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42 Postoperative Chronic Pain Assessment andTHOPA Philosophy
419
and/or hip is likely to provide the most high-yield
information. Moreover, a MR of lumbar-sacral
column and pelvis is useful to identify a different
cause of pain, other than postoperative pain: hip
joint injury such as stress fractures, labral tears,
femoroacetabular impingement, and iliopsoas
bursitis. As such, MR should be considered as
both the denitive and rst-line modality for the
most specic evaluation of the PCP. However,
this modality is radiologist dependent [11].
42.2 Treatment
Data in the literature are poor and inconsistent
due to limited information on the preoperative
demographics, differences in denition and evaluation of pain degree, and limited follow-up, so
comparison among different strategies and their
results is very difcult.
As previously written, PCP is a product of
neuropathic and nociceptive pain and is also
inuenced by socioeconomic, emotional, cognitive, and genetic factors. So, a multimodal, multidisciplinary approach to PCP is therefore
necessary. Early involvement and cooperation
with pain management specialists are important
for the optimal management of these patients.
Initial acute postoperative pain treatment
should be as effective as possible, and standard
pharmacological pain treatment (gabapentanoids,
tricyclics, etc.) [12] for neuropathic pain should
be instituted earlier in patients with severe pain.
The question of whether this may reduce development of chronic pain is debatable in the
absence of any conclusive data [13].
It has been proven that analgesic patches
(lidocaine patch (5%) and capsaicin (8%)) do not
reduce summed pain intensity (at rest, during
movement, and during pressure) [14].
Nerve inltration with anesthetics is a minimally invasive technique for treating peripheral
neuropathy after inguinal surgery [15, 16].
Varying success rates have been reported, but the
relative ease of application is a main advantage
[17, 18]. Several studies [19–27] reported the
use of diagnostic blocks presurgery. The use of
ultrasound- guided regional anesthesia has
increased in the last decade and enables direct
visualization of peripheral nerves, facilitating
the success rate of the blocks [17]. However,
there is no scientic evidence of any short-term
or long- term analgesic efcacy of local anesthetic blocks in PCP following inguinal hernia
repair.
If nerve blocks do provide short-term relief,
the patient should subsequently benet from neurolytic or neuroablative techniques. These include
chemical neurolysis with alcohol or phenol, cryoablation, or pulsed radiofrequency ablation.
Several different techniques of neuromodulation
have been proposed. Pulsed radiofrequency
(PRF) is an invasive pain treatment technique
that employs electromagnetic energy deposited
in or near nerve tissue [28, 29]. An insulated needle with an active tip is inserted at the vertebral
level or at the peripheral level. Paresthesias are
then elicited in the painful area, by electrical
stimulation as an indication of adequate positioning of the needle tip. The voltage applied to the
treatment needle is rapidly raised and lowered,
with voltages typically alternating between 0 and
40V with a frequency of 300–500kHz. The temperature is held below 42°C avoiding structural
damage to the nerve tissue. The moderate heating
of the nerve tissue is believed to temporarily
block the nerve conduction.
Conventional continuous radiofrequency
(CRF) produces temperatures at the tip of the
treatment needle of 45–80°C leading to irreversible thermocoagulation of nerve structures and
has proven to be considerably more efcacious
than PRF in various chronic pain states [28]. A
recent retrospective uncontrolled study reported
a longer duration of pain relief in the CRF group
than in the local anesthetic block group at
12-month control [30].
Peripheral nerve stimulation utilizing a transperitoneal laparoscopic approach with selective
implantation of quadripolar electrodes at the
genitofemoral nerve (anterior surface psoas
major muscle) or ilioinguinal nerve, iliohypogastric nerve, and femoro-cutaneous lateral
nerve (anterior surface quadratus lumborum
muscle) has recently been presented with promising result [31].
420
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G. Campanelli et al.
Although preliminary reports with neuromodulation techniques are enthusiastic and promising, the evidence is still of low quality, and the
strength of recommendation is weak to moderate
[29]. The scientic rigor is generally not considered adequate, and study designs should be
improved in regard to control groups, randomization, blinding procedures, and adequate sampling
sizes [32].
