found testicular atrophy or ‘‘prob-
The sensitive pubic bone area is also reachable via the lems’’ in 51 of 7622 operations (0.7%) with no statistical
preperitoneal route. The pectineal ligament along the pubic significant inter-group differences in articles reporting on
bone’s superior ramus is commonly used for suture fixa- this issue. 83, 84 Chronic postoperative pain was reported in
tion. This ligament thins medially and sutures or tacks in 598 of 8524 operations (7%), endoscopic 5%, and open
that area may reach periosteum. However, no publications 9%. Orchialgia and testicular problems represented 10% of
specifically address this issue. the chronic groin pain cases. 83, 84 A systematic review
Orchialgia found the incidence of testicular pain to be 1–6%. In
another article reporting on those with severe or very
Introduction severe groin pain, 22 of 120 (18%) had testicular pain and
Few CPIP patients develop testicular pain. If it develops, 2.6–4.5% had testicular atrophy. 146 A meta-analysis of
however, it can be debilitating and adversely affect sexual open preperitoneal versus Lichtenstein repair that included
function and quality of life. 2860 patients found testicular problems in 1.3 and 1.9%,
respectively, chronic pain in 7.1 and 12.3%, respectively,
Key question for a total of 1.6% incidence of testicular problems and a
9.8% incidence of chronic pain. 86 In four meta-analyses on
KQ19P.l What percentage of CPIP patients have lightweight versus heavyweight mesh in open hernia sur-
orchialgia? gery published from 2011 to 2013, testicular problems

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