George Taylor, Williams Eric H, Franklin Richard, Lee Dellon A
Greater Baltimore Medical Center, Towson, Maryland.
Ann Plast Surg. 2019 Jan;82(1):82-84. doi: 10.1097/SAP.0000000000001662.
An estimated 700,000 groin hernia repairs are performed in the United States each year. Studies have shown that up to 50% of patients who undergo groin hernia repair are affected by persistent pain beyond the first few days after surgery. At 2 to 5 years after either open or laparoscopic, mesh or without mesh, 10% to 12% of these patients will have persistent and disabling pain. If the ilioinguinal, iliohypogastric, or genitofemoral nerves are injured below the transversalis muscle layer, the traditional external, open approach to nerve resection will not help these patients. The traditional internal, laparoscopic, approach to the retroperitoneum can be used for nerve resection, but identification of the correct nerve is difficult. Therefore, we have developed a 2-team, dual approach, combining open and endoscopic approaches to solve this problem.
A retrospective review of the electronic medical records was performed to identify all patients who underwent a dual approach for groin denervation after persistent postherniorraphy pain. This dual approach included an external incision paired with a laparoscopic, retroperitoneal approach to identify and/or transect the ilioinguinal, iliohypogastic, lateral femoral cutaneous, and genital branch of the genitofemoral nerve. Inclusion criteria are persistent groin pain with alleviation after preoperative nerve block and either a failed attempt at an external approach groin denervation or pain after a primary laparotomy/laparoscopy procedure.
Thirteen patients met the inclusion criteria. All patients underwent a dual approach, and nerves were identified and confirmed in both the external groin and laparoscopic approaches. When placed on a scale from excellent/good to fair/poor relief of pain, 10 patients (77%) described excellent/good relief and 3 (23%) continued to have persistent pain.
A combined open surgical procedure, to identify the lateral femoral cutaneous nerve, and a laparoscopic procedure in the retroperitoneum have demonstrated the feasibility of this approach to identify correctly the nerve to be resected to relieve disabling groin pain.
在美国，每年估计有70万例腹股沟疝修补手术。研究表明，高达50%接受腹股沟疝修补手术的患者在术后头几天过后仍受持续性疼痛影响。在开放手术或腹腔镜手术（使用或不使用补片）后2至5年，这些患者中有10%至12%会出现持续性且致残的疼痛。如果髂腹股沟神经、髂腹下神经或生殖股神经在腹横肌层以下受损，传统的外部开放式神经切除术对这些患者并无帮助。传统的内部腹腔镜入路至腹膜后可用于神经切除术，但准确识别正确的神经很困难。因此，我们开发了一种双团队、双重入路的方法，将开放和内镜入路相结合来解决这个问题。
对电子病历进行回顾性分析，以确定所有在疝修补术后持续性疼痛后接受双重入路腹股沟去神经支配手术的患者。这种双重入路包括一个外部切口与一个腹腔镜腹膜后入路相结合，以识别和/或横断髂腹股沟神经、髂腹下神经、股外侧皮神经和生殖股神经的生殖支。纳入标准为术前神经阻滞后腹股沟持续性疼痛缓解，以及外部入路腹股沟去神经支配尝试失败或初次剖腹手术/腹腔镜手术后疼痛。
13例患者符合纳入标准。所有患者均接受了双重入路，在腹股沟外部和腹腔镜入路中均识别并确认了神经。按照疼痛缓解程度从优/良到中/差进行评分，10例患者（77%）描述为优/良缓解，3例（23%）仍有持续性疼痛。
一种联合的开放手术（用于识别股外侧皮神经）和腹膜后的腹腔镜手术已证明这种方法在正确识别要切除的神经以缓解致残性腹股沟疼痛方面的可行性。