Patients who are refractory to a conservative
regimen can be considered for operative intervention. However, successful surgical management is entirely dependent on selecting patients
with discrete, neuroanatomic problems that can
be corrected with previous surgery [33].
The working group of the international guidelines for prevention and management of PCP following inguinal hernia repair decided to consider
reasonable surgical treatment only after 1 year
postoperatively, when the inammatory response
has decreased and only when pain intensity curtails activity and conventional treatment has
failed (L.E. 5, G.R.D) [33].
Neuropathic pain not present before the operation, isolated to the inguinal distribution, with
demonstrated improvement from diagnostic and
therapeutic nerve blocks is most likely to benet
from operative neurectomy [4].
Surgical options proposed in literature for the
treatment of PCP are various and include selective neurolysis or neurectomy alone or along with
removal of mesh and xation material with revision of prior hernia repair [9, 10, 19–25, 32, 34–
47]. Most of the studies reported an open surgical
approach, few studies reported a laparoscopic
approach, and only three studies reported a combined approach. Consistently satisfactory results
in the majority of patients are reported.
Selective neurolysis or neurectomy may
improve a small subset of patients with PCP [19,
25, 26, 40, 43]. However, electron microscopy of
grossly normal nerves resected during triple neurectomy for CPIP demonstrates ultrastructural
damage contributing to PCP but unseen to the
naked eye [7, 19, 25, 40, 43]. There is also signicant variation and cross innervation of the
inguinal nerves in the retroperitoneum and inguinal canal, resulting in an overlap of their sensory
innervation, that make selective neurectomy less
reliable [19, 33, 48].
For these reasons, we always prefer triple
neurectomy.
About follow-up, it is important to remember
that nerve transection is known be associated with
delayed onset of neuropathic pain symptoms,
from months to years, so extended follow- up
times are suggested [32].
Data on surgical management clearly demonstrate that neurectomy with or without mesh
removal may provide long-lasting analgesic
effects in most patients with severe PCP following inguinal hernia repair.
Open anterior approach involves re- exploration
through the prior operative eld, and it permits the
removal of mesh and xation placed in the previous surgery but could be frustrating and challenging to proceed in a scarred eld to identify nerve,
and so the approach could become unreliable.
Endoscopic access in the retroperitoneum
allows for the identication of the ilioinguinal
nerve (IIN) and iliohypogastric nerve (IHN) at
the L1 nerve root overlying the quadratus lumborum and the genital and femoral branches of the
genitofemoral nerve (GFN) exiting from the
psoas muscle [21–23, 27]. The advantage of this
operation is the proximal access to potential sites
of peripheral neuropathy safety and separation
from the scar tissue of any prior inguinal hernia
repair, but mesh or plug removal is not feasible in
this way [21–23, 27].
After a clinical experience of more than 100
patients with PCP, we drafted and normally
adopt the Total Hope Pain Solving Approach
(THOPA.): in this approach, we try to operate
“against” all the possible causes of pain in order
to improve the patient’s chance to x his painful
symptoms.
So, we propose a total simultaneous double
anterior-posterior open approach to the inguinal
region: through a 6–8-cm-long suprapubic transverse lateral incision, 2 cm below the anterior
superior iliac spine (Fig.42.1), we rst approach
the preperitoneal space, and we identify IIN and
IHN on the quadratus lumborum (Fig.42.2) and
the genital and femoral branches of the GFN running on the psoas muscle (Fig.42.2) or along the
42 Postoperative Chronic Pain Assessment andTHOPA Philosophy
421
Pubic bone
ASIS
Fig. 42.1 Left inguinal region, the incision line (dotted)
is 2cm below the anterior superior iliac spine (ASIS)
IIN
IHN
Umbelicus
GFN
GFN
IA
Fig. 42.3 Right side, genitofemoral nerve (GFN) run-
ning along the iliac artery
plug
vas
cord
External oblique
aponeurosis
Fig. 42.2 Right side, approach to the preperitoneal space
and identication of iliohypogastric nerve (IHN) and ilioinguinal nerve (IIN) running on the quadratus lumborum
muscle and of the genitofemoral nerve (GFN) running on
the psoas muscle
iliac artery (Fig. 42.3) and proceed with triple
neurectomy.
