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Inguinodynia after Laparoscopic Inguinal Hernia Repair

There are reports about mesh repair of inguinal hernia undergone repair with no mesh. This confusion in terms
and its effect on testicular vasculature, and hence effect on suggested that the term “mesh inguinodynia” was not
testicular size and on sexual function as fibrotic healing supported by the data presented.
causes hardening and shrinking of the mesh that is in direct The recommended surgical treatment for chronic
contact with spermatic cord. A report describes a beneficial neuropathic pain after herniorrhaphy has been a two-stage
effect on sexual function that improved postoperatively while operation that includes ilioinguinal and iliohypogastric
another describes postoperative chronic inguinal pain with neurectomies through an inguinal approach and genital nerve
subsequent sexual dysfunction. Inguinal hernioplasty with neurectomy through a flank approach. Equally effective is
mesh repair is associated with improvement in both quality a one-stage procedure involving the resection of all 3 nerves
of life and sexual function. Improvement of sexual function from an anterior approach. Simultaneous resection of the
is attributed to improvement of quality of life. Also, inguinal ilioinguinal, iliohypogastric, and genital nerves is performed
hernia may be associated with increased vascular resistance with implantation of their proximal ends and without
that is reversed after surgery with increase of testicular mobilization of the spermatic cord.
perfusion. 7 Although inguinodynia is a potentially disabling condition,
Various systems exist for prosthesis fixation in hernia it remains an underrated complication of inguinal hernia
repair. These techniques vary in terms of postoperative repair. Surgeons are able to pay more attention to addressing
complications and pain. This study compares prosthesis pain because of the reduced recurrence rate caused by
fixation techniques employed in laparoscopic transabdominal advances in hernia surgery.
preperitoneal (TAPP) hernioplasty using a visual analog scale The pain complex syndrome of postherniorrhaphy
(VAS) to quantify postoperative pain. We found differences neuropathic inguinodynia includes pain (neuralgia), burning
in postoperative pain among different laparoscopic TAPP sensation (parenthesis), hypoesthesia, and hyperesthesia,
prosthesis fixation methods. The use of the biocompatible with radiation of the pain to the skin of the corresponding
fibrin sealant ‘Tissucol’ seems to significantly reduce hemiscrotum, labium majus, and Scarp's triangle. Symptoms
postoperative pain, complications, and resumption to work are frequently triggered or aggravated by walking, stooping,
times compared with other systems. 8 or hyperextension of the hip, and can be decreased by
Recent literature on laparoscopic inguinal hernia repair recumbency and flexion of the thigh. These aspects of the
(LIHR) has shown that laparoscopic hernioplasty is pain syndrome suggest that traction of the involved nerve
associated with reduced postoperative pain and wound plays a major role in the postherniorrhaphy pain syndrome,
infection, and an earlier return to normal daily activities. 9 an issue that must be addressed in the surgical treatment of
Inguinal hernia repair can result in significant complications. neuropathic inguinodynia.
Among these is postherniorrhaphy neuralgia, a potentially The neuropathic pain complex can also be reproduced
disabling condition. It is important to determine whether by tapping the skin, medial to the anterosuperior spine of
the patient had groin pain prior to hernia repair and whether the iliac bone or over an area of localized tenderness (Tinel's
the preoperative pain was the same in character as test). It is extremely difficult, if not impossible, to pinpoint
the postoperative pain. In addition, it is appropriate to the involved nerve for several reasons. First, peripheral
determine how long after hernia repair the patient's communication between the ilioinguinal, iliohypogastric, and
inguinodynia began and whether the patient can differentiate genital branch of the genital femoral nerve is very common
postoperative surgical pain from the pain of inguinodynia and results in an overlap of their sensory innervation. Second,
or not. Patients should be informed of the remote possibility the innervation fields of the 3 nerves overlap. Third, at the
of central and differentiated pain. spinal level both ilioinguinal and iliohypogastric nerves derive
In order not to raise a red flag, we avoid such terms as from the 12th thoracic and first lumbar nerve, and both the
"nerve entrapment" for compression of the nerve(s) caused genital and ilioinguinal nerves receive communication from
by "perineural fibrosis," a naturally occurring condition after the first lumbar nerve. Fourth, more than one involved nerve
inguinal hernia repair. Similarly, it is important not to use can cause postherniorrhaphy pain syndrome.
the term "mesh inguinodynia," which implies chronic pain
caused by the mesh itself. In a published series of 234 patients TREATMENT
with postherniorrhaphy neuralgia in which the term "mesh Peripheral nerve block or differential paravertebral root
inguinodynia" was used, seven i.e. only one-third of the block, although helpful for differentiating neuropathic from
patients had previous mesh repair; the remainder had nonneuropathic pain, is often inconclusive in the differential

World Journal of Laparoscopic Surgery, September-December 2010;3(3):135-138 137