Clinical Report: Neurectomy Methods for Chronic Pain After Inguinal Hernia Surgery

Overview

This systematic review and meta-analysis evaluates the effectiveness of different neurectomy techniques and surgical approaches in managing chronic post-herniorrhaphy pain (CPIP). The analysis highlights variable success rates between triple and double neurectomy and compares open versus minimally invasive surgical methods.

Background

Inguinal hernia repair is common, with mesh techniques reducing recurrence but not eliminating chronic postoperative pain, which can be nociceptive or neuropathic. CPIP affects quality of life and ranges widely in incidence due to differing definitions and assessments. When conservative treatments fail, surgical neurectomy targeting ilioinguinal, iliohypogastric, and genitofemoral nerves is considered, though the optimal neurectomy type and surgical approach remain uncertain.

Data Highlights

The meta-analysis included 439 titles screened and 56 full texts reviewed, incorporating randomized controlled trials, prospective and retrospective cohorts, and case series. Pain duration definitions varied, with chronic pain defined as lasting more than 3 to 6 months. Diagnostic criteria for neuropathic pain involved clinical features and imaging. Statistical methods included random-effects models and inverse variance pooling, with heterogeneity assessed by I² index.

Key Findings

• Triple neurectomy (ilioinguinal, iliohypogastric, genitofemoral nerves) has been proposed for persistent neuropathic CPIP but shows variable success rates.
• Double neurectomy may offer comparable pain relief with fewer complications compared to triple neurectomy.
• Open neurectomy involves direct access via a single incision, often extending previous incisions.
• Minimally invasive approaches (laparoscopic transabdominal, endoscopic retroperitoneal) are alternative surgical methods, but their comparative efficacy remains unclear.
• Diagnostic evaluation includes clinical examination, nerve blocks, and imaging to exclude other causes and identify mesh-related complications.
• Chronic pain definitions and assessment methods vary across studies, contributing to heterogeneity in reported outcomes.

Clinical Implications

Clinicians should consider both double and triple neurectomy techniques when managing CPIP, weighing potential benefits against complication risks. Surgical approach selection should be individualized, as evidence does not definitively favor open versus minimally invasive methods. Comprehensive preoperative assessment including clinical and imaging diagnostics is essential to guide appropriate surgical intervention.

Conclusion

Neurectomy surgery is a viable option for refractory CPIP, with double neurectomy potentially offering effective pain relief with fewer complications. Further high-quality studies are needed to clarify optimal neurectomy types and surgical approaches.

References

1. Stulz and Pfeiffer 1982 -- Surgical management of postoperative groin pain
2. Cochrane Handbook for Systematic Reviews of Interventions -- Statistical methods
3. PROSPERO CRD42023475401 -- Systematic review registration