Proceeding with a blunt dissection at retropubic level, the Retzius space is reached and
Cooper’s ligaments are identied. Going from
the pubic symphysis toward the psoas muscle, the
Bogros space is approached, and the external
iliac vessels, the cord, and the recurrent hernia
sac, if present, are identied.
If a plug has been placed during previous surgery, it can be safely removed now (even if not
always easily) (Fig.42.4).
If a mesh has been placed in the preperitoneal
space during the previous surgery, blunt dissec-
Fig. 42.4 Plug previously placed is carefully divided
from the cord and removed during the preperitoneal
approach
tion and its removal can be challenging: in this
case, we suggest to open the peritoneum, access
the abdominal cavity, and, after the viscera have
been safely reduced, cut the peritoneum all
around the mesh previously implanted. The peritoneal cavity can be closed then with a running
suture or with a bridged vicryl or biological
mesh, in case of loss of substance. Only in this
way, then it is possible to focus on the mesh and
remove it safely.
Then, through the same incision, after the
dissection of the skin and subcutaneous space
toward the pubic bone, the anterior region is
approached (Fig. 42.5), the external oblique
aponeurosis is open, and the meshoma or mesh
and suture or stitches placed can be completely
removed (Fig.42.6). It is important to remember that the cord may be found below the fascia
422
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Rectus muscle
G. Campanelli et al.
External oblique
aponeurosis
Rectus m.
Fig. 42.5 The drawing shows the double (anterior and
posterior) approach through the same incision in the right
inguinal region
External oblique
External oblique
aponeurosis and mesh
Fig. 42.6 Left inguinal region, the anterior region is
approached and the external oblique aponeurosis is open:
one nerve, probably the ilioinguinal, is isolated enclosed
in scar tissue and mesh previously placed
Internal
obl. m.
aponeurosis
Preperitoneal
space
but also above the fascia, in the subcutaneous
space, depending on the technique used in the
previous surgery. So, a prudent dissection is
required to identify and preserve the cord. The
IIN and IHN and the genital branch of GFN can
be sometimes reidentied and resected once
again (even if in scar tissue it is not reliable)
(Fig.42.7).
If, during preoperative evaluation of the
patient, we understand that a PIPS was likely
misdiagnosed and treated like an hernia and the
patient is still suffering from PIPS, we complete
the surgery with a partial calibrated tenotomy of
the abdominal rectus muscle and longus adductor muscle, like we usually do in PIPS treatment
(see Chap. 38) [49]. Both tenotomies can be
Cord in the
anterior space
Cord in the
preperitoneal space
Fig. 42.7 Left inguinal region after posterior and ante-
rior approach and removal of mesh previously placed. The
cord is isolated in both approaches
feasibly achieved during the anterior step at the
approach.
Finally, a new reinforcement is done with an
ultralight or biological mesh in the preperitoneal
space xed with glue [9].
We remove always the mesh previously placed
because the real reason of pain (neuropathic or
non-neuropathic) cannot be surely detected. The
choice of placing a new mesh in the preperitoneal
space is due to the fact that, even if at the moment
of surgery no recurrence is present, the removal
of mesh previously placed should make the posterior inguinal wall weak. For this reason, an
ultralight mesh is normally implanted.
In our experience (follow-up ranges between
6 and 108months), 80% of patients are free of
pain at 1year after surgery. As previously written, the late evaluation (almost 1year) is important because nerve transection can be associated
with delayed onset of neuropathic pain
symptoms.
In patients who underwent also a double partial calibrated tenotomy, a physio-kinetic program is established.
We wonder often what the reason of persisting
pain could be in some patients (20%), even if all
patients suffered with similar preoperative symptoms and underwent the same surgical procedure.
