Page 85 - International guidelines for groin hernia management

Hernia

Discussion Discussion
Given the limitations of the literature on this subject, no The literature quality on this subject area is poor, resulting
conclusions can be reached regarding mesh removal sans in weakly supported recommendations. Given that mesh
neurectomy. removal and neurectomy and the decisions around these
procedures are complex, this will likely be the situation for
Key question some time. A high level of expertise and experience is
required for positive outcomes. Neurectomy type is prob-
KQ19T.f What type of neurectomy should be performed in ably a secondary consideration relative to the selection of
patients with chronic neuropathic pain ([ 3 months) after appropriate patients likely to benefit from nerve resection.
IH repair?

Evidence in literature
High level evidence is lacking. In total, 25 papers were Chapter 20
identified. 171, 210, 257–276 Most are retrospective case series.
There are only two prospective studies. 260, 265 The first one
describes detailed preoperative and postoperative charac- Recurrent inguinal hernias
teristics using mesh removal and a selective neurectomy.
The second reports on 20 cases treated by endoscopic triple H. Tran, D. Weyhe, and F. Berrevoet
neurectomy (success rate 100%). There are no studies
comparing tailored and triple neurectomies. The results of
endoscopic triple neurectomies were reported in seven case Introduction
series/studies/trials. 171, 172, 210, 259, 263, 265, 266 The remaining
18 studies reported on patients treated with a tailored Recurrent inguinal hernia clearly still is a major health
neurectomy. 257, 258, 260–262, 264, 267–277 problem. It is estimated that, worldwide, approximately 20
278
The reported outcomes of triple neurectomy operations million primary IH operations are performed annually.
range from an 85–100% pain reduction. Selective single or Recurrence rates in this same population can be as high as
double neurectomy studies generally report lower success 15%. 279 This figure is difficult to pinpoint, since recurrence
rates. rates vary with length of follow-up. 280 Regardless, vast
Numerous confounding factors prohibit firm conclusions resources are committed to this problem.
regarding a preferred neurectomy technique. First of all, Over 35 years after the introduction of mesh and
most of the triple neurectomy data are derived from a 25 years after the first laparoendoscopic IH repair was
single institute with reports including sequentially accu- performed, recurrence rates when compared to open-repair
mulated data. Furthermore, pain scores, follow-up, ques- (tissue) techniques have not consistently decreased world-
49, 281, 282
tionnaire, and neurologic examination techniques are wide. This situation needs improvement. Reori-
inconsistent and mostly absent. Therefore, the hetero- enting our thinking, such that recurrence is routinely
geneity in patient data prohibits firm conclusions. considered a complication rather than an expectation is a
necessary first step.

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