Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 827 - файл

The diagnostic evaluation must also discrimi­nate specic types of pain including nociceptive, neuropathic, somatic, and visceral pain. Nociceptive pain is a result of tissue injury and

For most anterior inguinal hernia repairs and posterior approaches utilizing xation, multiple inguinal nerves may be involved or will be placed at risk with reoperation. Triple neurectomy is more effective but results in greater numbness and potential for deafferentation hypersensitivity. Selective neurectomy may be considered when the likely mechanism of injury, prior operation, physical examination, and dermatome mapping isolate to a discrete nerve without likely overlap

Operating in the scarred reoperative eld also contributes to the complexity of this operation. Bischoff et al. described their experience with selective neurectomy in 54 patients with chronic pain after open mesh repair. The ilioinguinal, ilio­hypogastric, and genitofemoral nerves were identi­ed in 40 (74%), 20 (37%), and 13 (24%) patients, respectively, illustrating the challenge of reopera­tive nerve identication even in experienced hands [10]. In the reoperative eld, it is difcult to pre­cisely isolate the inguinal nerves involved, and fre­quently there is more than one nerve implicated in postherniorrhaphy chronic neuropathic pain.

Triple neurectomy is an accepted surgical treatment for neuropathic pain refractory to con­servative measures and, in most cases, is arguably the most effective option [8, 9]. In our experience with over 800 patients using an open approach and over 90 selected cases using a laparoscopic retroperitoneal approach, we are able to achieve an 85% and 90% success rate, respectively [11]. Figures for efcacy rates of these operations should be interpreted in the context of rigorous and experienced patient selection which is by far the most important factor with regard to predict­ing successful intervention. When combined with “meshoma” excision and removal, open triple neurectomy provides effective relief in a majority of carefully selected patients with refractory neu­ropathic and nociceptive inguinodynia. Those most likely to benet from operative neurectomy are those with neuropathic pain that was not pres­ent prior to the original operation, that is isolated to the inguinal distribution, and that experienced improvement with therapeutic nerve blocks.

With widespread adoption of preperitoneal open and minimally invasive (laparoscopic and robotic) inguinal hernia repairs, chronic inguino-

For open extended triple neurectomy, a stan­dard anterior approach is used to address the ilio­inguinal and iliohypogastric nerves. The eld is then extended to expose the retroperitoneum dividing the inguinal oor utilizing the same split made in the internal oblique muscle during resec­tion of the intramuscular segment of the iliohypo­gastric nerve. The underlying transversus abdominis muscle is split, which exposes the parietal peritoneum. This is then swept medially and cephalad to expose the psoas muscle and the main trunk of the genitofemoral nerve as it courses over the body of the muscle (Fig.15.3). This approach treats neuropathic pain due to injury of the main trunk, the femoral branch, or the preperitoneal segment of the genital branch, which is inaccessible during standard triple neurectomy.

Neurectomy at this proximal level is highly reliable and effective but does not address recur­rence, nociceptive pain, or mesh-related etiolo­gies. It may be used alone or in conjunction with a hybrid approach with open mesh removal or repair. However, the same factors that make prox­imal neurectomy successful for neuropathic pain lead to its morbidities. Special consideration of the anticipated side effects and complications of proximal neurectomy must be considered, under­stood, and explained to the patient in the consent process. The resultant area of anticipated numb­ness is larger after proximal neurectomy. The entire eld of the nerve is affected along with the proximal branches that are preserved in open neurectomy. The iliohypogastric nerve typically has a posterior branch that extends toward the lower back and upper gluteal region. Neurectomy of a common genitofemoral trunk will sacrice sensation to the anterior upper thigh innervated by the femoral branch of the nerve. Larger areas of denervation may increase the risk for deaffer­entation hypersensitivity. Proximal iliohypogas­tric neurectomy will also result in loss of the motor innervation to the lower oblique muscles which may result in lateral bulging and abdomi­nal wall laxity. This typically improves with time due to cross-innervation and compensation but is a known result of proximal denervation. In gen­eral, it is preferable to perform a neurectomy as distal as reasonably possible where it is proximal to the likely site of injury with less unwanted side consequences.

In a subset of patients, orchialgia accompanies inguinodynia following inguinal hernia repair. It is important to distinguish testicular pain from the scrotal pain often associated with genital neu­ralgia. If this presents, triple neurectomy alone will not alleviate the pain. As with inguinodynia, postherniorrhaphy orchialgia may be caused by different overlapping etiologies. Nociceptive tes­ticular pain may be due to direct injury to the tes­ticular parenchyma or ischemia from vascular compromised from arterial infarction or venous obstruction. This type of pain is difcult to address and may be refractory to conservative measures as well as interventions including orchiectomy. Neuropathic testicular pain second­ary to hernia repair may be caused by neuropathy of the paravasal nerve bers, the autonomic nerve bers that run with the cord structures, and coalesce at the level of the internal ring to envelop the vas deferens. In patients identied with neu­ropathic orchialgia, paravasal neurectomy may be performed at the time of triple neurectomy or mesh removal. After an anterior repair with a at mesh, plug and patch, or bilayer mesh, this can be performed just proximal to the internal ring and mesh (Fig.15.8). In orchialgia after laparoscopic mesh repair, anterior vas neurolysis is unlikely to be effective due to the injury being proximal to cord structures. Accessing the paravasal auto­nomic nerve plexus proximal to the mesh may be