We think that psychological attitude should be
®
investigated, and we included the MMPI-2
test
in the preoperative evaluations, but, until now, no
clear connection has been found.
42 Postoperative Chronic Pain Assessment andTHOPA Philosophy
423
We strongly believe that more attention should
be paid to identify a test that can determine the
real cause of pain and optimize nonsurgical and
surgical options.
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Laparoscopic Approaches
toChronic Postoperative
InguinalPain
DavidK.Nguyen andDavidC.Chen
43
Inguinal hernia repair continues to be one of the
most commonly performed operations, with an
estimated 20 million cases performed worldwide
and 800,000in the United States per year [1–3].
The introduction of mesh and renement of tension-free techniques have markedly reduced
recurrence rates and improved patient outcomes.
However, chronic postoperative inguinal pain
(CPIP) remains a signicant complication. This
is dened as a new or different quality of pain
persisting 3 months after the hernia has been
repaired. Up to 63% of patients are affected by
some degree of chronic pain, with 6–8% experiencing signicant interference with quality of life
and activities of daily living [3–6].
CPIP can happen for multiple reasons. Hernia
recurrence must be ruled out. The patient can also
experience neuropathic pain associated with
injury to the ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves.
These injuries can happen during dissection, tissue handling, mesh xation, or scarring.
Nociceptive pain is another culprit, associated
with tissue injury and inammation caused by
tissue handling and trauma or foreign body
inammation due to meshoma [3–12].
Management of CPIP is difcult as there is often
not a discrete distinction between nociceptive
D. K. Nguyen · D. C. Chen (*)
Lichtenstein Amid Hernia Clinic at UCLA,
Los Angeles, CA, USA
e-mail: dcchen@mednet.ucla.edu
and neuropathic pain. Diagnosis is also often
complicated by psychosocial factors.
Most patients are successfully treated with
multimodal pharmacologic, interventional, and
behavioral therapies through a multidisciplinary
approach involving surgeons, pain specialists,
radiologists, psychiatrists, and primary physicians [3]. Some patients, however, will require
remedial surgery. With regard to neuropathic
inguinodynia, the most denitive of these surgeries is a triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerves. This was
rst described as a two-stage operation
approached through the inguinal and retroperitoneal elds but was rened by Amid into a singlestage, open operation in 1995. Recent technical
modications have yielded response rates of
85–95% [13].
With the evolution of mesh-based, tensionfree repairs, recurrence rates declined, and pain
became the more relevant clinical outcome of
inguinal repair. Surgical options for chronic postinguinal hernia repair pain have also progressed
and evolved to utilize minimally invasive operative approaches. The guiding principle is identication of the involved or at-risk inguinal nerves
with division proximal to the area of the repair.
However, identifying the three nerves in the
scarred re-operative eld is difcult, and the neuroanatomic variation increases along the course
of the nerves especially within the inguinal canal
[15–17].
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_43
425
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D. K. Nguyen and D. C. Chen
In the last three decades, use of the extraperitoneal space has become ubiquitous as a part of
endoscopic transabdominal preperitoneal
(TAPP) repairs, totally extraperitoneal (TEP)
repairs, and open preperitoneal repairs [18–20].
However, inguinodynia that arises after preperitoneal operations and those that cross both the
anterior and posterior planes pose a more complex challenge. Nerve injuries associated with
these operations are often too proximal to reach
through an open anterior inguinal approach, and
addressing preperitoneal mesh through an open
incision is also difcult [19–21]. Orchialgia
resulting from vas and spermatic cord injury
proximal to the internal ring is also a technical
challenge. These aforementioned challenges
make an endoscopic approach, either retroperitoneally or transabdominally, a desirable alternative [21–23].
