Brian Bassiri-Tehrani, MD, Donna Bahroloomi, MD, A. Douglas Heymann, MD, FACS. Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell
BACKGROUND: Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is an elusive cause of chronic abdominal pain that is secondary to the branches of the intercostal nerves becoming impinged as it pierces the anterior abdominal wall. Causes can include trauma, previous surgery, or pregnancy. The diagnosis is made on physical exam with a positive Carnett sign, and, usually with a therapeutic injection of local anesthetic at the focal area of pain and tenderness. These symptoms, however, are only temporarily treated by local anesthetic injections. Occasionally, patients require surgery to cut down to and resect a segment of the nerve branches known as an anterior neurectomy. This is effective in 75% of patients. For the remaining one-fourth of patients suffering from pain refractory to these interventions, pain is often described as “lateralizing” or migrating toward the lateral abdominal wall. Posterior neurectomy is a novel surgical approach that may provide sustained relief for patients with ACNES. This unique laparoscopic approach allows the surgeon to perform extensive lateral dissection of the intercostal nerves with minimal morbidity, and affords potential for removal of a longer segment of the lower thoracoabdominal intercostal nerves, thus eliminating the “lateralization” pain that some patients experience after an anterior release. This study is the first to describe the results of a laparoscopic posterior neurectomy in patients suffering from ACNES.
METHODS: A database of ACNES patients’ refractory to lidocaine injections who underwent a laparoscopic posterior neurectomy between the years of 2016 and 2018 in the Northwell Health System were retrospectively evaluated. Pain was recorded prior to treatment and after 6 weeks using a pain intensity numeric rating scale (0-10). Success was defined as a ≥50% pain score reduction or ≥2 point verbal rating scale reduction.
RESULTS: Three adult ACNES patients who had lidocaine injections with temporary relief were included in this study. One patient had a laparoscopic posterior neurectomy with pain relief, however had a recurrence of ACNES in 12 months and underwent a repeat laparoscopic posterior and open anterior neurectomy with good relief. The other two patients had a laparoscopic posterior neurectomy with sustained mitigation of symptoms (≥50% PI-NRS reduction) postoperatively.
CONCLUSIONS: Laparoscopic posterior neurectomy is a novel, minimally invasive surgical technique to treat ACNES that allows surgeons to resect a longer segment of nerves and its branches. This may potentially alleviate lateralization pain, although further studies with larger sample sizes need to be conducted in order to corroborate these results.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94510
Program Number: P608
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster