David Santos, MD, Shirin Towfigh, MD. Cedars Sinai Medical Center
OBJECTIVE: Chronic neuropathic pain after retroperitoneal inguinal hernia repair cannot be addressed with the well-described open anterior triple neurectomy. Thus, many patients with chronic pain are not candidates for surgical neurectomy if they have undergone laparoscopic inguinal hernia repair, or open posterior inguinal hernia repair using the Prolene Hernia System, Kugel patch, or Perfix plug. We present laparoscopic retroperitoneal triple neurectomy as a technique to relieve chronic neuralgia in this subset of patients.
METHODS: The patient is placed supine (for bilateral neurectomy) or in lateral decubitus (for unilateral neurectomy). Trocar positioning is similar to that for laparoscopic adrenalectomy. Key technical details are as follows: the colon is detached at the line of Toldt and the retroperitoneum is accessed.
The retroperitoneal dissection includes identification of the following structures: ureter and medial half of the psoas muscle (medially), 12th rib (superiorly), femoral nerve (inferiorly), iliac crest (laterally). The iliohypogastric and ilioinguinal nerves arise at a 45 degree angle from the posterolateral border of the psoas muscle, several centimeters caudad to the 12th rib. Our prior cadaveric study has shown that in 1/3 of cases, these two nerves share a common root and then branch as they extend toward the iliac crest. These anatomical details are important, as the 12th intercostal nerve may be mistaken as the iliohypogastric nerve, or the lateral femoral cutaneous nerve may be mistaken for the ilioinguinal nerve. The genitofemoral nerve exits from the mid-psoas muscle, and usually branches distally into a genital and femoral nerve. The ureter is found lateral to this nerve.
The nerves are transected proximally at their exiting path from the psoas muscle, and the proximal ends are implanted into muscle. The distal end is cut 5cm distally to prevent nerve communication. The specimens are submitted individually for pathologic confirmation.
RESULTS: Two patients (male, ages 37 and 57) suffered from chronic post-inguinal herniorrhaphy inguinodynia after laparoscopic inguinal herniorrhaphy (right, and bilateral, respectively); these were both performed using the totally extraperitoneal approach, with polypropylene mesh, and use of the Protack device. The patients presented with chronic inguinodynia unresponsive to medical therapy (660 and 690 days postoperatively, respectively). Both patients underwent mesh/tack removal and laparoscopic retroperitoneal triple neurectomies (right and bilateral, respectively). Postoperatively, the patients had no complications directly related to surgery. The dermatomal distribution from the neurectomies was appropriately numb postoperatively. Both patients have ongoing complicated chronic pain syndrome.
CONCLUSIONS: Laparoscopic retroperitoneal triple neurectomy is safe and appropriately provides numbness in the distribution of neuralgia after inguinal hernia repair. This procedure is an option for those who undergo laparoscopic inguinal hernia repair or open posterior inguinal hernia repair. Many of this subset of patients are inadequately treated in the early stages and present late with chronic pain syndrome. The feasibility of a minimally invasive technique may offer early treatment in this subset of patients.
Program Number: P336