Patients with CPIP should be offered surgical
intervention if there are appropriate targets for
remediation (meshoma, neuropathic pain, recurrence, orchialgia) after attempting and failing
conservative therapies for a minimum of 3 but
optimally 6months after the initial repair. CPIP
is traditionally dened by this 3-month chronicity, but the timing of mesh integration and resolution of normal postoperative scarring with
mesh-based repairs make 6months a more conservative time frame. The preoperative workup
needs to be thorough and methodical as successful intervention and the minimization of secondary complications are primarily predicated on
proper patient selection. Characterization of
symptoms, assessment of prior pharmacologic
and interventional treatments, as well as crosssectional imaging to identify recurrence,
meshoma, or other anatomic abnormalities
should be done. A plain lm of the pelvis or scout
lms from a CT scan may determine whether
metallic xation tacks were used and where they
were placed. Prior operative reports should be
reviewed to determine the type of operation, use
of mesh, location of mesh, xation, identication, and handling of nerves as all these factors
can inuence the most appropriate type of remedial operation. Dermatosensory mapping should
be used during the preoperative assessment to
help determine if neuropathic pain is present and
which nerve distributions are implicated.
Quantitative sensory testing when available is
also useful in characterizing neuropathic inguinodynia but is often too time and labor intensive for
daily clinical practice. All patients considered for
neurectomy should undergo diagnostic and therapeutic blocks of the ilioinguinal, iliohypogastric,
and genitofemoral nerves.
A thorough discussion of risks, benets, and
expectations should be carried out with the
patient undergoing remedial surgery [24, 25].
These include but are not limited to failure to
identify or resect all three nerves, persistent pain,
permanent numbness, bulging of the lateral
abdominal wall muscles due to motor denervation of the lower oblique muscles, labial numbness, testicular atrophy or loss, loss of cremasteric
reex, injury to the spermatic cord, and deafferentation hypersensitivity. If the patient has nociceptive pain caused by tissue injury, meshoma, or
other factors, their pain will not be alleviated
with triple neurectomy alone, and mesh-, hernia-,
or tissue-based causes must also be addressed.
Similarly, isolated orchialgia is unlikely to
resolve with inguinal neurectomy alone.
43.1 Surgical Techniques
43.1.1 Endoscopic Groin Exploration
Endoscopic groin exploration should be considered a part of the diagnostic evaluation and can
be used as an adjunct (with hybrid approaches to
the inguinal canal) or primary means to address
many of the pathologies associated with CPIP.It
is appropriate for patients with a prior history of
laparoscopic inguinal hernia repair (TEP or
TAPP) with evidence of meshoma and use of lateral penetrating xation or for patients with anterior or preperitoneal approach, equivocal
imaging, and unremitting pain that is meshrelated or neuropathic on physical exam.
Diagnostic laparoscopy is the rst step, as it
allows for identication of interstitial hernias,
recurrent hernias, mesh migration, and intraabdominal adhesions that could be contributing
43 Laparoscopic Approaches toChronic Postoperative Inguinal Pain
to the patient’s symptoms. Offending tacks or
other types of xation can also be identied and
often removed from the intraperitoneal working
space without violating the preperitoneal space.
Exploration of the preperitoneal space and
myopectineal orice, whether through a transabdominal or totally extraperitoneal approach, is
LFC
an important next step. Developing the preperitoneal view of the myopectineal orice helps to
rule out occult causes of pain including recurrence, retained lipoma, and mesh migration and
allows for subsequent preperitoneal mesh repair
of the resultant or recurrent hernia if desired.
This allows for visualization of the cord structures and hernia spaces and identication of the
lateral femoral cutaneous nerve and genitofemo-
Fig. 43.1 Left preperitoneal inguinal neuroanatomy.
Lateral femoral cutaneous (LFC) nerve over iliacus.
Genitofemoral nerve (GFN) with its genital (GB) and
femoral (FB) branches passing over the psoas medial to
the iliac vessels
ral nerves. The peritoneal ap should be initially
separated from the mesh and preserved; how-
43.1.2 Meshoma
ever, this is sometimes not possible. If the main
issue is recurrence and the mesh is otherwise
at, it may be left in place with creation of a
larger dissection space, and additional mesh is
placed. Alternatively, recurrence may be
addressed with an anterior Lichtenstein repair
avoiding the preperitoneal plane altogether.
