开放式腹股沟疝修补术后的神经管理和慢性疼痛：一项前瞻性两阶段研究。

Nerve management and chronic pain after open inguinal hernia repair: a prospective two phase study.

机构信息

Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburgerstr. 41, D-21465 Reinbek, Germany.

出版信息

Ann Surg. 2011 Jul;254(1):163-8. doi: 10.1097/SLA.0b013e31821d4a2d.

DOI:10.1097/SLA.0b013e31821d4a2d

PMID:21562403

Abstract

INTRODUCTION

This prospective cohort study involved 781 elective primary inguinal hernia operations performed on 736 patients at the Hernia Centre of Reinbek Hospital from April 2000 to April 2002.

MATERIAL AND METHODS

Small hernias were fixed by the Shouldice repair, and large defects by the Lichtenstein repair with conventional polypropylene mesh. Pain was assessed before the operation, on day 0, 1, 2, 7, 6 months and 5 years after the operation by the visual analogue scale (VAS). The follow-up was 90.1% after 6 months and 82.6% after 5 years. Chronic pain (CP) was assessed in relation to preoperative pain, nerve anatomy and intraoperative nerve management. The anatomy of the iliohypogastric nerve (IHN), ilioinguinal nerve (IIN), and genital branch of the genitofemoral nerve (GB) before and after surgery was recorded in every operation.

RESULTS

The preoperative pain rate was 41.0%. The CP and sensory disorder rate after 6 months were 16.4% and 15.9, respectively. The only independent significant parameters for CP after 6 months were preoperative pain (P < 0.002) and sensory disorder of the groin after 6 months (P < 0.0001). After 5 years 16.1% of patients reported pain and 20.3% sensory disorder of the groin. Independent significant predictors of CP were: Preoperative pain (P < 0.024), IIN neurolysis in Lichtenstein repair (=IIN mobilization from its natural bed and nerve preservation; P < 0.002), CP after 6 months (P < 0.006) and a sensory disorder after 5 years (P < 0.0001). Eleven of 12 patients with relevant CP (VAS > 3) after 5 years had had a Lichtenstein repair with IIN neurolysis. The CP population of preoperative pain free patients changed with time: 65% of the patients with CP after 6 months were pain free after 5 years, and 69% of the patients with CP after 5 years were asymptomatic after 6 months.

CONCLUSION

Mesh contact with a nerve removed from its natural bed may cause chronic long-term pain. The combination of IIN neurolysis and the Lichtenstein repair should be avoided.

摘要

引言

本前瞻性队列研究纳入了 2000 年 4 月至 2002 年 4 月 Reinbek 医院疝中心对 736 例患者的 781 例择期原发性腹股沟疝手术。

材料和方法

小疝采用 Shouldice 修补术固定，大缺损采用 Lichtenstein 修补术加传统聚丙烯网片。手术前、术后第 0、1、2、7、6 个月和 5 年，采用视觉模拟评分法（VAS）评估疼痛。术后 6 个月随访率为 90.1%，5 年随访率为 82.6%。慢性疼痛（CP）与术前疼痛、神经解剖和术中神经管理有关。在每次手术中记录手术前后髂腹下神经（IHN）、髂腹股沟神经（IIN）和生殖股神经生殖支（GB）的解剖结构。

结果

术前疼痛发生率为 41.0%。术后 6 个月 CP 和感觉障碍发生率分别为 16.4%和 15.9%。术后 6 个月 CP 的唯一独立显著参数为术前疼痛（P < 0.002）和术后 6 个月腹股沟感觉障碍（P < 0.0001）。术后 5 年，16.1%的患者报告疼痛，20.3%的患者报告腹股沟感觉障碍。CP 的独立显著预测因素为：术前疼痛（P < 0.024）、Lichtenstein 修复中 IIN 神经松解术（=IIN 从其自然床移动并保留神经；P < 0.002）、术后 6 个月 CP（P < 0.006）和术后 5 年感觉障碍（P < 0.0001）。术后 5 年有 12 例相关 CP（VAS > 3）的患者中，11 例接受了 Lichtenstein 修复术加 IIN 神经松解术。术前无疼痛患者的 CP 人群随时间变化：术后 6 个月有 CP 的患者中，65%在术后 5 年无疼痛，术后 5 年有 CP 的患者中，69%在术后 6 个月无症状。