However, if recurrence is not the only factor
leading to pain, hernia repair alone is unlikely to
remediate the problem.
Neuropathic pain that arises with laparoscopic
preperitoneal repair without traumatic xation
should by anatomy and mechanism be isolated to
the genitofemoral or lateral femoral cutaneous
nerves. Similarly, cases with dermatosensory
mapping suggestive of an isolated neuropathic
distribution involving the genital or lateral femoral cutaneous nerves can be addressed in the preperitoneal space without involvement of the
ilioinguinal and iliohypogastric nerves. The genital and femoral branches of the genitofemoral
nerve may be identied over the psoas and iliac
vessels as they pass toward the internal ring and
iliopubic tract. The lateral femoral cutaneous
nerve can be identied lateral to the psoas passing over the iliacus muscle toward the lateral
thigh. Neurectomy of these two nerves may be
safely and effectively performed during endoscopic groin exploration with minimal morbidity
in this location (Fig.43.1).
Meshoma pain after laparoscopic preperitoneal
repair may require mesh removal. Laparoscopic
mesh removal is difcult and fraught with potential dangers. However, compared to open mesh
removal, laparoscopic dissection and visualization allow for a broad assessment of mesh position and conguration, involvement of
surrounding visceral structures, and potential
mechanisms of pain. Laparoscopic dissection
also provides a controlled approach to removal of
the mesh especially with regard to adherence to
vascular structures. In the case of an isolated preperitoneal laparoscopic mesh (TEP, TAPP)
(Figs. 43.2 and 43.3), open preperitoneal mesh
placement (TIPP, Kugel, TREPP), or plug
(Fig.43.4a), removal may often be accomplished
entirely through a laparoscopic approach. With
repairs that traverse the anterior and posterior
plane (plug and patch and bilayered meshes),
laparoscopic mesh removal can address the posterior mesh component alone or may be used as
an adjunct to facilitate the posterior dissection as
part of a hybrid open inguinal and laparoscopic
preperitoneal approach (Fig.43.4).
Meshoma is typically scarred, xated, or contracted around the epigastric and iliac vessels
along with the cord structures. Occasionally the
bladder is adherent to the mesh as well.
Preoperative counseling must include discussion
Psoas M.
427
FB
GB
Iliac A.
GFN
428
cd
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D. K. Nguyen and D. C. Chen
a
b
Fig. 43.2 Laparoscopic removal of tack-xated preperitoneal mesh. (a) Intra-abdominal view (b) Preperitoneal view
with mesh and tacks (c) Tack removal (d) Mesh and tacks dissected off cord and vascular structures
about injury to these structures and contingency
plans to control bleeding and repair any potential
damage carefully thought out before starting the
operation. When separation from the vessels, the
viscera, or the spermatic cord is difcult, it is
surgery, may be helpful for complex cases as the
added range of motion, superior optics and visualization, and increased operative dexterity may
facilitate more precise mesh dissection and minimally invasive vascular repair.
often prudent and safer to leave a cuff of mesh
behind to minimize injury to these structures
especially in cases of xation with tacks and
43.1.3 Fixation
suture. With meshoma pain, patients typically are
affected by the amount of mesh present and its
three-dimensional conguration and bulk.
Reduction in the mass of the meshoma can potentially alleviate symptoms with decreased morbidity and risk by leaving small adherent areas of
mesh behind. Bladder decompression for laparoscopic mesh removal operations is recommended
to maximize the operative eld and facilitate
mesh removal or repair in the case of bladder erosion. Robotic-assisted groin exploration, following the same operative principles of laparoscopic
Penetrating xation with tacks or permanent
suture may cause nociceptive symptoms at the
point of xation or neuropathic injury with distal
dermatosensory effects. Tacks or other penetrating xation devices can be removed if they correspond to areas of targeted pain on preoperative
exam. Tack removal may be accomplished intraperitoneally or extraperitoneally. Isolated tack
pain can occasionally be addressed with simple
cutdown over the site of pain. However,
laparoscopic removal is recommended for multi-
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